RESUMEN
Delayed cerebral vasospasm is a major complication following subarachnoid hemorrhage and a primary cause of delayed cerebral ischemia. While various preventive treatments exist, some patients still develop severe vasospasm, highlighting the need for better rescue therapies. This article explores endovascular treatment as a rescue option for vasospasm, focusing on the clinical characteristics and roles of intra-arterial vasodilator injection therapy and percutaneous transluminal angioplasty(PTA). Despite a lack of strong evidence from large clinical trials, advancements in endovascular technology have positioned both intra-arterial vasodilator injection therapy and PTA as promising and safe rescue options for severe vasospasm. Careful selection of the appropriate approach is crucial for achieving optimal clinical outcomes, considering the unique characteristics, advantages, and limitations of each method. Further clinical trials are necessary to definitively confirm this hypothesis.
Asunto(s)
Procedimientos Endovasculares , Vasoespasmo Intracraneal , Humanos , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/terapia , Vasoespasmo Intracraneal/diagnóstico por imagen , Procedimientos Endovasculares/métodos , Vasodilatadores/administración & dosificación , Vasodilatadores/uso terapéutico , Hemorragia Subaracnoidea/cirugíaRESUMEN
OBJECTIVES: Vasospasm is a complication of aneurysmal subarachnoid hemorrhage (aSAH) that can change the trajectory of recovery and is associated with morbidity and mortality. Earlier detection of vasospasm could improve patient outcomes. Our objective is to evaluate the accuracy of smartphone-based quantitative pupillometry in the detection of radiographic vasospasm and delayed cerebral ischemia (DCI) after aSAH. MATERIALS AND METHODS: We prospectively collected pupillary light reflex (PLR) parameters from patients with aSAH admitted to a neurocritical care unit at a single hospital twice daily using quantitative smartphone pupillometry recordings. PLR parameters included: Maximum pupil diameter, minimum pupil diameter, percent change in pupil diameter, latency in beginning of pupil constriction to light, mean constriction velocity, maximum constriction velocity, and mean dilation velocity. Two-tailed t-tests for independent samples were performed to determine changes in average concurrent PLR parameter values between the following comparisons: (1) patients with and without radiographic vasospasm (defined by angiography with the need for endovascular intervention) and (2) patients with and without DCI. RESULTS: 49 subjects with aSAH underwent 323 total PLR recordings. For PLR recordings taken with (n=35) and without (n=241) radiographic vasospasm, significant differences were observed in MIN (35.0 ± 7.5 pixels with vasospasm versus 31.6 ± 6.2 pixels without; p=0.002). For PLR recordings taken with (n=43) and without (n=241) DCI, significant differences were observed in MAX (48.9 ± 14.3 pixels with DCI versus 42.5 ± 9.2 pixels without; p<0.001). CONCLUSIONS: Quantitative smartphone pupillometry has the potential to be used to detect radiographic vasospasm and DCI after aSAH.
Asunto(s)
Valor Predictivo de las Pruebas , Reflejo Pupilar , Teléfono Inteligente , Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/fisiopatología , Hemorragia Subaracnoidea/diagnóstico , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/diagnóstico , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/fisiopatología , Masculino , Persona de Mediana Edad , Femenino , Estudios Prospectivos , Anciano , Adulto , Reproducibilidad de los Resultados , Pupila/fisiología , Factores de Tiempo , Técnicas de Diagnóstico Oftalmológico/instrumentación , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatología , Isquemia Encefálica/etiología , Isquemia Encefálica/complicacionesRESUMEN
BACKGROUND: Carotid siphon calcification (CSC) serves as a marker of atherosclerosis and therefore may influence the outcome after subarachnoid hemorrhage (aSAH). We aimed to analyze the impact of CSC on neurological outcomes, ischemia, and vasospasm. METHODS: A total of 716 patients with aSAH were treated between December 2004 and June 2016 in our central European tertiary neurovascular care center in Essen, Germany. CSC was recorded using the Woodcock scale (grades 0-3) on a computed tomography scan. Study end points included an unfavorable outcome at 6 months post-aSAH (modified Rankin Scale score ≥4), vasospasm, and early cerebral ischemia (72 hours) and delayed cerebral ischemia (delayed cerebral ischemia; >72 hours) in the follow-up computed tomography scans. The associations were adjusted for patients' baseline characteristics and secondary complications. Finally, within a subgroup analysis, patients with and without daily aspirin intake after endovascular aneurysm occlusion were compared. RESULTS: Increasing grades of CSC were associated with lower rates of vasospasm in the anterior circulation. Severe CSC (grade 3) was independently related to the risk of an unfavorable outcome (adjusted odds ratio [aOR], 4.06 [95% CI, 1.98-8.33]; P<0.001) and early cerebral ischemia (aOR, 1.58 [95% CI, 1.03-2.43]; P=0.035) but not delayed cerebral ischemia (aOR, 1.08 [95% CI, 0.67-1.73]; P=0.763). In the aspirin subgroup analysis, the negative effect of severe CSC on functional outcome remained significant only in aSAH cases without aspirin (aOR, 5.47 [95% CI, 2.38-12.54]; P<0.001). In contrast, there was no association between severe CSC and unfavorable outcomes among individuals with daily aspirin intake (aOR, 0.84 [95% CI, 0.59-4.21]; P=0.603). CONCLUSIONS: Our data suggest CSC as a cerebrovascular risk factor resulting in higher rates of early cerebral ischemia and unfavorable outcomes after aSAH. However, by increasing arterial stiffness, CSC might lower the probability of vasospasm, which could explain the missing link between CSC and delayed cerebral ischemia. Additionally, aspirin intake seems to potentially mitigate the negative impact of CSC on aSAH outcome. Further investigations are needed to confirm the observations from the present study.
