Summary
In a retrospective study, pathological tissue enhancement was found in nearly two fifths of patients with acute SAH on contrastenhanced cranial computed tomography. By means of absorption measurements with the region of interest technique over the basal ganglia, it was proved indirectly that pathological tissue enhancement should be brought about not only by hyperaemia,i.e., a blood volume increase, but also by extravasation of the contrast material,i.e., blood-brain barrier (BBB) disruption. A similar conclusion was drawn from the retrospective isotope brain scintigraphy study. It was further established that, although the pathological contrast enhancement was most obvious in the cortex, and particularly in the neighbourhood of the subarachnoid spaces, the phenomenon is probably widespread throughout the brain. Patients with abnormal enhancement are likely to be in less favourable clinical grades, have a high incidence of marked or diffuse spasm, have a poorer outcome independent of surgical or conservative treatment, and develop cerebral infarction more frequently. Systemic arterial hypertension was associated with an increased incidence of abnormal enhancement. Pathological tissue contrast enhancement or isotope accumulation in the first few days of SAH may serve as prognostic signs indicative of the late development of vasospasm and ischaemia. As ischaemic disruption of the capillary system is not prominent in the initial days following any stroke, vasoactive substances arising from the breakdown of the blood clot should play important part in the BBB damage in the acute stage of SAH. The “cortical SAH” model developed in the animal experiments ensured a constant subarachnoid blood volume with minimal local brain damage. The intracranial pressure and mean arterial blood pressure did not change significantly, and perfusion defects did not arise. Thus, this model proved suitable for studying the influence on the BBB of vasoactive blood breakdown products (responsible for arterial spasm) without the accompanying effects of pathological conditions such as raised intracranial pressure, systemic hypertension, non-reflow phenomena, which also disrupt the BBB. Measurements on the water, electrolyte, albumin contents of brain tissue, as well as the immunohistochemical localization af albumin, clearly indicated that the brain oedema developing at the acute stage of experimental SAH could be classified as having a primary vasogenic component in addition to the cytotoxic component. This increased capillary permeability was found to be brought about by opening of tight junctions and pinocytosis in the endothelial cells. The pathological capillary permeability was uninfluenced by dexamethasone, antihistamines and calcium-blocking treatment, but decreased by the adenyl cyclase blocking agent. These findings may have implications in the clinical treatment of SAH, as the integrity of the BBB is essential for maintaining a constant environment for the nervous tissue.
Similar content being viewed by others
References
Agnoli, A. L., Schoch, P., Bayindir, S.,et al., Komputertomographische Befunde bei Gefäßmißbildungen der Hirnarterien. Röntgenblätter34 (1981), 55–60.
Ambrose, J., Computerized X-ray scanning of the brain. J. Neurosurg.40 (1974), 679–685.
Asano, T., Sano, K., Pathogenic role of no-reflow phenomenon in experimental subarachnoid hemorrhage in dogs. J. Neurosurg.46 (1977), 454–466.
Auer, L., Brain edema in acute arterial hypertension. I. Macroscopic findings. Acta Neuropathol.38 (1977), 67–72.
Barry, K. J., Gogjian, M. A., Stein, B. M., Small animal model for investigation of subarachnoid hemorrhage and cerebral vasospasm. Stroke10 (1979), 538–541.
Bell, B. A., Kendall, B. E., Symon, L., Computed tomography in aneurysmal subarachnoid haemorrhage. J. Neurol. Neurosurg. Psych.43 (1980), 522–524.
Boullin, D. J., Model systems for investigation of cerebral vasopasm. In: Cerbral Vasospasm (Boullin, D. J., ed.), pp. 241–293. Chichester-New York-Brisbane-Toronto: J. Wiley and Sons. 1980.
Boullin, D. J., Mohan, J., Grahame-Smith, D. G., Evidence for the presence of vasoactive substance (possibly involved in the aetiology of cerebral arterial spasm) in cerebro-spinal fluid from patients with subarachnoid haemorrhage. J. Neurol. Neurosurg. Psych.39 (1976), 756–766.
