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van der Harst JJ, Elting JWJ, Hijlkema J, Veeger NJGM, van Donkelaar CE, van Dijk JMC, Uyttenboogaart M. Diagnostic value of transcranial doppler to predict delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage : To predict delayed cerebral ischemia. Acta Neurochir (Wien) 2024; 166:278. [PMID: 38949680 PMCID: PMC11217085 DOI: 10.1007/s00701-024-06164-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 06/07/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Transcranial Doppler (TCD) is a technique to assess blood flow velocity in the cerebral arteries. TCD is frequently used to monitor aneurysmal subarachnoid hemorrhage (aSAH) patients. This study compares TCD-criteria for vasospasm and its association with Delayed Cerebral Ischemia (DCI). An overall score based on flow velocities of various intracranial arteries was developed and evaluated. METHODS A retrospective diagnostic accuracy study was conducted between 1998 and 2017 with 621 patients included. Mean flow velocity (MFV) of the cerebral artery was measured between 2-5 days and between 6-9 days after ictus. Cutoff values from the literature, new cutoff values, and a new composite score (Combined Severity Score) were used to predict DCI. Sensitivity, specificity, and area under the curve (AUC) were determined, and logistic regression analysis was performed. RESULTS The Combined Severity Score showed an AUC 0.64 (95%CI 0.56-.71) at days 2-5, with sensitivity 0.53 and specificity 0.74. The Combined Severity Score had an adjusted Odds Ratio of 3.41 (95CI 1.86-6.32) for DCI. MCA-measurements yielded the highest AUC to detect DCI at day 2-5: AUC 0.65 (95%CI 0.58-0.73). Optimal cutoff MFV of 83 cm/s for MCA resulted in sensitivity 0.73 and specificity 0.50 at days 2-5. CONCLUSION TCD-monitoring of aSAH patients may be a valuable strategy for DCI risk stratification. Lower cutoff values can be used in the early phase after the ictus (day 2-5) than are commonly used now. The Combined Severity Score incorporating all major cerebral arteries may provide a meaningful contribution to interpreting TCD measurements.
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Affiliation(s)
- J Joep van der Harst
- Departments of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Jan Willem J Elting
- Departments of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Johanna Hijlkema
- Departments of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nic J G M Veeger
- Department of Epidemiology, Uversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carlina E van Donkelaar
- Department of Neurosurger, Uversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J Marc C van Dijk
- Department of Neurosurger, Uversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Departments of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Hakim M, Kawnayn G, Hassan MS, Uddin MN, Hasan M, Huq MR. Transcranial Doppler in the Detection of Cerebral Vasospasm After Subarachnoid Hemorrhage. Cureus 2024; 16:e61569. [PMID: 38962631 PMCID: PMC11221191 DOI: 10.7759/cureus.61569] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/05/2024] Open
Abstract
Background Transcranial Doppler (TCD) is a simple, noninvasive, nonionizing, portable technique but not widely practiced to detect cerebral vasospasm after subarachnoid hemorrhage (SAH). Objective The aim of this study was to assess the performance of TCD in the detection of cerebral vasospasm in patients with SAH considering CT angiography (CTA) as a gold standard. Methods and material This cross-sectional study included 50 patients with acute SAH admitted to the National Institute of Neurosciences & Hospital (NINS & H), Dhaka, Bangladesh, from February to June 2021. The neurological status, severity of SAH, and initial CT findings were recorded. All patients were screened for cerebral vasospasm with TCD on the 4th, 7th, 10th, and 14th days after the event. Screening of cerebral vasospasm by CTA was done on the 14th day of the event or earlier if TCD suggested vasospasm. Results The mean age of the participants was 51.4 ±13.4 years (mean ± SD), and females were predominant (N=29, 58%). CTA detected cerebral vasospasm in 18 (36%) participants, but TCD could detect it in only 13 (26%) cases. Among the participants who had no vasospasm by CTA, all but one were also found to have no vasospasm by TCD. The agreement between TCD and CTA in detecting cerebral vasospasm was significant (p<0.001, κ=0.726). TCD shows good specificity (96.9%) and positive predictive value (92.8%), but sensitivity (72.2%) and negative predictive value (81.6%) were comparatively lower. Overall, the diagnostic accuracy of TCD in detecting cerebral vasospasm was 88%. Conclusions Although compared to CTA, TCD is a highly specific but less sensitive tool in detecting vasospasm, TCD remains a reliable screening tool for detecting vasospasm following SAH.
