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Advanced magnetic resonance imaging techniques in the study of patients after intracerebral hemorrhage
278 Developmental Outcome of Infants with Intraeranial Hemorrhage or Ischemic Stroke after Treatment with Extracorporeal Membrane Oxygenation in the Newborn Period. K Goldstein, K. O'Donnell, J. Oehler, M. Lohmeyer (Durham, North Carolina) Back~,round. Extracorporeal membrane oxygenation (ECMO) is a technology that utilizes cardiopulmonary bypass to treat newborn infants with severe respiratory failure. The most serious complication of ECMO is the occurrence of intraeranial hemorrhage or ischemic stroke. This study was performed to compare the long term developmental outcome associated with these two types of perinatal brain injury after ECMO. Methods. Cognitive and motor skills were assessed using the Bayley Scales of Infant Development at 2 years of age (MDI= Mental Developmental Index, PDI=Psyehomotor Developmental Index). The Peabody Infant Motor Scales (DMQ=Developmental Motor Quotien0 was used to further evaluate gross motor (GM) and fine motor (FM) skills. (All scores: mean=100+_SD= 15) Results. 71 infants treated with ECMO over a five year period were evaluated at 2 years of age. 15% of these infants had some type of intracranial hemorrhage or ischemic stroke. Infants with a hemorrhage did not differ significantly in cognitive skills (MDI--89+ 16 versus 91• or motor skills (PDI--92• versus 86-2.17) from those infants without a hemorrhage or infarction. However, infants with an ischemic stroke had significantly lower scores than those infants without an infarction (MDI=63+16 versus 90• PDI=58• versus 87+17; p<.001 for both). Both gross and fine motor skills were severely delayed in these children (DMQ-GM= 48-&36 versus 88_-t.15, DMQ-FM=46+ 28 versus 75+12; p<.001 for both). Conclusions. These data indicate than an intraeranial hemorrhage alone does not necessarily predict poor cognitive or motor outcome in infants treated with ECMO. An ischemic stroke, however, is associated with poor developmental outcome. Improved bedside monitoring of cerebral blood flow and oxygen delivery is needed to be able to detect when ischemie damage is occurring during treatment with ECMO. Advanced magnetic resonance imaging techniques in the study of patients after intracerebral hemorrhage
ABSTRACTS
CBF Reserve Based Stratification of Patients into High and Low Risk Groups for Delayed Ischemic Neurological Deficit Following Subarachnoid Hemorrhage. H. Yonas, A Karakus, C.A Jungreis, A.Kassam, H.A Kromer, R Pindzola, S.L Pentheny (Pittsburgh, PA). Introduction: Delayed ischemic neurological deficit (DIND) due to vasospasm continue to cause significant morbidity and mortality after subaraclmoid hemorrhage(SAH). Prediction of patients at high and low risk for DIND would help guide better use of vital resources. In this study we tried to predict DIND by CBF vasoreactivity measurements. Methods: In 50 patients on post SAH day seven or eight, cerebral blood flow (CBF) were measured by stable xenon computed tomography (Xe/CT) before and after t g of acetazolamide. Cerebral angiographies were obtained thirty minutes after Xe/CT study. Four groups were identified. Group A(n=14), no angiographic vasospasm (AV) and normal vasoreactivity; group B(n=l), no AV but steal in CBF; group C(n=l 3), with AV and normal vasoreactivity, group D(n=22), with both AV and steal in CBF. Steal was defined as a CBF decrease of > 5ml/100g/min. Results Eight patients in group D (36 %) subsequently developed DIND and none of the patients without steal phenomenon developed DIND (p<0.0001). Angiographic vasospasm was unable to predict DIND (19=0.08) Conclusions: CBF reserve testing does distinguish a group with very low versus moderate (36%) risk of developing DIND. Reserve testing is more specific (64 %) than angiography based prediction (36 %). Stratification of patients risk for developing DIND should allow for more specific and cost effective care.
Cerebral Blood Flow-Guided Phenylephrine -Induced Hypertensive Therapy After Subarachnoid Hemorrhage.
