Blood Pressure Affects the Early CT Perfusion Imaging in Patients with aSAH Reflecting Early Disturbed Autoregulation.
Aneurysmal subarachnoid hemorrhage
Blood pressure
CT
Computed tomography
Early perfusion
Mean transit time
Outcome
Journal
Neurocritical care
ISSN: 1556-0961
Titre abrégé: Neurocrit Care
Pays: United States
ID NLM: 101156086
Informations de publication
Date de publication:
08 2023
08 2023
Historique:
received:
07
10
2022
accepted:
26
01
2023
medline:
14
9
2023
pubmed:
22
2
2023
entrez:
21
2
2023
Statut:
ppublish
Résumé
Early computed tomography perfusion (CTP) is frequently used to predict delayed cerebral ischemia following aneurysmatic subarachnoid hemorrhage (aSAH). However, the influence of blood pressure on CTP is currently controversial (HIMALAIA trial), which differs from our clinical observations. Therefore, we aimed to investigate the influence of blood pressure on early CTP imaging in patients with aSAH. We retrospectively analyzed the mean transit time (MTT) of early CTP imaging within 24 h after bleeding prior to aneurysm occlusion with respect to blood pressure shortly before or after the examination in 134 patients. We correlated the cerebral blood flow with the cerebral perfusion pressure in the case of patients with intracranial pressure measurement. We performed a subgroup analysis of good-grade (World Federation of Neurosurgical Societies [WFNS] I-III), poor-grade (WFNS IV-V), and solely WFNS grade V aSAH patients. Mean arterial pressure (MAP) significantly correlated inversely with the mean MTT in early CTP imaging (R = - 0.18, 95% confidence interval [CI] - 0.34 to - 0.01, p = 0.042). Lower mean blood pressure was significantly associated with a higher mean MTT. Subgroup analysis revealed an increasing inverse correlation when comparing WFNS I-III (R = - 0.08, 95% CI - 0.31 to 0.16, p = 0.53) patients with WFNS IV-V (R = - 0.2, 95% CI - 0.42 to 0.05, p = 0.12) patients, without reaching statistical significance. However, if only patients with WFNS V are considered, a significant and even stronger correlation between MAP and MTT (R = - 0.4, 95% CI - 0.65 to 0.07, p = 0.02) is observed. In patients with intracranial pressure monitoring, a stronger dependency of cerebral blood flow on cerebral perfusion pressure is observed for poor-grade patients compared with good-grade patients. The inverse correlation between MAP and MTT in early CTP imaging, increasing with the severity of aSAH, suggests an increasing disturbance of cerebral autoregulation with the severity of early brain injury. Our results emphasize the importance of maintaining physiological blood pressure values in the early phase of aSAH and preventing hypotension, especially in patients with poor-grade aSAH.
Sections du résumé
BACKGROUND
Early computed tomography perfusion (CTP) is frequently used to predict delayed cerebral ischemia following aneurysmatic subarachnoid hemorrhage (aSAH). However, the influence of blood pressure on CTP is currently controversial (HIMALAIA trial), which differs from our clinical observations. Therefore, we aimed to investigate the influence of blood pressure on early CTP imaging in patients with aSAH.
METHODS
We retrospectively analyzed the mean transit time (MTT) of early CTP imaging within 24 h after bleeding prior to aneurysm occlusion with respect to blood pressure shortly before or after the examination in 134 patients. We correlated the cerebral blood flow with the cerebral perfusion pressure in the case of patients with intracranial pressure measurement. We performed a subgroup analysis of good-grade (World Federation of Neurosurgical Societies [WFNS] I-III), poor-grade (WFNS IV-V), and solely WFNS grade V aSAH patients.
RESULTS
Mean arterial pressure (MAP) significantly correlated inversely with the mean MTT in early CTP imaging (R = - 0.18, 95% confidence interval [CI] - 0.34 to - 0.01, p = 0.042). Lower mean blood pressure was significantly associated with a higher mean MTT. Subgroup analysis revealed an increasing inverse correlation when comparing WFNS I-III (R = - 0.08, 95% CI - 0.31 to 0.16, p = 0.53) patients with WFNS IV-V (R = - 0.2, 95% CI - 0.42 to 0.05, p = 0.12) patients, without reaching statistical significance. However, if only patients with WFNS V are considered, a significant and even stronger correlation between MAP and MTT (R = - 0.4, 95% CI - 0.65 to 0.07, p = 0.02) is observed. In patients with intracranial pressure monitoring, a stronger dependency of cerebral blood flow on cerebral perfusion pressure is observed for poor-grade patients compared with good-grade patients.
