Cerebral Vasospasm and Hemodynamic Alterations Following Aneurysmal Subarachnoid Hemorrhage Revealed with Combined CT Perfusion and CT Angiography 

Authors

  • Yiping Zhao Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, P. R. 110001, China
  • Bo Zhang Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, P. R. 110001, China
  • He Zhang Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, P. R. 110001, China
  • Ke Xu Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, P. R. 110001, China
  • Songbai Li Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, P. R. 110001, China

DOI:

https://doi.org/10.12974/2309-6179.2014.02.02.3

Keywords:

Computed tomography, perfusion, subarachnoid hemorrhage, cerebral vasospasm.

Abstract

Purpose: Vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is considered to be one of the major factors leading to neurological deficits and is associated with poor outcome in SAH. In this study, we utilized combined computed tomography angiography (CTA) and CT perfusion (CTP) techniques to assess radiographic cerebral vasospasm with attempts (1) to determine if cerebral vasospasms can be detected in patients with onset of SAH less than 3 days, and (2) to assess the perfusion deficits or hemodynamic alterations of the affected brain tissues following acute or delayed SAH. 

Materials and Methods: Thirty-eight patients with SAH and seven without SAH were recruited in the present study. After SAH was confirmed with a baseline non-enhanced head CT scan, the combined CTA-CTP procedures were performed and the CTP maps were created simultaneously. Quantitative CTP measurements including cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT) and time-to-peak (TTP) were carried out for each of the territories in the anterior cerebral artery (ACA), the middle cerebral artery (MCA) and the posterior cerebral artery (PCA), respectively. 

Results: Among 38 patients with SAH, a total of 33 aneurysms were detected and their anatomic locations were as follows: PCA (17), ACA (10) and MCA (6), respectively. Furthermore, multiple aneurysms were also present in 7 of the 33 patients with SAH. Whole-brain CTP measurements showed perfusion deficits in all of the patients with SAH. Both CBV and CBF values were significantly reduced in the affected areas of brain tissues. The incidence of cerebral vasospasm was significantly higher in the patients with delayed SAH (61.5%) than those with onset of SAH in less than 3 days (12%) (Fisher exact test, p<0.05). Additionally, quantitative analysis of CTP measurements of the patient without cerebral vasospasms with those with CVS reveals that, when compared to the control, all the patients with or without cerebral vasospasms showed significant differences in all four parameters measured (p<0.05, one-way ANOVA). Furthermore, according to their corresponding territories of the ACA, MCA and PCA, there were significant decreases in the mean CBV and CBF values of the ACA, MCA and PCA of SAH patients compared to the control patients, respectively. Moreover, a significant prolongation in the mean MTT and TTP values in SAH patients was also evident. 

Conclusion: Although a much higher incidence of cerebral vasospasms usually occurs in the delayed SAH, cerebral vasospasm could be detected in less than three days following the onset of acute SAH. Furthermore, the combined CTA-CTP procedures, along with the baseline CT scan, could also offer diagnostic benefits for assessing changes in global perfusion following the onset of aneurysmal SAH. 

References

Broderick JP, Brott TG, Duldner JE, et al. Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage. Stroke 1994; 25(7): 1342-1347. http://dx.doi.org/10.1161/01.STR.25.7.1342

Hop JW, Rinkel GJ, Algra A, et al. Case-fatality rates and functional outcome after subarachnoid hemorrhage: A systematic review. Stroke 1997; 28(3): 660-664. http://dx.doi.org/10.1161/01.STR.28.3.660

Oyama K, Criddle L. Vasospasm after aneurysmal subarachnoid hemorrhage. Crit Care Nurse 2004; 24: 58-67.

Weir B, Grace M, Hansen J, et al. Time course of vasospasm in man. J Neurosurg 1978; 48(2): 173-178. http://dx.doi.org/10.3171/jns.1978.48.2.0173

Dietrich HH, Dacey RG Jr. Molecular keys to the problems of cerebral vasospasm. Neurosurgery 2000; 46(3): 517-530. http://dx.doi.org/10.1097/00006123-200003000-00001

Cenic A, Nabavi DG, Craen RA, et al. A CT method to measure hemodynamics in brain tumors: validation and application of cerebral blood flow maps. AJNR Am J Neuroradiol 2000; 21(3): 462-470.

Lubicz B, Levivier M, Francois O, et al. Sixty-Four-Row Multisection CT Angiography for detection and evaluation of ruptured intracranial aneurysms: Interobserver and intertechnique reproducibility. AJNR Am J Neuroradiol 2007; 28(10): 1949-1955. http://dx.doi.org/10.3174/ajnr.A0699

Aralasmak A, Akyuz M, Ozkaynak C, et al. CT angiography and perfusion imaging in patients with subarachnoid hemorrhage: Correlation of vasospasm to perfusion abnormality. Neuroradiology 2009; 51(2): 85-93. http://dx.doi.org/10.1007/s00234-008-0466-7

Yoon DY, Choi CS, Kim KH, et al. Multidetector-row CT angiography of cerebral vasospasm after aneurysmal subarachnoid hemorrhage: comparison of volume-rendered images and digital subtraction angiography. AJNR Am J Neuroradiol 2006; 27(2): 370-377.

