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CT perfusion predicts secondary cerebral infarction after aneurysmal subarachnoid hemorrhage

From the Departments of Neuroradiology (M.P., A.W., A.J.B., L.S., M.B.), Neurosurgery (C.L., K.R.), and Neurology (W.M.), University of Würzburg, Germany.

Address correspondence and reprint requests to Dr. M. Pham, Department of Neuroradiology, University of Würzburg, Josef-Schneider-Str.11, D-97080 Würzburg, Germany pham{at}neuroradiologie.uni-wuerzburg.de

Objective: To prospectively assess the diagnostic accuracy of CT perfusion (CTP) and transcranial Doppler sonography (TCD) for the prediction of secondary cerebral infarction (SCI) after aneurysmal subarachnoid hemorrhage (SAH).

Methods: During 2 weeks after SAH, 38 consecutive patients completed an average of 3.5 CT/CTP and 10.7 TCD examinations at regular intervals as required by the study protocol. SCI was defined as delayed infarction on native CT between 3 and 14 days after SAH and developed in n = 14 patients (n = 24 without SCI). Analysis was based on examination dates before SCI. Common measures of diagnostic accuracy were calculated for qualitative CTP (visual color-map ratings from two blinded observers) and TCD assessments (mean flow velocity >120 cm/s in anterior, middle, and posterior cerebral artery territories). Quantitative measures, which for CTP were obtained from cortical a priori regions of interest corresponding to the vascular territories, were analyzed by binary logistic regression.

Results: Time of prediction for SCI by CTP was at a median of 3 days (range 2 to 5 days) before manifestation of complete infarction on native CT. Visual assessment of time-to-peak (TTP) color maps performed best for the prediction of SCI with 0.93 sensitivity (95% CI: 0.7 to 1.0) and 0.67 specificity (95% CI: 0.53 to 0.7). On quantitative analysis, the odds ratio (OR) for 1 second of side-to-side delay in TTP was 1.4 (p = 0.01, Wald ² = 8.57, CI: 1.07 to 1.82). Daily TCD measures were not significantly related to SCI at any time before complete infarction on native CT.

Conclusions: Time to peak as indicated by CT perfusion is a sensitive and early predictor of secondary cerebral infarction.

M.B. holds a professorship donated by Schering GmbH (Berlin, Germany) to the University of Würzburg but has no financial interest.

Disclosure: The authors report no conflicts of interest.

Received November 7, 2006. Accepted in final form March 22, 2007.

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