Transcranial Doppler Ultrasound in the Acute Phase of Aneurysmal Subarachnoid Hemorrhage

Carrera, Emmanuel; Schmidt, J. Michael; Oddo, Mauro; Ostapkovich, Noeleen; Claassen, Jan; Rincón, Fred; Seder, David B.; Gordon, Errol; Kurtz, Pedro; Lee, Ki-Won; Connolly, E. Sander; Badjatia, Neeraj; Mayer, Stephan A.

doi:10.1159/000214222

Cited by 28 publications

(14 citation statements)

References 20 publications

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“…Thirty-three studies (63%) were rated as HQ. [9][10][11][12][13]15,16,[18][19][20]22,[28][29][30][31]35,36,38,39,[41][42][43]46,[48][49][50][51][52][53][54][55][56][57] Appendix 1 summarizes the study characteristics and the investigated variables. Altogether, 33 variables were reported.…”

Section: Resultsmentioning

confidence: 99%

Delayed Cerebral Ischemia After Subarachnoid Hemorrhage

Rooij

Rinkel

Dankbaar

et al. 2013

Stroke

165

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Background and Purpose— Established predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage are large amounts of extravasated blood and poor clinical condition on admission. The predictive value of other factors is uncertain. Methods— We searched MEDLINE (1960–2012) for clinical, laboratory, and radiological predictors routinely available within 72 hours after subarachnoid hemorrhage. The studies were categorized according to methodological quality. Crude data and effect estimates (odds ratio [OR], hazard ratios, and risk ratio) with 95% CI were extracted, (re-)calculated and pooled if possible. For every potential predictor we assessed all effect estimates on consistency (point estimates in equal direction) and clinical relevance (size and 95% CI). Results— Fifty-two studies on 33 potential predictors were included. There was strong evidence (≥3 high-quality studies) for a higher risk of delayed cerebral ischemia in smokers (pooled OR, 1.2; 95% CI, 1.1–1.4), and moderate evidence (2 high-quality studies) for an increased risk in patients with hyperglycemia (OR, 3.2; 1.8–5.8 and hazard ratios, 1.7; 1.1–2.5), hydrocephalus (OR, 1.3; 1.1–1.5 and OR, 2.6; 1.2–5.5), history of diabetes mellitus (pooled OR, 6.7; 1.7–26), and early systemic inflammatory response syndrome (pooled OR, 2.1; 1.4–3.3). Evidence was limited for increased risk in women (pooled OR, 1.3; 1.1–1.6) and in patients with history of hypertension (pooled OR, 1.5; 1.3–1.7). The evidence on initial loss of consciousness, history of migraine, previous use of selective serotonin reuptake inhibitors, hypomagnesemia, low hemoglobin, or high blood flow on early transcranial Doppler was also limited. Conclusions— There is strong evidence that smoking is a predictor of delayed cerebral ischemia. For several other potential predictions the evidence is moderate, limited, or inconsistent.

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Section: Resultsmentioning

confidence: 99%

Delayed Cerebral Ischemia After Subarachnoid Hemorrhage

Rooij

Rinkel

Dankbaar

et al. 2013

Stroke

165

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“…5,7,43 Consequently, this lack of quality evidence has led to inconsistent and unpredictable utilization of this important resource in neurological intensive care units. 4,21,28 No prior systematic reviews/metaanalyses have addressed the impact of TCD evidence of vasospasm on patient-centered outcomes. This systematic review and meta-analysis sought to evaluate the clinical impact and predictive value of TCD evidence of vasospasm with the hypothesis that TCD evidence of vasospasm impacts clinical outcomes (i.e., DCI, functional outcome, and mortality).…”

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confidence: 99%

Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Kumar¹,

Shahripour²,

Harrigan

2016

JNS

150

100

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C erebral vasospasm is a major cause of poor outcomes in aneurysmal subarachnoid hemorrhage (aSAH), resulting in cerebral ischemia, infarction, disability, and death. 20,25 Cerebral vasospasm is noted on angiography in as many as 70% of patients following aSAH and is predicted by high mean flow velocities (MFVs) on transcranial Doppler (TCD) ultrasonography. 19,24,26,35 Vasospasm is strongly associated with delayed cerebral ischemia (DCI) 12 and cerebral infarction, 11,39,49 although poor outcomes can still occur in its absence. Of the current techniques available for diagnosing cerebral vasospasm, catheter angiography and CT angiography are invasive, and require contrast-dye injection and radiation exposure, and therefore do not allow dynamic monitoring of vasospasm. 31The radiation exposure and invasive nature of angiography implies that it is not useful for identifying subclinical vasospasm prior to the onset of the condition, and that its use is frequently restricted to confirm prevalent vasospasm abbreviatioNs aSAH = aneurysmal subarachnoid hemorrhage; CI = confidence interval; DCI = delayed cerebral ischemia; df = degrees of freedom; MFV = mean flow velocity; MWE = mean weighted estimate; NPV = negative predictive value; PPV = positive predictive value; TCD = transcranial Doppler. obJective The impact of transcranial Doppler (TCD) ultrasonography evidence of vasospasm on patient-centered clinical outcomes following aneurysmal subarachnoid hemorrhage (aSAH) is unknown. Vasospasm is known to lead to delayed cerebral ischemia (DCI) and poor outcomes. This systematic review and meta-analysis evaluates the predictive value of vasospasm on DCI, as diagnosed on TCD. methods MEDLINE, Scopus, the Cochrane trial register, and clinicaltrials.gov were searched through September 2014 using key words and the terms "subarachnoid hemorrhage," "aneurysm," "aneurysmal," "cerebral vasospasm," "vasospasm," "transcranial Doppler," and "TCD." Sensitivities, specificities, and positive and negative predictive values were pooled by a DerSimonian and Laird random-effects model. results Seventeen studies (n = 2870 patients) met inclusion criteria. The amount of variance attributable to heterogeneity was significant (I 2 > 50%) for all syntheses. No studies reported the impact of TCD evidence of vasospasm on functional outcome or mortality. TCD evidence of vasospasm was found to be highly predictive of DCI. Pooled estimates for TCD diagnosis of vasospasm (for DCI) were sensitivity 90% (95% confidence interval [CI] 77%-96%), specificity 71% (95% CI 51%-84%), positive predictive value 57% (95% CI 38%-71%), and negative predictive value 92% (95% CI 83%-96%). coNclusioNs TCD evidence of vasospasm is predictive of DCI with high accuracy. Although high sensitivity and negative predictive value make TCD an ideal monitoring device, it is not a mandated standard of care in aSAH due to the paucity of evidence on clinically relevant outcomes, despite recommendation by national guidelines. High-quality randomized trials evaluating the impact ...

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“…However, strong correlation was found between emboli detected by TCD and the Coulter counter, suggesting that TCD may serve as a surrogate measure of LME during cardiac surgery. To non-invasively monitor intracranial circulation by TCD is not new and TCD has previously been used for a variety of diagnostic purposes [16][17][18][19][20][21][22][23][24][25][26] . Micro-emboli detection has, however, up until now, mainly been restricted to detection of air or atherosclerotic plaque debris emboli.…”

Section: Discussionmentioning

confidence: 99%