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Clinical Research
Available online 16 January 2024
Aneurysmal subarachnoid haemorrhage: Volumetric quantification of the blood distribution pattern to accurately predict the ruptured aneurysm location
Hemorragia subaracnoidea aneurismática: cuantificación volumétrica del patrón de distribución hemática en la predicción del aneurisma índice
Alejandra Mosteiroa, Diego Culebrasa, Alberto Vargas Solanob, Javier Luis Moreno Negreteb, Antonio López-Ruedab, Laura Llullc, Daniel Santanac, Leire Pedrosad, Sergio Amaroc,d, Ramón Tornéa,d,
Corresponding author
torne@clinic.cat

Corresponding author.
, Joaquim Enseñata,d
a Department of Neurosurgery, Hospital Clínic of Barcelona, University of Barcelona, Spain
b Department of Radiology, Hospital Clínic of Barcelona, University of Barcelona, Spain
c Comprehensive Stroke Center, Department of Neurology, Hospital Clínic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
d August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
Received 08 June 2023. Accepted 24 November 2023
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Tables (3)
Table 1. Baseline characteristics of the sample of patients with spontaneous subarachnoid haemorrhage and a single ruptured aneurysm.
Table 2. Association between the location of the ruptured aneurysm and the pattern of blood distribution. The specific combinations of regions of blood distribution were initially obtained after the observation of relative ratios of bleeding distribution according to aneurysm site. After the multivariate analysis confirmed the association between bleeding distribution and aneurysm site, a post-hoc analysis was performed to establish the individual correlations between site of rupture and bleeding pattern.
Table 3. Association between the total amount of blood assessed by volumetric quantification and the primary clinical outcomes in SAH patients. The amount of blood is expressed as mean (standard deviation) in squared centimetres.
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Abstract
Background

In spontaneous subarachnoid haemorrhage (SAH) accurate determination of the bleeding source is paramount to guide treatment. Traditionally, the bleeding pattern has been used to predict the aneurysm location. Here, we have tested a software-based tool, which quantifies the volume of intracranial blood and stratifies it according to the regional distribution, to predict the location of the ruptured aneurysm.

Methods

A consecutive series of SAH patients admitted to a single tertiary centre between 2012–2018, within 72 h of onset, harbouring a single intracranial aneurysm. A semi-automatized method of blood quantification, based on the relative density increase, was applied to initial non-contrast CTs. Five regions were used to define the bleeding patterns and to correlate them with aneurysm location: perimesencephalic, interhemispheric, right/left hemisphere and intraventricular.

Results

68 patients were included for analysis. There was a strong association between the distribution of blood and the aneurysm location (p < 0.001). In particular: ACom and interhemispheric fissure (p < 0.001), MCA and ipsilateral hemisphere (p < 0.001), ICA and ipsilateral hemisphere and perimesencephalic cisterns (p < 0.001), PCom and hemispheric, perimesencephalic and intraventricular (p = 0.019), and PICA and perimesencephalic and intraventricular (p < 0.001). The internal diagnostic value was high (AUROC ≥ 0.900) for these locations.

Conclusion

Regional automatised volumetry seems a reliable and objective tool to quantify and describe the distribution of blood within the subarachnoid spaces. This tool accurately predicts the location of the ruptured aneurysm; its use may be prospectively considered in the emergency setting when speed and simplicity are attained.

Keywords:
Subarachnoid haemorrhage
Bleeding pattern
Aneurysm
Volumetric
Quantification
Abbreviations:
ACA
ACom
BA
CI
CT
CTA
DSA
DCI
EVD
ICA
MCA
mFisher
mRS
NCCT
PCA
PCom
PICA
ROC
SAH
SCA
SD
VP shunt
WFNS
Resumen
Antecedentes

En la hemorragia subaracnoidea espontánea (HAS), la determinación fehaciente del punto de sangrado es fundamental para guiar el tratamiento. De forma tradicional, la determinación de la localización del aneurisma se basa en el patrón de sangrado. En el presente estudio, evaluamos una herramienta computarizada, capaz de cuantificar el volumen de sangre intracraneal y de estratificarlo según la distribución regional, con el objetivo de predecir la localización del aneurisma roto.

Métodos

Una serie consecutiva de pacientes ingresados en nuestro centro terciario durante el periodo 2012–2018, con hemorragia subaracnoidea de debut en < 72 h y con aneurisma único. Se aplicó el método cuantitativo semiautomatizado a las tomografías computarizadas basales de dichos pacientes. La detección del sistema se basa en el aumento relativo de densidad atribuido a la presencia de sangre. Se contemplaron cinco regiones para definir los patrones de sangrado y para su posterior correlación con la localización del aneurisma: perimesencefálico, interhemisférico, hemisférico derecho/izquierdo e intraventricular.

Resultados

El análisis incluyó 68 pacientes. Se detectó una fuerte asociación entre el patrón de sangrado y la localización del aneurisma (p < 0,001). En concreto: ACom con la distribución interhemisférica (p < 0,001); ACM con la hemisférica ipsilateral (p < 0,001); ACI con la hemisférica ipsilateral y perimesencefálica (p < 0,001); ACoP la hemisférica ipsilateral, perimesencefálica e intraventricular (p = 0,019); ACPI con la perimesencefálica e intraventricular (p < 0,001). El valor diagnóstico interno del modelo fue elevado para estas localizaciones (AUROC ≥ 0.900).

Conclusiones

La volumetría regional automatizada parece una herramienta fiable y objetiva para cuantificar y describir la distribución de sangre en los espacios subaracnoideos. Este método es capaz de predecir de forma precisa la localización del aneurisma roto; su aplicación prospectiva es en la medicina de urgencias, una vez asegurada la agilidad y simplicidad del funcionamiento.

Palabras clave:
Hemorragia subaracnoidea
Patrón de sangrado
Aneurisma
Volumetría
Cuantificación

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