Aneurysmal subarachnoid haemorrhage: Volumetric quantification of the blood distribution pattern to accurately predict the ruptured aneurysm location

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Five areas are distinguished: 1, Perimesencephalic; 2, Interhemispheric; 3, Right hemisphere; 4, Left hemisphere; 5, Intraventricular." ] ] ] "textoCompleto" => "IntroductionIn the diagnostic workup after spontaneous subarachnoid haemorrhage (SAH), multiple aneurysms are found in about 20% of the cases.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> In such a context, accurate identification of the source of rupture is paramount to guide treatment, as inappropriate aneurysm selection could have devastating consequences due to rebleeding.<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a> In fact, the need for certainty has become even more relevant with the change in trend in the treatment technique, for open surgery provides direct confirmation of the rupture status of the aneurysm while endovascular approaches do not.Traditionally, specialists have relied on the pattern of bleeding distribution within the cisterns to predict the location of the aneurysm.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Indeed, several studies based on de visu assessment of non-contrast computed tomography images (NCCT) have reported acceptable predicting rates for aneurysms sitting in the middle cerebral (MCA) or the anterior communicating (ACom) arteries.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> However, this does not hold true for other locations. In addition, the human eye has its boundaries in discriminating the grey colour range, which hampers the evaluation of cases in which the differences in the amount of haemorrhage among the cisterns is small. To overcome this limitation, the development of computer-based software can provide reliable quantification of blood and its distribution within the subarachnoid space regions.We have tested the hypothesis that machine-based quantification of blood volumes stratified according to the distribution in a set of subarachnoid regions could predict the location of the ruptured aneurysm after spontaneous SAH.MethodsPatient selectionThis study is part of a larger project evaluating the utility of Radiomics in improving the diagnostic and prognostic yield of NCCT for spontaneous SAH. Sampling consisted in the consecutive inclusion of adult subjects admitted to our tertiary neurovascular centre with spontaneous SAH, between January 2012 and December 2018. Inclusion criteria required admission within 72 h of symptom onset and the performance of CTA and/or DSA. Exclusion criteria involved the absence of aneurysm in the vascular imaging and, conversely, the presence of more than one aneurysm or the presence of an intracerebral hematoma. Subjects whose CT imaging had insufficient quality for running the quantification software were also excluded. The first 30 subjects were used to develop the automatized method and for training purposes. These and the subsequent subjects were included for the formal analysis. Imaging data were codified to prevent individual identification.The study protocol was approved by the institution’s Clinical Research Ethics Committee (HCB/2019/0930) and complies with national legislation of biomedical research, the protection of personal data (15/1999), the standards of Good Clinical Practice and the Helsinki Declaration (1975 and 1983 revisions). Patient informed consent was waived by the ethics committee.Imaging protocolWhole-brain NCCT was performed in two scanners, SOMATOM Sensation 64 and SOMATOM Definition Flash 128 (Siemens, Erlangen, Germany), with the following parameters: 120 kV, 380 mAs, reconstruction kernel H40s, and 2.5 mm pitch. All cases were reconstructed to 5 mm slices parallel to the orbitomeatal plane, which was used as a reference for segmentation purposes.Volumetric analysis and segmentationThe method of blood detection and quantification is based on the relative density increase in NCCT attributed to the presence of blood. Manual segmentation of the areas of blood distribution was performed in 3DSlicer by three experienced neuroradiologists, according to anatomic references. Doubtful cases were solved by consensus between two of them. A threshold-paint tool with HU set in the range 50–150 was used. The specified range permits identification and differentiation of densities other than blood (i.e., grey matter, white matter and cerebrospinal fluid and bone), which were not considered for quantification. Five areas were considered to quantitatively describe the distribution of blood in the SAH patients (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). These were: Perimesencephalic (including the perimesencephalic and prepontine cisterns), Interhemispheric (within the interhemispheric fissure), Right hemisphere (within the right Silvian fissure and the cortical sulcus adjacent to it), Left hemisphere and Intraventricular (inside the ventricular system).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The quantity of blood present in each area was adjusted to the total amount of blood present intracranially. To this aim, the blood present in each area is expressed as the ratio between the quantity of blood in that given area per the total amount of blood.Other features of interestBesides the quantification of blood and its distribution, other features of interest were: demographic variables, World Federation of Neurosurgical Societies (WFNS) score at admission, modified Fisher grade (mF), location of the aneurysm according to the DSA, presence of clinically relevant hydrocephalus (requiring an external ventricular drain, EVD), development of chronic hydrocephalus (requiring a ventriculo-peritoneal shunt, VP shunt), presence of angiographic vasospasm and delayed cerebral ischemia (DCI), and modified Rankin Scale (mRS) at three months. DCI was defined as a neurological worsening (increase in ≥ 2 points on NIHSS scale or decrease in ≥ 2 points on Glasgow Coma Scale), happening 48 h after the initial haemorrhage, lasting for at least one hour, and without other attributable causes.Statistical analysisStatistical analysis of the data was performed with SPSS statistics version 27 (IBM). Graphics were constructed with Excel calculation software (Microsoft Office) version 2019. Data were summarised by means ± standard deviation or proportions. Continuous variables were analysed with Student t-test or ANOVA. A p-value of < 0.05 was considered an indicator of statistical significance. Internal validation of the predictive patterns was represented in a receiver operating characteristic (ROC) curve (SPSS statistics). The Youden Index was used to determine the optimal cut-off value of each diagnostic test.ResultsBetween 2012 and 2018, 322 patients suffering from spontaneous SAH were admitted to our institution within 72 h from symptom onset. CTA and DSA were performed to identify the bleeding source. Of all, 24 patients were excluded because of harbouring multiple aneurysms, in 40 no aneurysms were found, 75 had a concomitant intraparenchymal hematoma and 2 patients died before CTA or DSA was performed. Additionally, 113 subjects had to be excluded as they were referred from peripheral centres and their NCCT could not be run in our software. In the end, 68 patients were included for the analysis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Data on patient and aneurysm characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Aneurysm location and bleeding distributionThe location of the aneurysms in the sample was representative of both anterior and posterior circulation and, particularly, included: 23 (35%) anterior communicating artery (ACom), 1 (1%) anterior cerebral artery (ACA), 7 (10%) middle cerebral artery (MCA), 7 (10%) internal carotid artery (ICA), 16 (24%) posterior communicating artery (PCom), 2 (3%) posterior cerebral artery (PCA), 5 (7%) posteroinferior cerebellar artery (PICA), 2 (2%) anteroinferior cerebellar artery (AICA), 1 (1%) superior cerebellar artery (SCA), and 4 (6%) basilar artery (BA) aneurysms. Mean volumetric values of the total blood and regional bleeding distribution according to the location of the ruptured aneurysm are displayed in Supplementary Table S1.Association between bleeding pattern and aneurysm siteTo uniformly define the bleeding pattern, in every case the volume of blood present in each of the five pre-specified regions of distribution was compensated by the global amount of blood (ratio regional blood/total blood). Overall, univariate analysis showed a strong association between the distribution of blood and the aneurysm location (p < 0.001). Meanwhile, the total amount of blood was not associated with aneurysm location (p = 0.918).Certain bleeding patterns were associated with specific sites of aneurysm rupture (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). ACom rupture was predominantly distributed within the interhemispheric fissure (p < 0.001), while MCA bleed preferentially towards the ipsilateral hemisphere (i.e., Silvian fissure and sulcus of the lateral convexity) (p < 0.001), and ICA affected both the ipsilateral hemisphere and the perimesencephalic cisterns (p < 0.001) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The PCom bleeding distribution affected the ipsilateral hemisphere, perimesencephalic and intraventricular spaces (p = 0.019); and that of the PICA was predominantly perimesencephalic and intraventricular (p < 0.001). Nonetheless, a significant correlation between the bleeding vessel and the distribution could not be demonstrated for other posterior circulation aneurysms, like the AICA and the BA (p > 0.05). <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarizes the associations between each specific pattern of blood distribution and the location of the aneurysm found in our sample.