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Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/diagnóstico por imagen , Masculino , Femenino , Persona de Mediana Edad , Anciano , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/etiología , Isquemia Encefálica/diagnóstico por imagen , Adulto , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/complicaciones , Resultado del Tratamiento , Arteria Carótida Interna/diagnóstico por imagen , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/complicaciones , Procedimientos Endovasculares/métodos , Aspirina/uso terapéutico , Calcinosis/diagnóstico por imagen , Estudios RetrospectivosRESUMEN
BACKGROUND: Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by diffuse, multifocal segmental narrowing of cerebral arteries and can result in ischaemic stroke. Causal factors, identified in 60% of cases, include immunosuppressant pharmacotherapy. The few reports following heart transplantation are almost all in Asian recipients. We report on a Caucasian Australian patient with immunotherapy induced RCVS post heart transplantation to highlight the state of knowledge of the condition and the treatment dilemma it poses. CASE PRESENTATION: A 51-year-old female underwent orthotopic heart transplantation at our institution. Induction immunotherapy comprised basiliximab, mycophenolate mofetil and methylprednisolone. On day 6 post-transplantation the patient was transitioned to oral prednisolone and tacrolimus. On day 7 the patient began to experience bilateral, severe, transient occipital and temporal headaches. On day 9 tacrolimus dose was up-titrated. A non-contrast computed tomography brain (CTB) was normal. Endomyocardial biopsy on day 12 demonstrated moderate Acute Cellular Rejection (ACR), which was treated with intravenous methylprednisolone. That evening the patient experienced a 15-minute episode of expressive dysphasia. The following morning she became confused, aphasic, and demonstrated right sided neglect and right hemianopia. A CT cerebral perfusion scan demonstrated hypoperfusion in the left middle cerebral artery (MCA) territory and cerebral angiography revealed widespread, focal multi-segmental narrowing of the anterior and posterior circulations. A diagnosis of RCVS was made, and nimodipine was commenced. As both steroids and tacrolimus are potential triggers of RCVS, cyclosporin replaced tacrolimus and methylprednisolone dose was reduced. A further CTB demonstrated a large left MCA territory infarct with left M2 MCA occlusion. The patient made steady neurological improvement. She was discharged 34 days post-transplantation with mild residual right lower limb weakness and persistent visual field defect on verapamil, cyclosporine, everolimus, mycophenolate mofetil and prednisolone. CONCLUSION: Reversible cerebral vasoconstriction syndrome is rare after orthotopic heart transplantation. Until now, RCVS has been almost exclusively described in Asian recipients, and is typically caused by immunotherapy. The condition may lead to permanent neurological deficits, and in the absence of definitive treatments, early recognition and imaging based diagnosis is essential to provide the opportunity to remove the causal agent(s). Co-existent ACR, can pose unique treatment difficulties.
