1. Presentation: eP-26

2. There is no conflict of interest in this presentation

3. “ Subarachnoid hemorrhage is a major devastating event; with 15% mortality before reaching the hospital and of the survivors only 20-25% will be back to their normal baseline health and cognitive ability ” Subarachnoid haemorrhage. van Gijn J et.al Lancet. 2007 Jan 27; Aneurysmal subarachnoid hemorrhage. Suarez JI et. al N Engl J Med. 2006 Jan 26; 85% arise from rupture of saccular aneurysm Ingall T.J., Wiebers D.O. Natural history of subarachnoid hemorrhage. In: Whisnant J.P., (Ed.). Stroke: Populations, Cohorts, and Clinical Trials. Boston, Mass: Butterworth- Heinemann Ltda; 1993. Domitille millon, et al.Nontraumatic subarachnoid hemorrhage Management: Evaluation with Reduced Iodine Volume at CT Angiography Radiology: Volume 264: July 2012. Introduction

4. Introduction SUBARACHNOID HEMORRHAGE CauseComplicationsLate Control Identification Control Initial Treatment Prevention of secondary damage Mortality Save BrainPreserve BrainSave Life “Neuroimaging is an important tool in the management of patients suffering from subarachnoid hemorrhage (SAH)” Aneurysmal subarachnoid haemorrhage from a neuroimaging perspective; de Oliveira Manoel et al. Critical Care 2014

5. Introduction SUBARACHNOID HEMORRHAGE CauseComplicationsLate Control Identification Control Initial Treatment Prevention of secondary damage Mortality Save BrainPreserve BrainSave Life Aneurysmal subarachnoid haemorrhage from a neuroimaging perspective; de Oliveira Manoel et al. Critical Care 2014 “Neuroimaging is an important tool in the management of patients suffering from subarachnoid hemorrhage (SAH)”

6. POOR PREDICTORS IN SUBARACHNOID HEMORRHAGE FROM ANEURYSMAL DISEASE Introduction Clinical findings Hypotension Age Decreased level of consciousness Clinical signs of delayed stroke Clinical vasospasm Image findings ARTERIAL VASOSPASM Hydrocephalus Ventricular hemorrhage Intraparenchymal hemorrhage Delayed Stroke Vasospasm: Until now it has been the only potential tractable factor for delayed stroke Neurol Int. 2009 Nov 16 Therapeutic approaches to cerebral vasospasm complicating ruptured aneurysm. Barbarawi M1, et al

7. Primary Objective Identify possible subgroups of patients with imaging findings that impose more risk to present delayed cerebral ischemia (DCI) after acute SAH. Primary Objective Identify possible subgroups of patients with imaging findings that impose more risk to present delayed cerebral ischemia (DCI) after acute SAH. Purpose Secondary Objectives Correlate detection from severe vasospasm by CTA and DSA. Incidence of DCI in patients with severe vasospasm. Secondary Objectives Correlate detection from severe vasospasm by CTA and DSA. Incidence of DCI in patients with severe vasospasm.

8. Inclusion criteria Patients with SAH diagnosis until 72 hours of ictus. Perform control study with DSA and CTA between 3 -10 days of ictus. Inclusion criteria Patients with SAH diagnosis until 72 hours of ictus. Perform control study with DSA and CTA between 3 -10 days of ictus. Exclusion criteria Non-aneurysmal SAH. Control study CTA and DSA later than 72 hours between both. Patients that did not complete all the proposed protocol. Exclusion criteria Non-aneurysmal SAH. Control study CTA and DSA later than 72 hours between both. Patients that did not complete all the proposed protocol. Method

9. SAH < 72 hours of ictus Clinical and epidemiological criteria Fisher Grade Control DSA and CTA exams between 3- 10 days of ictus. Follow up until 3 months Method

