Abdel-Tawab et al.

Egyptian Journal of Radiology and Nuclear Medicine

(2020) 51:61
Egyptian Journal of Radiology
https://doi.org/10.1186/s43055-020-00180-8 and Nuclear Medicine

RESEARCH Open Access

Prognostic factors of delayed cerebral

ischemia after subarachnoid hemorrhage
including CT perfusion: a prospective
cohort study
Mohamed Abdel-Tawab1*, Afaf A. Hasan1, Mohamed A. Ahmed2, Hany M. A. Seif1 and Hazem A. Yousif1

Abstract
Background: Delayed cerebral ischemia (DCI) is the worst sequel following subarachnoid hemorrhage (SAH),
representing a challenge in prediction and prevention. The current study aims to identify the optimum predictors
of DCI including CT perfusion (CTP) and to determine the best prognostic thresholds.
This prospective study included 49 SAH patients. All patients were treated with the standard therapy and underwent
non-contrast CT, CTP, and CTA within 3 days after SAH. Hunt and Hess and Fisher scales were assessed besides
quantitative CTP parameters. The primary endpoint was DCI within 21 days after SAH, defined as clinical deterioration
or infarction.
Results: Out of 49 eligible patients with SAH, 9 patients developed DCI. Univariate analysis revealed that Hunt and
Hess scale, Fisher scale, the presence of a cerebral aneurysm, and mean transit time (MTT) were predictive for DCI.
Diagnostic threshold values by ROC curve analysis with optimal sensitivity and specificity were Hunt and Hess scale >
2, Fisher scale > 2, and MTT of 4.65 s.
Conclusion: MTT is a sensitive and specific predictor of DCI. However, Hunt and Hess scale has the optimal sensitivity
and specificity to distinguish between patients who developed DCI and clinically stable patients.
Keywords: CT perfusion, Delayed cerebral ischemia, Fisher scale, Hunt and Hess scale, Subarachnoid hemorrhage,
Vasospasm

Background death and disability among patients with SAH [5]. DCI
Subarachnoid hemorrhage (SAH) is a critical condition occurs mostly due to vasospasm, however, recent studies
with an incidence ranging from 6 to 15 cases per 100, proved that vasospasm is not considered the only lead-
000 [1]. Following SAH, nearly one-third of patients will ing factor of DCI as impaired cerebral autoregulation
die, one-third will survive with a disability, and one-third also plays a role [6]. DCI is defined clinically as a new
will survive with good recovery [2]. Besides the direct ef- unexplained neurological deficit, (e.g., hemiparesis or
fect of hemorrhage, rebleeding and DCI are considered aphasia) or a drop in the level of consciousness (more
the major complications of SAH [3]. The risk of rebleed- than 2 points on Glasgow Coma Scale) lasting for 2 h
ing has been significantly reduced by early aneurysmal [7]. Radiologically, it is defined as a hypodense area on
closure [4]. In contrast, DCI is still a significant cause of CT or hyperintense area in FLAIR and DWI MRI [8].
Early diagnosis and aggressive treatment with intra-
* Correspondence: dr.m.tawab@gmail.com arterial vasodilators and balloon angioplasty must be
1
Department of Radiology, Faculty of Medicine, Assiut University, Assiut, performed as early as possible to prevent the morbid
Egypt
Full list of author information is available at the end of the article and fatal consequences of DCI [9]. However, clinical