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Affiliation(s)
- Maliha Hakim
- Neurology, National Institute of Neurosciences and Hospital, Dhaka, BGD
| | | | | | | | - Mashfiqul Hasan
- Endocrinology, Diabetes, and Metabolism, National Institute of Neurosciences and Hospital, Dhaka, BGD
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Joos GS, Gottschalk A, Ewelt C, Holling M, Stummer W, Englbrecht JS. Risk factors associated with vasospasm after non-traumatic subarachnoid hemorrhage: a retrospective analysis of 456 patients. J Neurosurg Sci 2023; 67:576-584. [PMID: 35416450 DOI: 10.23736/s0390-5616.22.05497-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The pathophysiology of vasospasm (VS) after non-traumatic subarachnoid hemorrhage is not completely understood. Several risk factors associated with VS were previously reported, partially with conflicting results. The aim of this study was to identify patients at increased risk for VS. METHODS Retrospective analysis of data from all patients treated in our institutional intensive care unit (ICU) between 2010 and 2016 after non-traumatic subarachnoid hemorrhage. Possible contributing factors for VS studied were: age, sex, aneurysm-localization, treatment option, ICU-stay, ICU mortality, pre-existing condition, medication history, World Federation of Neurosurgical Societies (WFNS) grading system, modified Fisher scale. RESULTS We obtained data from 456 patients. 184 were male and 272 female patients, respectively. Mean age was 57.7±13.9 and was not different between sexes. In 119 patients, VS was diagnosed after subarachnoid hemorrhage. Incidence of VS was not different between sexes (male: 22.3%, female: 28.7%, P=0.127). Patients with VS were significantly younger (mean age 52.2 vs. 59.7, P<0.001), meanwhile patients aged 36-40 yrs. had the highest incidence of VS. Most VS were found after rupture of middle cerebral artery-aneurysms. Higher incidence of VS was found after aneurysm clipping compared to coiling. VS developed more often in patients with more severe WFNS grade and Fisher scale. In multivariate analysis, age, previous drug abuse and history of anticoagulants were associated with the incidence of VS. CONCLUSIONS Younger age, middle cerebral artery-aneurysms, aneurysm clipping, previous drug abuse and history of anticoagulants were associated with a higher incidence of VS after non-traumatic subarachnoid hemorrhage. No gender difference was found.
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Affiliation(s)
- Gunther S Joos
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Antje Gottschalk
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, St. Barbara-Clinic Hamm-Heessen, Hamm, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Jan S Englbrecht
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany -
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Harrar DB, Sun LR, Segal JB, Lee S, Sansevere AJ. Neuromonitoring in Children with Cerebrovascular Disorders. Neurocrit Care 2023; 38:486-503. [PMID: 36828980 DOI: 10.1007/s12028-023-01689-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Cerebrovascular disorders are an important cause of morbidity and mortality in children. The acute care of a child with an ischemic or hemorrhagic stroke or cerebral sinus venous thrombosis focuses on stabilizing the patient, determining the cause of the insult, and preventing secondary injury. Here, we review the use of both invasive and noninvasive neuromonitoring modalities in the care of pediatric patients with arterial ischemic stroke, nontraumatic intracranial hemorrhage, and cerebral sinus venous thrombosis. METHODS Narrative review of the literature on neuromonitoring in children with cerebrovascular disorders. RESULTS Neuroimaging, near-infrared spectroscopy, transcranial Doppler ultrasonography, continuous and quantitative electroencephalography, invasive intracranial pressure monitoring, and multimodal neuromonitoring may augment the acute care of children with cerebrovascular disorders. Neuromonitoring can play an essential role in the early identification of evolving injury in the aftermath of arterial ischemic stroke, intracranial hemorrhage, or sinus venous thrombosis, including recurrent infarction or infarct expansion, new or recurrent hemorrhage, vasospasm and delayed cerebral ischemia, status epilepticus, and intracranial hypertension, among others, and this, is turn, can facilitate real-time adjustments to treatment plans. CONCLUSIONS Our understanding of pediatric cerebrovascular disorders has increased dramatically over the past several years, in part due to advances in the neuromonitoring modalities that allow us to better understand these conditions. We are now poised, as a field, to take advantage of advances in neuromonitoring capabilities to determine how best to manage and treat acute cerebrovascular disorders in children.
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Affiliation(s)
- Dana B Harrar
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.
