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Burden of cerebral hypoperfusion in patients with delayed cerebral ischemia after subarachnoid hemorrhage.
J Neurosurg. 2019 May 31 [Online ahead of print]JN

Abstract

OBJECTIVE

Delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) may result in focal neurological deficits and cerebral infarction, believed to result from critical regional rather than global impairments in cerebral blood flow (CBF). However, the burden of such regional hypoperfusion has not been evaluated by gold-standard voxel-by-voxel CBF measurements. Specifically, the authors sought to determine whether the proportion of brain affected by hypoperfusion was greater in patients with DCI than in SAH controls without DCI and whether the symptomatic hemisphere (in those with lateralizing deficits) exhibited a greater cerebral hypoperfusion burden.

METHODS

Sixty-one patients with aneurysmal SAH underwent 15O PET to measure regional CBF during the period of risk for DCI (median 8 days after SAH, IQR 7-10 days). Regions of visibly abnormal brain on head CT studies, including areas of hemorrhage and infarction, were excluded. Burden of hypoperfusion was defined as the proportion of PET voxels in normal-appearing brain with CBF < 25 ml/100 g/min. Global CBF and hypoperfusion burden were compared between patients with and those without DCI at the time of PET. For patients with focal impairments from DCI, the authors also compared average CBF and hypoperfusion burden in symptomatic versus asymptomatic hemispheres.

RESULTS

Twenty-three patients (38%) had clinical DCI at the time of PET. Those with DCI had higher mean arterial pressure (MAP; 126 ± 14 vs 106 ± 12 mm Hg, p < 0.001) and 18 (78%) were on vasopressor therapy at the time of PET study. While global CBF was not significantly lower in patients with DCI (mean 39.4 ± 11.2 vs 43.0 ± 8.3 ml/100 g/min, p = 0.16), the burden of hypoperfusion was greater (20%, IQR 12%-23%, vs 12%, 9%-16%, p = 0.006). Burden of hypoperfusion performed better than global CBF as a predictor of DCI (area under the curve 0.71 vs 0.65, p = 0.044). Neither global CBF nor hypoperfusion burden differed in patients who responded to therapy compared to those who had not improved by the time of PET. Although hemispheric CBF was not lower in the symptomatic versus contralateral hemisphere in the 13 patients with focal deficits, there was a trend toward greater burden of hypoperfusion in the symptomatic hemisphere (21% vs 18%, p = 0.049).

CONCLUSIONS

The burden of hypoperfusion was greater in patients with DCI, despite hemodynamic therapies, higher MAP, and equivalent global CBF. Similarly, hypoperfusion burden was greater in the symptomatic hemisphere of DCI patients with focal deficits even though the average CBF was similar to that in the contralateral hemisphere. Evaluating the proportion of the brain with critical hypoperfusion after SAH may better capture the extent of DCI than averaging CBF across heterogenous brain regions.

Authors+Show Affiliations

2Radiology, and.Departments of1Neurology.Departments of1Neurology.Departments of1Neurology. 2Radiology, and.3Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri.Departments of1Neurology.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31151110