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Abdel-Tawab et al. Egyptian Journal of Radiology and Nuclear Medicine (2020) 51:61 Page 2 of 10

diagnosis of DCI in patients with altered consciousness Imaging technique

or those who are sedated is impossible as clinical recog- CT, CTP, and CTA imaging were carried out on a 64-
nition of the drop of consciousness level may not be channel Multichannel CT scanner (Aquilion; Toshiba
consistent [10]. Besides, clinical monitoring in fully con- Medical Systems, Tokyo, Japan). Non-ionic contrast ma-
scious patients only allows the diagnosis but not the terial (Iopromide, Ultravist, 370; Schering, Berlin,
prognosis of DCI, thus limiting initiation of prompt Germany) was used for CTP and CTA.
prophylactic therapy [11]. After non-contrast brain CT was obtained, CTP was
Many parameters have been widely investigated for pre- performed on 4 adjacent 8-mm-thick sections, at the
diction of DCI, including patient demographics (e.g., age level of the basal ganglia. At this level, ACA, MCA, and
and gender), clinical scales at presentation (e.g., Hunt and PCA vascular territories can be visualized. Time delay of
Hess scale), the amount of SAH (e.g., Fisher scale), and 5 s was achieved after injection of 50 mL of the non-
site of an aneurysm [12]. ionic contrast agent at a flow rate of 5 mL/s, a 45-s cine
Among different imaging techniques evaluating cere- series was obtained with the following parameters: 120
bral perfusion, CTP is characterized by availability, low kVp, 200 mA, 0.4 s rotation time.
costs, rapid imaging, and high spatial resolution [13]. CTA was acquired 5 min after the CTP and after in-
CTP is done by monitoring the first pass of an iodinated jection of 50 mL saline to wash the brain from residual
contrast agent bolus through the cerebral circulation contrast. Administration of 50 mL of contrast was
[14]. A series of slices are produced by repeatedly scan- achieved at a flow rate of 5 mL/s. Bolus tracking tech-
ning the same region with a non-moving table, i.e., the nique was used to optimize the timing of imaging.
same z-position [15]. As there is a linear relationship be- Parameters for CTA were 120 kVp, 350 mAs, spiral
tween the iodine concentration and the density changes mode, 0.6 s rotation time; collimation, 64 × 0.5 mm;
in the tissue, perfusion parameters are calculated by the pitch, 0.828; section thickness, 0.5 mm; reconstruction
deconvolution analysis [14]. interval, 0.4 mm.
Diffusion-weighted imaging (DWI) is the modality of
choice in the diagnosis of infarction [16]; however, it Data processing and analysis
only detects the irreversible infarcted tissue which could Post-processing of the perfusion maps was performed by
not replace perfusion studies that are superior in detect- Vitrea workstation (Vital Images, Inc.), a commercially
ing reversibly ischemic tissues [17]. available software using the deconvolution method. After
In our study, we aim to investigate the previously defining arterial input and venous output reference
mentioned predictors and stress on the role of early points, perfusion maps of cerebral blood volume (CBV),
CTP including CBF and MTT and to establish prognos- cerebral blood flow (CBF), mean transit time (MTT),
tic thresholds for DCI. and time to peak (TTP) were generated. These maps are
assessed both qualitatively and quantitatively by two ra-
Methods diologists and measurements at the areas of least CBF
Study participants were recorded.
This study was a clinically registered (NCT03214705), CTA interpretation was focusing on detecting cerebral
prospective cohort study. It included patients with SAH aneurysms and vasospasm. For aneurysm detection, raw
who were admitted to the neurology department from data, MIP, and volume rendering images were used. For
March 2016 to February 2018. The study was approved vasospasm evaluation, MIP and volume rendering im-
from the institutional review board and written in- ages were used. CTA criteria for vasospasm were deter-
formed consent was obtained; either from the patients mined by arterial narrowing compared with the normal
themselves (29 patients) or their relatives (20 patients) patent vessel diameter. The review of the CTA typically
as those patients were unconscious or complaining se- lasted 10–15 min for each patient and was performed by
vere headache. All patients received standard treatment 2 readers in agreement.
including oral nimodipine. The diagnosis of SAH and
the site of the origin were determined by CT and CTA. Statistical analysis
CTP was performed during the first 72 h. Follow-up For statistical analysis, we used a commercially available
was done by daily clinical examination to detect any software package SPSS release 23.0 program (SPSS for
new neurological deficit. Radiological DCI was deter- Windows; SPSS Inc, Chicago, IL, USA) and MedCalc
mined by CT or MRI at the time of deterioration other- version 18.2.1 ((MedCalc Software, 9030 Mariakerke,
wise follow up CT/MRI was performed before Belgium).
discharge at 14th–21st day after ictus. Patients were Continuous data were reported as mean ± standard
then classified into two groups: those who developed deviation if normally distributed and in median (inter-
DCI and those who did not. quartile range) if not normally distributed. Categorical
Abdel-Tawab et al. Egyptian Journal of Radiology and Nuclear Medicine (2020) 51:61 Page 3 of 10

