Vasospasm after SAH due to aneurysm rupture of the anterior circle of Willis: value of TCD monitoring

Fontanella, M; Valfrè, Walter; Benech, Franco; Carlino, Christian; Garbossa, Diego; Ferrio, M. F.; Perez, Rosa; Berardino, Maurizio; Bradac, Gianni Boris; Ducati, Alessandro

doi:10.1179/016164107x229939

Cited by 27 publications

(18 citation statements)

References 40 publications

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“…Further-more, we previously demonstrated the attenuation of inflammatory reactions during combined hypothermia and barbiturate coma in patients with severe SAH [45]. The strong correlation between elevated blood flow velocities from TCD and radiological evidence of cerebral vasospasm has been reported previously [28,46]. Accordingly, we observed higher MFVMCA before and during early hypothermia in patients with DCI (7 of 11 patients with MCA vasospasm) compared to patients with intracranial hyper-tension.…”

Section: Discussionsupporting

confidence: 76%

“…In addition the diameter of the proximal segment of the middle cerebral artery has been shown to remain constant during moderate changes in MAP and PaCO2 [26,27]. However, vasospasm of the middle cerebral artery is frequently observed after SAH and may increase MFVMCA, as confirmed previously [28]. If TCD is performed serially after SAH there is usually a steady rise in blood flow velocity with peak values around 1 week from SAH and recovery back to normal values over another week, reflecting the time course of pathological changes in arteries occurring during cerebral vasospasm [29].…”

Section: Discussionsupporting

confidence: 71%

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Therapeutic Hypothermia Reduces Middle Cerebral Artery Flow Velocity in Patients with Severe Aneurysmal Subarachnoid Hemorrhage

et al. 2013

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Background: Transcranial Doppler (TCD) is widely used to detect and follow up cerebral vasospasm after sub-arachnoid hemorrhage (SAH). Therapeutic hypothermia might influence blood flow velocities assessed by TCD. The aim of the study was to evaluate the effect of hypo-thermia on Doppler blood flow velocity after SAH. Methods: In 20 patients treated with hypothermia (33°) due to refractory intracranial hypertension or delayed cerebral ischemia (DCI), mean flow velocity of the middle cerebral artery (MFVMCA) was assessed by TCD. Thirteen patients were treated with combined hypothermia and barbiturate coma and seven with hypothermia alone. MFVMCA was obtained within 24 h before and after induction of hypothermia as well as before and after rewarming. Results: Hypothermia was induced on average 5 days after SAH (range 1-12) and maintained for 144 h (range 29-270). After hypothermia induction, MFVMCA decreased from 113.7 ± 49.0 to 93.8 ± 44.7 cm/s (p = 0.001). The decrease was independent of SAH-related complications and barbiturate coma. MFVMCA further decreased by 28.2 cm/s between early and late hypothermia (p < 0.001). This second decrease was observed in patients with DCI (p < 0.001), but not in patients with intracranial hypertension (p = 0.715). Compared to late hypothermia, MFVMCA remained unchanged after rewarming (65.6 ± 32.1 vs 70.3 ± 36.8 cm/s; p = 0.219). However, patients treated with hypothermia alone showed an increase in MFVMCA after rewarming (p = 0.016). Conclusion: Therapeutic hypothermia after SAH decrea-ses Doppler blood flow velocity in both intracranial hypertension and DCI cases. The results can be the effect of hypothermiarelated mechanisms or resolving cerebral vasospasm during prolonged hypothermia. AbstractBackground: Transcranial Doppler (TCD) is widely used to detect and follow up cerebral vasospasm after sub-arachnoid hemorrhage (SAH). Therapeutic hypothermia might influence blood flow velocities assessed by TCD. The aim of the study was to evaluate the effect of hypo-thermia on Doppler blood flow velocity after SAH. Methods: In 20 patients treated with hypothermia (33°) due to refractory intracranial hypertension or delayed cerebral ischemia (DCI), mean flow velocity of the middle cerebral artery (MFVMCA) was assessed by TCD. Thirteen patients were treated with combined hypothermia and barbiturate coma and seven with hypothermia alone. MFVMCA was obtained within 24 h before and after induction of hypothermia as well as before and after rewarming. Results: Hypothermia was induced on average 5 days after SAH (range 1-12) and maintained for 144 h (range 29-270). After hypothermia induction, MFVMCA decreased from 113.7 ± 49.0 to 93.8 ± 44.7 cm/s (p = 0.001). The decrease was independent of SAH-related complications and barbiturate coma. MFVMCA further decreased by 28.2 cm/s between early and late hypothermia (p < 0.001). This second decrease was observed in patients with DCI (p < 0.001), but not in patients with intracranial hypertension (p = 0.715). Compared to late hypotherm...

