Article Figures & Data
Figures
- Fig 1.
Patient transferred at day 8 to our neurovascular ICU from an outside institution after coiling of a ruptured ACom aneurysm. NCT obtained at the admission of the patient in our neurovascular ICU demonstrated extensive residual SAH and suspicious loss of gray-white matter contrast in the left superior frontal gyrus (white arrows). The tip of a right ventricular drain catheter is also visible. On PCT, significantly abnormal brain perfusion in the distribution of the anterior and inferior branches of the left (and also, to a lesser extent, right) ACA (arrowheads) and of the right posterior MCA branches is seen primarily on MTT and TTP maps. The rCBF was also slightly decreased in the same territories, whereas rCBV was mainly preserved (it is lowered only in the left superior frontal gyrus [star]). CTA confirmed the suspicion of moderate vasospasm of both A2 and A3 segments of the ACA (arrows), ultimately verified by gold-standard DSA. No abnormality of the right posterior MCA branches was identified. The artifacts created by the coils on the CTA images, obscuring the A1 segments bilaterally and interfering with their evaluation, are noteworthy. Endovascular therapy (intra-arterial verapamil) was performed in the ACA territories during the DSA.
- Fig 2.
Patient transferred to our neurovascular ICU from an outside institution at day 4 after rupture of an ACom aneurysm (arrow). Admission TCD ultrasonography demonstrated increased absolute FV of 135 cm/s in ACAs. A CTA and PCT survey were obtained to rule out vasospasm; the PCT was completely normal and the CTA demonstrated the ACom aneurysm (arrow), but no vasospasm. DSA was performed determine the configuration of the aneurysm and to determine the best therapeutic strategy (endovascular coiling vs neurosurgical clipping). It confirmed the absence of vasospasm. TCD false-positive results were most likely related to the triple H (hypertensive, hypervolemic, hemodilutional) therapy undergone by the patient at the time of the TCD examination.
Tables
NCT CTA PCT TCD DSA Hypodensities rCBV MTT rCBF TTP Absolute FV Values EICA or VA/BA Ratios Left ACA and MCA Left ICA Left ACA and MCA Left ICA bifurcation Left ICA bifurcation Left ICA Right ACA and MCA Right ICA Right ACA and MCA Right ICA bifurcation Right ICA bifurcation Right ICA Left inferior ACA Left A1 Left ACA (inferior slab) Left ACA Left ACA Left A1 Left superior ACA Left A2 Left ACA (superior slab) Left ACA Left ACA Left A2 Left superior ACA Distal left ACA Left ACA (superior slab) Left ACA Left ACA Distal left ACA Right inferior ACA Right A1 Right ACA (inferior slab) Right ACA Right ACA Right A1 Right superior ACA Right A2 Right ACA (superior slab) Right ACA Right ACA Right A2 Right superior ACA Distal right ACA Right ACA (superior slab) Right ACA Right ACA Distal right ACA Left deep MCA Left M1 Left deep MCA Left MCA Left MCA Left M1 Left inferior MCA Left M2 Left MCA (inferior slab) Left MCA Left MCA Left M2 Left superior MCA Distal left MCA Left MCA (superior slab) Left MCA Left MCA Distal left MCA Right deep MCA Right M1 Right deep MCA Right MCA Right MCA Right M1 Right inferior MCA Right M2 Right MCA (inferior slab) Right MCA Right MCA Right M2 Right superior MCA Distal right MCA Right MCA (superior slab) Right MCA Right MCA Distal right MCA Left thalamus Left P1 Left thalamus Left PCA Left BA/VA ratio Left P1 Left PCA Distal left PCA Left PCA Left PCA Left BA/VA ratio Distal left PCA Right thalamus Right P1 Right thalamus Right PCA Right BA/VA ratio Right P1 Right PCA Distal right PCA Right PCA Right PCA Right BA/VA ratio Distal right PCA Note:— ACA indicates anterior cerebral artery; MCA, middle cerebral artery; PCA, posterior cerebral artery.