data were reported in frequencies and percentages and excluded due to severe motion artifact, 4 patients were
analyzed with chi-square test when appropriate. Quanti- excluded due to improper technique, 3 patients were lost
tative data for all patients were evaluated for statistically to follow-up, and 6 patients were excluded due to death
significant differences between both groups utilizing a not attributed to DCI (either not performing follow up
two-tailed, independent Student’s t test if data were nor- CT before death in 2 patients or death from other
mally distributed and Mann-Whitney test if data not causes, i.e., rebleeding), shown in Fig. 1.
normally distributed. Statistical significance was The characteristics of DCI and non-DCI groups are
accepted at p < 0.05. A univariate analysis yielding odds shown in Table 1. Both groups were homogenous in
ratios with 95% confidence intervals (95% CIs) was ap- baseline socio-demographic data without significant dif-
plied to test predictive factors for DCI. Predictors with p ferences in mean age, gender and risk factors including
< 0.05 were entered in a ROC curve analysis to detect hypertension and diabetes. As regards Hunt and Hess
cut-off values, sensitivity, specificity, positive and nega- scale and Fisher scale at presentation, there were highly
tive predictive values, and accuracy. significant differences between the two groups (p value
= 0.000, 0.014, respectively). No significant difference
was found as regards to the presence of intracerebral
Results hematoma (p value = 0.07). The site of SAH showed a
A total of 49 patients (22 women) aged 20 to70 years significant difference (p value = 0.03). Both the presence
(mean, 49 years) presented with SAH were included in and site of a cerebral aneurysm showed statistically sig-
the statistical analysis of the 64 enrolled patients. Fifteen nificant differences between the two groups (p value =
patients were excluded as the following: 2 patients were 0.024, 0.01, respectively).

Fig. 1 Study flow chart. DCI, delayed cerebral ischemia

Abdel-Tawab et al. Egyptian Journal of Radiology and Nuclear Medicine (2020) 51:61 Page 4 of 10

Table 1 Baseline demographics in the DCI and Non-DCI groups Table 2 Absolute and relative CTP values among patients with
Variable DCI (N = 9) Non-DCI (N = 40) p value and without DCI
Age 48.7 (15.5) 49.8 (11.8) 0.811 Variable DCI No-DCI p value

