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Abstract：
BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is frequently complicated by delayed cerebral ischemia (DCI), leading to poor outcomes. Early diagnosis of DCI is crucial for improving survival and outcomes but remains challenging in comatose patients. In this study, we aimed to evaluate computed tomography with angiography and perfusion (P-CT) as a screening modality on postictal days four and eight for impending DCI after aSAH in comatose patients using vasospasm with hypoperfusion (hVS) as a surrogate and DCI-related infarction as an outcome measure. Two objectives were set: (1) to evaluate the screening\'s ability to accurately risk stratify patients and (2) to assess the validity of P-CT screening.
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.
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.
摘要：
背景：动脉瘤性蛛网膜下腔出血（aSAH）经常并发迟发性脑缺血（DCI），导致糟糕的结果。DCI的早期诊断对于改善生存率和预后至关重要，但在昏迷患者中仍然具有挑战性。在这项研究中,我们的目的是在第4天和第8天,以血管痉挛伴灌注不足(hVS)作为替代指标,并以DCI相关的梗死作为结局指标,对昏迷患者aSAH后即将发生的DCI进行评估.设定了两个目标：（1）评估筛查对患者进行准确风险分层的能力；（2）评估P-CT筛查的有效性。
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。
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。