Bradbury, M. W. B., The Concept of Blood Brain-Barrier, pp. 369–374. Chichester-New York-Brisbane-London: J. Wiley and Sons, 1979.
Burch, H. Ch., Histologische Technik, pp. 105–106. Stuttgart: G. Thieme. 1969.
Caille, J. M., Guibert, F., Bidabe, A. M.,et al., Enhancement of cerebral infarcts with CT. J. Comput. Assist. Tomogr.4 (1980), 73–77.
Clasen, R. A., Huckman, M. S., von Roenn, K. A.,et al., A correlative study of computed tomography and histology in human and experimental vasogenic cerebral oedema. J. Comput. Assist. Tomogr.5 (1981), 313–327.
Crompton, M. R., The pathogenesis of cerebral infarction following rupture of cerebral aneurysms. Brain87 (1964), 491–510.
Cserr, H. F., Relationship between cerebrospinal fluid and intestinal fluid of brain. Fed. Proc.33 (1974), 2075–2078.
Davis, K. R., New, P. F. J., Ojemann, R. F.,et al., Computerized tomographic evaluation of haemorrhage secondary to intracranial aneurysm. Am. J. Roentgenol.127 (1976), 143–153.
Davis, J. M., Davis, K. R., Crowell, R. M., Subarachnoid haemorrhage secondary to ruptured intracranial aneurysm. Am. J. Neuroradiol.1 (1980), 17–21.
Dóczi, T., Huszka, E., Blood-brain barrier in SAH (Letters). J. Neurosurg.59 (1983), 1109–1110.
Dóczi, T., O'Laoire, S. A., Ambrose, J., The significance of contrast enhancement in cranial computed tomography following subarachnoid hemorrhage. J. Neurosurg.60 (1984), 335–343.
Dóczi, T., László, F. A., Szerdahelyi, P., Joó, F., Involvement of vasopressin in brain edema formation: further evidence obtained from the Brattleboro Diabetes Insipidus Rat with experimental subarachnoid hemorrhage. Neurosurgery14 (1984), 436–440.
DuBulay, G. N., Cerebral blood flow in man and animals. In: Cerebral Vasospasm (Boullin, D. J., ed.), pp. 91–111. Chichester-New York-Brisbane-Toronto: J. Wiley and Sons. 1980.
Fein, J. M., Cerebral energy metabolism after subarachnoid hemorrhage. Stroke6 (1975), 1–8.
Fisher, C. M., Kistler, J. P., Davis, J. M., Relation of cerebral vasospasm to subarachnoid haemorrhage visualized by computed tomography. Neurosurgery6 (1980), 1–9.
Fox, J. L., Ko, J. P., Cerebral vasospasm: A clinical observation. Surg. Neurol.10 (1978), 269–275.
Fraser, R. A., Cerebral Vasospasm, After 15 Years in the Laboratory. In: Cerebral Arterial Spasm (Wilkins, R. N., ed.), pp. 287–291. Baltimore-London: Williams and Wilkins. 1980.
Gado, M. H., Phelps, M. E., Coleman, R. E., An extravascular component of contrast enhancement in cranial computed tomography. Part I: The tissue blood ratio of contrast enhancement. Radiology117 (1975), 589–593.
Gado, M. H., Phelps, M. E., Coleman, R. E., An extravascular component of contrast enhancement in cranial computed tomography. Part II: Contrast enhancement and the blood tissue barrier. Radiology117 (1975), 595–597.
Grubb, R. L., Raichle, M. E., Eichung, J. O.,et al., Effects of subarachnoid haemorrhage on cerebral blood volume, blood flow, and oxygen utilization in humans. J. Neurosurg.46 (1977), 446–453.