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Section: Discussionsupporting

confidence: 76%

Section: Discussionsupporting

confidence: 71%

Therapeutic Hypothermia Reduces Middle Cerebral Artery Flow Velocity in Patients with Severe Aneurysmal Subarachnoid Hemorrhage

et al. 2013

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“…Seventeen studies (n = 2870 patients) met inclusion criteria. 3,13,15,16,22,27,29,30,33,34,[39][40][41]44,46,47,51 Study characteristics are summarized in Table 1. No studies addressed the comparative impact of TCD vasospasm on functional outcome and mortality.…”

Section: Resultsmentioning

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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“…Está bien aceptado que vfm mayores de 200 cm/segundos en las ACM, corresponden a un espasmo severo que equivale en la arteriografía a una disminución mayor del 50% del calibre del vaso 19 , y registros superiores de 50 cm/segundos en un intervalo de 24 horas son elementos que predisponen al vasoespasmo sintomático 24 .…”

Section: Desempeño Del Dtc En La Detección Del Vasoespasmounclassified

Utilidad del doppler transcraneal en la hemorragia subaracnoidea: Revisión

Scherle-Matamoros

Pérez-Nellar

2011

Rev. chil. neuro-psiquiatr.

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This review summarizes the usefulness of transcranial Doppler (TCD) ARTÍCULO DE REVISIÓN IntoducciónL a idea de estudiar la circulación intracraneal con ultrasonido fue inicialmente propuesta en 1960 por Kaneko en Osaka 1 . Hasta ese momento el cráneo se consideraba una barrera infranqueable para el ultrasonido y sólo había sido estudiado el estado de la circulación cerebral con métodos invasivos. En 1965 Miyazaki y Kato utilizaron por primera vez caudalímetros direccionales ultrasónicos basados en el empleo del efecto Doppler para el estudio de las arterias carótidas, y desde ese momento comienza a utilizarse el ultrasonido de forma rutinaria para el estudio de los vasos extracraneales, mientras los vasos intracraneales sólo habían sido abordados en el curso de intervenciones quirúrgicas o en niños con fontanelas abiertas ya que el hueso de los adultos atenuaba excesivamente las ondas de los aparatos diagnósticos, que operaban a frecuencias de 5 a 10 MHz 2 .En 1982, Rune Aslid se percata de que el problema de penetrar el ultrasonido dentro del cráneo podía resolverse utilizando una menor frecuencia de ultrasonido y aprovechando áreas del cráneo donde el hueso fuera más fi no. De esta forma, utilizando una probeta de 2 MHz y un equipo designado originalmente para uso cardíaco introduce en la práctica clínica el Doppler transcraneal (DTC) 3 . Dos años después de haber descrito en sujetos normales las características del fl ujo sanguíneo en los segmentos proximales de los vasos que conforman el polígono de Willis, comenzó a aplicarlo en el diagnóstico y seguimiento del vasoespasmo en la HSA 4 .En poco tiempo, impulsado por su naturaleza no invasiva y la ventaja de poder realizarse junto al enfermo, el DTC comienza a ser introducido en la evaluación de otras afecciones cerebrovasculares 5 .Hasta el año 1994, las investigaciones se concentraron en el vasoespasmo de la circulación anterior REV CHIL NEURO-PSIQUIAT 2011; 49 (1): 79-85

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Vasospasm after SAH due to aneurysm rupture of the anterior circle of Willis: value of TCD monitoring

Abstract: Our study shows a good correlation between TCD and angiography to detect vasospasm on MCA, but the correlation is low for ACA. TCD alone cannot discriminate different hemodynamic pathways after SAH.

Cited by 27 publications

References 40 publications

Therapeutic Hypothermia Reduces Middle Cerebral Artery Flow Velocity in Patients with Severe Aneurysmal Subarachnoid Hemorrhage

Therapeutic Hypothermia Reduces Middle Cerebral Artery Flow Velocity in Patients with Severe Aneurysmal Subarachnoid Hemorrhage

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

Utilidad del doppler transcraneal en la hemorragia subaracnoidea: Revisión

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