Age group 1.0 CBF 33.2 (10.5 42.4 ± 16.0 0.105

≥ 50 years 5 (55.6%) 20 (50%) CBV 2.48 ± 0.6 2.37 ± 0.8 0.709

< 50 years 4 (44.4%) 20 (50%) MTT 5.0 ± 1.0 3.9 ± 1.0 0.005a

Gender (male%) 6 (66.7%) 21 (52.5%) 0.488 TTP 17.6 ± 4.9 18.0 ± 5.1 0.801

Hypertension 2 (22.2%) 22 (55%) 0.138 CBF difference 19.4 (17.8) 9.0 (7.9) 0.187

Diabetes 0 (0%) 7 (17.5%) 0.217 CBV difference − 0.3 (1.3) − 0.2 (0.5) 0.826

Hunt and Hess scale MTT difference 0.68 (0.8) 0.4 (0.8) 0.147

1 0 (0%) 24 (60%) 0.000 a TTP difference − 0.7 (6.1) 0.2 (1.2) 0.255

2 0 (0%) 12 (30%) CBF ratio 0.8 (0.4) 0.9 (0.1) 0.067

3 5 (55.6%) 4 (10%) CBV ratio 0.8 (0.8) 1.0 (0.2) 0.178

4 2 (22.2%) 0 (0%) MTT ratio 1.2 (0.3) 1.1 (0.3) 0.245

5 2 (22.2%) 0 (0%) TTP ratio 1.0 (0.4) 1.0 (0.1) 0.067

Data expressed in mean (standard deviation)
Hunt and Hess groups
CBF cerebral blood flow, CBV cerebral blood flow, DCI delayed cerebral
≥3 9 (100%) 3 (7.5%) 0.000a ischemia, MTT mean transit time, TTP time to peak
a
Statistically significant
<3 0 (0%) 37 (92.5%)
Modified Fisher score 0.014a The site of SAH did not exhibit predictive value (p value
1 1 (12.5%) 24 (60%) = 0.135). The presence of a cerebral aneurysm had a sig-
2 1 (12.5%) 7 (17.5%) nificant predictive value (p value = 0.026 and 0.03, OR =
3 2 (22.2%) 2 (5%)
9.5 and 6.5, respectively). Moreover, the anterior com-
municating artery aneurysm was a specific aneurysmal
4 5 (55.6%) 7 (17.5%)
site related to DCI (p value = 0.026, OR = 9.5). Of the
Modified Fisher groups perfusion parameters, only MTT had a significant pre-
≥3 7 (77.8%) 9 (22.5%) 0.003a dictive value (p value = 0.024, OR = 2.598) (Table 3).
<3 2 (22.2%) 31 (77.5%) A ROC curve analysis including Hunt and Hess scale,
Intracerebral hematoma 4 (44.4%) 6 (15%) 0.07 Fisher-scale, the presence of an aneurysm, and pro-
Site of SAH 0.01a
longed MTT in a predictive model produced an area
Anterior interhemispheric 4 (44.4%) 7 (17.4%)
Table 3 Logistic regression of predictors of DCI
Insular 5 (55.6%) 6 (15%)
beta p OR 95% CI
Perimesencephalic 0 (0%) 11 (27.5%) value
Lower Upper
Global (non-specific) 0 (0%) 16 (40%)
AGE 0.007 0.806 1.007 0.950 1.068
Presence of aneurysm 7 (77.8%) 14 (35%) 0.028a
Age group 0.223 0.764 1.25 0.292 5.348
Site of aneurysm 0.01a
Male gender − 0.593 0.553 0.553 0.121 2.523
Anterior circulation 7 (77.8%) 10 (25%)
Hypertension − 1.453 0.092 0.234 0.043 1.267
Posterior circulation 0 (0%) 3 (7.5%)
Hunt and Hess scale 2.171 0.002* 8.766 2.175 35.321
DCI delayed cerebral ischemia
N (%) number and percentage Fisher scale 0.921 0.006* 2.511 1.299 4.851
a
Statistically significant
Site of SAH − 1.163 0.135 0.313 0.68 1.438
Aneurysm 1.872 0.03* 6.5 1.187 35.598
As regards the CTP parameters, only MTT showed a
statistically significant difference, p value 0.005. None of ACOM aneurysm 2.251 0.026* 9.5 1.304 69.191
the other absolute and relative parameters showed a sta- CBF 0.047 0.159 1.048 0.982 1.118
tistically significant difference, shown in Table 2. CBV − 0.054 0.116 0.947 0.885 1.014
We found that neither age, gender, nor hypertension MTT 0.955 0.024* 2.598 1.137 5.937
could predict DCI. Hunt and Hess scale had the most
TTP − 0.019 0.796 0.981 0.849 1.133
statistically significant predictive value (p value = 0.002,
ACOM anterior communicating artery, CI confidence interval, OR odds ratio,
OR = 8.766). It is followed by Fisher scale that had com- SAH subarachnoid hemorrhage
parable significant values (p value = 0.006, OR = 2.511). *Statistically significant difference (p < 0.05)
Abdel-Tawab et al. Egyptian Journal of Radiology and Nuclear Medicine (2020) 51:61 Page 5 of 10

