DSA-Based 2D Perfusion Measurements in Delayed Cerebral Ischemia to Estimate the Clinical Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage: A Technical Feasibility Study

(1) Background: To predict clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH) and delayed cerebral ischemia (DCI) by assessment of the cerebral perfusion using a 2D perfusion angiography (2DPA) time–contrast agent (CA) concentration model. (2) Methods: Digital subtraction angiography (DSA) data sets of n = 26 subjects were acquired and post-processed focusing on changes in contrast density using a time–concentration model at three time points: (i) initial presentation with SAH (T0); (ii) vasospasm-associated acute clinical impairment (T1); and (iii) directly after endovascular treatment (T2) of SAH-associated large vessel vasospasm (LVV), which resulted in n = 78 data sets. Maximum slope (MS in SI/ms), time-to-peak (TTP in ms), and maximum amplitude of a CA bolus (dSI) were measured in brain parenchyma using regions of interest (ROIs). First, acquired parameters were standardized to the arterial input function (AIF) and then statistically analyzed as mean values. Additionally, data were clustered into two subsets consisting of patients with regredient or with stable/progredient symptoms (or Doppler signals) after endovascular treatment (n = 10 vs. n = 16). (3) Results: Perfusion parameters (MS, TTP, and dSI) differed significantly between T0 and T1 (p = 0.003 each). Significant changes between T1 and T2 were only detectable for MS (0.041 ± 0.016 vs. 0.059 ± 0.026; p = 0.011) in patients with regredient symptoms at T2 (0.04 ± 0.012 vs. 0.066 ± 0.031; p = 0.004). For dSI, there were significant differences between T0 and T2 (5095.8 ± 2541.9 vs. 3012.3 ± 968.3; p = 0.001), especially for those with stable symptoms at T2 (5685.4 ± 2967.2 vs. 3102.8 ± 1033.2; p = 0.02). Multiple linear regression analysis revealed that a) the difference in MS between T1 and T2 and b) patient’s age (R = 0.6; R(2) = 0.34; p = 0.009) strongly predict the modified Rankin Scale (mRS) at discharge. (4) Conclusions: 2DPA allows the direct measurement of treatment effects in SAH associated DCI and may be used to predict outcomes in these critically ill patients.