Introduction: To share our experience of Contrast-enhanced and Perfusion CT (CEPCT) study in traumatic brain injury patients and also review the pertinent literature regarding other clinical implication of perfusion CT in these patients
Methods: In a prospective study named Contrast-enhanced and Perfusion CT (CEPCT) study, we evaluated the clinical significance of early PCT in moderate and severe TBI patients.
Results: We made several important observations in this study. First, PCT can be used to assess the salvageability of patients with poor GCS and/or uncal herniation. In a study period of 26 months, we only enrolled 16 patients with poor GCS and uncal herniation who CEPCT were performed before aggressive surgical treatment. In all cases, the attending neurosurgeon was present during the exam and transport of these critically ill patients. The preserved CBF and CBV in the midbrain were shown on the PCT map. The patient had good neurological recovery after surgery. Similarly, among the 9 patients with uncal herniation and acceptable perfusion of the midbrain and thalamus, 5 had favorable outcome and the other 4 had unfavorable outcome after emergent surgery (Table 1). In contrast, all the 7 patients with infarction of midbrain or/and thalamus, all had unfavorable outcome even after emergent surgery (5 death and 2 persistent vegetative state) (Table 1). Analogous to the PCT data for patients with poor-grade aneurysmal SAH, these data suggest that TBI patients with hemispheric or global severe hypoperfusion or infarction have poor outcome even after aggressive treatment.
Conclusions: This early information provided by CEPCT is pivotal for both the surgeon and the family in terms of outcome prediction and clinical decision-making. Other clinical implications includes understanding BBB pathophysiology, surgical planning, brain death prediction/diagnosis, and diagnosis of the motor trephine syndrome.
Patient Care: 1. outcome prediction of severe TBI patients
2. if validated in a larger study, irreversible injured patients should not receive aggressive surgery
Learning Objectives: 1. Early CEPCT can be used to assess the reversibility of moderate and severe traumatic brain injury patients
2. Most patients with global or hemispheric irreversible ischemic change will expire despite aggressive surgery
3. Theoretically, the irreversible tissues may be removed during surgery to provide more decompression
References: Wintermark M, Chiolero R, van Melle G, Revelly JP, Porchet F, Regli L, et al: Relationship between brain perfusion computed tomography variables and cerebral perfusion pressure in severe head trauma patients. Crit Care Med 32:1579-1587, 2004
Stiver SI, Wintermark M, Manley GT: Reversible monoparesis following decompressive hemicraniectomy for traumatic brain injury. J Neurosurg 109:245-254, 2008
Shlosberg D, Benifla M, Kaufer D, Friedman A: Blood-brain barrier breakdown as a therapeutic target in traumatic brain injury. Nat Rev Neurol 6:393-403, 2010
Pellon R, de Lucas EM, Fernandez CG, Florez AF, Piedra T: Usefulness of addition of CT perfusion to CT angiography for brain death diagnosis in a child. Neuropediatrics 41:189-192, 2010