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Trasplante de Corazón , Humanos , Femenino , Persona de Mediana Edad , Trasplante de Corazón/efectos adversos , Inmunosupresores/uso terapéutico , Inmunosupresores/administración & dosificación , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/tratamiento farmacológico , Vasoconstricción/fisiologíaRESUMEN
BACKGROUND: The occurrence of delayed cerebral ischemia and vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) results in high morbidity and mortality, but the diagnosis remains challenging. This study aimed to identify neuroimaging perfusion parameters indicative of delayed cerebral ischemia in patients with suspected vasospasm. METHODS: This is a case-control study. Cases were adult aSAH patients who underwent magnetic resonance perfusion or computed tomography perfusion (CTP) imaging ≤ 24 h before digital subtraction angiography performed for vasospasm diagnosis and treatment. Controls were patients without aSAH who underwent CTP. Quantitative perfusion parameters at different thresholds, including Tmax 4-6-8-10 s delay, cerebral blood flow and cerebral blood volume were measured and compared between cases and controls. The Vasospasm Index Score was calculated as the ratio of brain volume with time-to-max (Tmax) delay > 6 s over volume with Tmax > 4 s. RESULTS: 54 patients with aSAH and 119 controls without aSAH were included. Perfusion parameters with the strongest prediction of vasospasm on cerebral angiography were the combination of the Vasospasm Index Score (Tmax6/Tmax4) + CBV ≤ 48 % (area under the curve value of 0.85 [95 % CI 0.78-0.91]) with a sensitivity of 63 % and specificity of 95 %. CONCLUSION: The Vasospasm Index Score in combination with CBV ≤ 48 % on cerebral perfusion imaging reliably identified vasospasm as the cause of DCI on perfusion imaging.
Asunto(s)
Isquemia Encefálica , Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/complicaciones , Femenino , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/etiología , Masculino , Persona de Mediana Edad , Estudios de Casos y Controles , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/complicaciones , Isquemia Encefálica/etiología , Anciano , Imagen de Perfusión/métodos , Angiografía de Substracción Digital/métodos , Adulto , Sensibilidad y Especificidad , Angiografía Cerebral/métodos , Tomografía Computarizada por Rayos X/métodos , Circulación Cerebrovascular , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: Transcranial Doppler (TCD) is a technique to assess blood flow velocity in the cerebral arteries. TCD is frequently used to monitor aneurysmal subarachnoid hemorrhage (aSAH) patients. This study compares TCD-criteria for vasospasm and its association with Delayed Cerebral Ischemia (DCI). An overall score based on flow velocities of various intracranial arteries was developed and evaluated. METHODS: A retrospective diagnostic accuracy study was conducted between 1998 and 2017 with 621 patients included. Mean flow velocity (MFV) of the cerebral artery was measured between 2-5 days and between 6-9 days after ictus. Cutoff values from the literature, new cutoff values, and a new composite score (Combined Severity Score) were used to predict DCI. Sensitivity, specificity, and area under the curve (AUC) were determined, and logistic regression analysis was performed. RESULTS: The Combined Severity Score showed an AUC 0.64 (95%CI 0.56-.71) at days 2-5, with sensitivity 0.53 and specificity 0.74. The Combined Severity Score had an adjusted Odds Ratio of 3.41 (95CI 1.86-6.32) for DCI. MCA-measurements yielded the highest AUC to detect DCI at day 2-5: AUC 0.65 (95%CI 0.58-0.73). Optimal cutoff MFV of 83 cm/s for MCA resulted in sensitivity 0.73 and specificity 0.50 at days 2-5. CONCLUSION: TCD-monitoring of aSAH patients may be a valuable strategy for DCI risk stratification. Lower cutoff values can be used in the early phase after the ictus (day 2-5) than are commonly used now. The Combined Severity Score incorporating all major cerebral arteries may provide a meaningful contribution to interpreting TCD measurements.
Asunto(s)
Isquemia Encefálica , Hemorragia Subaracnoidea , Ultrasonografía Doppler Transcraneal , Humanos , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/complicaciones , Ultrasonografía Doppler Transcraneal/métodos , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/etiología , Anciano , Adulto , Velocidad del Flujo Sanguíneo/fisiología , Valor Predictivo de las Pruebas , Circulación Cerebrovascular/fisiología , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/etiología , Sensibilidad y EspecificidadRESUMEN
INTRODUCTION: Reversible cerebral vasoconstriction syndrome is a clinicoradiological entity with a self-limiting course that manifests with recurrent episodes of thunderclap headache, and is associated with certain triggers. Recurrence is very rare, and the pathophysiology is thought to be related to altered autoregulation of the cerebrovascular tone. We present a clinical case that raises questions about possible recurrences and triggers. CASE REPORT: A 44-year-old woman with a history of multiple sclerosis treated with interferon beta-1b who had four episodes of thunderclap headache while resting, after completing a course of corticosteroids due to a flare-up of optic neuritis. Three years earlier, the patient had presented several episodes of explosive-onset headache during a self-limited period of one month, only occurring during sexual intercourse. In the year prior to our assessment, she had suffered three thunderclap headaches with similar characteristics, but they were triggered only by intense physical exercise. She had not consulted a physician about these events. A cranial computed tomography scan was performed after the administration of contrast media and a cerebral arteriography, which were consistent with cerebral vasoconstriction syndrome, and its reversibility was confirmed three months later. CONCLUSIONS: Reversible cerebral vasoconstriction syndrome shares a phenotypic expression with primary exertion headaches. It is associated with drugs with vasoactive effects, including interferons, and corticosteroids are associated with a worse prognosis, and such their administration should be avoided.