under the curve of 0.894, 0.794, 0.714, and 0.849, re- Hypertension also had no significant predictive value
spectively. The analysis demonstrated that Hunt and of DCI (OR 0.234, p = 0.09), in agreement with a previ-
Hess scale > 2 was the best potential predictor of DCI ous study [21]. This can be explained as all patients were
with sensitivity (88.9 %), specificity (90%), PPV (66.7%), receiving nimodipine, a calcium channel blocker, pre-
NPV (97.3%), and accuracy (78.89%). Fisher scale > 2 venting vasospasm by its vasodilator effect and subse-
also predicted DCI with sensitivity (77.8%), specificity quently controlling the blood pressure [22].
(77.5%), PPV (43.8%), NPV (93.9%), and accuracy The most important clinically relevant finding in our
(79.4%). Presence of an aneurysm could predict DCI study was Hunt and Hess scale where high scales were
with sensitivity (77.8 %), specificity (77.8%), PPV (33.3%), significantly associated with a higher likelihood of DCI
NPV (92.9%), and accuracy (42.78%). Anterior commu- (OR 8.766, p = 0.002) with sensitivity 88.9% and specifi-
nicating artery aneurysm location as a predictor of DCI city 90%. We found that Hunt and Hess scale was the
had low sensitivity (33.33%), high specificity (95.0%), most sensitive and specific predictor among all studied
PPV (60.0%), NPV (86.4%), and low accuracy (28.33%). predictors (AUC = 0.849). This study supports evidence
Prolonged MTT > 4.65 s could predict DCI with sensi- from the previously published studies [23, 24]. High
tivity (88.9%), specificity (72.5%), PPV (42.1%), NPV Hunt and Hess scales are clearly associated with poor
(96.7%), and accuracy (61.39%) (Table 4) and (Fig. 2). survival rates.
We found that the early qualitative CTP could not dis- Another important finding was the value of Fisher
criminate minor perfusion deficits (Fig. 3), while late scale as a predictor of DCI. We found that high Fisher
CTP performed closely after clinical deterioration could scales were significantly associated with a higher likeli-
clearly depict perfusion deficit (Fig. 4). We found that hood of DCI (OR 2.511, p = 0.006) with a sensitivity of
the presence of early vasospasm does not inevitably lead 77.8% and specificity 77.5%. In accordance with the
to DCI (Fig. 5). We found that most of the patients re- present results, previous studies demonstrated that high
covered from SAH without developing vasospasm or Fisher scale was associated with a greater risk of DCI
DCI (Fig. 6). [23, 24]. The more amount of subarachnoid blood adds
more irritative injury to the brain.
Previous studies evaluating the risk of a cerebral
Discussion aneurysm in developing vasospasm and DCI observed
Up to our knowledge, this is the first study investigating higher likelihood in aneurysmal SAH versus non-
this issue in the Middle East population. Also, it is the aneurysmal SAH (e.g., perimesencephalic SAH) (OR
first prospective study investigating the predictive value 3.79, p = 0.009) [25]. Our results support this evidence
of many clinical and radiological parameters, including from previous studies as we found that the presence of a
CTP, that may have a role in the development of DCI. cerebral aneurysm was associated with a higher prob-
We found that age was not a great risk factor for DCI ability of DCI (OR 6.5, p = 0.03), in accordance with
and the occurrence of DCI was not affected by age what previously published [26]. Moreover, we found that
group. This finding agrees with those of Gross et al. [18] ACOM aneurysm had an additive risk of DCI (OR 9.5, p
and Zaidat et al. [19] who showed that age was not a = 0.026) having the worst disease course compared to
predictor of DCI. These results differ from that of Said other aneurysmal locations. This result agrees with the
et al. [20] who revealed a better outcome in the younger previous conclusion described by Abla et al. [27].
age group (p = 0.007). These contradictory results may Many studies investigated the CTP parameters in pre-
be partly explained by the differences in patients’ dicting and diagnosing DCI. Some researchers used the
demographics. absolute values of CTP and others used the relative
We also found that a patient’s gender was not a sig- values which are the differences and ratios between both
nificant predictor of DCI. Also, a study conducted by cerebral hemispheres. The predictive role of CTP is still
Gross et al. [18] found the same results. up till now controversial [28]. In this study, we measured