- Table 2:
Measured values of TCD and PCT parameters in the four categories of arterial territories defined according to DSA and TCD findings
Territories n TCD Absolute FV (cm/s) TCD EICA Ratios PCT rCBV (cc × 100 g−1) PCT rCBF (cc × 100 g−1 × min−1) PCT MTT (s) PCT TTP (s) DSA-negative and TCD-negative 402 77.4 (42.0–113.8) 1.4 (0.8–2.0) 4.3 (2.2–6.1) 49.2 (42.6–56.9) 5.3 (2.8–7.2) 21.8 (16.7–26.8) }* }* TCD-positive but DSA-negative 105 122.9 (54.6–181.7) 2.4 (1.1–3.6) 4.3 (2.7–5.8) 49.0 (42.3–56.5) 5.2 (3.3–6.9) 22.1 (17.1–28.0) }* }* }* DSA-positive without endovascular treatment 63 117.1 (36.2–206.7) 2.0 (1.2–3.6) 4.5 (3.2–7.3) 41.5 (27.7–47.7) 7.4 (5.9–9.4) 26.2 (22.6–29.8) DSA-positive with endovascular treatment 60 152.6 (62.3–243.2) 3.1 (1.0–5.2) 4.1 (1.3–6.2) 37.2 (17.5–42.8) 7.8 (5.9–10.2) 27.5 (23.0–31.1) Kruskal-Wallis P < 0.001 P < 0.001 P = 0.960 P < 0.001 P < 0.001 P < 0.001 Note:— FV indicates flow velocity; EICA, extracranial to intracranial; rCBV, relative cerebral blood volume; rCBF, relative cerebral blood flow; MTT, mean transit time; TTP, time-to-peak; }*, Wilcoxon test, P < 0.001.
- Table 3:
Accuracy, sensitivity, specificity, NPV, and PPV of the different imaging techniques for the diagnosis of angiographic vasospasm
Presence or Absence of Angiographic Vasospasm DSA Gold Standard TCD Absolute FV (cm/s) TCD EICA Ratios NCT Hypodensities CTA PCT rCBV (cc × 100 g−1) PCT rCBF (cc × 100 g−1 × min−1) PCT MTT (s) PCT TTP (s) Thresholds >120 >3.00 Presence or Absence Presence or Absence <4.4 <44.3 >6.4 >24.4 TN 507 449 455 498 483 378 477 460 452 FP 0 58 52 9 24 129 30 747 55 FN 0 40 35 108 30 89 24 6 16 TP 123 83 88 15 93 34 99 117 107 Accuracy 100.0% 84.4% 86.2% 81.4% 91.4% 65.4% 91.4% 91.6% 88.7% Sensitivity 100.0% 67.5% 71.5% 12.2% 75.6% 27.6% 80.5% 95.1% 87.0% Specificity 100.0% 88.6% 89.7% 98.2% 95.3% 74.6% 94.1% 90.7% 89.2% NPV 100.0% 91.8% 92.9% 82.2% 94.2% 80.9% 95.2% 98.7% 96.6% PPV 100.0% 58.9% 62.9% 62.5% 79.5% 20.9% 76.7% 71.3% 66.0% Note:— MTT with a threshold of 6.4 s was the most accurate parameter for the diagnosis of angiographic vasospasm, with especially a very high negative predictive value of 98.7%. FV indicates flow velocity; EICA, extracranial to intracranial; rCBV, relative cerebral blood volume; rCBF, relative cerebral blood flow; MTT, mean transit time; TTP, time-to-peak; TP, true- positives; FP, false-positives; FN, false-negatives; TP, true-positives; NPV, negative predictive value; PPV, positive predictive value.
- Table 4:
Accuracy, sensitivity, specificity, NPV, and PPV of the different imaging techniques for the diagnosis of vasospasm requiring endovascular treatment
Endovascular Treatment or Not DSA Gold Standard TCD Absolute FV (cm/s) TCD EICA Ratios CTA PCT rCBV (cc × 100 g−1) PCT rCBF (cc × 100 g−1 × min−1) PCT MTT (s) PCT TTP (s) PCT MTT + CTA Thresholds >180 >6.00 Presence or Absence of Severe <4.3 <39.3 >7.6 >26.8 TN 570 501 532 549 314 560 499 561 487 FP 0 69 38 21 256 10 71 10 83 FN 0 48 54 28 34 23 18 33 25 TP 60 12 6 32 26 37 42 27 35 Accuracy 100.0% 81.4% 85.4% 92.2% 54.0% 94.8% 85.9% 93.2% 82.9% Sensitivity 100.0% 20.0% 10.0% 53.3% 43.3% 61.7% 70.0% 45.0% 58.3% Specificity 100.0% 87.9% 93.3% 96.3% 55.1% 98.2% 87.5% 98.2% 85.4% NPV 100.0% 91.3% 90.8% 95.1% 90.2% 96.1% 96.5% 94.4% 95.1% PPV 100.0% 14.8% 13.6% 60.4% 9.2% 78.7% 37.2% 73.0% 29.7% Note:— MTT was again the parameter with the highest NPV, but with this time a threshold at 7.6 s, whereas PCT rCBF with a threshold at 39.3 cc × 100 g−1 × min−1 was the most accurate indicator for endovascular therapy. FV indicates flow velocity; EICA, extracranial to intracranial; rCBV, relative cerebral blood volume; rCBF, relative cerebral blood flow; MTT, mean transit time; TTP, time-to-peak; TP, true-positives; FP, false-positives; FN, false-negatives; TP, true-positives; NPV, negative predictive value; PPV, positive predictive value.
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