METHODS: We conducted a retrospective review of the records of comatose patients with aSAH from January 2019 to December 2021 who were monitored with P-CT scans on days four and eight. The event rates of DCI-related infarction, hVS, and endovascular rescue therapy (ERT) were analyzed, and the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for DCI were calculated. DCI-related infarction was defined as new secondary cerebral infarction > 48 h < 6 weeks post aSAH not attributable to other causes, and hVS was defined as arterial narrowing with corresponding hypoperfusion on P-CT.
RESULTS: Fifty-six comatose patients were included, and 98 P-CT scans were performed. The incidence of DCI-related infarction was 40%. Screening P-CT on days four and eight found vasospasm in 23% of all patients, including 11% with hVS. A positive hVS on day four or eight revealed a relative risk of 2.4 [95% confidence interval (CI) 1.13-5.11, p = 0.03], sensitivity of 23% (95% CI 8-45, p = 0.03), specificity of 95% (95% CI 36-100, p = 0.03), PPV of 0.83 (95% CI 0.36-1.00, p = 0.03), and NPV of 0.65 (95% CI 0.50-0.78). Six positive P-CT scans led to digital subtraction angiography in five patients, three of whom received ERT. All ERT-intervened patients developed DCI-related infarction.
CONCLUSIONS: P-CT resulted in few interventions and often resulted in late detection of DCI at an irreversible stage. Although a positive P-CT result accurately predicts impending DCI-related infarction, screening on days four and eight alone in comatose patients with aSAH often fails to timely detect impending DCI. Based on our analysis, we cannot recommend P-CT as a screening modality. P-CT is likely best used as a confirmatory test prior to invasive interventions when guided by continuous multimodal monitoring; however, prospective studies with comparison groups are warranted. The need for a reliable continuous screening modality is evident because of the high rate of deterioration and narrow treatment window.
方法:我们对2019年1月至2021年12月在第4天和第8天接受P-CT扫描监测的aSAH昏迷患者的记录进行了回顾性回顾。DCI相关梗死的事件发生率,hVS,血管内抢救治疗(ERT)进行分析,和灵敏度,特异性,负预测值(NPV),并计算DCI的阳性预测值(PPV)。DCI相关梗死定义为新的继发性脑梗死>48小时<6周后,aSAH后不是归因于其他原因。在P-CT上,hVS被定义为动脉狭窄并伴有相应的灌注不足。
结果:纳入56例昏迷患者,共进行了98次P-CT扫描。DCI相关梗死的发生率为40%。在第4天和第8天进行P-CT筛查时,所有患者中有23%发现血管痉挛,包括11%的hVS。第4天或第8天的阳性hVS显示相对风险为2.4[95%置信区间(CI)1.13-5.11,p=0.03],灵敏度为23%(95%CI8-45,p=0.03),特异性为95%(95%CI36-100,p=0.03),PPV为0.83(95%CI0.36-1.00,p=0.03),净现值为0.65(95%CI0.50-0.78)。六个阳性的P-CT扫描导致五个患者的数字减影血管造影,其中三人接受了ERT。所有ERT介入患者均发生DCI相关梗死。
结论:P-CT导致很少的干预措施,通常导致在不可逆阶段延迟发现DCI。尽管P-CT阳性结果能准确预测DCI相关梗死的发生,在昏迷的aSAH患者中,仅在第4天和第8天进行筛查通常无法及时发现即将发生的DCI。根据我们的分析,我们不推荐P-CT作为筛查方式.在连续多模态监测的指导下,P-CT可能最好用作侵入性干预前的确认测试;然而,有必要进行比较组的前瞻性研究.由于高的恶化率和狭窄的治疗窗口,对可靠的连续筛选方式的需要是明显的。