TITLE: Síndrome de vasoconstricción cerebral reversible. Recurrencia de cefaleas en trueno tras tratamiento con corticoides.Introducción. El síndrome de vasoconstricción cerebral reversible es una entidad clinicorradiológica de curso autolimitado que se manifiesta con episodios de cefalea en trueno recurrentes y que se asocia a determinados desencadenantes. La recidiva es muy poco frecuente y la fisiopatología se cree que está en relación con la alteración de la autorregulación del tono vascular cerebral. Presentamos un caso clínico que plantea cuestiones sobre posibles recurrencias y desencadenantes. Caso clínico. Mujer de 44 años con antecedente de esclerosis múltiple en tratamiento con interferón beta-1b que consultó por cuatro episodios de cefalea en trueno en reposo, tras finalizar un ciclo de corticoides por un brote de neuritis óptica. Tres años antes, la paciente había presentado varios episodios de cefalea de inicio explosivo durante un período autolimitado de un mes, únicamente producidos en el contexto de relaciones sexuales. El año previo a nuestra valoración padeció en tres ocasiones cefalea en trueno de características similares, pero exclusivamente desencadenadas con el ejercicio físico intenso. No había consultado por estos eventos. Se realizó una tomografía computarizada craneal tras la administración de contraste y una arteriografía cerebral, que fueron compatibles con síndrome de vasoconstricción cerebral, y se confirmó su reversibilidad tres meses después. Conclusiones. El síndrome de vasoconstricción cerebral reversible comparte expresión fenotípica con el grupo de cefaleas primarias por esfuerzo físico. Se asocia a fármacos con efectos vasoactivos, entre los que se encuentran los interferones, y los corticoides se asocian a un peor pronóstico, por lo que es importante evitar su administración.
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Cefaleas Primarias , Recurrencia , Humanos , Femenino , Adulto , Cefaleas Primarias/tratamiento farmacológico , Cefaleas Primarias/etiología , Vasoconstricción/efectos de los fármacos , Vasoespasmo Intracraneal/tratamiento farmacológico , Vasoespasmo Intracraneal/inducido químicamente , Vasoespasmo Intracraneal/diagnóstico por imagen , Síndrome , Corticoesteroides/uso terapéuticoRESUMEN
A recent systematic review indicated that gut-microbiota-brain axis contributes to growth and rupture of intracranial aneurysms. However, gaps were detected in the role of intestinal microbiome in cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage (aSAH). This is the first pilot study aiming to test study feasibility and identify differences in gut microbiota between subjects with and without CVS following aSAH. A prospective nested case-control pilot study with 1:1 matching was conducted recruiting subjects with aSAH: cases with CVS; and controls without CVS based on the clinical picture and structured bedside transcranial Doppler (TCD). Fecal samples for microbiota analyses by means of 16S rRNA gene amplicon sequencing were collected within the first 96 h after ictus. Operational taxonomic unit tables were constructed, diversity metrics calculated, phylogenetic trees built, and differential abundance analysis (DAA) performed. At baseline, the groups did not differ significantly in basic demographic and aneurysm-related characteristics (p > 0.05). Alpha-diversity (richness and Shannon Index) was significantly reduced in cases of middle cerebral artery (MCA) vasospasm (p < 0.05). In DAA, relative abundance of genus Acidaminococcus was associated with MCA vasospasm (p = 0.00013). Two butyrate-producing genera, Intestinimonas and Butyricimonas, as well as [Clostridium] innocuum group had the strongest negative correlation with the mean blood flow velocity in anterior cerebral arteries (p < 0.01; rho = - 0.63; - 0.57, and - 0.57, respectively). In total, 16 gut microbial genera were identified to correlate with TCD parameters, and two intestinal genera correlated with outcome upon discharge. In this pilot study, we prove study feasibility and present the first preliminary evidence of gut microbiome signature associating with CVS as a significant cause of stroke in subjects with aSAH.