| | - Lisa R Sun
- Divisions of Pediatric Neurology and Vascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Bradley Segal
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Arnold J Sansevere
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
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Su R, Zhou J, Zhu N, Chen X, Zhou JX, Li HL. Efficacy and safety of remifentanil dose titration to correct the spontaneous hyperventilation in aneurysmal subarachnoid haemorrhage: protocol and statistical analysis for a prospective physiological study. BMJ Open 2022; 12:e064064. [PMID: 36351728 PMCID: PMC9664281 DOI: 10.1136/bmjopen-2022-064064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Spontaneous hyperventilation (SHV) is common in aneurysmal subarachnoid haemorrhage (aSAH). The reduction in arterial partial pressure of carbon dioxide (PaCO2) may change the brain physiology, such as haemodynamics, oxygenation, metabolism and may lead to secondary brain injury. However, how to correct SHV safely and effectively in patients with aSAH has not been well investigated. The aim of this study is to investigate the efficacy and safety of remifentanil dose titration to correct hyperventilation in aSAH, as well as the effect of changes in PaCO2 on cerebral blood flow (CBF). METHODS AND ANALYSIS This study is a prospective, single-centre, physiological study in patients with aSAH. The patients who were mechanically ventilated and who meet with SHV (tachypnoea combined with PaCO2 <35 mm Hg and pH >7.45) will be enrolled. The remifentanil will be titrated to correct the SHV. The predetermined initial dose of remifentanil is 0.02 μg/kg/min and will be maintained for 30 min, and PaCO2 and CBF will be measured. After that, the dose of remifentanil will be sequentially increased to 0.04, 0.06, and 0.08 μg/kg/min, and the measurements for PaCO2 and CBF will be repeated 30 min after each dose adjustment and will be compared with their baseline values. ETHICS AND DISSEMINATION This study has been approved by the Institutional Review Board of Beijing Tiantan Hospital, Capital Medical University (KY 2021-006-02) and has been registered at ClinicalTrials.gov. The results of this study will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT04940273.
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Affiliation(s)
- Rui Su
- Capital Medical University, Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, Beijing, China
| | - Jianfang Zhou
- Capital Medical University, Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, Beijing, China
| | - Ning Zhu
- Capital Medical University, Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, Beijing, China
| | - Xiaolin Chen
- Capital Medical University, Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, Beijing, China
| | - Jian-Xin Zhou
- Capital Medical University, Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, Beijing, China
- Capital Medical University, Department of Critical Care Medicine, Beijing Shijitan Hospital, Beijing, Beijing, China
| | - Hong-Liang Li
- Capital Medical University, Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, Beijing, China
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Muacevic A, Adler JR, Soares MF, Fonseca AC. Follow-Up by Transcranial Doppler After Rupture of a Giant Intracranial Aneurysm. Cureus 2022; 14:e31951. [PMID: 36582551 PMCID: PMC9795273 DOI: 10.7759/cureus.31951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 11/29/2022] Open
Abstract
Giant intracranial aneurysms (GIA) are rare and manifest primarily through subarachnoid hemorrhage (SAH), cerebral ischemia, or progressive symptoms of mass effect. Transcranial Doppler (TCD) can be used to monitor cerebral vasospasm after treatment of intracranial aneurysm allowing the adjustment of therapeutics and avoiding complications. The authors present a clinical case of a patient with a ruptured intracranial giant aneurysm in which TCD was essential to monitor vasospasm and intracranial hypertension (IH). A 53-year-old male was admitted due to a sudden headache and impaired consciousness, left hemiparesis, and dysarthria. Cerebral CT scan and CT angiography at admission showed a giant aneurysm of the right middle cerebral artery (MCA) with extensive and diffuse intraventricular SAH of Fisher grade IV and Hunt and Hess grade 4. Clipping, placement of an intracranial pressure sensor, and external ventricular drain (EVD) were performed on the same day, with difficulty in preserving the M2 branch and complicated by postoperative extensive right MCA ischemia. On day three of hospitalization, TCD revealed an increased pulsatility index (>1.5) with clinical deterioration leading to re-intervention for a decompressive craniectomy. On day six, a TCD follow-up was performed to monitor blood flow complications, and particularly vasospasm, showing a severe increase in middle blood flow velocity (MBFV) in the right MCA of 205 cm/s and Lindegaard Index > 6. Daily surveillance by TCD was maintained to guide clinical management since the attempt to withdraw the EVD led to clinical deterioration with subsequent worsening of vasospasm. Improvement occurred after surgery as ventriculoperitoneal shunt insertion was performed. TCD had a major role in the clinical orientation of SAH as well as in intracranial pressure management and was decisive to establish long-term treatment.
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Andersen CR, English SW, Delaney A. Made to measure—Selecting outcomes in aneurysmal subarachnoid hemorrhage research. Front Neurol 2022; 13:1000454. [PMID: 36212648 PMCID: PMC9532574 DOI: 10.3389/fneur.2022.1000454] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/30/2022] [Indexed: 11/25/2022] Open
Abstract
There has been limited new high-level evidence generated to guide aneurysmal subarachnoid hemorrhage (aSAH) management in the past decade. The choice of outcome measures used in aSAH clinical trials may be one of the factors hindering progress. In this narrative review we consider the current process for determining “what” to measure in aSAH and identify some of the shortcomings of these approaches. A consideration of the unique clinical course of aSAH is then discussed and how this impacts on selecting the best timepoints to assess change in the chosen constructs. We also review the how to critically appraise different measurement instruments and some of the issues with how these are applied in the context of aSAH. We conclude with current initiatives to improve outcome selection in aSAH and future directions in the research agenda.