Hashi, K., Meyer, J. S., Shinmaru, S., Changes in cerebral motor reactivity to CO2 and autoregulation following experimental subarachnoid hemorrhage. J. Neurol. Sci.17 (1972), 15–22.
Hopkins, L. N., Long, D. M., (eds.), Clinical Management of Intracranial Aneurysm (Seminars in Neurological Surgery). New York: Raven Press. 1982.
Hayward, R. D., O'Reilly, G. V. A., Inracerebral haemorrhage. Accuracy of computerized transverse axial scanning in predicting the underlying aetiology. Lancet1 (1976), 1–4.
Hirata, Y., Matsukado, Y., Fukumura, A., Subarachnoid enhancement secondary to subarachnoid haemorrhage with special reference to the clinical significance and pathogenesis. Neurosurgery11 (1982), 367–371.
Hossmann, K. A., Olsson, Y., The effect of transient cerebral ischemia on the vascular permeability to protein tracers. Acta Neuropathol.18 (1971), 103–112.
Hunt, W. E., Hess, W. H., Surgical risk as related to time of intervention in the repair of intracranial aneurysm. J. Neurosurg.28 (1968), 14–19.
Inoue, Y., Saiwai, S., Miyamoto, T.,et al., Post-contrast computed tomography in subarachnoid haemorrhage from ruptured aneurysm. J. Comput. Assist. Tomogr.5 (1981), 341–344.
Johansson, B. B., Effect of an acute increase of the intravascular pressure on the blood-brain barrier. Stroke9 (1978), 588–590.
Johansson, B. B., Strangaard, S., Lassen, N. A., On the pathogenesis of hypertensive encephalopathy: the hypertensive break-through of autoregulation of cerebral blood flow with forced vasodilatation, flow increase and blood-brain barrier damage. Circ. Res.34/35 (Suppl. I) (1974), 167–171.
Joó, F., Rakonczay, Z., Wollemann, M., cAMP-mediated regulation of the permeability in the brain capillaries. Experimentia31 (1975), 582–583.
Kamiya, K., Kuyama, L., Symon, L., An experimental study of the acute stage of subarachnoid haemorrhage. J. Neurosurg.59 (1983), 917–924.
Katzman, R., Pappius, H. M., Brain Electrolytes and Fluid Metabolism, pp. 519–524. Baltimore: Waverley Press. 1973.
Klatzo, I., Neuropathological aspects of brain edema. J. Neuropathol. Exp. Neurol.26 (1967), 1–14.
Kendall, B. E., Lee, B. C. P., Claveria, E., Computerized tomography and angiography in subarachnoid haemorrhage. Br. J. Radiol.49 (1976), 483–501.
Kendall, B. E., Pullicino, P., Intravascular contrast injection of ischaemic lesions. Part II: Effect on prognosis. Neuroradiology19 (1980), 241–243.
Kendall, B. E., Neuroradiology. In: Brain Tumours (Thomas, D. G. T., Graham, D. I., eds.), pp. 233–234. London-Boston-Sidney-Wellington-Durban-Toronto: Butterworths. 1980.
Kingsley, D. P. E., Kendall, B. E., Greitz, T.,et al., Extravasation of contrast enhanced blood into the subarachnoid space during CT. Neuroradiology18 (1979), 259–262.
König, T. F. R., Klippel, R. A., The Rat Brain. New York: Krieger. 1967.
Lacy, P. S., Earle, A. M., A small animal model for ECG abnormalities observed after an experimental subarachnoid hemorrhage. Stroke14 (1983), 371–377.
Levin, E., Are the terms blood brain barrier and brain capillary permeability synonymous? In: The Ocular and Cerebrospinal Fluids, (Bito, L. Z., Davson, H., Fenstermacher, J. D., eds.), pp. 191–199. London-New York-San Francisco: Academic Press. 1977.
Liliequist, B., Lindquist, M., Valdimarsson, E., Computed tomography and subarachnoid haemorrhage. Neuroradiology14 (1977), 21–26.