<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The internal value of the predictive model was analysed with ROC curves and cut-off values are provided in ratios (regional blood/total blood) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). According to the Youden Index, the best cut-off point for an interhemispheric pattern to predict an ACom aneurysm was 0.134 (AUROC 0.891, CI 0.803−0.979, sensitivity 87% and specificity 82%). For an ipsilateral hemispheric pattern to predict an MCA aneurysm was 0.482 (AUROC 0.981, CI 0.951–1.000, sensitivity 100% and specificity 92%). A cut-off of 0.656 was obtained for the combined ipsilateral hemispheric and perimesencephalic pattern to predict an ICA aneurysm (AUROC 0.836, CI 0.819−0.989, sensitivity 86% and specificity 84%). In posterior circulation, the cut-off point for a PCom aneurysm was 0.743 with a combined ipsilateral hemispheric, perimesencephalic and intraventricular pattern (AUROC 0.616, CI 0.482−0.750, sensitivity 60% and specificity 60%); and that for a PICA aneurysm was 0.740 with a perimesencephalic and intraventricular pattern (AUROC 0.929, CI 0.863−0.995, sensitivity 100% and specificity 87%).<elsevierMultimedia ident="fig0025"></elsevierMultimedia>Bleeding pattern and clinical outcomesThe association between blood quantity and distribution in the subarachnoid space and clinical outcomes was a secondary objective in this study. The total volume of blood was associated with worse clinical status at admission (WFNS 4−5, p = 0.030) and also with worse performance status at three months (mRS > 2, p < 0.001). A non-significant trend was found in acute hydrocephalus (p = 0.059) and delayed cerebral ischemia (p = 0.085). No association was found between the bleeding pattern and the development of chronic hydrocephalus (VP shunt) or the occurrence of asymptomatic angiographic vasospasm (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Regarding the bleeding distribution, intraventricular haemorrhage was indeed associated with the development of acute hydrocephalus (p = 0.012). Neither the intraventricular nor the perimesencephalic bleeding volumes seemed to correlate with DCI (p = 0.191 and p = 0.129, respectively).DiscussionIn the present study, a semi-automatic computerized volumetric software was used to quantify and determine in detail the bleeding pattern after aneurysmal subarachnoid haemorrhage. This tool could accurately predict the location of the ruptured aneurysm, with high sensitivity and specificity values. A potential application in the emergency setting may be pursued, provided that speed and simplicity are attained with full automatization of the process.About 20% of patients with spontaneous SAH have multiple aneurysms in the admission vascular imaging studies.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> Moreover, in an additional 10%–30% of patients no aneurysms are initially detected.<a class="elsevierStyleCrossRefs" href="#bib0045">9–11</a> In these cases, identification of the actual point of bleeding is essential to guide treatment and prevent complications. In fact, predicting the aneurysm location is a recurrent topic in the literature, given its implications.<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a>Conventionally, experts have relied on the pattern of blood distribution within the subarachnoid spaces to determine the probable source of bleeding. With the irruption of the digital era, fallible visual-based methods of prediction<a class="elsevierStyleCrossRefs" href="#bib0030">6–8,12</a> were challenged by machine-based tools.<a class="elsevierStyleCrossRefs" href="#bib0065">13–15</a> Yet, to date, these novel predictive models are based in parameters other than the widely accepted bleeding pattern, like patient characteristics, aneurysm morphology and haemodynamic factors. The latter two require a CTA or a DSA reconstruction and the careful assessment by experienced neuroradiologists, which limit their applicability in the busy emergency setting and in non-stroke referral centres.The method that we propose is an upgrade of the well-established procedure of prediction by which the location of the ruptured aneurysm can be predicted by looking at the distribution of blood within the different subarachnoid cisterns.<a class="elsevierStyleCrossRefs" href="#bib0020">4,16</a> In fact, our results could be regarded as a contemporary confirmation of the effectiveness of tradition regarding SAH patterns of bleeding and aneurysm site determination. With this favourable background, our automatised tool provides a reliable and rigorous method for volumetric quantification of the regional distribution of blood, with specific cut-off values to predict the aneurysm-site, all of which are obtained in a timely and convenient manner.Of note, the predictive value of our model was internally robust for most of anterior and posterior circulation lesions. As shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>, the AUROC for ACom, MCA, ICA and PICA were roughly 0.900 or above, therefore conferring a high sensitivity and specificity for this pattern-based diagnostic tool. For PCom aneurysms, the predictive value was moderate (AUROC 0.616), but still acceptable. As we objectively demonstrated, ACom rupture is predominantly distributed within the interhemispheric fissure, while MCA bleeds preferentially towards the ipsilateral hemisphere, and ICA affects both the hemisphere and the perimesencephalic cisterns. PICA aneurysms showed the higher relative volumes of intraventricular haemorrhage, as previously described,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> and the combined presence of intraventricular and perimesencephalic bleeding was predictive of a PICA location of the aneurysm.It seems that the main limitation to the automatized method is actually shared with the conventional visual assessment, and that is the determination of posterior circulation aneurysm location.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> We were not able to predict BA, SCA or AICA locations, however the limited number of these cases in our sample might have precluded the detection of such association. Other possible explanations are the lower resolution of CT scan to evaluate the posterior fossa, and also, the difficulty in delineating regions of bleeding distribution within the basal cisterns.A potential bias in the validation of a rupture prediction model is the selection of the diagnostic technique used as a reference for determining the location of the ruptured aneurysm. In our study, we used CTA or DSA for defining the ruptured aneurysm. However, to date, only visual inspection of the aneurysm sac and surrounding parenchyma, by means of intraoperative observation sac or postmortem studies, allow a true confirmation of the rupture status. To avoid this plausible bias, we decided to exclude patients with multiple aneurysms. While this simplified in testing the accuracy of the prediction capacity, it also hampered its validation in these cases of difficult diagnosis.As a secondary objective in this study, the volume and distribution of blood was tested as a predictor of clinical outcomes. The otherwise common agreement that the amount of blood is a major determinant of neurological presentation and evolution<a class="elsevierStyleCrossRefs" href="#bib0095">19–23</a> was confirmed in our set, where both poor WFNS at admission and unfavourable mRS at three months were associated with the total blood volume quantification. In this line, automatised measurements, rather than classic visual scales<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a> decrease the interobserver variability and provide a quantitative metric for comparison. Our results increase the validation yield established by Boers et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> from MCA aneurysms to a diversity of aneurysm locations. While Boers et al. centred their study on MCA aneurysms, we included a variety of locations; still, it is worth remarking that we excluded patients with concomitant intraparenchymal hematomas and therefore an underrepresentation of MCA aneurysms can be expected in our sample.An exhaustive analysis of the bleeding distribution and the development of vasospasm and DCI is out of the scope of this study. Despite, in our sample, a non-significant trend was found between higher volumes of blood and the incidence of DCI; this was not the case for angiographic vasospasm. None of the specific regions of blood spread seemed to elicit DCI. Interestingly, Friedman et al.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> also used a software-based tool to precisely quantify the bleeding in Fisher grade 3 SAH and found DCI to be associated with larger cisternal and total haemorrhage volumes, yet no regional volume alone was predictive of DCI in their study. Similar results were obtained by van der Steen et al. in 2018.