Table 4 Sensitivity, specificity, PPV, PPV, accuracy, and AUC of the potential predictors
Cut-off value Sensitivity Specificity PPV NPV Accuracy AUC
Hunt >2 88.9% 90% 66.7% 97.3% 78.89% 0.894
Fisher >2 77.8% 77.5% 43.8% 93.9% 79.40% 0.794
Aneurysm >0 77.8% 65% 33.3% 92.9% 42.78% 0.714
ACOM aneurysm >0 33.33% 95% 60% 86.4% 28..33% 0.642
MTT 4.65 71.40% 87.50% 42.1% 96.7% 61.39% 0.849
ACOM anterior communicating artery, PPV positive predictive value, NPV negative predictive value, AUC area under the curve
Abdel-Tawab et al. Egyptian Journal of Radiology and Nuclear Medicine (2020) 51:61 Page 6 of 10

Fig. 2 ROC curves of the studied predictors. a Hunt and Hess scale, b modified Fisher scale, c presence of an aneurysm, d ACOM aneurysm, e
MTT, and f comparison of variables shows that Hunt and Hess scale has the optimal sensitivity and specificity. ACOM, anterior communicating
artery; MTT, mean transit time

Fig. 3 A 36-year-old male patient presented with severe headache, neck stiffness, and mild left-sided hemiparesis. Non-contrast CT (a, b) shows
right temporal hematoma and SAH within the right Sylvian and anterior interhemispheric fissures (asterisks in a and b). MIP (c) and volume
rendering (d) images of CTA show a saccular aneurysm at the right internal carotid artery; posterior communicating segment (arrowheads in c
and d). No vasospasm. CT perfusion maps show subtle perfusion deficit on the right-side following territory of right MCA; CBV (e), CBF (f), MTT
(g), and TTP (h)
Abdel-Tawab et al. Egyptian Journal of Radiology and Nuclear Medicine (2020) 51:61 Page 7 of 10

Fig. 4 On follow-up after 10 days, the patient developed left-sided hemiparesis and confusion. Non-contrast CT (a, b) shows multiple infarcts
involving the right lentiform nucleus (asterisk in a) and right frontal periventricular white matter (asterisk in b). MIP (c) and volume rendering (d)
images of CTA show severe vasospasm of the right MCA segments M1 and M2 (arrows in c and d) as well as the right ACA segment A1. CT
perfusion maps show significant perfusion deficit at the right side; reduced CBV (e), reduced CBF (f), prolonged MTT (g), and prolonged TTP (h)

Fig. 5 A 45-year-old female patient presented with severe headache and neck stiffness of 1-day duration with no motor deficit. On admission
non-contrast CT (a) shows right temporal hematoma with surrounding edema and right Sylvian fissure SAH. Volume rendering image (b) of CTA
done 1 day after SAH shows a right MCA saccular aneurysm (arrow) having multiple off branches. Moderate vasospasm of the right MCA M1 and
M2 segments. Multiple collaterals are evident. Follow-up CT on discharge after 15 days (c) shows reduction of size and density of the hematoma,
i.e., clot retraction, with no infarcts. CT perfusion maps (d–f) done 1 day after SAH revealed mild perfusion deficit on the right side; reduced CBF
(d), maintained CBV (e), and prolonged MTT (e). The maintained CBV despite vasospasm is due to collaterals and autoregulation
Abdel-Tawab et al. Egyptian Journal of Radiology and Nuclear Medicine (2020) 51:61 Page 8 of 10

