Vasospasm in Intracerebral Hemorrhage with Ventricular Involvement: A Prospective Pilot Transcranial Doppler Sonography Study

Abstract

Background: Cerebral vasospasm (VSP) is a common complication after subarachnoid hemorrhage (SAH), but has rarely been reported after intracerebral hemorrhage (ICH) without subarachnoidal bleeding. The underlying pathophysiological mechanism is mainly mediated by circulating heme products within the cerebrospinal fluid, and thus patients with ICH and ventricular involvement (IVH) may also be in danger of developing VSP. The incidence and role of VSP in IVH, however, have not been systematically studied. Methods: We prospectively enrolled 115 patients with ICH with or without IVH into the study between April 2009 and April 2010. All patients received serial extracranial and transcranial Doppler sonography (TCD) at baseline, on days 3–5 and 7–9 to detect and monitor VSP. In addition, CT scans taken on admission, after 24 h and before discharge were evaluated for the occurrence of delayed cerebral ischemia. Results: Three out of 53 patients (5.7%) with IVH showed a significant elevation of flow velocities over the examined timeframe. One of these patients developed severe VSP resulting in secondary ischemic infarction. None of the ICH patients without IVH showed significantly elevated flow velocities or secondary infarction. Conclusions: Cerebral VSP with secondary infarction may occur in patients with spontaneous IVH, though far less frequently than in SAH; thus, systematic screening of all patients with IVH may not be warranted. However, serial TCD should be considered in patients with secondary clinical worsening or extensive IVH.

Is Hypothermia Helpful in Severe Subarachnoid Hemorrhage? An Exploratory Study on Macro Vascular Spasm, Delayed Cerebral Infarction and Functional Outcome after Prolonged Hypothermia

“…All cerebral vessels were insonated at specific depths for the assessment of flow velocities (e.g. peak flow velocities) and were converted by validated conversion formula, as previously described [22] . We used middle cerebral artery (MCA) velocities to compare possible treatment effects between patients receiving TH and those not receiving TH [23] .…”

“…We used middle cerebral artery (MCA) velocities to compare possible treatment effects between patients receiving TH and those not receiving TH [23] . Definition of Doppler-based vasospasm, referred to as macrovascular spasm throughout the manuscript consisted of present mean flow velocities greater than 120 cm/s and/or a Lindegaard ratio higher than 3, which was chosen for early detection [1,17,22,24] . Macrovascular spasm was confirmed as angiographic vasospasm by diagnostic subtraction angiography (n = 15), CT angiography and perfusion scanning (n = 25) as well as by MRI (n = 6).…”

Diffusion tensor imaging in hemorrhagic stroke

“…In other experiments decreased diffusion has been demonstrated in cerebral locations remote from the primary site of ICH (51, 52). In yet other experiments vasospasm that is usually the cause of delayed cerebra ischemia has been implicated in remote ischemia in ICH involving the ventricles (53, 54). Shu-Jan Fan et al in their study show that in those ICH rodent models which were associated with ventricular involvement showed early decreased diffusivity on DTI in bilateral PY.…”

Relevance of bleeding pattern on clinical appearance and outcome in patients with hemorrhagic brain arteriovenous malformations

“…In fact, heme products circulating within the cerebrospinal fluid may trigger a cascade of events that increase the risk of cerebral vasospasm, especially after 3-7 days from bleeding [32][33][34][35]. Furthermore, the leakage of blood in the subarachnoid space may lead to ICP elevation, reduction of brain perfusion with subsequent microvascular injury, plugging of vessels, release of vasoactive substances by platelet aggregates, alterations in the nitric oxide pathway and lipid peroxidation as well as favors the occurrence of acute hydrocephalus [34].…”