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>Potential applications of the volumetric examination tool that we present are objectively and accurately determining the source of bleeding in cases of multiple aneurysms, and estimating the most probable location of an aneurysm in cases of non-perimesencephalic (classic) pattern of SAH with negative CTA and DSA. These two particular subtypes of SAH patients – multiple aneurysms and no aneurysms – were excluded in our study so as to test this novel tool in cases with a definitive diagnosis of aneurysm location. Provided that the proposed tool is well-powered and reliable, an extrapolation to these more complex situations should be sought. In the end, performing this volumetric test systematically could increase the pre-test probability when undergoing a repeated diagnostic DSA. Moreover, in the bustling emergency setting, the use of this rapid and simple method could accelerate the decision making and serve as a reassurance in case of peripheral centres lacking an expert neuroradiologist. The use of heat maps to represent the differences in density (regional amount of blood) could make the software more user-friendly and facilitate the visual estimation of aneurysm location.Weaknesses of the study include the limited sample size and the heterogeneous numeric representation of the aneurysm sites, though this reflects the epidemiology of the disease. Moreover, the apparent loss of 113 candidates must be addressed: these were patients referred to our tertiary institution, in which the initial CT was done in peripheral centres and could not be run in our software. Prospective studies in larger cohorts could increase the predictive yield in certain vessel locations, especially in posterior circulation aneurysms. As previously stated, confirmation of the rupture status is only possible with direct inspection; therefore, a prospective series of surgical cases exclusively would confirm the validity of the method. Still, this would require either a multicentric cooperation or a lengthy study period. On the other hand, the generalization of these results and the applicability of the method rely on the availability of the volumetric software among the different institutions.ConclusionComputer-based semi-automatic volumetric analysis seems a reliable and objective tool to quantify and describe the distribution of blood within the subarachnoid and intraventricular spaces after spontaneous subarachnoid haemorrhage. We provide a pattern-based diagnostic tool to accurately predict the aneurysm location after spontaneous SAH. For anterior communicating, middle cerebral, internal carotid and posteroinferior cerebellar artery aneurysms, this model is well-powered (AUROC ≥ 0.900); however, its value in posterior communication artery and other posterior circulation aneurysms deserves further optimization. Prospective studies are encouraged to determine the external validation of the proposed tool, particularly in the cases of difficult diagnosis, like the in the presence of multiple aneurysms or in those cases with negative DSA. Also of interest would be to estimate the impact of the software in the emergency department workflow.Statements and declarationsNothing to disclose.FundingWe thank the Spanish Ministry of Economy and Competitiveness for the grant given to SA and RT (project PI19/00936 funded by Instituto de Salud Carlos III and co-funded by the European Regional Development Fund [ERDF])." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres2138776" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1815912" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1815914" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres2138775" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1815913" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patient selection" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Imaging protocol" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Volumetric analysis and segmentation" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Other features of interest" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistical analysis" ] ] ] 7 => array:3 [ "identificador" => "sec0040" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Aneurysm location and bleeding distribution" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Association between bleeding pattern and aneurysm site" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Bleeding pattern and clinical outcomes" ] ] ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Statements and declarations" ] 11 => array:2 [ "identificador" => "sec0075" "titulo" => "Funding" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-06-08" "fechaAceptado" => "2023-11-24" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1815912" "palabras" => array:5 [ 0 => "Subarachnoid haemorrhage" 1 => "Bleeding pattern" 2 => "Aneurysm" 3 => "Volumetric" 4 => "Quantification" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1815914" "palabras" => array:23 [ 0 => "ACA" 1 => "ACom" 2 => "BA" 3 => "CI" 4 => "CT" 5 => "CTA" 6 => "DSA" 7 => "DCI" 8 => "EVD" 9 => "ICA" 10 => "MCA" 11 => "mFisher" 12 => "mRS" 13 => "NCCT" 14 => "PCA" 15 => "PCom" 16 => "PICA" 17 => "ROC" 18 => "SAH" 19 => "SCA" 20 => "SD" 21 => "VP shunt" 22 => "WFNS" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1815913" "palabras" => array:5 [ 0 => "Hemorragia subaracnoidea" 1 => "Patrón de sangrado" 2 => "Aneurisma" 3 => "Volumetría" 4 => "Cuantificación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundIn 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. MethodsA 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. Results68 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. ConclusionRegional 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." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "AntecedentesEn 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. MétodosUna 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. ResultadosEl 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). ConclusionesLa 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." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0085" ] ] ] ] "multimedia" => array:9 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2107 "Ancho" => 3341 "Tamanyo" => 695514 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Semi-automatized method of regional segmentation of blood distribution. Five areas are distinguished: 1, Perimesencephalic; 2, Interhemispheric; 3, Right hemisphere; 4, Left hemisphere; 5, Intraventricular." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1406 "Ancho" => 1675 "Tamanyo" => 127478 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Diagram of the sampling process. Flowchart of the study." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1489 "Ancho" => 2508 "Tamanyo" => 223689 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Blood distribution according to the site of the aneurysm. Blood quantification is expressed as the ratio between the amounts of blood in a given region per the total amount of intracranial blood." ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1321 "Ancho" => 1675 "Tamanyo" => 172878 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Schematic representation of the bleeding distribution according to the location of the ruptured aneurysm. (**) denote statistically significant associations found in our sample." ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1285 "Ancho" => 3341 "Tamanyo" => 256922 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Sensitivity and specificity values, plotted on a receiver operating characteristic curve, of each bleeding pattern to predict a certain aneurysm location. The AUROC, CI, Youden Index, Sensivity and Specificity values are summarized in the accessory table beneath." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ACom, anterior communicating artery; ACA, anterior cerebral artery; MCA, middle cerebral artery; ICA, internal carotid artery; PCA, posterior cerebral artery; PCom, posterior communicating artery; PICA, posteroinferior cerebellar artery; SCA, superior cerebellar artery; BA, basilar artery." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SAH patients (N = 68) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex female, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 (63) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">WFNS, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1−3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49 (72) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4−5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (28) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Modified Fisher, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53 (78) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aneurysm location, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ACom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (35) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ACA right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MCA right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MCA left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICA right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICA left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PCom right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (23) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PCom left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PCA left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PICA right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PICA left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AICA right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AICA left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SCA right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (6) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3525745.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of the sample of patients with spontaneous subarachnoid haemorrhage and a single ruptured aneurysm." ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ACom, anterior communicating artery; ACA, anterior cerebral artery; MCA, middle cerebral artery; ICA, internal carotid artery; PCA, posterior cerebral artery; PCom, posterior communicating artery; PICA, posteroinferior cerebellar artery; SCA, superior cerebellar artery; BA, basilar artery." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Aneurysm location \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Bleeding pattern \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-Value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ACom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interhemispheric \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ACA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interhemispheric & perimesencephalic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.437 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MCA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hemisphere (ipsilateral) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hemisphere (ipsilateral) & perimesencephalic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PCom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hemisphere (ipsilateral), perimesencephalic & IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.019 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PICA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Perimesencephalic & IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AICA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Perimesencephalic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.400 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Perimesencephalic, interhemispheric & IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.258 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3525744.png" ] ] ] ] "descripcion" => array:1 [ "en" => "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." ] ] 7 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "VP, ventriculo-peritoneal; mRS, modified Rankin scale." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Outcome \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Amount of blood (cm3) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-Value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">WFNS admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.030 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1−3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11,638 (12,249) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4−5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26,763 (17,523) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acute hydrocephalus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.059 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18,974 (14,487) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11,893 (12,463) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic hydrocephalus (VP shunt) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.556 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18,112 (12,847) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15,112 (15,622) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rebleeding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.325 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">183,680/20,220) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14,914 (14,345) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Angiographic vasospasm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.820 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15,209 (14,564) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16,074 (16,117) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Delayed cerebral ischemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.085 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28,728 (19,326) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13,897 (13,854) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">mRS 3-months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0−2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10,985 (11,458) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3−5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13,967 (6305) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29,154 (18,808) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3525743.png" ] ] ] ] "descripcion" => array:1 [ "en" => "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." ] ] 8 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 22163 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Natural history of unruptured intracranial aneurysms: a long-term follow-up study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Juvela" 1 => "K. Poussa" 2 => "H. Lehto" 3 => "M. Porras" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/STROKEAHA.113.001838" "Revista" => array:6 [ "tituloSerie" => "Stroke" "fecha" => "2013" "volumen" => "44" "paginaInicial" => "2414" "paginaFinal" => "2421" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23868274" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence and outcome of multiple intracranial aneurysms in a defined population" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Kaminogo" 1 => "M. Yonekura" 2 => "S. 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Estadísticas

Clinical Research

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,

Autor para correspondencia

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

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In the diagnostic workup after spontaneous subarachnoid haemorrhage &#40;SAH&#41;&#44; multiple aneurysms are found in about 20&#37; of the cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> In such a context&#44; accurate identification of the source of rupture is paramount to guide treatment&#44; as inappropriate aneurysm selection could have devastating consequences due to rebleeding&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> In fact&#44; the need for certainty has become even more relevant with the change in trend in the treatment technique&#44; for open surgery provides direct confirmation of the rupture status of the aneurysm while endovascular approaches do not&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Traditionally&#44; specialists have relied on the pattern of bleeding distribution within the cisterns to predict the location of the aneurysm&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Indeed&#44; several studies based on <span class="elsevierStyleItalic">de visu</span> assessment of non-contrast computed tomography images &#40;NCCT&#41; have reported acceptable predicting rates for aneurysms sitting in the middle cerebral &#40;MCA&#41; or the anterior communicating &#40;ACom&#41; arteries&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> However&#44; this does not hold true for other locations&#46; In addition&#44; the human eye has its boundaries in discriminating the grey colour range&#44; which hampers the evaluation of cases in which the differences in the amount of haemorrhage among the cisterns is small&#46; To overcome this limitation&#44; the development of computer-based software can provide reliable quantification of blood and its distribution within the subarachnoid space regions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We have tested the hypothesis that machine-based quantification of blood volumes stratified according to the distribution in a set of subarachnoid regions could predict the location of the ruptured aneurysm after spontaneous SAH&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patient selection</span><p id="par0020" class="elsevierStylePara elsevierViewall">This study is part of a larger project evaluating the utility of Radiomics in improving the diagnostic and prognostic yield of NCCT for spontaneous SAH&#46; Sampling consisted in the consecutive inclusion of adult subjects admitted to our tertiary neurovascular centre with spontaneous SAH&#44; between January 2012 and December 2018&#46; Inclusion criteria required admission within 72&#160;h of symptom onset and the performance of CTA and&#47;or DSA&#46; Exclusion criteria involved the absence of aneurysm in the vascular imaging and&#44; conversely&#44; the presence of more than one aneurysm or the presence of an intracerebral hematoma&#46; Subjects whose CT imaging had insufficient quality for running the quantification software were also excluded&#46; The first 30 subjects were used to develop the automatized method and for training purposes&#46; These and the subsequent subjects were included for the formal analysis&#46; Imaging data were codified to prevent individual identification&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study protocol was approved by the institution&#8217;s Clinical Research Ethics Committee &#40;HCB&#47;2019&#47;0930&#41; and complies with national legislation of biomedical research&#44; the protection of personal data &#40;15&#47;1999&#41;&#44; the standards of Good Clinical Practice and the Helsinki Declaration &#40;1975 and 1983 revisions&#41;&#46; Patient informed consent was waived by the ethics committee&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Imaging protocol</span><p id="par0030" class="elsevierStylePara elsevierViewall">Whole-brain NCCT was performed in two scanners&#44; SOMATOM Sensation 64 and SOMATOM Definition Flash 128 &#40;Siemens&#44; Erlangen&#44; Germany&#41;&#44; with the following parameters&#58; 120&#160;kV&#44; 380&#160;mAs&#44; reconstruction kernel H40s&#44; and 2&#46;5&#160;mm pitch&#46; All cases were reconstructed to 5&#160;mm slices parallel to the orbitomeatal plane&#44; which was used as a reference for segmentation purposes&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Volumetric analysis and segmentation</span><p id="par0035" class="elsevierStylePara elsevierViewall">The method of blood detection and quantification is based on the relative density increase in NCCT attributed to the presence of blood&#46; Manual segmentation of the areas of blood distribution was performed in 3DSlicer by