Top

Published in:

01-06-2014 | Original Article

Value of Transcranial Doppler, Perfusion-CT and Neurological Evaluation to Forecast Secondary Ischemia after Aneurysmal SAH

Authors: Thomas Westermaier, Mirko Pham, Christian Stetter, Nadine Willner, Laszlo Solymosi, Ralf-Ingo Ernestus, Giles Hamilton Vince, Ekkehard Kunze

Published in: Neurocritical Care | Issue 3/2014

Abstract

Introduction

This study was conducted to prospectively evaluate the diagnostic value of detailed neurological evaluation, transcranial Doppler sonography (TCD) and Perfusion-CT (PCT) to predict delayed vasospasm (DV) and delayed cerebral infarction (DCI) within the following 3 days in patients with aneurysmal subarachnoid hemorrhage (SAH).

Methods

A total of 61 patients with aneurysmal SAH were included in the study. All patients were amenable for neurological evaluation throughout the critical phase to develop secondary ischemia after SAH. The neurological status was assessed three times a day according to a detailed examination protocol. Mean flow velocities (MFV) in intracranial vessel trunks were measured daily by TCD. Native CT and PCT were routinely acquired at 3-day intervals and, in addition, whenever it was thought to be of diagnostic relevance. The predictive values of abnormal PCT and accelerations in TCD (MFV > 140 cm/s) to detect angiographic DV and DCI within the following 2 days were calculated and compared to the predictive value of delayed ischemic neurological deficits (DIND).

Results

The accuracy of TCD and PCT to predict DV or DCI was 0.65 and 0.63, respectively. In comparison, DIND predicted DV or DCI with an accuracy of 0.96. Pathological PCT findings had a higher sensitivity (0.93) and negative predictive value (0.98) than TCD (0.81 and 0.96).

Conclusion

Neurological assessment at close intervals is the most accurate parameter to detect DV and DCI in the following 3 days. However, DIND may not be reversible. The routine acquisition of PCT in addition to daily TCD examinations seems reasonable, particularly in patients who are not amenable to a detailed neurological examination since it has a higher sensitivity and negative predictive value than TCD and leaves a lower number of undetected cases of vasospasm and infarction.

Rosengart AJ, Schultheiss KE, Tolentino J, Macdonald RL. Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke. 2007;38(8):2315–21.PubMedCrossRef

Dreier JP, Woitzik J, Fabricius M, et al. Delayed ischaemic neurological deficits after subarachnoid haemorrhage are associated with clusters of spreading depolarizations. Brain. 2006;129(Pt 12):3224–37.PubMedCrossRef

Jones TH, Morawetz RB, Crowell RM, et al. Thresholds of focal cerebral ischemia in awake monkeys. J Neurosurg. 1981;54(6):773–82.PubMedCrossRef

Beck J, Raabe A, Lanfermann H, et al. Effects of balloon angioplasty on perfusion- and diffusion-weighted magnetic resonance imaging results and outcome in patients with cerebral vasospasm. J Neurosurg. 2006;105(2):220–7.PubMedCrossRef

Westermaier T, Stetter C, Vince GH, et al. Prophylactic intravenous magnesium sulfate for treatment of aneurysmal subarachnoid hemorrhage: a randomized, placebo-controlled, clinical study. Crit Care Med. 2010;38(5):1284–90.PubMed

Kunze E, Pham M, Raslan F, et al. Value of perfusion CT, transcranial doppler sonography, and neurological examination to detect delayed vasospasm after aneurysmal subarachnoid hemorrhage. Radiol Res Pract. 2012;2012:231206. doi:10.1155/2012/231206.PubMedCentralPubMed

Pham M, Johnson A, Bartsch AJ, et al. CT perfusion predicts secondary cerebral infarction after aneurysmal subarachnoid hemorrhage. Neurology. 2007;69(8):762–5.PubMedCrossRef

Wintermark M, Dillon WP, Smith WS, et al. Visual grading system for vasospasm based on perfusion CT imaging: comparisons with conventional angiography and quantitative perfusion CT. Cerebrovasc Dis. 2008;26(2):163–70.PubMedCrossRef

von Kummer R, Bourquain H, Bastianello S, et al. Early prediction of irreversible brain damage after ischemic stroke at CT. Radiology. 2001;219(1):95–100.CrossRef

10.

Macdonald RL, Kassell NF, Mayer S, et al. Clazosentan to overcome neurological ischemia and infarction occurring after subarachnoid hemorrhage (CONSCIOUS-1): randomized, double-blind, placebo-controlled phase 2 dose-finding trial. Stroke. 2008;39(11):3015–21.PubMedCrossRef

11.

Ma J, Huang S, Ma L, Liu Y, Li H, You C. Endothelin-receptor antagonists for aneurysmal subarachnoid hemorrhage: an updated meta-analysis of randomized controlled trials. Crit Care. 2012;16(5):R198.PubMedCentralPubMedCrossRef

12.

Chaichana KL, Pradilla G, Huang J, Tamargo RJ. Role of inflammation (leukocyte–endothelial cell interactions) in vasospasm after subarachnoid hemorrhage. World Neurosurg. 2010;73(1):22–41.PubMedCrossRef

13.