10. Method CTA x DSA Diameter reduction > 50 % to diagnosis of severe vasospasm

11. Total: Excluded: Results 86 patients from August 2012 to January 2015 50 patients from August 2012 to January 2015 Remaining patients: 36 patients *DSA and CTA Not performed both exams* Gap longer than 72 hours* between both exams Postoperative Changes Age:11-70 years Average: 49,8 years Men women Frequency

12. Results CTA : 24/36: 66,6 % DSA 26/36: 72,2 %

13. Results Incidence of severe vasospasm CTADSAConcordance between methods Vasospasm n (%)24/36 (66,6) 26/36 (72,2)92,6% Discordant Cases: 1 vasospasm aca (a2) 1 case hypoplasia Sensibility: 92,8 % Specificity: 90,9 % The diagnostic of severe vasospasm revealed by multislice CTA was significantly correlated with the severe vasospasm by DSA (p < 0,001) and the quality of the CTA as a method for vasospasm was “almost perfect” (Cohen’s Kappa = 0.86), CI = 95%.

14. Results CTA : 24/36: 66,6 % DSA: 26/36: 72,2 % There was a significant difference in Fisher exact test and the occurrence of vasospasm ADS ( X² = 20,405,Degrees of freedom = 3, p = 0.0001 ) There was a significant difference in Fisher exact test and the occurrence of vasospasm ADS ( X² = 20,405, degrees of freedom = 3, p = 0.0001 )

15. Results Anterior CerebralMiddle CerebralCircle of WillisVertebrobasilar Anterior CerebralMiddle CerebralCircle of WillisVertebrobasilar

16. Results DSA Vasospasm Anterior Cerebral Vasospam Middle Cerebral Vasospam Basilar Vasospam

17. Results Ischemic Stroke Vasospasm n (%) 14/26 (53,8) Severe vasospasm and Delayed Ischemic Stroke Fisher 1 e 2 Fisher 3 e 4 Absolute frequency of patients according Fisher and the occurrence of occurrence of delayed stroke. Frequency positive negative

18. Results SAH < 72 hours of ictus Control DSA and CTA exams between 3- 10 days of ictus. Follow up 3 weeks 56 years-old, female, systemic hypertension and Smoker Fisher 4

19. Severe VasospasmDelayed Ischemic Stroke Discussion Low Correlation PERFUSION COLLATERAL VESSELS “ one-half of the patients with severe ACV (>50% decrease in vessel diameter) will not develop DCI and up to 20% of patients without ACV (0 to 25% decrease in vessel diameter) will develop symptoms". Dhar R. MTRelationship between angiographic vasospasm and regional hypoperfusion in aneurysmal subarachnoid hemorrhage. Stroke 2012,....Macdonald RL: Delayed neurological deterioration after subarachnoid haemorrhage. Nat Rev Neurol 2014 + Radiation Exposure + Iodinated Contrast + Health Care Costs

20. CTA Vasospasm Fisher 1 and 2 Absent or Small DCI Presence of DCI Perfusion and Collateral Investigation (+ results) Prospects Fisher 3 and 4 (- results) YES NO

21. The CTA demonstrate high accuracy for detecting severe vasospasm presentations, with statistically significant agreement with DSA. Can CTA allow diagnosis of severe vasospasm ? Conclusion

22. The diagnosis of severe vasospasm (> 50%) with CTA was predictor of DCI. Occurred in about half of patients with severe vasospasm after acute aneurysmal SAH. What is the incidence of DCI in patients with severe vasospasm after acute SAH? Conclusion

23. Patients with acute SAH, Fisher 1 or 2, do not show any case of severe vasospasm by CTA ​ or DSA. No patient in this subgroup had DCI. The occurrence of SAH, Fisher 3 or 4, demonstrate higher incidence of vasospasm and DCI. The diagnosis of severe vasospasm (> 50 % ) with CTA, regardless of the location of the aneurysm, was a predictor of DCI. Which subgroups were identified from the imaging findings in patients with acute aneurysmal SAH? Conclusion