three experienced neuroradiologists&#44; according to anatomic references&#46; Doubtful cases were solved by consensus between two of them&#46; A threshold-paint tool with HU set in the range 50&#8211;150 was used&#46; The specified range permits identification and differentiation of densities other than blood &#40;i&#46;e&#46;&#44; grey matter&#44; white matter and cerebrospinal fluid and bone&#41;&#44; which were not considered for quantification&#46; Five areas were considered to quantitatively describe the distribution of blood in the SAH patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; These were&#58; Perimesencephalic &#40;including the perimesencephalic and prepontine cisterns&#41;&#44; Interhemispheric &#40;within the interhemispheric fissure&#41;&#44; Right hemisphere &#40;within the right Silvian fissure and the cortical sulcus adjacent to it&#41;&#44; Left hemisphere and Intraventricular &#40;inside the ventricular system&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The quantity of blood present in each area was adjusted to the total amount of blood present intracranially&#46; To this aim&#44; the blood present in each area is expressed as the ratio between the quantity of blood in that given area per the total amount of blood&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Other features of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">Besides the quantification of blood and its distribution&#44; other features of interest were&#58; demographic variables&#44; World Federation of Neurosurgical Societies &#40;WFNS&#41; score at admission&#44; modified Fisher grade &#40;mF&#41;&#44; location of the aneurysm according to the DSA&#44; presence of clinically relevant hydrocephalus &#40;requiring an external ventricular drain&#44; EVD&#41;&#44; development of chronic hydrocephalus &#40;requiring a ventriculo-peritoneal shunt&#44; VP shunt&#41;&#44; presence of angiographic vasospasm and delayed cerebral ischemia &#40;DCI&#41;&#44; and modified Rankin Scale &#40;mRS&#41; at three months&#46; DCI was defined as a neurological worsening &#40;increase in &#8805; 2 points on NIHSS scale or decrease in &#8805; 2 points on Glasgow Coma Scale&#41;&#44; happening 48&#160;h after the initial haemorrhage&#44; lasting for at least one hour&#44; and without other attributable causes&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Statistical analysis of the data was performed with SPSS statistics version 27 &#40;IBM&#41;&#46; Graphics were constructed with Excel calculation software &#40;Microsoft Office&#41; version 2019&#46; Data were summarised by means&#160;&#177;&#160;standard deviation or proportions&#46; Continuous variables were analysed with Student <span class="elsevierStyleItalic">t</span>-test or ANOVA&#46; A p-value of &#60; 0&#46;05 was considered an indicator of statistical significance&#46; Internal validation of the predictive patterns was represented in a receiver operating characteristic &#40;ROC&#41; curve &#40;SPSS statistics&#41;&#46; The Youden Index was used to determine the optimal cut-off value of each diagnostic test&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">Between 2012 and 2018&#44; 322 patients suffering from spontaneous SAH were admitted to our institution within 72&#160;h from symptom onset&#46; CTA and DSA were performed to identify the bleeding source&#46; Of all&#44; 24 patients were excluded because of harbouring multiple aneurysms&#44; in 40 no aneurysms were found&#44; 75 had a concomitant intraparenchymal hematoma and 2 patients died before CTA or DSA was performed&#46; Additionally&#44; 113 subjects had to be excluded as they were referred from peripheral centres and their NCCT could not be run in our software&#46; In the end&#44; 68 patients were included for the analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Data on patient and aneurysm characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Aneurysm location and bleeding distribution</span><p id="par0060" class="elsevierStylePara elsevierViewall">The location of the aneurysms in the sample was representative of both anterior and posterior circulation and&#44; particularly&#44; included&#58; 23 &#40;35&#37;&#41; anterior communicating artery &#40;ACom&#41;&#44; 1 &#40;1&#37;&#41; anterior cerebral artery &#40;ACA&#41;&#44; 7 &#40;10&#37;&#41; middle cerebral artery &#40;MCA&#41;&#44; 7 &#40;10&#37;&#41; internal carotid artery &#40;ICA&#41;&#44; 16 &#40;24&#37;&#41; posterior communicating artery &#40;PCom&#41;&#44; 2 &#40;3&#37;&#41; posterior cerebral artery &#40;PCA&#41;&#44; 5 &#40;7&#37;&#41; posteroinferior cerebellar artery &#40;PICA&#41;&#44; 2 &#40;2&#37;&#41; anteroinferior cerebellar artery &#40;AICA&#41;&#44; 1 &#40;1&#37;&#41; superior cerebellar artery &#40;SCA&#41;&#44; and 4 &#40;6&#37;&#41; basilar artery &#40;BA&#41; aneurysms&#46; Mean volumetric values of the total blood and regional bleeding distribution according to the location of the ruptured aneurysm are displayed in Supplementary Table S1&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Association between bleeding pattern and aneurysm site</span><p id="par0065" class="elsevierStylePara elsevierViewall">To uniformly define the bleeding pattern&#44; in every case the volume of blood present in each of the five pre-specified regions of distribution was compensated by the global amount of blood &#40;ratio regional blood&#47;total blood&#41;&#46; Overall&#44; univariate analysis showed a strong association between the distribution of blood and the aneurysm location &#40;p&#160;&#60;&#160;0&#46;001&#41;&#46; Meanwhile&#44; the total amount of blood was not associated with aneurysm location &#40;p&#160;&#61;&#160;0&#46;918&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Certain bleeding patterns were associated with specific sites of aneurysm rupture &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; ACom rupture was predominantly distributed within the interhemispheric fissure &#40;p&#160;&#60;&#160;0&#46;001&#41;&#44; while MCA bleed preferentially towards the ipsilateral hemisphere &#40;i&#46;e&#46;&#44; Silvian fissure and sulcus of the lateral convexity&#41; &#40;p&#160;&#60;&#160;0&#46;001&#41;&#44; and ICA affected both the ipsilateral hemisphere and the perimesencephalic cisterns &#40;p&#160;&#60;&#160;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The PCom bleeding distribution affected the ipsilateral hemisphere&#44; perimesencephalic and intraventricular spaces &#40;p&#160;&#61;&#160;0&#46;019&#41;&#59; and that of the PICA was predominantly perimesencephalic and intraventricular &#40;p&#160;&#60;&#160;0&#46;001&#41;&#46; Nonetheless&#44; a significant correlation between the bleeding vessel and the distribution could not be demonstrated for other posterior circulation aneurysms&#44; like the AICA and the BA &#40;p&#160;&#62;&#160;0&#46;05&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarizes the associations between each specific pattern of blood distribution and the location of the aneurysm found in our sample&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The internal value of the predictive model was analysed with ROC curves and cut-off values are provided in ratios &#40;regional blood&#47;total blood&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; According to the Youden Index&#44; the best cut-off point for an interhemispheric pattern to predict an ACom aneurysm was 0&#46;134 &#40;AUROC 0&#46;891&#44; CI 0&#46;803&#8722;0&#46;979&#44; sensitivity 87&#37; and specificity 82&#37;&#41;&#46; For an ipsilateral hemispheric pattern to predict an MCA aneurysm was 0&#46;482 &#40;AUROC 0&#46;981&#44; CI 0&#46;951&#8211;1&#46;000&#44; sensitivity 100&#37; and specificity 92&#37;&#41;&#46; A cut-off of 0&#46;656 was obtained for the combined ipsilateral hemispheric and perimesencephalic pattern to predict an ICA aneurysm &#40;AUROC 0&#46;836&#44; CI 0&#46;819&#8722;0&#46;989&#44; sensitivity 86&#37; and specificity 84&#37;&#41;&#46; In posterior circulation&#44; the cut-off point for a PCom aneurysm was 0&#46;743 with a combined ipsilateral hemispheric&#44; perimesencephalic and intraventricular pattern &#40;AUROC 0&#46;616&#44; CI 0&#46;482&#8722;0&#46;750&#44; sensitivity 60&#37; and specificity 60&#37;&#41;&#59; and that for a PICA aneurysm was 0&#46;740 with a perimesencephalic and intraventricular pattern &#40;AUROC 0&#46;929&#44; CI 0&#46;863&#8722;0&#46;995&#44; sensitivity 100&#37; and specificity 87&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Bleeding pattern and clinical outcomes</span><p id="par0080" class="elsevierStylePara elsevierViewall">The association between blood quantity and distribution in the subarachnoid space and clinical outcomes was a secondary objective in this study&#46; The total volume of blood was associated with worse clinical status at admission &#40;WFNS 4&#8722;5&#44; p&#160;&#61;&#160;0&#46;030&#41; and also with worse performance status at three months &#40;mRS&#160;&#62;&#160;2&#44; p&#160;&#60;&#160;0&#46;001&#41;&#46; A non-significant trend was found in acute hydrocephalus &#40;p&#160;&#61;&#160;0&#46;059&#41; and delayed cerebral ischemia &#40;p&#160;&#61;&#160;0&#46;085&#41;&#46; No association was found between the bleeding pattern and the development of chronic hydrocephalus &#40;VP shunt&#41; or the occurrence of asymptomatic angiographic vasospasm &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Regarding the bleeding distribution&#44; intraventricular haemorrhage was indeed associated with the development of acute hydrocephalus &#40;p&#160;&#61;&#160;0&#46;012&#41;&#46; Neither the intraventricular nor the perimesencephalic bleeding volumes seemed to correlate with DCI &#40;p&#160;&#61;&#160;0&#46;191 and