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Affiliation(s)
- Christopher R. Andersen
- Northern Clinical School, Sydney University, Sydney, NSW, Australia
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
- Intensive Care Department, Royal North Shore Hospital, Sydney, NSW, Australia
- *Correspondence: Christopher R. Andersen
| | - Shane W. English
- Department of Medicine (Critical Care), uOttawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada
| | - Anthony Delaney
- Northern Clinical School, Sydney University, Sydney, NSW, Australia
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
- Intensive Care Department, Royal North Shore Hospital, Sydney, NSW, Australia
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Shen Y, Wei Y, Bokkers RPH, Uyttenboogaart M, Van Dijk JMC. Patient-Specific Cerebral Blood Flow Simulation Based on Commonly Available Clinical Datasets. Front Bioeng Biotechnol 2022; 10:835347. [PMID: 35309980 PMCID: PMC8931461 DOI: 10.3389/fbioe.2022.835347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Cerebral hemodynamics play an important role in the development of cerebrovascular diseases. In this work, we propose a numerical framework for modeling patient-specific cerebral blood flow, using commonly available clinical datasets. Our hemodynamic model was developed using Simscape Fluids library in Simulink, based on a block diagram language. Medical imaging data obtained from computerized tomography angiography (CTA) in 59 patients with aneurysmal subarachnoid hemorrhage was used to extract arterial geometry parameters. Flow information obtained from transcranial Doppler (TCD) measurement was employed to calibrate input parameters of the hemodynamic model. The results show that the proposed numerical model can reproduce blood flow in the circle of Willis (CoW) per patient per measurement set. The resistance at the distal end of each terminal branch was the predominant parameter for the flow distribution in the CoW. The proposed model may be a promising tool for assessing cerebral hemodynamics in patients with cerebrovascular disease.
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Affiliation(s)
- Yuanyuan Shen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Yanji Wei
- Faculty of Science and Engineering, University of Groningen, Groningen, Netherlands
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Maarten Uyttenboogaart
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - J. Marc C. Van Dijk
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- *Correspondence: J. Marc C. Van Dijk,
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Darsaut T, Keough M, Chan A, Farzin B, Findlay J, Chow M, Chagnon M, Zehr J, Gevry G, Raymond J. Transcranial Doppler Velocities and Angiographic Vasospasm after SAH: A Diagnostic Accuracy Study. AJNR Am J Neuroradiol 2022; 43:80-86. [PMID: 34794947 PMCID: PMC8757545 DOI: 10.3174/ajnr.a7347] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/14/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE After aneurysmal SAH, transcranial Doppler is commonly used to monitor cerebral vasospasm. The diagnostic accuracy of transcranial Doppler flow velocity values in detecting angiographic vasospasm in patients requiring urgent endovascular intervention has not been established. MATERIALS AND METHODS We performed a retrospective analysis of a consecutive series of patients with aneurysmal SAH who underwent transcranial Doppler (index test) within 24 hours of conventional angiography (reference test). The judgment of 33%, 50%, and 66% degree of vessel narrowing on angiography was independently established by multiple neuroendovascular clinicians. Vessel-specific per-segment and per-patient transcranial Doppler velocities were studied using receiver operating characteristic curves, the Youden index, and minimal acceptable sensitivity models. Optimal mean flow-velocity thresholds were explored to calculate sensitivity and specificity using a per-patient judgment of vasospasm of at least 50% angiographic narrowing in any large arterial segment except A1. RESULTS In 221 patients, vasospasm was found in 15%, 8%, and 4% of arteries when the degree of reference angiographic luminal narrowing was 33%, 50%, and 66%, respectively. Mean flow velocities were significantly higher in vasospastic segments (P = . 001), but per-segment exploratory analyses yielded unsound mean flow velocity thresholds. The Youden and minimal acceptable sensitivity models proposed mean flow velocity thresholds of approximately 160 cm/s for the anterior circulation and 80 cm/s for the posterior circulation in the per-patient diagnosis of angiographic vasospasm (≥50%), yielding a sensitivity of 80%-90% (95% CI, 0.77-0.96), but with a corresponding specificity of 50% (95% CI, 0.40-0.56). CONCLUSIONS In this study, a threshold transcranial Doppler mean flow-velocity value that would accurately diagnose ≥50% angiographic vasospasm remained elusive.