Moran, C. V., Naidich, T. P., Gado, M. H.,et al., Leptomeningeal findings in CT of subarachnoid haemorrhages. J. Comput. Assist. Tomogr.2 (1978), 520–521.
Nagata, I., Handa, N., Hashimoto, N., Hazama, F., Experimentally induced cerebral aneurysms in rats. Part VII. Surg. Neurol.16 (1981), 291–296.
Naidich, T. P., Pudlowski, R. M., Leeds, N. E.,et al., The normal contrast enhanced computed axial tomogram of the brain. J. Comput. Assist. Tomogr.1 (1977), 16–29.
Nagy, Z., Mathieson, G., Hüttner, L, Blood-brain barrier opening to horseradish peroxydase in acute arterial hypertension. Acta Neuropathol.48 (1979), 45–53.
Neuwelt, E. A., Maravilla, K. R., Frenkel, E. P.,et al., Use of enhanced computed tomography to evaluate osmotic bloodbrain barrier disruption. Neurosurgery6 (1980), 49–56.
Nornes, H., Magnaes, B., Intracranial pressure in patients with ruptured saccular aneurysm. J. Neurosurg.36 (1972), 537–547.
Nornes, H., The role of intracracranial pressure in the arrest of haemorrhage in patients with ruptured intracranial aneurysm. J. Neurosurg.39 (1973), 226–234.
Nornes, H., Knutzen, H. B., Wikeby, P., Cerebral arterial blood flow and aneurysm surgery. J. Neurosurg.47 (1977), 819–827.
Pappius, H. M., Evolution of edema in experimental cerebral infarction. In: Cerebrovascular Diseases. Eleventh Princton Conference (Price, T. R., Nelson, E., eds.), pp. 131–141. New York: Raven Press. 1979.
Pertuiset, B., Management of subarachnoid haemorrhage. Postgraduate Course of the European Neurosurgical Societies. Bratislava, Sept. 1–7, 1982.
Peterson, E. W., Cardoso, E. R., The blood-brain barrier following experimental subarachnoid hemorrhage. J. Neurosurg.58 (1983), 338–344.
Peterson, E. W., Cardoso, E. R., The blood-brain barrier following experimental subarachnoid hemorrhage. Response to mercuric chloride infusion. J. Neurosurg.58 (1983), 345–351.
Pia, H. W., Aneurysm surgery-grading and timing. Neurosurg. Rev.1 (1982), 89–104.
Pia, H. W., Grading of cerebral aneurysms and timing of operation. Neurosurg. Rev.4 (1981), 143–150.
Rapaport, S. I., Blood-Brain Barrier in Physiology and Medicine, pp. 25–37. New York: Raven Press. 1976.
Rothberg, C., Weir, B., Overton, T.,et al., Response to experimental subarachnoid hemorrhage in the spontaneously breathing primate. J. Neurosurg.52 (1980), 302–308.
Rössner, W., Tempel, K., Quantitative Bestimmung der Permeabilität der sogenannten Blut-Hirnschranke für Evans-Blau. Med. Pharmacol. exp.14 (1966), 169–182.
Scotti, G., Ethier, R., Melancon, D.,et al., Computed tomography in the evaluation of intracranial aneurysms and subarachnoid haemorrhage. Radiology123 (1977), 85–90.
Shibata, S., Hodge, C. P., Pappius, H. M., Effect of experimental ischemia on cerebral water and electrolytes. J. Neurosurg.41 (1974), 146–159.
Shigeno, T., Fritschka, E., Shigeno, S.,et al., Cerebral oedema following experimental subarachnoid haemorrhage. J. Cerebr. Blood Flow Metab. Suppl.1 (1981), 558–559.
Sicuteri, F., Fanciulacci, M., Bavazzano, A.,et al., Kinins and intracranial haemorrhages. Angiology21 (1970), 139–145.