p&#160;&#61;&#160;0&#46;129&#44; respectively&#41;&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">In the present study&#44; a semi-automatic computerized volumetric software was used to quantify and determine in detail the bleeding pattern after aneurysmal subarachnoid haemorrhage&#46; This tool could accurately predict the location of the ruptured aneurysm&#44; with high sensitivity and specificity values&#46; A potential application in the emergency setting may be pursued&#44; provided that speed and simplicity are attained with full automatization of the process&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">About 20&#37; of patients with spontaneous SAH have multiple aneurysms in the admission vascular imaging studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Moreover&#44; in an additional 10&#37;&#8211;30&#37; of patients no aneurysms are initially detected&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a> In these cases&#44; identification of the actual point of bleeding is essential to guide treatment and prevent complications&#46; In fact&#44; predicting the aneurysm location is a recurrent topic in the literature&#44; given its implications&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Conventionally&#44; experts have relied on the pattern of blood distribution within the subarachnoid spaces to determine the probable source of bleeding&#46; With the irruption of the digital era&#44; fallible visual-based methods of prediction<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8&#44;12</span></a> were challenged by machine-based tools&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> Yet&#44; to date&#44; these novel predictive models are based in parameters other than the widely accepted bleeding pattern&#44; like patient characteristics&#44; aneurysm morphology and haemodynamic factors&#46; The latter two require a CTA or a DSA reconstruction and the careful assessment by experienced neuroradiologists&#44; which limit their applicability in the busy emergency setting and in non-stroke referral centres&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The method that we propose is an upgrade of the well-established procedure of prediction by which the location of the ruptured aneurysm can be predicted by looking at the distribution of blood within the different subarachnoid cisterns&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;16</span></a> In fact&#44; our results could be regarded as a contemporary confirmation of the effectiveness of tradition regarding SAH patterns of bleeding and aneurysm site determination&#46; With this favourable background&#44; our automatised tool provides a reliable and rigorous method for volumetric quantification of the regional distribution of blood&#44; with specific cut-off values to predict the aneurysm-site&#44; all of which are obtained in a timely and convenient manner&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Of note&#44; the predictive value of our model was internally robust for most of anterior and posterior circulation lesions&#46; As shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#44; the AUROC for ACom&#44; MCA&#44; ICA and PICA were roughly 0&#46;900 or above&#44; therefore conferring a high sensitivity and specificity for this pattern-based diagnostic tool&#46; For PCom aneurysms&#44; the predictive value was moderate &#40;AUROC 0&#46;616&#41;&#44; but still acceptable&#46; As we objectively demonstrated&#44; ACom rupture is predominantly distributed within the interhemispheric fissure&#44; while MCA bleeds preferentially towards the ipsilateral hemisphere&#44; and ICA affects both the hemisphere and the perimesencephalic cisterns&#46; PICA aneurysms showed the higher relative volumes of intraventricular haemorrhage&#44; as previously described&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and the combined presence of intraventricular and perimesencephalic bleeding was predictive of a PICA location of the aneurysm&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">It seems that the main limitation to the automatized method is actually shared with the conventional visual assessment&#44; and that is the determination of posterior circulation aneurysm location&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> We were not able to predict BA&#44; SCA or AICA locations&#44; however the limited number of these cases in our sample might have precluded the detection of such association&#46; Other possible explanations are the lower resolution of CT scan to evaluate the posterior fossa&#44; and also&#44; the difficulty in delineating regions of bleeding distribution within the basal cisterns&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A potential bias in the validation of a rupture prediction model is the selection of the diagnostic technique used as a reference for determining the location of the ruptured aneurysm&#46; In our study&#44; we used CTA or DSA for defining the ruptured aneurysm&#46; However&#44; to date&#44; only visual inspection of the aneurysm sac and surrounding parenchyma&#44; by means of intraoperative observation sac or postmortem studies&#44; allow a true confirmation of the rupture status&#46; To avoid this plausible bias&#44; we decided to exclude patients with multiple aneurysms&#46; While this simplified in testing the accuracy of the prediction capacity&#44; it also hampered its validation in these cases of difficult diagnosis&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">As a secondary objective in this study&#44; the volume and distribution of blood was tested as a predictor of clinical outcomes&#46; The otherwise common agreement that the amount of blood is a major determinant of neurological presentation and evolution<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;23</span></a> was confirmed in our set&#44; where both poor WFNS at admission and unfavourable mRS at three months were associated with the total blood volume quantification&#46; In this line&#44; automatised measurements&#44; rather than classic visual scales<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> decrease the interobserver variability and provide a quantitative metric for comparison&#46; Our results increase the validation yield established by Boers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> from MCA aneurysms to a diversity of aneurysm locations&#46; While Boers et al&#46; centred their study on MCA aneurysms&#44; we included a variety of locations&#59; still&#44; it is worth remarking that we excluded patients with concomitant intraparenchymal hematomas and therefore an underrepresentation of MCA aneurysms can be expected in our sample&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">An exhaustive analysis of the bleeding distribution and the development of vasospasm and DCI is out of the scope of this study&#46; Despite&#44; in our sample&#44; a non-significant trend was found between higher volumes of blood and the incidence of DCI&#59; this was not the case for angiographic vasospasm&#46; None of the specific regions of blood spread seemed to elicit DCI&#46; Interestingly&#44; Friedman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> also used a software-based tool to precisely quantify the bleeding in Fisher grade 3 SAH and found DCI to be associated with larger cisternal and total haemorrhage volumes&#44; yet no regional volume alone was predictive of DCI in their study&#46; Similar results were obtained by van der Steen et al&#46; in 2018&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Potential applications of the volumetric examination tool that we present are objectively and accurately determining the source of bleeding in cases of multiple aneurysms&#44; and estimating the most probable location of an aneurysm in cases of non-perimesencephalic &#40;classic&#41; pattern of SAH with negative CTA and DSA&#46; These two particular subtypes of SAH patients &#8211; multiple aneurysms and no aneurysms &#8211; were excluded in our study so as to test this novel tool in cases with a definitive diagnosis of aneurysm location&#46; Provided that the proposed tool is well-powered and reliable&#44; an extrapolation to these more complex situations should be sought&#46; In the end&#44; performing this volumetric test systematically could increase the pre-test probability when undergoing a repeated diagnostic DSA&#46; Moreover&#44; in the bustling emergency setting&#44; the use of this rapid and simple method could accelerate the decision making and serve as a reassurance in case of peripheral centres lacking an expert neuroradiologist&#46; The use of heat maps to represent the differences in density &#40;regional amount of blood&#41; could make the software more user-friendly and facilitate the visual estimation of aneurysm location&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Weaknesses of the study include the limited sample size and the heterogeneous numeric representation of the aneurysm sites&#44; though this reflects the epidemiology of the disease&#46; Moreover&#44; the apparent loss of 113 candidates must be addressed&#58; these were patients referred to our tertiary institution&#44; in which the initial CT was done in peripheral centres and could not be run in our software&#46; Prospective studies in larger cohorts could increase the predictive yield in certain vessel locations&#44; especially in posterior circulation aneurysms&#46; As previously stated&#44; confirmation of the rupture status is only possible with direct inspection&#59; therefore&#44; a prospective series of surgical cases exclusively would confirm the validity of the method&#46; Still&#44; this would require either a multicentric cooperation or a lengthy study period&#46; On the other