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Affiliation(s)
- T.E. Darsaut
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M.B. Keough
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - A.M. Chan
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - B. Farzin
- Department of Radiology (B.F., G.G., J.R.), Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - J.M. Findlay
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M.M. Chow
- From the Division of Neurosurgery (T.E.D., M.B.K., A.M.C., J.M.F., M.M.C.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M. Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Quebec, Canada
| | - J. Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Pavillon André-Aisenstadt, Montreal, Quebec, Canada
| | - G. Gevry
- Department of Radiology (B.F., G.G., J.R.), Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - J. Raymond
- Department of Radiology (B.F., G.G., J.R.), Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
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Chalard K, Szabo V, Pavillard F, Djanikian F, Dargazanli C, Molinari N, Manna F, Costalat V, Chanques G, Perrigault PF. Long-term outcome in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation. PLoS One 2021; 16:e0247942. [PMID: 33711023 PMCID: PMC7954305 DOI: 10.1371/journal.pone.0247942] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 02/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients affected with aneurysmal subarachnoid hemorrhage (aSAH) often require intensive care, and then present distinctive outcome from less severe patients. We aimed to specify their long-term outcome and to identify factors associated with poor outcome. METHODS We conducted a retrospective study in a French university hospital intensive care unit. Patients with aSAH requiring mechanical ventilation hospitalized between 2010 and 2015 were included. At least one year after initial bleeding, survival and degree of disability were assessed using the modified Rankin Scale (mRS) via telephone interviews. A multivariable logistic regression analysis was performed to determine independent factors associated with poor outcome defined as mRS≥3. RESULTS Two-hundred thirty-six patients were included. Among them, 7 were lost to follow-up, and 229 were analyzed: 73 patients (32%) had a good outcome (mRS<3), and 156 (68%) had a poor outcome (mRS≥3). The estimated 1-year survival rate was 63%. One-hundred sixty-three patients patients (71%) suffered from early brain injuries (EBI), 33 (14%) from rebleeding, 80 (35%) from vasospasm and 63 (27%) from delayed cerebral ischemia (DCI). Multivariable logistic regression identified independent factors associated with poor outcome including delay between aSAH diagnosis and mRS assessment (OR, 0.96; 95% CI, 0.95-0.98; p<.0001), age (OR per 10 points, 1.57; 95% CI, 1.12-2.19; p = 0.008), WFNS V versus WFNS III (OR, 5.71; 95% CI 1.51-21.61; p = 0.004), subarachnoid rebleeding (OR, 6.47; 95% CI 1.16-36.06; p = 0.033), EBI (OR, 4.52; 95% CI 1.81-11.29; p = 0.001) and DCI (OR, 4.73; 95% CI, 1.66-13.49; p = 0.004). CONCLUSION Among aSAH patients requiring assisted ventilation, two-third of them survived at one year, and one-third showed good long-term outcome. As it appears as an independant factor associated with poor outcome, DCI shoud retain particular attention in future studies beyond angiographic vasospasm.
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Affiliation(s)
- Kevin Chalard
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
- IGF, Univ. Montpellier, CNRS, Inserm, Montpellier, France
- * E-mail:
| | - Vivien Szabo
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
- IGF, Univ. Montpellier, CNRS, Inserm, Montpellier, France
| | - Frederique Pavillard
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Flora Djanikian
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Nicolas Molinari
- IMAG, CNRS, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Federico Manna
- Epidemiology and Clinical Research Department, University Hospital of Montpellier, Montpellier, France
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Gerald Chanques
- Department of Critical Care Medicine and Anesthesiology (DAR B), Saint Eloi University Hospital of Montpellier and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Pierre-Francois Perrigault
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
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Western E, Sorteberg A, Brunborg C, Nordenmark TH. Prevalence and predictors of fatigue after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2020; 162:3107-3116. [PMID: 32809068 PMCID: PMC7593293 DOI: 10.1007/s00701-020-04538-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/11/2020] [Indexed: 11/25/2022]
Abstract
Background Fatigue is a common and disabling sequel after aneurysmal subarachnoid hemorrhage (aSAH). At present, prevalence estimates of post-aSAH fatigue in the chronic phase are scarce and vary greatly. Factors from the acute phase of aSAH have hitherto barely been associated with post-aSAH fatigue in the chronic phase. Methods Prospective study assessing prevalence of fatigue using the Fatigue Severity Scale (FSS) in patients who were living independently 1 to 7 years after aSAH. We compared demographic, medical, and radiological variables from the acute phase of aSAH between patients with and without fatigue (FSS ≥ 4 versus < 4) and searched for predictors of fatigue among these variables applying univariable and multivariable regression analyses. Results Of 726 patients treated for aSAH in the period between January 2012 and December 2017, 356 patients completed the assessment. The mean FSS score was 4.7 ± 1.7, and fatigue was present in 69.7%. The frequency of patients with fatigue did not decline significantly over time. Univariable analysis identified nicotine use, loss of consciousness at ictus (LOCi), rebleed prior to aneurysm repair, reduced consciousness to Glasgow Coma Scale (GCS) < 14, large amounts of subarachnoid blood, the presence of acute hydrocephalus, and severe vasospasm as factors that were significantly associated with fatigue. In multivariable analysis, nicotine use, reduced GCS, and severe vasospasm were independent predictors that all more than doubled the risk to develop post-aSAH fatigue. Conclusions Fatigue is a frequent sequel persisting several years after aSAH. Nicotine use, reduced consciousness at admission, and severe vasospasm are independent predictors of fatigue from the acute phase of aSAH. We propose inflammatory cytokines causing dopamine imbalance to be a common denominator for post-aSAH fatigue and the presently identified predictors.
