Bedside three-dimensional acoustic angiography and perfusion imaging for early detection of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: A Feasibility study

Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition with high rates of secondary complications such as delayed cerebral ischemia (DCI). Early detection of perfusion deficits is critical but remains challenging with conventional imaging modalities that are intermittent, non-portable, and provide limited temporal resolution. Here, we evaluate a novel investigational platform for volumetric acoustic angiography and bedside cerebral perfusion imaging using three-dimensional contrast-enhanced ultrasound (3D CEUS). In a prospective feasibility study, eleven aSAH patients underwent bilateral 3D CEUS at admission, day 5, and day 10 in the neurocritical care unit. The system enabled reconstruction of 3D microvascular volumes and time-intensity evolution (TIE) curves for cerebral blood flow (CBF) assessment. Global perfusion measurements were successful in 95% of acquisitions. Notably, TIE-derived perfusion patterns at day 5 showed strong correlation with poor neurological outcome (88.9% accuracy) suggesting the prognostic potential of the technique. This study demonstrates, for the first time, the feasibility of bedside volumetric CEUS for dynamic assessment of cerebral perfusion in patients with aSAH. The method offers high spatial and temporal resolution, real-time feedback, and correlation with clinical trajectory. These findings position three dimensional CEUS-based acoustic angiography as a promising tool for early detection of DCI and improved neuromonitoring in the intensive care unit.