CONCLUSIONS
The inverse correlation between MAP and MTT in early CTP imaging, increasing with the severity of aSAH, suggests an increasing disturbance of cerebral autoregulation with the severity of early brain injury. Our results emphasize the importance of maintaining physiological blood pressure values in the early phase of aSAH and preventing hypotension, especially in patients with poor-grade aSAH.
Identifiants
pubmed: 36802010
doi: 10.1007/s12028-023-01683-8
pii: 10.1007/s12028-023-01683-8
pmc: PMC10499698
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
125-134Commentaires et corrections
Type : CommentIn
Type : CommentIn
Informations de copyright
© 2023. The Author(s).
Références
Macdonald RL. Delayed neurological deterioration after subarachnoid haemorrhage. Nat Rev Neurol. 2014;10:44–58.
pubmed: 24323051
doi: 10.1038/nrneurol.2013.246
van Lieshout JH, Dibue-Adjei M, Cornelius JF, et al. An introduction to the pathophysiology of aneurysmal subarachnoid hemorrhage. Neurosurg Rev. 2018;41:917–30.
pubmed: 28215029
doi: 10.1007/s10143-017-0827-y
Neulen A, Pantel T, Kosterhon M, et al. Neutrophils mediate early cerebral cortical hypoperfusion in a murine model of subarachnoid haemorrhage. Sci Rep. 2019;9:8460.
pubmed: 31186479
pmcid: 6560094
doi: 10.1038/s41598-019-44906-9
Kamp MA, Heiroth HJ, Beseoglu K, Turowski B, Steiger HJ, Hanggi D. Early CT perfusion measurement after aneurysmal subarachnoid hemorrhage: a screening method to predict outcome? Acta Neurochir Suppl. 2012;114:329–32.
pubmed: 22327717
doi: 10.1007/978-3-7091-0956-4_63
Schubert GA, Seiz M, Hegewald AA, Manville J, Thomé C. Acute hypoperfusion immediately after subarachnoid hemorrhage: a xenon contrast-enhanced CT study. J Neurotrauma. 2009;26:2225–31.
pubmed: 19929373
doi: 10.1089/neu.2009.0924
Etminan N, Beseoglu K, Heiroth HJ, Turowski B, Steiger HJ, Hanggi D. Early perfusion computerized tomography imaging as a radiographic surrogate for delayed cerebral ischemia and functional outcome after subarachnoid hemorrhage. Stroke. 2013;44:1260–6.
pubmed: 23539527
doi: 10.1161/STROKEAHA.111.675975
Tsuang F-Y, Chen J-Y, Lee C-W, et al. Risk profile of patients with poor-grade aneurysmal subarachnoid hemorrhage using early perfusion computed tomography. World Neurosurg. 2012;78:455–61.
pubmed: 22381309
doi: 10.1016/j.wneu.2011.12.004
Dankbaar JW, de Rooij NK, Rijsdijk M, et al. Diagnostic threshold values of cerebral perfusion measured with computed tomography for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Stroke. 2010;41:1927–32.
pubmed: 20689085
doi: 10.1161/STROKEAHA.109.574392
Mir DIA, Gupta A, Dunning A, et al. CT perfusion for detection of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Am J Neuroradiol. 2014;35:866.
pubmed: 24309123
pmcid: 4159608
doi: 10.3174/ajnr.A3787
Sanelli PC, Ugorec I, Johnson CE, et al. Using quantitative CT perfusion for evaluation of delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage. Am J Neuroradiol. 2011;32:2047.
pubmed: 21960495
pmcid: 3237788
doi: 10.3174/ajnr.A2693
Hofmann BB, Fischer I, Engel A, et al. MTT heterogeneity in perfusion CT imaging as a predictor of outcome after aneurysmal SAH. AJNR Am J Neuroradiol. 2021;43:1387–95. https://doi.org/10.3174/ajnr.A7169
doi: 10.3174/ajnr.A7169
Rabinstein AA, Lanzino G, Wijdicks EFM. Multidisciplinary management and emerging therapeutic strategies in aneurysmal subarachnoid haemorrhage. Lancet Neurol. 2010;9:504–19.
pubmed: 20398858
doi: 10.1016/S1474-4422(10)70087-9
Wintermark M, Ko NU, Smith WS, Liu S, Higashida RT, Dillon WP. Vasospasm after subarachnoid hemorrhage: utility of perfusion CT and CT angiography on diagnosis and management. Am J Neuroradiol. 2006;27:26.