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Affiliation(s)
- Elin Western
- Department of Neurosurgery, Oslo University Hospital, P O Box 4950, Nydalen, 0424, Oslo, Norway.
| | - Angelika Sorteberg
- Department of Neurosurgery, Oslo University Hospital, P O Box 4950, Nydalen, 0424, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Cathrine Brunborg
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Tonje Haug Nordenmark
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
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12
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Rasulo FA, Togni T, Romagnoli S. Essential Noninvasive Multimodality Neuromonitoring for the Critically Ill Patient. Crit Care 2020; 24:100. [PMID: 32204723 PMCID: PMC7092614 DOI: 10.1186/s13054-020-2781-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Frank A Rasulo
- Division of Anesthesiology, Intensive Care & Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy.
| | - Tommaso Togni
- Division of Anesthesiology, Intensive Care & Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy
| | - Stefano Romagnoli
- Department of Health Science, University of Florence, Florence, Italy
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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13
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Lau VI, Jaidka A, Wiskar K, Packer N, Tang JE, Koenig S, Millington SJ, Arntfield RT. Better With Ultrasound: Transcranial Doppler. Chest 2019; 157:142-150. [PMID: 31580841 DOI: 10.1016/j.chest.2019.08.2204] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/15/2019] [Accepted: 08/31/2019] [Indexed: 02/02/2023] Open
Abstract
Transcranial Doppler (TCD) ultrasound is a noninvasive method of obtaining bedside neurologic information that can supplement the physical examination. In critical care, this can be of particular value in patients who are unconscious with an equivocal neurologic examination because TCD findings can help the physician in decisions related to more definitive imaging studies and potential clinical interventions. Although TCD is traditionally the domain of sonographers and radiologists, there is increasing adoption of goal-directed TCD at the bedside in the critical care environment. The value of this approach includes round-the-clock availability and a goal-directed approach allowing for repeatability, immediate interpretation, and quick clinical integration. This paper presents a systematic approach to incorporating the highest yield TCD techniques into critical care bedside practice, and includes a series of illustrative figures and narrated video presentations to demonstrate the techniques described.
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Affiliation(s)
| | | | - Katie Wiskar
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Seth Koenig
- Hofstra North Shore - Long-Island Jewish School of Medicine, Hempstead, NY
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14
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The Role of Transcranial Doppler as a Monitoring Tool in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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15
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Robba C, Goffi A, Geeraerts T, Cardim D, Via G, Czosnyka M, Park S, Sarwal A, Padayachy L, Rasulo F, Citerio G. Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review. Intensive Care Med 2019; 45:913-927. [PMID: 31025061 DOI: 10.1007/s00134-019-05610-4] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/26/2019] [Indexed: 12/20/2022]
Abstract
Brain ultrasonography can be used to evaluate cerebral anatomy and pathology, as well as cerebral circulation through analysis of blood flow velocities. Transcranial colour-coded duplex sonography is a generally safe, repeatable, non-invasive, bedside technique that has a strong potential in neurocritical care patients in many clinical scenarios, including traumatic brain injury, aneurysmal subarachnoid haemorrhage, hydrocephalus, and the diagnosis of cerebral circulatory arrest. Furthermore, the clinical applications of this technique may extend to different settings, including the general intensive care unit and the emergency department. Its increasing use reflects a growing interest in non-invasive cerebral and systemic assessment. The aim of this manuscript is to provide an overview of the basic and advanced principles underlying brain ultrasonography, and to review the different techniques and different clinical applications of this approach in the monitoring and treatment of critically ill patients.
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Affiliation(s)
- Chiara Robba
- Department of Anaesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Geeraerts
- Department of Anaesthesia and Intensive Care, University Hospital of Toulouse, Toulouse NeuroImaging Center (ToNIC), Inserm-UPS, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Soojin Park
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University, New York, USA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Llewellyn Padayachy
- Department of Neurosurgery, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Frank Rasulo
- Department of Anaesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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16
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Abecasis F, Oliveira V, Robba C, Czosnyka M. Transcranial Doppler in pediatric emergency and intensive care unit: a case series and literature review. Childs Nerv Syst 2018; 34:1465-1470. [PMID: 29955941 DOI: 10.1007/s00381-018-3877-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/21/2018] [Indexed: 02/03/2023]
Abstract
PURPOSE Transcranial Doppler (TCD) has been used for more than 30 years in clinical practice. Although adult intensive care is relatively well covered, pediatric cases are still underrepresented. We intend to review a series of pediatric cases where TCD was determinant in clinical decisions and a literature review on this topic. METHODS We describe cases with different pathologies where TCD had an important role in clinical management of the patients. We discuss TCD utility and potential role both in the emergency department and the intensive care unit. RESULTS Five patients with different neurologic insults are presented. TCD was useful in the identification of intracranial hypertension in traumatic brain injury, hydrocephalus and central nervous system infection; identification of decreased cerebral perfusion pressure in hypovolemic shock and the diagnosis of impending cerebral circulatory arrest in a child with meningococcal septicemia. We discuss how TCD can be used in emergency and intensive care settings, reviewing relevant literature and our own experience. CONCLUSIONS Non-invasive testing using TCD can aid clinical decisions. More widespread use of this technique will allow for better care of children with neurologic insults.