Simeone, F. A., Vinall, P. E., Evaluation of animal models of cerebral vasospasm. In: Cerebral Arterial Spasm (Wilkins, R. H., ed.), pp. 284–287. Baltimore-London: Williams and Wilkins. 1980.
Skriver, E. B., Olsen, T. S., Transient disappearance of cerebral infarcts on CT scan, the so called fogging effect. Neuroradiology22 (1981), 61–65.
Skriver, E. B., Olsen, T. S., Contrast enhancement of cerebral infarcts. Incidence and clinical value in different states of cerebral infarction. Neuroradiology23 (1982), 259–265.
Starling, L. M., Boullin, D. J., Grahame-Smith, D. G.,et al., Responses of isolated human basilar arteries to 5 HT, NA, serum platelets and erythrocytes. J. Neurol. Neurosurg. Psych.38 (1975), 650–656.
Sternberger, L. A., Immunocytochemistry. Englewood Cliffs, New Jersey: Prentice Hall. 1980.
Strangaard, S., Olesen, J., Skinhoj, E.,et al., Autoregulation of brain circulation in severe arterial hypertension. Brit. Med. J.1 (1973), 507–510.
Symon, L., Pásztor, E., Summary of session E: Subarachnoid haemorrhage. In: Proceedings of the 3rd International Conference on Intracranial Pressure—Intracranial Pressure III (Beck J. F., Bosch, D. A., Brock, M., eds.), pp. 168–169. Berlin-Heidelberg-New York: Springer. 1976.
Symon, L., Disordered cerebro-vascular physiology in aneurysmal subarachnoid haemorrhage. Acta Neurochir. (Wien)41 (1978), 7–22.
Suzuki, J., Komatsu, S., Sato, T.,et al., Correlation between CT findings and subsequent development of cerebral infarction due to vasospasm in subarachnoid haemorrhage. Acta Neurochir. (Wien)55 (1980), 63–70.
Tazawa, T., Mizukami, M., Kawase, T.,et al., Relationship between contrast enhancement on CT and cerebral vasospasm in patients with SAH. Neurosurgery12 (1983), 643–648.
Trojanowski, T., Blood-brain barrier changes after experimental subarachnoid haemorrhage. Acta Neurochir. (Wien)60 (1982), 45–54.
Yock, D. H., Marshall, W. H., Recent ischaemic brain infarcts at computed tomography: Appearances pre- and post-contrast infusion. Radiology117 (1975), 599–608.
Yock, D. H., Jr., Larson, D. A., Computed tomography of haemorrhage from anterior communicating artery aneurysm with angiographic correlation. Radiology134 (1980), 399–407.
Weir, B. K. A., The incidence and onset vasospasm after SAH from ruptured aneurysm. In: Cerebral Arterial Spasm (Wilkins, R. H., ed.), pp. 397–408. Baltimore/London: Williams and Wilkins. 1980.
Westergaard, E., Enhanced vesicular transport of exogenous peroxidase across cerebral vessels, induced by serotonin. Acta Neuropathol.32 (1975), 27–42.
Wilkins, R. H., Cerebral Arterial Spasm. Part B. Biochemistry, pp. 144–229. Baltimore-London: Williams and Wilkins. 1980.
Wilmes, F., Hossmann, K. A., A specific immunofluorescence technique for the demonstration of vasogenic brain oedema in paraffin embedded material. Acta Neuropathol. (Berl.)45 (1979), 47–51.
Author information
Authors and Affiliations
Additional information
The autor has been awarded the 1984 Upjohn Prize of the European Association of Neurosurgical Societies for this scientific work.
Rights and permissions
About this article
Cite this article
Dóczi, T. The pathogenetic and prognostic significance of blood-brain barrier damage at the acute stage of aneurysmal subarachnoid haemorrhage. Clinical and experimental studies. Acta neurochir 77, 110–132 (1985). https://doi.org/10.1007/BF01476215
Issue Date:
DOI: https://doi.org/10.1007/BF01476215