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Isquemia Encefálica , Microbioma Gastrointestinal , Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Hemorragia Subaracnoidea/microbiología , Hemorragia Subaracnoidea/complicaciones , Vasoespasmo Intracraneal/microbiología , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/diagnóstico por imagen , Proyectos Piloto , Persona de Mediana Edad , Masculino , Femenino , Estudios Prospectivos , Estudios de Casos y Controles , Isquemia Encefálica/microbiología , Anciano , ARN Ribosómico 16S/genética , Heces/microbiología , AdultoRESUMEN
PURPOSE: Transcranial doppler based diagnostic criteria for cerebral vasospasm are not well established in the pediatric population because there is no published normative data to support the diagnosis. Studies have relied on expert consensus, but the definitions have not been validated in children diagnosed with angiographic evidence of vasospasm. Obtaining normative data is a prerequisite to defining pediatric cerebral vasospasm and the Lindegaard Ratio (LR). In this study, we obtained normative data and calculation of the normal LR from healthy children aged 10-16 years. METHODS: TCD and carotid ultrasonography was used to measure steady state velocities of both the middle cerebral artery (VMCA) and the extracranial internal cerebral artery (VEICA) in healthy children aged 10-16 years. Demographic information, hemodynamic characteristics and the calculated LR (VMCA/VEICA) was determined for each subject using descriptive statistics. RESULTS: Of the 26 healthy children, 13 were male and 13 were female. VMCA ranged between 53 and 93 cm/sec. LR ranged between 1 and 2.2 for the cohort. VMCA for both males and females were within 2 standard deviations (SD) of the normal mean flow velocity. As the VMCA velocities approached 2 SD above the mean, LR did not exceed 2.2. CONCLUSION: Our results help define a threshold for LR which can be used to establish radiographic criteria for cerebral vasospasm in children. Our data suggests that using VMCA criteria alone would overestimate cerebral vasospasm and raises question of whether an LR threshold other than 3 is more appropriate for the cut off between hyperemia versus vasospasm in children.
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Ultrasonografía Doppler Transcraneal , Humanos , Niño , Femenino , Masculino , Adolescente , Ultrasonografía Doppler Transcraneal/métodos , Valores de Referencia , Arteria Cerebral Media/diagnóstico por imagen , Velocidad del Flujo Sanguíneo/fisiología , Vasoespasmo Intracraneal/diagnóstico por imagen , Circulación Cerebrovascular/fisiologíaAsunto(s)
Encéfalo , Cefalea , Hemorragia Subaracnoidea , Cardiomiopatía de Takotsubo , Vasoespasmo Intracraneal , Femenino , Humanos , Persona de Mediana Edad , Enfermedad Aguda , Encéfalo/diagnóstico por imagen , Diagnóstico Diferencial , Cefalea/etiología , Imagen por Resonancia Magnética , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/etiología , Cardiomiopatía de Takotsubo/complicaciones , Cardiomiopatía de Takotsubo/diagnóstico , Cardiomiopatía de Takotsubo/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Vasoespasmo Intracraneal/complicaciones , Vasoespasmo Intracraneal/diagnóstico , Vasoespasmo Intracraneal/diagnóstico por imagen , SíndromeRESUMEN
Delayed cerebral ischemia is a major neurological complication of aneurysmal subarachnoid hemorrhage. Its unpredictable course and potentially unfavorable outcome draw attention to clinicians to improve the methods for its prediction, prevention, and diagnosis. The computed tomography perfusion (CTP) technique of the brain is one of the promising methods for revealing brain areas endangered by cerebral vasospasm and delayed cerebral ischemia.
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Isquemia Encefálica , Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Isquemia Encefálica/etiología , Isquemia Encefálica/complicaciones , Hemorragia Subaracnoidea/complicaciones , Tomografía Computarizada por Rayos X , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/diagnóstico por imagenRESUMEN
Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a singular pathological entity necessitating early diagnostic approaches and both prophylactic and curative interventions. This retrospective before-after study investigates the effects of a management strategy integrating perfusion computed tomography (CTP), vigilant clinical monitoring and standardized systemic administration of milrinone on the occurrence of delayed cerebral infarction (DCIn). The "before" period included 277 patients, and the "after" one 453. There was a higher prevalence of Modified Fisher score III/IV and more frequent diagnosis of vasospasm in the "after" period. Conversely, the occurrence of DCIn was reduced with the "after" management strategy (adjusted OR 0.48, 95% CI [0.26; 0.84]). Notably, delayed ischemic neurologic deficits were less prevalent at the time of vasospasm diagnosis (24 vs 11%, p = 0.001 ), suggesting that CTP facilitated early detection. In patients diagnosed with vasospasm, intravenous milrinone was more frequently administered (80 vs 54%, p < 0.001 ) and associated with superior hemodynamics. The present study from a large cohort of aSAH patients suggests, for one part, the interest of CTP in early diagnosis of vasospasm and DCI, and for the other the efficacy of CT perfusion-guided systemic administration of milrinone in both preventing and treating DCIn.