J. R. Carhuapoma, P.Y. Wang, P. B. Barker, N. J. Beauchamp, D. F. Hanley (Baltimore, Maryland)
A.Karakus, H.Yonas, G.Pavesi, C.A.Jungreis, H.A.Kromer, S.L.Pentheny, A.Kassam (Pittsburgh,PA).
Objective: To determine feasibility of IH-MRS/DWI/PWI in studying human ICH and define early metabolic profiles of hematoma-surrounding neuronal tissue. Methods: Prospective recruitment of acute ICH patients. Results: Nine patients enrolled, age: 63.4 (36-87) years; time-to-initial MRI: 3.4 (1-9) days Three patients had follow-up studies. ICH etiology: HTN (6 patients), probable AVM (1 patient), probable AA (1 patient), cocaine (1 patient). Location: striaturn/thalamus (patients), lobar (3 patients); MAP: 102.2 (85-130) mmHg; hematoma volume: 35.4 (5-80) cc. DWl studies were performed in every patient, ~H-MRS in 5, and PWl in 1. ADC values were uniformly increased in all patients studied: 172.5 (120.0-302.5)x10Smm2/sec and 87.6 (76.5-102.1)x I 0"Smm2/sec in ipsi- and contralateral ROI's, respectively. A patient showed delayed TTP posterior to the hematoma, improving after surgical evacuation; another patient showed an additional reduced ADC region, suggesting ischemia 1H-MRS revealed reduced NAA around the hematoma in 5 patients, as it did in the contralateral hemisphere in 4. Two patients showed lactate surrounding the hematoma. Conclusions: tH-MRS/DWI/PWI can be applied to ICH patients. Inflammation may play a role in secondary neuronal injury after ICH Prospective studies using DWI/PWI/~H-M-RS might help better define the nature, course, and clinical significance of pathologic processes triggered by human ICH
Background: Hypertension in addition to hypervolemic hemodilution is the most common treatment for patients suspected of having delayed ischemic neurological deficit (DIND) due to vasospasm after subaractmoid hemorrage (SAH). Pharmacological-induced hypertension, however, can be associated with morbidity.To clarify its indications and its effectiveness, we examined xenon/computed tomography (Xe/CT) cerebral blood flow (CBF) studies without and then with phenylephrine-induced hypertension in 13 patients who were believed to have DIND and elevated flow velocities after SAH. Methods: Upon suspicion of a DIND, phenylephrine infusion was started after a baseline CBF measurement, and the second study performed 20 minutes thereafter. Results: Of the 13 patients, 5 had no identifiable ischemia. Ischemic flows of 8 patients was raised to above 20ml/100g/min in 89 % with induced hypertension (p<0.0001).However, in some of the previously non-ischemic territories, CBF was paradoxically lower during hypertension. Conclusion: Phenylephrine is an effective treatment for vasospasm-induced ischemia because it reliably increases perfusion within ischemic regions usually to non-ischemic levels. However, it also can decrease perfusion in previously normal territories. A significant number of patients do not have ischemia despite clinical and TCD indications. Quantitative CBF information can help determine the indications for hypertensive therapy.
ABSTRACTS
CBF Reserve Based Stratification of Patients into High and Low Risk Groups for Delayed Ischemic Neurological Deficit Following Subarachnoid Hemorrhage. H. Yonas, A Karakus, C.A Jungreis, A.Kassam, H.A Kromer, R Pindzola, S.L Pentheny (Pittsburgh, PA). Introduction: Delayed ischemic neurological deficit (DIND) due to vasospasm continue to cause significant morbidity and mortality after subaraclmoid hemorrhage(SAH). Prediction of patients at high and low risk for DIND would help guide better use of vital resources. In this study we tried to predict DIND by CBF vasoreactivity measurements. Methods: In 50 patients on post SAH day seven or eight, cerebral blood flow (CBF) were measured by stable xenon computed tomography (Xe/CT) before and after t g of acetazolamide. Cerebral angiographies were obtained thirty minutes after Xe/CT study. Four groups were identified. Group A(n=14), no angiographic vasospasm (AV) and normal vasoreactivity; group B(n=l), no AV but steal in CBF; group C(n=l 3), with AV and normal vasoreactivity, group D(n=22), with both AV and steal in CBF. Steal was defined as a CBF decrease of > 5ml/100g/min. Results Eight patients in group D (36 %) subsequently developed DIND and none of the patients without steal phenomenon developed DIND (p<0.0001). Angiographic vasospasm was unable to predict DIND (19=0.08) Conclusions: CBF reserve testing does distinguish a group with very low versus moderate (36%) risk of developing DIND. Reserve testing is more specific (64 %) than angiography based prediction (36 %). Stratification of patients risk for developing DIND should allow for more specific and cost effective care.