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Affiliation(s)
- Francisco Abecasis
- Pediatric Intensive Care Unit, Centro Hospitalar Lisboa Norte, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
| | - Vitor Oliveira
- Department of Neurology, Centro Hospitalar Lisboa Norte, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Chiara Robba
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRSSS for Oncology, Genoa, Italy
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, UK.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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17
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Blood free Radicals Concentration Determined by Electron Paramagnetic Resonance Spectroscopy and Delayed Cerebral Ischemia Occurrence in Patients with Aneurysmal Subarachnoid Hemorrhage. Cell Biochem Biophys 2017; 75:351-358. [PMID: 28948569 PMCID: PMC5691099 DOI: 10.1007/s12013-017-0820-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 07/29/2017] [Indexed: 12/22/2022]
Abstract
Pathophysiology of delayed cerebral ischemia and cerebral vasospasm following aneurysmal subarachnoid hemorrhage is still poorly recognized, however free radicals are postulated as one of the crucial players. This study was designed to scrutinize whether the concentration of free radicals in the peripheral venous blood is related to the occurrence of delayed cerebral ischemia associated with cerebral vasospasm. Twenty-four aneurysmal subarachnoid hemorrhage patients and seven patients with unruptured intracranial aneurysm (control group) have been studied. Free radicals in patients’ blood have been detected by the electron paramagnetic resonance (CMH.HCl spin probe, 150 K, ELEXSYS E500 spectrometer) on admission and at least 72 h from disease onset. Delayed cerebral ischemia monitoring was performed by daily neurological follow-up and transcranial color coded Doppler. Delayed cerebral ischemia observed in six aneurysmal subarachnoid hemorrhage patients was accompanied by cerebral vasospasm in all six cases. No statistically significant difference in average free radicals concentration between controls and study subgroups was noticed on admission (p = .3; Kruskal–Wallis test). After 72 h free radicals concentration in delayed cerebral ischemia patients (3.19 ± 1.52 mmol/l) differed significantly from the concentration in aneurysmal subarachnoid hemorrhage patients without delayed cerebral ischemia (0.65 ± 0.37 mmol/l) (p = .012; Mann–Whitney test). These findings are consistent with our assumptions and seem to confirm the role of free radicals in delayed cerebral ischemia development. Preliminary results presented above are promising and we need perform further investigation to establish whether blood free radicals concentration may serve as the biomarker of delayed cerebral ischemia associated with cerebral vasospasm.
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18
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Viski S, Olah L. Use of Transcranial Doppler in Intensive Care Unit. ACTA ACUST UNITED AC 2017; 3:99-104. [PMID: 29967879 PMCID: PMC5769900 DOI: 10.1515/jccm-2017-0021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 07/21/2017] [Indexed: 11/25/2022]
Abstract
Use of transcranial Doppler has undergone much development since its introduction in 1982, making the technique suitable for general use in intensive care units. The main application in intensive care units is to assess intracranial pressure, confirm the lack of cerebral circulation in brain death, detect vasospasm in subarachnoid haemorrhage, and monitor the blood flow parameters during thrombolysis and carotid endarterectomy, as well as measuring stenosis of the main intracranial arteries in sickle cell disease in children. This review summarises the use of transcranial Doppler in intensive care units.
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Affiliation(s)
- Sandor Viski
- Department of Family and Occupational Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Laszlo Olah
- Department of Neurology, University of Debrecen, Móricz Zs. krt. 22, H-4032, Debrecen, Hungary
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19
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Vinciguerra L, Bösel J. Noninvasive Neuromonitoring: Current Utility in Subarachnoid Hemorrhage, Traumatic Brain Injury, and Stroke. Neurocrit Care 2017; 27:122-140. [PMID: 28004334 DOI: 10.1007/s12028-016-0361-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Noninvasive neuromonitoring is increasingly being used to monitor the course of primary brain injury and limit secondary brain damage of patients in the neurocritical care unit. Proposed advantages over invasive neuromonitoring methods include a lower risk of infection and bleeding, no need for surgical installation, mobility and portability of some devices, and safety. The question, however, is whether noninvasive neuromonitoring is practical and trustworthy enough already. We searched the recent literature and reviewed English-language studies on noninvasive neuromonitoring in subarachnoid hemorrhage, traumatic brain injury, and ischemic and hemorrhagic stroke between the years 2010 and 2015. We found 88 studies that were eligible for review including the methods transcranial ultrasound, electroencephalography, evoked potentials, near-infrared spectroscopy, bispectral index, and pupillometry. Noninvasive neuromonitoring cannot yet completely replace invasive methods in most situations, but has great potential being complementarily integrated into multimodality monitoring, for guiding management, and for limiting the use of invasive devices and in-hospital transports for imaging.
