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Routine use of perfusion computed tomography for the detection of delayed cerebral ischemia in unconscious patients after aneurysmal subarachnoid hemorrhage

  • Original Article - Neurosurgical intensive care
  • Published:
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Abstract

Background

Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) is difficult to diagnose in unconscious patients, but it is essential for the prognosis. We analyzed the diagnostic value of routinely performed perfusion computed tomography (rPCT) to detect DCI-related hypoperfusion in this subgroup of patients.

Methods

Retrospective analysis of unconscious aSAH patients who underwent rPCT according to a predefined protocol. We exclusively analyzed PCT examinations in patients who were clinically and functionally asymptomatic with regard to transcranial Doppler ultrasound (TCD) and invasive neuromonitoring at the time of the PCT examination. The perfusion maps were quantitatively evaluated to detect DCI-related hypoperfusion. Possible clinical risk factors for the occurrence of DCI-related hypoperfusion in rPCT imaging were analyzed by multivariate analyses.

Results

One hundred thirty-six rPCTs were performed in 55 patients. New onset of DCI-related hypoperfusion was observed in 18% of rPCTs. The positive predictive value of rPCT to detect angiographic CVS was 0.80. Between examination days 6 and 10, the rate of DCI-related hypoperfusion was increased significantly (p < 0.05). After rPCT imaging with proof of DCI-related hypoperfusion, short-term follow-up showed secondary cerebral infarction (SCI) in 38%, compared with 5% for patients with normal perfusion on rPCT. The parameters “high risk phase (examination days 6-10)” and “new onset of DCI-related SCI” were significantly associated with the occurrence of DCI-related hypoperfusion in rPCT.

Conclusions

In unconscious and asymptomatic aSAH patients, rPCT identifies DCI-related hypoperfusion in a relevant number of examinations. However, despite timely endovascular rescue therapy, a significant proportion of secondary infarction still occurs in this subgroup.

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Authors and Affiliations

  1. Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany

    Claudia Ditz, Mathis Hartlieb, Jan Leppert, Volker M. Tronnier & Jan Küchler

  2. Department of Neuroradiology, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany

    Alexander Neumann & Hannes Schacht

  3. Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany

    Björn Machner

  4. Department of Pediatric Neurosurgery, Altonaer Kinderkrankenhaus, Hamburg, Germany

    Kara L. Krajewski

  5. Department of Neurosurgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lubeck, Germany

    Jan Küchler

Authors
  1. Claudia Ditz
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  2. Mathis Hartlieb
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  3. Alexander Neumann
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  4. Björn Machner
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  5. Hannes Schacht
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  6. Kara L. Krajewski
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  7. Jan Leppert
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  8. Volker M. Tronnier
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Mathis Hartlieb, Alexander Neumann, and Hannes Schacht. Data analysis and statistical analysis were performed by Claudia Ditz and Jan Küchler. The first draft of the manuscript was written by Claudia Ditz and Jan Küchler, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Jan Küchler.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was approved by the Institutional Review Board of the University of Lübeck (19-104A). For this type of retrospective study, formal consent is not required. This article does not contain any studies with human participants or animals performed by any of the authors.

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Presentation at a conference:

71st Annual Meeting of the German Society of Neurosurgery (DGNC), 8th Joint Meeting with the Japan Neurosurgical Society (JNS), Digital congress 21-24 June 2020.

This article is part of the Topical Collection on Neurosurgical intensive care

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Ditz, C., Hartlieb, M., Neumann, A. et al. Routine use of perfusion computed tomography for the detection of delayed cerebral ischemia in unconscious patients after aneurysmal subarachnoid hemorrhage. Acta Neurochir 163, 151–160 (2021). https://doi.org/10.1007/s00701-020-04571-8

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  • DOI: https://doi.org/10.1007/s00701-020-04571-8

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