Cerebral Blood Flow-Guided Phenylephrine -Induced Hypertensive Therapy After Subarachnoid Hemorrhage.
J. R. Carhuapoma, P.Y. Wang, P. B. Barker, N. J. Beauchamp, D. F. Hanley (Baltimore, Maryland)
A.Karakus, H.Yonas, G.Pavesi, C.A.Jungreis, H.A.Kromer, S.L.Pentheny, A.Kassam (Pittsburgh,PA).
Objective: To determine feasibility of IH-MRS/DWI/PWI in studying human ICH and define early metabolic profiles of hematoma-surrounding neuronal tissue. Methods: Prospective recruitment of acute ICH patients. Results: Nine patients enrolled, age: 63.4 (36-87) years; time-to-initial MRI: 3.4 (1-9) days Three patients had follow-up studies. ICH etiology: HTN (6 patients), probable AVM (1 patient), probable AA (1 patient), cocaine (1 patient). Location: striaturn/thalamus (patients), lobar (3 patients); MAP: 102.2 (85-130) mmHg; hematoma volume: 35.4 (5-80) cc. DWl studies were performed in every patient, ~H-MRS in 5, and PWl in 1. ADC values were uniformly increased in all patients studied: 172.5 (120.0-302.5)x10Smm2/sec and 87.6 (76.5-102.1)x I 0"Smm2/sec in ipsi- and contralateral ROI's, respectively. A patient showed delayed TTP posterior to the hematoma, improving after surgical evacuation; another patient showed an additional reduced ADC region, suggesting ischemia 1H-MRS revealed reduced NAA around the hematoma in 5 patients, as it did in the contralateral hemisphere in 4. Two patients showed lactate surrounding the hematoma. Conclusions: tH-MRS/DWI/PWI can be applied to ICH patients. Inflammation may play a role in secondary neuronal injury after ICH Prospective studies using DWI/PWI/~H-M-RS might help better define the nature, course, and clinical significance of pathologic processes triggered by human ICH
Background: Hypertension in addition to hypervolemic hemodilution is the most common treatment for patients suspected of having delayed ischemic neurological deficit (DIND) due to vasospasm after subaractmoid hemorrage (SAH). Pharmacological-induced hypertension, however, can be associated with morbidity.To clarify its indications and its effectiveness, we examined xenon/computed tomography (Xe/CT) cerebral blood flow (CBF) studies without and then with phenylephrine-induced hypertension in 13 patients who were believed to have DIND and elevated flow velocities after SAH. Methods: Upon suspicion of a DIND, phenylephrine infusion was started after a baseline CBF measurement, and the second study performed 20 minutes thereafter. Results: Of the 13 patients, 5 had no identifiable ischemia. Ischemic flows of 8 patients was raised to above 20ml/100g/min in 89 % with induced hypertension (p<0.0001).However, in some of the previously non-ischemic territories, CBF was paradoxically lower during hypertension. Conclusion: Phenylephrine is an effective treatment for vasospasm-induced ischemia because it reliably increases perfusion within ischemic regions usually to non-ischemic levels. However, it also can decrease perfusion in previously normal territories. A significant number of patients do not have ischemia despite clinical and TCD indications. Quantitative CBF information can help determine the indications for hypertensive therapy.