hand&#44; the generalization of these results and the applicability of the method rely on the availability of the volumetric software among the different institutions&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclusion</span><p id="par0145" class="elsevierStylePara elsevierViewall">Computer-based semi-automatic volumetric analysis seems a reliable and objective tool to quantify and describe the distribution of blood within the subarachnoid and intraventricular spaces after spontaneous subarachnoid haemorrhage&#46; We provide a pattern-based diagnostic tool to accurately predict the aneurysm location after spontaneous SAH&#46; For anterior communicating&#44; middle cerebral&#44; internal carotid and posteroinferior cerebellar artery aneurysms&#44; this model is well-powered &#40;AUROC&#160;&#8805;&#160;0&#46;900&#41;&#59; however&#44; its value in posterior communication artery and other posterior circulation aneurysms deserves further optimization&#46; Prospective studies are encouraged to determine the external validation of the proposed tool&#44; particularly in the cases of difficult diagnosis&#44; like the in the presence of multiple aneurysms or in those cases with negative DSA&#46; Also of interest would be to estimate the impact of the software in the emergency department workflow&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Statements and declarations</span><p id="par0150" class="elsevierStylePara elsevierViewall">Nothing to disclose&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">We thank the Spanish <span class="elsevierStyleGrantSponsor" id="gs0005">Ministry of Economy and Competitiveness</span> for the grant given to SA and RT &#40;project PI19&#47;00936 funded by <span class="elsevierStyleGrantSponsor" id="gs0010">Instituto de Salud Carlos III</span> and co-funded by the <span class="elsevierStyleGrantSponsor" id="gs0015">European Regional Development Fund</span> &#91;ERDF&#93;&#41;&#46;</p></span></span>"
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              "identificador" => "sec0015"
              "titulo" => "Patient selection"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Imaging protocol"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Volumetric analysis and segmentation"
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            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Other features of interest"
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            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Statistical analysis"
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        ]
        7 => array:3 [
          "identificador" => "sec0040"
          "titulo" => "Results"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Aneurysm location and bleeding distribution"
            ]
            1 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Association between bleeding pattern and aneurysm site"
            ]
            2 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Bleeding pattern and clinical outcomes"
            ]
          ]
        ]
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          "identificador" => "sec0060"
          "titulo" => "Discussion"
        ]
        9 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "Conclusion"
        ]
        10 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Statements and declarations"
        ]
        11 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Funding"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2023-06-08"
    "fechaAceptado" => "2023-11-24"
    "PalabrasClave" => array:2 [
      "en" => array:2 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1815912"
          "palabras" => array:5 [
            0 => "Subarachnoid haemorrhage"
            1 => "Bleeding pattern"
            2 => "Aneurysm"
            3 => "Volumetric"
            4 => "Quantification"
          ]
        ]
        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1815914"
          "palabras" => array:23 [
            0 => "ACA"
            1 => "ACom"
            2 => "BA"
            3 => "CI"
            4 => "CT"
            5 => "CTA"
            6 => "DSA"
            7 => "DCI"
            8 => "EVD"
            9 => "ICA"
            10 => "MCA"
            11 => "mFisher"
            12 => "mRS"
            13 => "NCCT"
            14 => "PCA"
            15 => "PCom"
            16 => "PICA"
            17 => "ROC"
            18 => "SAH"
            19 => "SCA"
            20 => "SD"
            21 => "VP shunt"
            22 => "WFNS"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1815913"
          "palabras" => array:5 [
            0 => "Hemorragia subaracnoidea"
            1 => "Patr&#243;n de sangrado"
            2 => "Aneurisma"
            3 => "Volumetr&#237;a"
            4 => "Cuantificaci&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">In spontaneous subarachnoid haemorrhage &#40;SAH&#41; accurate determination of the bleeding source is paramount to guide treatment&#46; Traditionally&#44; the bleeding pattern has been used to predict the aneurysm location&#46; Here&#44; we have tested a software-based tool&#44; which quantifies the volume of intracranial blood and stratifies it according to the regional distribution&#44; to predict the location of the ruptured aneurysm&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">A consecutive series of SAH patients admitted to a single tertiary centre between 2012&#8211;2018&#44; within 72&#160;h of onset&#44; harbouring a single intracranial aneurysm&#46; A semi-automatized method of blood quantification&#44; based on the relative density increase&#44; was applied to initial non-contrast CTs&#46; Five regions were used to define the bleeding patterns and to correlate them with aneurysm location&#58; perimesencephalic&#44; interhemispheric&#44; right&#47;left hemisphere and intraventricular&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">68 patients were included for analysis&#46; There was a strong association between the distribution of blood and the aneurysm location &#40;p&#160;&#60;&#160;0&#46;001&#41;&#46; In particular&#58; ACom and interhemispheric fissure &#40;p&#160;&#60;&#160;0&#46;001&#41;&#44; MCA and ipsilateral hemisphere &#40;p&#160;&#60;&#160;0&#46;001&#41;&#44; ICA and ipsilateral hemisphere and perimesencephalic cisterns &#40;p&#160;&#60;&#160;0&#46;001&#41;&#44; PCom and hemispheric&#44; perimesencephalic and intraventricular &#40;p&#160;&#61;&#160;0&#46;019&#41;&#44; and PICA and perimesencephalic and intraventricular &#40;p&#160;&#60;&#160;0&#46;001&#41;&#46; The internal diagnostic value was high &#40;AUROC&#160;&#8805;&#160;0&#46;900&#41; for these locations&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Regional automatised volumetry seems a reliable and objective tool to quantify and describe the distribution of blood within the subarachnoid spaces&#46; This tool accurately predicts the location of the ruptured aneurysm&#59; its use may be prospectively considered in the emergency setting when speed and simplicity are attained&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">En la hemorragia subaracnoidea espont&#225;nea &#40;HAS&#41;&#44; la determinaci&#243;n fehaciente del punto de sangrado es fundamental para guiar el tratamiento&#46; De forma tradicional&#44; la determinaci&#243;n de la localizaci&#243;n del aneurisma se basa en el patr&#243;n de sangrado&#46; En el presente estudio&#44; evaluamos una herramienta computarizada&#44; capaz de cuantificar el volumen de sangre intracraneal y de estratificarlo seg&#250;n la distribuci&#243;n regional&#44; con el objetivo de predecir la localizaci&#243;n del aneurisma roto&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Una serie consecutiva de pacientes ingresados en nuestro centro terciario durante el periodo 2012&#8211;2018&#44; con hemorragia subaracnoidea de debut en &#60; 72&#160;h y con aneurisma &#250;nico&#46; Se aplic&#243; el m&#233;todo cuantitativo semiautomatizado a las tomograf&#237;as computarizadas basales de dichos pacientes&#46; La detecci&#243;n del sistema se basa en el aumento relativo de densidad atribuido a la presencia de sangre&#46; Se contemplaron cinco regiones para definir los patrones de sangrado y para su posterior correlaci&#243;n con la localizaci&#243;n del aneurisma&#58; perimesencef&#225;lico&#44; interhemisf&#233;rico&#44; hemisf&#233;rico derecho&#47;izquierdo e intraventricular&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">El an&#225;lisis incluy&#243; 68 pacientes&#46; Se detect&#243; una fuerte asociaci&#243;n entre el patr&#243;n de sangrado y la localizaci&#243;n del aneurisma &#40;p&#160;&#60;&#160;0&#44;001&#41;&#46; En concreto&#58; ACom con la distribuci&#243;n interhemisf&#233;rica &#40;p&#160;&#60;&#160;0&#44;001&#41;&#59; ACM con la hemisf&#233;rica ipsilateral &#40;p&#160;&#60;&#160;0&#44;001&#41;&#59; ACI con la hemisf&#233;rica ipsilateral y perimesencef&#225;lica &#40;p&#160;&#60;&#160;0&#44;001&#41;&#59; ACoP la hemisf&#233;rica ipsilateral&#44; perimesencef&#225;lica e intraventricular &#40;p&#160;&#61;&#160;0&#44;019&#41;&#59; ACPI con la perimesencef&#225;lica e intraventricular &#40;p&#160;&#60;&#160;0&#44;001&#41;&#46; El valor diagn&#243;stico interno del modelo fue elevado para estas localizaciones &#40;AUROC&#160;&#8805;&#160;0&#46;900&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">La volumetr&#237;a regional automatizada parece una herramienta fiable y objetiva para cuantificar y describir la distribuci&#243;n de sangre en los espacios subaracnoideos&#46; Este m&#233;todo es capaz de predecir de forma precisa la localizaci&#243;n del aneurisma roto&#59; su aplicaci&#243;n prospectiva es en la medicina de urgencias&#44; una vez asegurada la agilidad y simplicidad del funcionamiento&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Antecedentes"