pubmed: 16418351
pmcid: 7976085
Sviri GE, Britz GW, Lewis DH, Newell DW, Zaaroor M, Cohen W. Dynamic perfusion computed tomography in the diagnosis of cerebral vasospasm. Neurosurgery. 2006;59:319–25.
pubmed: 16883171
doi: 10.1227/01.NEU.0000222819.18834.33
Shi D, Jin D, Cai W, et al. Serial low-dose quantitative CT perfusion for the evaluation of delayed cerebral ischaemia following aneurysmal subarachnoid haemorrhage. Clin Radiol. 2020;75:131–9.
pubmed: 31699431
doi: 10.1016/j.crad.2019.10.007
Bacigaluppi S, Zona G, Secci F, et al. Diagnosis of cerebral vasospasm and risk of delayed cerebral ischemia related to aneurysmal subarachnoid haemorrhage: an overview of available tools. Neurosurg Rev. 2015;38:603–18.
pubmed: 25732522
doi: 10.1007/s10143-015-0617-3
Kanazawa R, Kato M, Ishikawa K, Eguchi T, Teramoto A. Convenience of the computed tomography perfusion method for cerebral vasospasm detection after subarachnoid hemorrhage. Surg Neurol. 2007;67:604–11.
pubmed: 17397909
doi: 10.1016/j.surneu.2006.09.026
Rubbert C, Patil KR, Beseoglu K, et al. Prediction of outcome after aneurysmal subarachnoid haemorrhage using data from patient admission. Eur Radiol. 2018;28:4949–58.
pubmed: 29948072
doi: 10.1007/s00330-018-5505-0
Rodriguez-Régent C, Hafsa M, Turc G, et al. Early quantitative CT perfusion parameters variation for prediction of delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage. Eur Radiol. 2016;26:2956–63.
pubmed: 26670321
doi: 10.1007/s00330-015-4135-z
Beseoglu K, Etminan N, Hanggi D. The value of perfusion computed tomography (PCT) imaging after aneurysmal subarachnoid hemorrhage: a review of the current data. Acta Neurochir Suppl. 2015;120:35–8.
pubmed: 25366596
doi: 10.1007/978-3-319-04981-6_6
Gathier CS, Dankbaar JW, van der Jagt M, et al. Effects of induced hypertension on cerebral perfusion in delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a randomized clinical trial. Stroke. 2015;46:3277–81.
pubmed: 26443829
doi: 10.1161/STROKEAHA.115.010537
Gathier CS, van den Bergh WM, van der Jagt M, et al. Induced hypertension for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a randomized clinical trial. Stroke. 2018;49:76–83.
pubmed: 29158449
doi: 10.1161/STROKEAHA.117.017956
Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1711–37.
pubmed: 22556195
doi: 10.1161/STR.0b013e3182587839
Hofmann BB, Rubbert C, Turowski B, Hänggi D, Muhammad S. Treatment of unique bilateral distal fusiform superior cerebellar artery aneurysms with mini-flow diverter device implantation: case report. J Neurol Surg Part A Cent Eur Neurosurg. 2021. https://doi.org/10.1055/s-0041-1739212 .
doi: 10.1055/s-0041-1739212
Turowski B, Haenggi D, Wittsack J, Beck A. Moedder U [cerebral perfusion computerized tomography in vasospasm after subarachnoid hemorrhage: diagnostic value of MTT]. RoFo: Fortschr Gebiete Rontgenstrahlen Nukl. 2007;179:847–54.
doi: 10.1055/s-2007-963197
Turowski B, Haenggi D, Wittsack HJ, Beck A. Aurich V [computerized analysis of brain perfusion parameter images]. RoFo: Fortschr Gebiete Rontgenstrahlen Nukl. 2007;179:525–9.
doi: 10.1055/s-2007-962853
Khamis H. Measures of association: how to choose? J Diagn Med Sonogr. 2008;24:155–62.
doi: 10.1177/8756479308317006
Hänggi D, Turowski B, Beseoglu K, Yong M, Steiger HJ. Intra-arterial nimodipine for severe cerebral vasospasm after aneurysmal subarachnoid hemorrhage: influence on clinical course and cerebral perfusion. Am J Neuroradiol. 2008;29:1053.
pubmed: 18372422
pmcid: 8118836
doi: 10.3174/ajnr.A1005
Beseoglu K, Etminan N, Hänggi D. The value of perfusion computed tomography (PCT) imaging after aneurysmal subarachnoid hemorrhage: a review of the current data. In: Fandino J, Marbacher S, Fathi A-R, Muroi C, Keller E, editors. Neurovascular events after subarachnoid hemorrhage: towards experimental and clinical standardisation. Cham: Springer International Publishing; 2015. p. 35–8.