Citation

Jafri, Hussain, et al. "Burden of Cerebral Hypoperfusion in Patients With Delayed Cerebral Ischemia After Subarachnoid Hemorrhage." Journal of Neurosurgery, 2019, pp. 1-8.
Jafri H, Diringer MN, Allen M, et al. Burden of cerebral hypoperfusion in patients with delayed cerebral ischemia after subarachnoid hemorrhage. J Neurosurg. 2019.
Jafri, H., Diringer, M. N., Allen, M., Zazulia, A. R., Zipfel, G. J., & Dhar, R. (2019). Burden of cerebral hypoperfusion in patients with delayed cerebral ischemia after subarachnoid hemorrhage. Journal of Neurosurgery, 1-8. https://doi.org/10.3171/2019.3.JNS183041
Jafri H, et al. Burden of Cerebral Hypoperfusion in Patients With Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. J Neurosurg. 2019 May 31;1-8. PubMed PMID: 31151110.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Burden of cerebral hypoperfusion in patients with delayed cerebral ischemia after subarachnoid hemorrhage. AU - Jafri,Hussain, AU - Diringer,Michael N, AU - Allen,Michelle, AU - Zazulia,Allyson R, AU - Zipfel,Gregory J, AU - Dhar,Rajat, Y1 - 2019/05/31/ PY - 2018/11/02/received PY - 2019/03/04/accepted PY - 2019/6/1/pubmed PY - 2019/6/1/medline PY - 2019/6/1/entrez KW - AUC = area under the curve KW - CBF = cerebral blood flow KW - DCI = delayed cerebral ischemia KW - MAP = mean arterial pressure KW - NNICU = neurology/neurosurgery intensive care unit KW - ROC = receiver operating characteristic KW - SAH = subarachnoid hemorrhage KW - cerebral blood flow KW - delayed cerebral ischemia KW - subarachnoid hemorrhage KW - vascular disorders SP - 1 EP - 8 JF - Journal of neurosurgery JO - J. Neurosurg. N2 - OBJECTIVE: Delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) may result in focal neurological deficits and cerebral infarction, believed to result from critical regional rather than global impairments in cerebral blood flow (CBF). However, the burden of such regional hypoperfusion has not been evaluated by gold-standard voxel-by-voxel CBF measurements. Specifically, the authors sought to determine whether the proportion of brain affected by hypoperfusion was greater in patients with DCI than in SAH controls without DCI and whether the symptomatic hemisphere (in those with lateralizing deficits) exhibited a greater cerebral hypoperfusion burden. METHODS: Sixty-one patients with aneurysmal SAH underwent 15O PET to measure regional CBF during the period of risk for DCI (median 8 days after SAH, IQR 7-10 days). Regions of visibly abnormal brain on head CT studies, including areas of hemorrhage and infarction, were excluded. Burden of hypoperfusion was defined as the proportion of PET voxels in normal-appearing brain with CBF < 25 ml/100 g/min. Global CBF and hypoperfusion burden were compared between patients with and those without DCI at the time of PET. For patients with focal impairments from DCI, the authors also compared average CBF and hypoperfusion burden in symptomatic versus asymptomatic hemispheres. RESULTS: Twenty-three patients (38%) had clinical DCI at the time of PET. Those with DCI had higher mean arterial pressure (MAP; 126 ± 14 vs 106 ± 12 mm Hg, p < 0.001) and 18 (78%) were on vasopressor therapy at the time of PET study. While global CBF was not significantly lower in patients with DCI (mean 39.4 ± 11.2 vs 43.0 ± 8.3 ml/100 g/min, p = 0.16), the burden of hypoperfusion was greater (20%, IQR 12%-23%, vs 12%, 9%-16%, p = 0.006). Burden of hypoperfusion performed better than global CBF as a predictor of DCI (area under the curve 0.71 vs 0.65, p = 0.044). Neither global CBF nor hypoperfusion burden differed in patients who responded to therapy compared to those who had not improved by the time of PET. Although hemispheric CBF was not lower in the symptomatic versus contralateral hemisphere in the 13 patients with focal deficits, there was a trend toward greater burden of hypoperfusion in the symptomatic hemisphere (21% vs 18%, p = 0.049). CONCLUSIONS: The burden of hypoperfusion was greater in patients with DCI, despite hemodynamic therapies, higher MAP, and equivalent global CBF. Similarly, hypoperfusion burden was greater in the symptomatic hemisphere of DCI patients with focal deficits even though the average CBF was similar to that in the contralateral hemisphere. Evaluating the proportion of the brain with critical hypoperfusion after SAH may better capture the extent of DCI than averaging CBF across heterogenous brain regions. SN - 1933-0693 UR - https://www.unboundmedicine.com/medline/citation/31151110/Burden_of_cerebral_hypoperfusion_in_patients_with_delayed_cerebral_ischemia_after_subarachnoid_hemorrhage_ L2 - https://thejns.org/doi/10.3171/2019.3.JNS183041 DB - PRIME DP - Unbound Medicine ER -
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