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            "titulo" => "M&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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          0 => array:4 [
            "apendice" => "<p id="par0165" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0085"
          ]
        ]
      ]
    ]
    "multimedia" => array:9 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2107
            "Ancho" => 3341
            "Tamanyo" => 695514
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Fig&#46; "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Semi-automatized method of regional segmentation of blood distribution&#46; Five areas are distinguished&#58; 1&#44; Perimesencephalic&#59; 2&#44; Interhemispheric&#59; 3&#44; Right hemisphere&#59; 4&#44; Left hemisphere&#59; 5&#44; Intraventricular&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1406
            "Ancho" => 1675
            "Tamanyo" => 127478
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Fig&#46; "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diagram of the sampling process&#46; Flowchart of the study&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1489
            "Ancho" => 2508
            "Tamanyo" => 223689
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
            "detalle" => "Fig&#46; "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Blood distribution according to the site of the aneurysm&#46; Blood quantification is expressed as the ratio between the amounts of blood in a given region per the total amount of intracranial blood&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "fig0020"
        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1321
            "Ancho" => 1675
            "Tamanyo" => 172878
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
            "detalle" => "Fig&#46; "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Schematic representation of the bleeding distribution according to the location of the ruptured aneurysm&#46; &#40;&#42;&#42;&#41; denote statistically significant associations found in our sample&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "fig0025"
        "etiqueta" => "Fig&#46; 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1285
            "Ancho" => 3341
            "Tamanyo" => 256922
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0025"
            "detalle" => "Fig&#46; "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Sensitivity and specificity values&#44; plotted on a receiver operating characteristic curve&#44; of each bleeding pattern to predict a certain aneurysm location&#46; The AUROC&#44; CI&#44; Youden Index&#44; Sensivity and Specificity values are summarized in the accessory table beneath&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
            "identificador" => "at0030"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">ACom&#44; anterior communicating artery&#59; ACA&#44; anterior cerebral artery&#59; MCA&#44; middle cerebral artery&#59; ICA&#44; internal carotid artery&#59; PCA&#44; posterior cerebral artery&#59; PCom&#44; posterior communicating artery&#59; PICA&#44; posteroinferior cerebellar artery&#59; SCA&#44; superior cerebellar artery&#59; BA&#44; basilar artery&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SAH patients &#40;N&#160;&#61;&#160;68&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Age&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#8722;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">49 &#40;72&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#8722;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">19 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Modified Fisher&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53 &#40;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aneurysm location&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ACom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ACA right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MCA right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MCA left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ICA right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ICA left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PCom right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PCom left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PCA left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PICA right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PICA left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AICA right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AICA left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SCA right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of the sample of patients with spontaneous subarachnoid haemorrhage and a single ruptured aneurysm&#46;</p>"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ACom&#44; anterior communicating artery&#59; ACA&#44; anterior cerebral artery&#59; MCA&#44; middle cerebral artery&#59; ICA&#44; internal carotid artery&#59; PCA&#44; posterior cerebral artery&#59; PCom&#44; posterior communicating artery&#59; PICA&#44; posteroinferior cerebellar artery&#59; SCA&#44; superior cerebellar artery&#59; BA&#44; basilar artery&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Aneurysm location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Bleeding pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ACom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Interhemispheric&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ACA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Interhemispheric &#38; perimesencephalic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemisphere &#40;ipsilateral&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ICA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemisphere &#40;ipsilateral&#41; &#38; perimesencephalic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PCom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemisphere &#40;ipsilateral&#41;&#44; perimesencephalic &#38; IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PICA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perimesencephalic &#38; IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AICA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perimesencephalic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perimesencephalic&#44; interhemispheric &#38; IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;258&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Association between the location of the ruptured aneurysm and the pattern of blood distribution&#46; The specific combinations of regions of blood distribution were initially obtained after the observation of relative ratios of bleeding distribution according to aneurysm site&#46; After the multivariate analysis confirmed the association between bleeding distribution and aneurysm site&#44; a post-hoc analysis was performed to establish the individual correlations between site of rupture and bleeding pattern&#46;</p>"
        ]
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at0040"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">VP&#44; ventriculo-peritoneal&#59; mRS&#44; modified Rankin scale&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Amount of blood &#40;cm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">WFNS admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;030&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#8722;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#44;638 &#40;12&#44;249&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#8722;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#44;763 &#40;17&#44;523&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute hydrocephalus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;059&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;974 &#40;14&#44;487&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#44;893 &#40;12&#44;463&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic hydrocephalus &#40;VP shunt&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;556&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;112 &#40;12&#44;847&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#44;112 &#40;15&#44;622&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rebleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;325&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">183&#44;680&#47;20&#44;220&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;914 &#40;14&#44;345&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angiographic vasospasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;820&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#44;209 &#40;14&#44;564&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;074 &#40;16&#44;117&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Delayed cerebral ischemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;085&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#44;728 &#40;19&#44;326&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#44;897 &#40;13&#44;854&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">mRS 3-months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#8722;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#44;985 &#40;11&#44;458&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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Información del artículo

ISSN: 11301473
Idioma original: Inglés

DOI:10.1016/j.neucir.2023.11.003

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