doi: 10.1007/978-3-319-04981-6_6
Murphy A, Manoel AL, Burgers K, et al. Early CT perfusion changes and blood-brain barrier permeability after aneurysmal subarachnoid hemorrhage. Neuroradiology. 2015;57:767–73.
pubmed: 25868518
doi: 10.1007/s00234-015-1529-1
Murphy A, de Oliveira Manoel AL, Macdonald RL, et al. Changes in cerebral perfusion with induced hypertension in aneurysmal subarachnoid hemorrhage: a pilot and feasibility study. Neurocrit Care. 2017;27:3–10.
pubmed: 28244000
doi: 10.1007/s12028-017-0379-6
Francoeur CL, Mayer SA. Management of delayed cerebral ischemia after subarachnoid hemorrhage. Crit Care. 2016;20:277.
pubmed: 27737684
pmcid: 5064957
doi: 10.1186/s13054-016-1447-6
Budohoski KP, Czosnyka M, Kirkpatrick PJ, Smielewski P, Steiner LA, Pickard JD. Clinical relevance of cerebral autoregulation following subarachnoid haemorrhage. Nat Rev Neurol. 2013;9:152–63.
pubmed: 23419369
doi: 10.1038/nrneurol.2013.11
Jaeger M, Schuhmann MU, Soehle M, Nagel C, Meixensberger J. Continuous monitoring of cerebrovascular autoregulation after subarachnoid hemorrhage by brain tissue oxygen pressure reactivity and its relation to delayed cerebral infarction. Stroke. 2007;38:981–6.
pubmed: 17272764
doi: 10.1161/01.STR.0000257964.65743.99
Rasmussen G, Hauerberg J, Waldemar G, Gjerris F, Juhler M. Cerebral blood flow autoregulation in experimental subarachnoid haemorrhage in rat. Acta Neurochir. 1992;119:128–33.
pubmed: 1481739
doi: 10.1007/BF01541796
Hattingen E, Blasel S, Dettmann E, et al. Perfusion-weighted MRI to evaluate cerebral autoregulation in aneurysmal subarachnoid haemorrhage. Neuroradiology. 2008;50:929.
pubmed: 18560816
doi: 10.1007/s00234-008-0424-4
Aaslid R, Lindegaard KF, Sorteberg W, Nornes H. Cerebral autoregulation dynamics in humans. Stroke. 1989;20:45–52.
pubmed: 2492126
doi: 10.1161/01.STR.20.1.45
Armstead WM. Cerebral blood flow autoregulation and dysautoregulation. Anesthesiol Clin. 2016;34:465–77.
pubmed: 27521192
pmcid: 4988341
doi: 10.1016/j.anclin.2016.04.002
Eng CC, Lam AM, Byrd S, Newell DW. The diagnosis and management of a perianesthetic cerebral aneurysmal rupture aided with transcranial Doppler ultrasonography. Anesthesiology. 1993;78:191–4.
pubmed: 8424553
doi: 10.1097/00000542-199301000-00026
Hassler W, Steinmetz H, Pirschel J. Transcranial Doppler study of intracranial circulatory arrest. J Neurosurg. 1989;71:195–201.
pubmed: 2664095
doi: 10.3171/jns.1989.71.2.0195
Sundgreen C, Larsen FS, Herzog TM, Knudsen GM, Boesgaard S, Aldershvile J. Autoregulation of cerebral blood flow in patients resuscitated from cardiac arrest. Stroke. 2001;32:128–32.
pubmed: 11136927
doi: 10.1161/01.STR.32.1.128
Pham P, Bindra J, Chuan A, Jaeger M, Aneman A. Are changes in cerebrovascular autoregulation following cardiac arrest associated with neurological outcome? Results of a pilot study. Resuscitation. 2015;96:192–8.
pubmed: 26316278
doi: 10.1016/j.resuscitation.2015.08.007
Dewey RC, Pieper HP, Hunt WE. Experimental cerebral hemodynamics. Vasomotor tone, critical closing pressure, and vascular bed resistance. J Neurosurg. 1974;41:597–606.
pubmed: 4214313
doi: 10.3171/jns.1974.41.5.0597
Rose JC, Mayer SA. Optimizing blood pressure in neurological emergencies. Neurocrit Care. 2004;1:287–99.
pubmed: 16174926
doi: 10.1385/NCC:1:3:287
Rosner MJ, Coley IB. Cerebral perfusion pressure, intracranial pressure, and head elevation. J Neurosurg. 1986;65:636–41.
pubmed: 3772451
doi: 10.3171/jns.1986.65.5.0636