Fig. 6 A 48-year-old male patient presented with mild headache and neck stiffness of 1-day duration with no motor deficit. On admission non-
contrast CT (a) shows global SAH mainly in the anterior interhemispheric, suprasellar, and left Sylvian cisterns. Volume rendering image (b) of CTA
done 1 day after SAH shows an ACOM saccular aneurysm is seen (arrow) and absent right A1 segment of right ACA. Follow-up CT on discharge
after 16 days (c) near-total resolution of SAH with no infarcts. CT perfusion maps (d–f) done 1 day after SAH revealed normal perfusion parameters CBF
(d), CBV (e), and MTT (e)

CBF, CBV, MTT, and TTP in the area of least perfusion. other reports support the role of MTT in predicting DCI
Also, we calculated the relative CTP values. [30, 31].
As regards the absolute CTP values, we found that pro- As regards the relative CTP values obtained in our study,
longed MTT was the only parameter that had a statisti- we found DCI was not significantly related to such relative
cally significant difference between the DCI group and perfusion values. None of these values could exhibit any sta-
non-DCI group. We found that MTT prolongation is the tistically significant difference between the two groups in-
most sensitive perfusion parameter to detect early ische- cluding differences and ratios, with subsequent low
mic events before becoming clinically evident. MTT sensitivity and specificity when entering their values in ROC
threshold > 4.65 s can predict DCI with sensitivity curve analysis. A study made by van der Schaaf et al. [13] in-
(88.9%), specificity (72.5%), PPV (42.1%), NPN (96.7%), vestigated the relative CTP values and found that CBF and
and accuracy (61.39%). None of the other parameters CBV ratios and MTT and TTP differences had predictive
showed any statistically significant difference between the thresholds with moderate sensitivities and specificities. This
two groups. CBF was even lower in those who developed discrepancy in results can be explained by the different
DCI; however, its p value was not statistically significant. methods of perfusion measurement. Also, many patients
A previous study investigated the absolute CTP values in have bilateral and diffuse ischemia after SAH and the inter-
predicting DCI found near our results as regards the MTT hemispheric differences of measurements might be not sig-
with a much higher threshold of 5.9 s and found a sensi- nificant. Therefore, the relative CTP parameters had worse
tivity of 50% and a specificity of 95% [29]. Also, many diagnostic properties [32].
Abdel-Tawab et al. Egyptian Journal of Radiology and Nuclear Medicine (2020) 51:61 Page 9 of 10

A strength of this study is that the usage of Vitrea Ethical consideration

workstation that has the advantage of a sharp definition
1. Risk Benefit assessment for all patients were indicated for the
of the arterial input function (AIF) via crosshair avoiding examination during this study.
the partial volume effect of region of interest (ROI) el- 2. Confidentiality: All patients’ data were confidentially kept.
lipse. Another strong point is the sharp definition of 3. The research done by scientifically qualified and trained personnel
only.
DCI and the exclusion of patients with other causes of 4. The procedures included in this study had been already used in
deterioration such as rebleeding. hospital and centers in and outside Egypt.
Our study had several potential limitations. Given that
the number of patients with SAH in our study is still Consent for publication
A consent to publish was obtained.
small, especially for subgroup analyses, further research
of a larger sample size is needed. However, such sample
Competing interests
size was due to the limited period of the study and a The authors declare that they have no competing interests.
relatively lower incidence of SAH in our region. Also,
this study includes aneurysmal and non-aneurysmal Author details
1
Department of Radiology, Faculty of Medicine, Assiut University, Assiut,
SAH patients that may play a confounding role in the Egypt. 2Department of Neurology, Faculty of Medicine, Assiut University,
results. Assiut, Egypt.

Received: 10 February 2020 Accepted: 15 April 2020

Conclusion
Hunt and Hess scale has the optimal sensitivity and speci-
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