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Infarto Cerebral , Milrinona , Hemorragia Subaracnoidea , Tomografía Computarizada por Rayos X , Vasoespasmo Intracraneal , Humanos , Hemorragia Subaracnoidea/tratamiento farmacológico , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/diagnóstico por imagen , Milrinona/administración & dosificación , Masculino , Femenino , Persona de Mediana Edad , Infarto Cerebral/tratamiento farmacológico , Infarto Cerebral/diagnóstico por imagen , Infarto Cerebral/prevención & control , Infarto Cerebral/etiología , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/métodos , Anciano , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/tratamiento farmacológico , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/prevención & control , Adulto , Administración IntravenosaRESUMEN
Teratomas account for 18-20% of all intracranial germ cell tumors and mostly occur in the pineal region with only a few cases of pediatric sellar and suprasellar teratomas described in the literature. Here, we present a case of a child with an intracranial mature teratoma with pancreatic features causing vasospasm and subsequent stroke, found to be positive for CDKN2A-an independent variant associated with malignancy and small vessel disease leading to stroke.
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Neoplasias Encefálicas , Accidente Cerebrovascular , Teratoma , Vasoespasmo Intracraneal , Humanos , Teratoma/complicaciones , Teratoma/cirugía , Teratoma/diagnóstico por imagen , Neoplasias Encefálicas/complicaciones , Neoplasias Encefálicas/diagnóstico por imagen , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/diagnóstico por imagen , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/complicaciones , Síndromes Paraneoplásicos , Masculino , Niño , FemeninoRESUMEN
The Circle of Willis (CoW) is a ring-like network of blood vessels that perfuses the brain. Flow in the collateral pathways that connect major arterial inputs in the CoW change dynamically in response to vessel narrowing or occlusion. Vasospasm is an involuntary constriction of blood vessels following subarachnoid hemorrhage (SAH), which can lead to stroke. This study investigated interactions between localization of vasospasm in the CoW, vasospasm severity, anatomical variations, and changes in collateral flow directions. Patient-specific computational fluid dynamics (CFD) simulations were created for 25 vasospasm patients. Computed tomographic angiography scans were segmented capturing the anatomical variation and stenosis due to vasospasm. Transcranial Doppler ultrasound measurements of velocity were used to define boundary conditions. Digital subtraction angiography was analyzed to determine the directions and magnitudes of collateral flows as well as vasospasm severity in each vessel. Percent changes in resistance and viscous dissipation were analyzed to quantify vasospasm severity and localization of vasospasm in a specific region of the CoW. Angiographic severity correlated well with percent changes in resistance and viscous dissipation across all cerebral vessels. Changes in flow direction were observed in collateral pathways of some patients with localized vasospasm, while no significant changes in flow direction were observed in others. CFD simulations can be leveraged to quantify the localization and severity of vasospasm in SAH patients. These factors as well as anatomical variation may lead to changes in collateral flow directions. Future work could relate localization and vasospasm severity to clinical outcomes like the development of infarct.
