Adam de Havenon MD, Presenter: Nothing to Disclose

David Tirschwell MD, MSc, Abstract Co-Author: Nothing to Disclose

Yoshimi Anzai MD, Abstract Co-Author: Nothing to Disclose

Ali Sultan-Qurraie, Abstract Co-Author: Nothing to Disclose

Wendy A. Cohen MD, Abstract Co-Author: Nothing to Disclose

Mahmud Mossa-Basha MD, Abstract Co-Author: Nothing to Disclose

Jalal Badi Andre MD, Abstract Co-Author: Consultant, Hobbitview, Inc Research Grant, Koninklijke Philips NV

To determine the prognostic value of arterial spin labeling (ASL) MRI after hypoxic-anoxic brain injury (HAI).

A retrospective database and patient chart review was performed in adult patients (>17 years of age) with HAI, admitted to the ICU from 2012-2014 with GCS 100 mL/100g/min. Correlation with electroencephalogram (EEG) was made for 14/15 patients, with cerebrospinal fluid creatine kinase BB isoenzyme (CSF CK-BB) for 8/15 patients, and with somatosensory evoked potentials (SSEPs) for 8/15 patients.

15 of the 17 patients who met inclusion criteria had hyperperfusion on ASL and abnormal diffusion weighted imaging (DWI), typically involving cerebral cortex and/or the basal ganglia. 14/15 patients with abnormal CBF died. The ASL abnormalities comprised smaller volumes than the diffusion restriction. 8/15 had prominent or isolated hyperperfusion of the bilateral medial occipital lobes on ASL; in this group 7/8 EEGs showed a burst suppression pattern and 4/5 SSEPs were bilaterally absent, both indicators of poor prognosis. In the 7 patients without medial occipital hyperperfusion, only 1/7 EEGs showed burst suppression, with the remainder mostly showing non-specific slowing, and 2/4 SSEPs were bilaterally absent. CSF CK-BB, a sensitive and specific marker of severe brain injury, was higher in 5/8 patients with medial occipital hyperperfusion, in whom the mean was 829 ng/mL versus 263 ng/mL for 3/7 patients without medial occipital hyperperfusion. In 7/7 hyperperfusion patients with susceptibility weighted imaging, there was absence of venous deoxyhemoglobin signal in matched areas of infarct and hyperperfusion. Two patients in this study had normal CBF, both of whom had negative DWI and an excellent clinical outcome.

ASL hyperperfusion may have a complimentary role in the evaluation of patients with severe HAI and warrants further study. The positive predictive value of death is 93% and rises to 100% when restricted to patients with medial occipital lobe hyperperfusion, which may be a particularly malignant pattern given the discordantly elevated rates of burst suppression on EEG, bilaterally absent SSEPs, and high CSF CK-BB in that subgroup.

Hypoxic-anoxic brain injury is a potentially devastating neurologic illness with uncertain prognosis. Multimodal and accurate diagnostic testing, perhaps including ASL, is crucial for decision-making in the acute setting.

de Havenon, A, Tirschwell, D, Anzai, Y, Sultan-Qurraie, A, Cohen, W, Mossa-Basha, M, Andre, J, Medial Occipital Lobe Hyperperfusion— A Poor Prognostic Sign for Patients with Hypoxic-anoxic Injury.  Radiological Society of North America 2014 Scientific Assembly and Annual Meeting, - ,Chicago IL. http://archive.rsna.org/2014/14045678.html