Zetterling M, Hallberg L, Hillered L, Karlsson T, Enblad P, Ronne EE. Brain energy metabolism in patients with spontaneous subarachnoid hemorrhage and global cerebral edema. Neurosurgery. 2010;66(6):1102–10.PubMedCrossRef

14.

Bosche B, Graf R, Ernestus RI, et al. Recurrent spreading depolarizations after subarachnoid hemorrhage decreases oxygen availability in human cerebral cortex. Ann Neurol. 2010;67(5):607–17.PubMedCentralPubMedCrossRef

15.

Stein SC, Levine JM, Nagpal S, LeRoux PD. Vasospasm as the sole cause of cerebral ischemia: how strong is the evidence? Neurosurg Focus. 2006;21(3):2.CrossRef

16.

Crowley RW, Medel R, Dumont AS, et al. Angiographic vasospasm is strongly correlated with cerebral infarction after subarachnoid hemorrhage. Stroke. 2011;42(4):919–23.PubMedCrossRef

17.

Chaudhary SR, Ko N, Dillon WP, et al. Prospective evaluation of multidetector-row CT angiography for the diagnosis of vasospasm following subarachnoid hemorrhage: a comparison with digital subtraction angiography. Cerebrovasc Dis. 2008;25(1–2):144–50.PubMedCrossRef

18.

Yao GE, Li Q, Jiang XJ, et al. Vasospasm after subarachnoid hemorrhage: a 3D rotational angiography study. Acta Neurochir Suppl. 2011;110(Pt 2):221–5.PubMed

19.

Lindegaard KF, Nornes H, Bakke SJ, Sorteberg W, Nakstad P. Cerebral vasospasm after subarachnoid haemorrhage investigated by means of transcranial Doppler ultrasound. Acta Neurochir Suppl (Wien). 1988;42:81–4.PubMedCrossRef

20.

Kassell NF, Sasaki T, Colohan AR, Nazar G. Cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Stroke. 1985;16(4):562–72.PubMedCrossRef

21.

Dorsch NW. Cerebral arterial spasm: a clinical review. Br J Neurosurg. 1995;9(3):403–12.PubMedCrossRef

22.

van den Bergh WM, Algra A, van Kooten F, et al. Magnesium sulfate in aneurysmal subarachnoid hemorrhage: a randomized controlled trial. Stroke. 2005;36(5):1011–5.PubMedCrossRef

23.

Frontera JA, Fernandez A, Schmidt JM, et al. Defining vasospasm after subarachnoid hemorrhage: what is the most clinically relevant definition? Stroke. 2009;40(6):1963–8.PubMedCrossRef

24.

Aralasmak A, Akyuz M, Ozkaynak C, Sindel T, Tuncer R. CT angiography and perfusion imaging in patients with subarachnoid hemorrhage: correlation of vasospasm to perfusion abnormality. Neuroradiology. 2009;51(2):85–93.PubMedCrossRef

25.

Carrera E, Schmidt JM, Oddo M, et al. Transcranial Doppler for predicting delayed cerebral ischemia after subarachnoid hemorrhage. Neurosurgery. 2009;65(2):316–23.PubMedCrossRef

26.

Hickmann AK, Langner S, Kirsch M et al. The value of perfusion computed tomography in predicting clinically relevant vasospasm in patients with aneurysmal subarachnoid hemorrhage. Neurosurg Rev. 2012.

27.

Lee JY, Lee MS, Whang K, Lee JM, Kim SH, Lee SS. Accuracy of transcranial Doppler sonography for predicting cerebral infarction in aneurysmal subarachnoid hemorrhage. J Clin Ultrasound. 2006;34(8):380–4.PubMedCrossRef

Title: Value of Transcranial Doppler, Perfusion-CT and Neurological Evaluation to Forecast Secondary Ischemia after Aneurysmal SAH
Authors: Thomas Westermaier
Mirko Pham
Christian Stetter
Nadine Willner
Laszlo Solymosi
Ralf-Ingo Ernestus
Giles Hamilton Vince
Ekkehard Kunze
Publication date: 01-06-2014
Publisher: Springer US
Published in: Neurocritical Care / Issue 3/2014
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI: https://doi.org/10.1007/s12028-013-9896-0

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Value of Transcranial Doppler, Perfusion-CT and Neurological Evaluation to Forecast Secondary Ischemia after Aneurysmal SAH

Abstract

Introduction

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 3/2014

The Utility of Serum Procalcitonin in Distinguishing Systemic Inflammatory Response Syndrome from Infection After Aneurysmal Subarachnoid Hemorrhage

Heart Rate Variability for Preclinical Detection of Secondary Complications After Subarachnoid Hemorrhage

NMDA Antagonists for Refractory Seizures

Brain Injury Biomarkers as Outcome Predictors in Pediatric Severe Traumatic Brain Injury

Changes in Neuron-Specific Enolase are More Suitable Than Its Absolute Serum Levels for the Prediction of Neurologic Outcome in Hypothermia-Treated Patients with Out-of-Hospital Cardiac Arrest

Sphenoid and Subdural Hemorrhage as a Presenting Sign of Ruptured Clinoid Aneurysm