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Circulación Cerebrovascular , Círculo Arterial Cerebral , Modelos Cardiovasculares , Vasoespasmo Intracraneal , Humanos , Círculo Arterial Cerebral/fisiopatología , Círculo Arterial Cerebral/diagnóstico por imagen , Vasoespasmo Intracraneal/fisiopatología , Vasoespasmo Intracraneal/diagnóstico por imagen , Femenino , Masculino , Persona de Mediana Edad , Hidrodinámica , Anciano , Circulación Colateral , AdultoRESUMEN
BACKGROUND: The pathological mechanisms following aneurysmal subarachnoid hemorrhage (SAH) are poorly understood. Limited clinical evidence exists on the association between cerebrospinal fluid (CSF) volume and the risk of delayed cerebral ischemia (DCI) or cerebral vasospasm (CV). In this study, we raised the hypothesis that the amount of CSF or its ratio to hemorrhage blood volume, as determined from non-contrast Computed Tomography (NCCT) images taken on admission, could be a significant predictor for CV and DCI. METHODS: The pilot study included a retrospective analysis of NCCT scans of 49 SAH patients taken shortly after an aneurysm rupture (33 males, 16 females, mean age 56.4 ± 15 years). The SynthStrip and Slicer3D software tools were used to extract radiological factors - CSF, brain, and hemorrhage volumes from the NCCT images. The "pure" CSF volume (VCSF) was estimated in the range of [-15, 15] Hounsfield units (HU). RESULTS: VCSF was negatively associated with the risk of CV occurrence (p = 0.0049) and DCI (p = 0.0069), but was not associated with patients' outcomes. The hemorrhage volume (VSAH) was positively associated with an unfavorable outcome (p = 0.0032) but was not associated with CV/DCI. The ratio VSAH/VCSF was positively associated with, both, DCI (p = 0.031) and unfavorable outcome (p = 0.002). The CSF volume normalized by the brain volume showed the highest characteristics for DCI prediction (AUC = 0.791, sensitivity = 0.80, specificity = 0.812) and CV prediction (AUC = 0.769, sensitivity = 0.812, specificity = 0.70). CONCLUSION: It was demonstrated that "pure" CSF volume retrieved from the initial NCCT images of SAH patients (including CV, Non-CV, DCI, Non-DCI groups) is a more significant predictor of DCI and CV compared to other routinely used radiological biomarkers. VCSF could be used to predict clinical course as well as to personalize the management of SAH patients. Larger multicenter clinical trials should be performed to test the added value of the proposed methodology.
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Hemorragia Subaracnoidea , Tomografía Computarizada por Rayos X , Humanos , Masculino , Femenino , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/líquido cefalorraquídeo , Hemorragia Subaracnoidea/complicaciones , Persona de Mediana Edad , Proyectos Piloto , Estudios Retrospectivos , Líquido Cefalorraquídeo/diagnóstico por imagen , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/líquido cefalorraquídeo , Vasoespasmo Intracraneal/etiología , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/líquido cefalorraquídeo , Isquemia Encefálica/complicaciones , Anciano , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/complicaciones , Aneurisma Roto/líquido cefalorraquídeo , Valor Predictivo de las Pruebas , Adulto , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Delayed cerebral ischemia and vasospasm are the most common causes of late morbidity following aneurysmal SAH, but their diagnosis remains challenging. PURPOSE: This systematic review and meta-analysis investigated the diagnostic performance of CTP for detection of delayed cerebral ischemia and vasospasm in the setting of aneurysmal SAH. DATA SOURCES: Studies evaluating the diagnostic performance of CTP in the setting of aneurysmal SAH were searched on the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Clinical Answers, Cochrane Methodology Register, Ovid MEDLINE, EMBASE, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, Health Technology Assessment, National Health Service Economic Evaluation Database, PubMed, and Google Scholar from their inception to September 2023. STUDY SELECTION: Thirty studies were included, encompassing 1786 patients with aneurysmal SAH and 2302 CTP studies. Studies were included if they compared the diagnostic accuracy of CTP with a reference standard (clinical or radiologic delayed cerebral ischemia, angiographic spasm) for the detection of delayed cerebral ischemia or vasospasm in patients with aneurysmal SAH. The primary outcome was accuracy for the detection of delayed cerebral ischemia or vasospasm. DATA ANALYSIS: Bivariate random effects models were used to pool outcomes for sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. Subgroup analyses for individual CTP parameters and early-versus-late study timing were performed. Bias and applicability were assessed using the modified QUADAS-2 tool. DATA SYNTHESIS: For assessment of delayed cerebral ischemia, CTP demonstrated a pooled sensitivity of 82.1% (95% CI, 74.5%-87.8%), specificity of 79.6% (95% CI, 73.0%-84.9%), positive likelihood ratio of 4.01 (95% CI, 2.94-5.47), and negative likelihood ratio of 0.23 (95% CI, 0.12-0.33). For assessment of vasospasm, CTP showed a pooled sensitivity of 85.6% (95% CI, 74.2%-92.5%), specificity of 87.9% (95% CI, 79.2%-93.3%), positive likelihood ratio of 7.10 (95% CI, 3.87-13.04), and negative likelihood ratio of 0.16 (95% CI, 0.09-0.31). LIMITATIONS: QUADAS-2 assessment identified 12 articles with low risk, 11 with moderate risk, and 7 with a high risk of bias. CONCLUSIONS: For delayed cerebral ischemia, CTP had a sensitivity of >80%, specificity of >75%, and a low negative likelihood ratio of 0.23. CTP had better performance for the detection of vasospasm, with sensitivity and specificity of >85% and a low negative likelihood ratio of 0.16. Although the accuracy offers the potential for CTP to be used in limited clinical contexts, standardization of CTP techniques and high-quality randomized trials evaluating its impact are required.
