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Screening Computed Tomography Angiography to Identify Patients at Low Risk for Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage
Introduction: Delayed cerebral ischemia (DCI) occurs during a risk period of 3–21 days following aneurysmal subarachnoid hemorrhage (aSAH) and is associated with worse outcomes. The identification of patients at low risk for DCI might permit triage to less intense monitoring and management. While la...
Autores principales: | , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
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Frontiers Media S.A.
2021
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Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8632862/ https://www.ncbi.nlm.nih.gov/pubmed/34867722 http://dx.doi.org/10.3389/fneur.2021.740241 |
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author | Nguyen, Andrew M. Williamson, Craig A. Pandey, Aditya S. Sheehan, Kyle M. Rajajee, Venkatakrishna |
author_facet | Nguyen, Andrew M. Williamson, Craig A. Pandey, Aditya S. Sheehan, Kyle M. Rajajee, Venkatakrishna |
author_sort | Nguyen, Andrew M. |
collection | PubMed |
description | Introduction: Delayed cerebral ischemia (DCI) occurs during a risk period of 3–21 days following aneurysmal subarachnoid hemorrhage (aSAH) and is associated with worse outcomes. The identification of patients at low risk for DCI might permit triage to less intense monitoring and management. While large-vessel vasospasm (LVV) is a distinct clinical entity from DCI, the presence of moderate-to-severe LVV is associated with a higher risk of DCI. Our hypothesis was that the absence of moderate-to-severe LVV on screening computed tomographic angiography (CTA) performed within the first few days of the DCI risk period will accurately identify patients at low risk for subsequent DCI. Methods: This was a retrospective cohort study. Our institutional SAH outcomes registry was queried for all aSAH patients admitted in 2016–2019 who underwent screening CTA brain between days 4 and 8 following ictus. We excluded patients diagnosed with DCI prior to the first CTA performed during this time period. All variables are prospectively entered into the registry, and outcomes including DCI and LVV are prospectively adjudicated. We evaluated the predictive value and accuracy of moderate-to-severe LVV on CTA performed 4–8 days following ictus for the prediction of subsequent DCI. Results: A total of 243 aSAH patients were admitted during the study timeframe. Of the 54 patients meeting the eligibility criteria, 11 (20%) had moderate-to-severe LVV on the screening CTA study performed during the risk period. Seven of the 11 (64%) patients with moderate-to-severe LVV on the days 4–8 screening CTA vs. six of 43 (14%) patients without, subsequently developed DCI. On multivariate analysis, the presence of LVV on days 4–8 screening CTA was an independent predictor of DCI (odds ratio 10.26, 95% CI 1.69–62.24, p = 0.011). NPV for the subsequent development of DCI was 86% (95% CI 77–92%). Sensitivity was 54% (25–81%), specificity 90% (77–97%), and positive predictive value 64% (38–83%). Conclusions: The presence of moderate-to-severe LVV on screening CTA performed between days 4 and 8 following aSAH was an independent predictor of DCI, but achieved only moderate diagnostic accuracy, with NPV 86% and sensitivity 54%. Complementary risk-stratification strategies are likely necessary. |
format | Online Article Text |
id | pubmed-8632862 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | Frontiers Media S.A. |
record_format | MEDLINE/PubMed |
spelling | pubmed-86328622021-12-02 Screening Computed Tomography Angiography to Identify Patients at Low Risk for Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage Nguyen, Andrew M. Williamson, Craig A. Pandey, Aditya S. Sheehan, Kyle M. Rajajee, Venkatakrishna Front Neurol Neurology Introduction: Delayed cerebral ischemia (DCI) occurs during a risk period of 3–21 days following aneurysmal subarachnoid hemorrhage (aSAH) and is associated with worse outcomes. The identification of patients at low risk for DCI might permit triage to less intense monitoring and management. While large-vessel vasospasm (LVV) is a distinct clinical entity from DCI, the presence of moderate-to-severe LVV is associated with a higher risk of DCI. Our hypothesis was that the absence of moderate-to-severe LVV on screening computed tomographic angiography (CTA) performed within the first few days of the DCI risk period will accurately identify patients at low risk for subsequent DCI. Methods: This was a retrospective cohort study. Our institutional SAH outcomes registry was queried for all aSAH patients admitted in 2016–2019 who underwent screening CTA brain between days 4 and 8 following ictus. We excluded patients diagnosed with DCI prior to the first CTA performed during this time period. All variables are prospectively entered into the registry, and outcomes including DCI and LVV are prospectively adjudicated. We evaluated the predictive value and accuracy of moderate-to-severe LVV on CTA performed 4–8 days following ictus for the prediction of subsequent DCI. Results: A total of 243 aSAH patients were admitted during the study timeframe. Of the 54 patients meeting the eligibility criteria, 11 (20%) had moderate-to-severe LVV on the screening CTA study performed during the risk period. Seven of the 11 (64%) patients with moderate-to-severe LVV on the days 4–8 screening CTA vs. six of 43 (14%) patients without, subsequently developed DCI. On multivariate analysis, the presence of LVV on days 4–8 screening CTA was an independent predictor of DCI (odds ratio 10.26, 95% CI 1.69–62.24, p = 0.011). NPV for the subsequent development of DCI was 86% (95% CI 77–92%). Sensitivity was 54% (25–81%), specificity 90% (77–97%), and positive predictive value 64% (38–83%). Conclusions: The presence of moderate-to-severe LVV on screening CTA performed between days 4 and 8 following aSAH was an independent predictor of DCI, but achieved only moderate diagnostic accuracy, with NPV 86% and sensitivity 54%. Complementary risk-stratification strategies are likely necessary. Frontiers Media S.A. 2021-11-12 /pmc/articles/PMC8632862/ /pubmed/34867722 http://dx.doi.org/10.3389/fneur.2021.740241 Text en Copyright © 2021 Nguyen, Williamson, Pandey, Sheehan and Rajajee. https://creativecommons.org/licenses/by/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. |
spellingShingle | Neurology Nguyen, Andrew M. Williamson, Craig A. Pandey, Aditya S. Sheehan, Kyle M. Rajajee, Venkatakrishna Screening Computed Tomography Angiography to Identify Patients at Low Risk for Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage |
title | Screening Computed Tomography Angiography to Identify Patients at Low Risk for Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage |
title_full | Screening Computed Tomography Angiography to Identify Patients at Low Risk for Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage |
title_fullStr | Screening Computed Tomography Angiography to Identify Patients at Low Risk for Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage |
title_full_unstemmed | Screening Computed Tomography Angiography to Identify Patients at Low Risk for Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage |
title_short | Screening Computed Tomography Angiography to Identify Patients at Low Risk for Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage |
title_sort | screening computed tomography angiography to identify patients at low risk for delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage |
topic | Neurology |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8632862/ https://www.ncbi.nlm.nih.gov/pubmed/34867722 http://dx.doi.org/10.3389/fneur.2021.740241 |
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