Shankar JJ, Lum C. Whole Brain CT perfusion on a 320-slice CT scanner. Indian J Radiol Imaging 2011; 21(3): 209-214. http://dx.doi.org/10.4103/0971-3026.85370

Orrison WW Jr, Snyder KV, Hopkins LN, et al. Whole-brain dynamic CT angiography and perfusion imaging. Clin Radiol 2011; 66(6): 566-574. http://dx.doi.org/10.1016/j.crad.2010.12.014

Rijsdijk M, van der Schaaf IC, Velthuis BK, et al. Global and focal cerebral perfusion after aneurysmal subarachnoid hemorrhage in relation with delayed cerebral ischemia. Neuroradiology 2008; 50(9): 813-820. http://dx.doi.org/10.1007/s00234-008-0416-4

Vajkoczy P, Horn P, Thome C, et al. Regional cerebral blood flow monitoring in the diagnosis of delayed ischemia following aneurismal subarachnoid hemorrhage. J Neurosurg 2003; 98(6): 1227-1234. http://dx.doi.org/10.3171/jns.2003.98.6.1227

Binaghi S, Colleoni ML, Maeder P, et al. CT angiography and perfusion CT in cerebral vasospasm after subarachnoid hemorrhage. AJNR Am J Neuroraiol 2007; 28(4): 750-758.

Xiang Li, Chunzhi Li, Songbai Li, et al. Clinical Application of CTA coupled with whole brain CT perfused blood flow after onset of aneurismal subarachnoid hemorrhage. J of China Clinic Medical Imaging 2011; 22(6): 385-388.

Liu-Deryke X, Rhoney DH. Cerebral vasospasm after aneurysmal subarachnoid hemorrhage: an overview of pharmacologic management. Pharmacotherapy 2006; 26(2): 182-203. http://dx.doi.org/10.1592/phco.26.2.182

Bederson JB, Connolly ES Jr, Batjer HH, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009; 40(3): 994-1025. http://dx.doi.org/10.1161/STROKEAHA.108.191395

Alaraj A, Charbel FT, Amin-Hanjani S. Peri-operative measures for treatment and prevention of cerebral vasospasm following subarachnoid hemorrhage. Neurol Res 2009; 31(6): 651-659. http://dx.doi.org/10.1179/174313209X382395

Kassell NF, Sasaki T, Colohan AR, et al. Cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Stroke 1985; 16(4): 562-572. http://dx.doi.org/10.1161/01.STR.16.4.562

Sanelli PC, Jou A, Gold R, et al. Using CT perfusion during the early baseline period in aneurysmal subarachnoid hemorrhage to assess for development of vasospasm. Neuroradiology 2011; 53(6): 425-434. http://dx.doi.org/10.1007/s00234-010-0752-z

Rabinstein AA, Weigand S, Atkinson JL, et al. Patterns of cerebral infarction in aneurysmal subarachnoid hemorrhage. Stroke 2005; 36(5): 992-997. http://dx.doi.org/10.1161/01.STR.0000163090.59350.5a

Eskridge JM, McAuliffe W, Song JK, et al. Balloon angioplasty for the treatment of vasospasm: results of first 50 cases. Neurosurgery 1998; 42(3): 510-517. http://dx.doi.org/10.1097/00006123-199803000-00016

Otawara Y, Ogasawara K, Ogawa A, et al. Evaluation of vasospasm after subarachnoid hemorrhage by use of multislice computed tomographic angiography. Neurosurgery 2002; 51(4): 939-943.

Baldwin ME, Macdonald RL, Huo D, et al. Early vasospasm on admission angiography in patients with aneurysmal subarachnoid hemorrhage is a predictor for in-hospital complications and poor outcome. Stroke 2004; 35(11): 2506- 2511. http://dx.doi.org/10.1161/01.STR.0000144654.79393.cf

Drake CG, Hunt WE, Sano K, et al. Report of World Federation of Neurological Surgeons Committee on a universal subarachnoid hemorrhage grading scale. J Neurosurg 1988; 68(6): 985-986.

Grubb RL Jr, Raichle ME, Eichling JO, et al. Effects of subarachnoid hemorrhage on cerebral blood volume, blood flow, and oxygen utilization in humans. J Neurosurg 1977; 46(4): 446-453. http://dx.doi.org/10.3171/jns.1977.46.4.0446

Hirashima Y, Kurimoto M, Hori E, et al. Lower incidence of symptomatic vasospasm after subarachnoid hemorrhage owing to ruptured vertebrobasilar aneurysms. Neurosurgery 2005; 57(6): 1110-1116. http://dx.doi.org/10.1227/01.NEU.0000185632.69374.C9

Wintermark M, Ko NU, Smith WS, et al. Vasospasm after subarachnoid hemorrhage: utility of perfusion CT and CT angiography on diagnosis and management. AJNR Am J Neuroradiol 2006; 27(1): 26-34.

Kidwell CS, Saver JL, Mattiello J, et al. Diffusion-perfusion MRI characterization of post-recanalization hyperperfusion in humans. Neurology 2001; 57(11): 2015-2021. http://dx.doi.org/10.1212/WNL.57.11.2015

Rajendran JG, Lewis DH, Newell DW, et al. Brain SPECT used to evaluate vasospasm after subarachnoid hemorrhage: correlation with angiography and transcranial Doppler. Clin Nucl Med 2001; 26(2): 125-130. http://dx.doi.org/10.1097/00003072-200102000-00007

Dankbaar JW, Rijsdijk M, van der Schaaf IC, et al. Relationship between vasospasm, cerebral perfusion, and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Neuroradiology 2009; 51(12): 813-819. http://dx.doi.org/10.1007/s00234-009-0575-y

Downloads

Published

2014-07-25

How to Cite

Zhao, Y., Zhang, B., Zhang, H., Xu, K., & Li, S. (2014). Cerebral Vasospasm and Hemodynamic Alterations Following Aneurysmal Subarachnoid Hemorrhage Revealed with Combined CT Perfusion and CT Angiography . Journal of Neurology and Epidemiology, 2(2), 65–75. https://doi.org/10.12974/2309-6179.2014.02.02.3

Issue

Section

Articles