Asunto(s)
Isquemia Encefálica , Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/etiología , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/complicaciones , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/complicaciones , Sensibilidad y Especificidad , Angiografía Cerebral/métodos , Tomografía Computarizada por Rayos X , Imagen de Perfusión/métodosRESUMEN
Preterm neonates are at risk for neurodevelopmental impairment, especially those with intraventricular hemorrhage (IVH). Cerebral vasospasm (VSP) is a common complication after subarachnoid hemorrhage (SAH) in adult population, but it is unknown if preterm neonates with IVH may develop it. We prospectively enrolled premature newborns < 32 weeks with IVH and without IVH. All patients received serial transcranial sonography through the temporal window of the middle cerebral artery, anterior cerebral artery, posterior cerebral artery, and the internal carotid artery with transcranial Doppler sonography days 2, 4, and 10 of life. Cerebral blood velocities (CBFVs) were measured including median velocity flow (MV), peak systolic velocity (PSV), and maximum end-diastolic velocity (EDV). Resistance index and pulsatility index were calculated. VSP was defined as an increase of 50% in the baseline velocity per day and/or a Lindegaard ratio higher than 3. Fifty subjects were enrolled. None of the patients with IVH showed elevation of MV or a Lindegaard ratio > 3. There were no differences between IVH and without IVH groups regarding resistance index and pulsatility index. Conclusion: Preterm infants with IVH do not present a pattern of VSP analyzed by Doppler transcranial ultrasound in this pilot study. What is Known: ⢠In adult population with subarachnoid hemorrhage the most treatable cause of cerebral ischemia is due cerebral vasospasm but is unknown if premature newborn may have vasospasm due the extravasation of blood in the context of intraventricular hemorrhage What is New: â¢In this pilot study we did not find in premature newborn with intraventricular hemorrhage signs of vasoespam measured by transcranial color doppler ultrasound.
Asunto(s)
Recien Nacido Prematuro , Ultrasonografía Doppler Transcraneal , Vasoespasmo Intracraneal , Humanos , Proyectos Piloto , Recién Nacido , Ultrasonografía Doppler Transcraneal/métodos , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/fisiopatología , Femenino , Masculino , Estudios Prospectivos , Enfermedades del Prematuro/diagnóstico por imagen , Enfermedades del Prematuro/fisiopatología , Circulación Cerebrovascular/fisiología , Velocidad del Flujo Sanguíneo/fisiología , Hemorragia Cerebral Intraventricular/diagnóstico por imagen , Hemorragia Cerebral Intraventricular/etiologíaRESUMEN
OBJECTIVES: Unruptured cerebral aneurysms (UCAs) often coexist with the ruptured one but are typically left unsecured during the weeks following aneurysmal subarachnoid hemorrhage (aSAH). We compared the rate of UCAs rupture or volume growth (≥5 mm3) between patients exposed to induced arterial hypertension (iHTN) for vasospasm and those not exposed (control group). MATERIALS AND METHODS: From 2013 to 2021, we retrospectively included consecutive adult patients with aSAH who had ≥1 UCA. Custom software for digital subtraction angiography (DSA) image analysis characterized UCAs volume, going beyond merely considering UCAs long axis. RESULTS: We analyzed 118 patients (180 UCAs): 45 in the iHTN group (64 UCAs) and 73 in the control group (116 UCAs). Systolic blood pressure in the iHTN group was significantly higher than in the control group for several days after aSAH. During the 107 day-monitoring period [interquartile range(IQR):92;128], no UCA rupture occurred in either group. UCA volume analysis was performed in 44 patients (60 UCAs): none of the UCAs in the iHTN group and 3 out of 42 (7%) in the control group had a >5 mm3 volume growth (p=0.55). Other morphologic parameters did not exhibit any variations that might indicate an increased risk of rupture in the iHTN group compared to the control group. CONCLUSION: iHTN did not increase the risk of rupture or volume growth of UCAs within several weeks following aSAH. These reassuring results encourage not to refrain, because of the existence of UCAs, from iHTN as an option to prevent cerebral infarction during cerebral vasospasm.