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Affiliation(s)
- Luisa Vinciguerra
- Department GF Ingrassia, Section of Neurosciences, University of Catania, Via Santa Sofia, 78, 95123, Catania, Italy
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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20
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Ryu J, Ko N, Hu X, Shadden SC. Numerical Investigation of Vasospasm Detection by Extracranial Blood Velocity Ratios. Cerebrovasc Dis 2017; 43:214-222. [PMID: 28241122 DOI: 10.1159/000454992] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/04/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Early diagnosis of vasospasm following subarachnoid hemorrhage can prevent cerebral ischemia and improve neurological outcomes. This study numerically evaluates the relevance of extracranial blood velocity indices to detect vasospasm. METHODS A numerical model of cerebral blood flow was used to evaluate the hemodynamics associated with anterior and posterior vasospasm under normal and impaired cerebral autoregulation conditions. Extracranial blood velocities at the carotid and vertebral arteries and their ratios between ipsilateral and contralateral, anterior and posterior, and downstream and upstream arteries were monitored during vasospasm progression. RESULTS For current clinical indices that track blood velocities at vasospastic arterial segments using transcranial Doppler (TCD), we observed that velocities increased initially and then decreased with vasospasm progression. This nonmonotonic behavior can lead to false-negative decisions in moderate to severe vasospasm. Alternatively, volumetric flow decreased monotonically at the affected arteries, leading to blood velocities upstream of the vasospastic artery also decreasing monotonically. Based on this principle, we demonstrate that velocity ratios between the carotid and vertebral arteries may better identify moderate to severe vasospasm and improve sensitivity and specificity of vasospasm detection. CONCLUSION The velocity indices proposed in this study may enable new or improved noninvasive diagnosis of vasospasm using extracranial Doppler ultrasound. Compared to current clinical indices, the new indices may improve the handling of (1) scenarios of severe vasospasm or impaired cerebral autoregulation, (2) systemic changes in blood pressure and cardiac output, (3) vasospasm occurring in arteries distal to the cerebral circle region, and (4) cases with insufficient acoustic bone window for TCD. The results provide a concrete basis for future clinical evaluation of extracranial indices for vasospasm detection.
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Affiliation(s)
- Jaiyoung Ryu
- School of Mechanical Engineering, Chung-Ang University, Seoul, Korea
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21
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Shakur SF, Aletich VA, Amin-Hanjani S, Hussein AE, Charbel FT, Alaraj A. Quantitative assessment of parent vessel and distal intracranial hemodynamics following pipeline flow diversion. Interv Neuroradiol 2016; 23:34-40. [PMID: 27703060 DOI: 10.1177/1591019916668842] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Pipeline embolization devices (PEDs) are commonly used for endovascular treatment of cerebral aneurysms but can be associated with delayed ipsilateral intraparenchymal hemorrhage. Although intra-aneurysmal hemodynamic changes have been studied, parent vessel and intracranial hemodynamics after PED use are unknown. We examine the impact of flow diversion on parent artery and distal intracranial hemodynamics. Method Patients with internal carotid cerebral aneurysms treated with PED who had flow volume rate, flow velocities, pulsatility index, resistance index, Lindegaard ratio, and wall shear stress (WSS) obtained after treatment using quantitative magnetic resonance angiography were reviewed. Means were compared between ipsilateral and contralateral internal carotid artery (ICA) and middle cerebral artery (MCA) using paired t tests. Results A total of 18 patients were included. Mean flow volume rate was lower in the ipsilateral versus contralateral ICA ( p = 0.04) but tended to be higher in the ipsilateral versus contralateral MCA ( p = 0.08). Lindegaard ratio was higher ipsilateral to the PED in diastole ( p = 0.05). Although there was no significant difference in flow velocities, pulsatility or resistance indices, and WSS, the two cases in our cohort with hemorrhagic complications did display significant changes in MCA flows and MCA WSS. Conclusion PED placement appears to alter the elasticity of the stented ICA segment, with lower flows in the ipsilateral versus contralateral ICA. Conversely, MCA flows and MCA WSS are higher in the ipsilateral MCA among patients with hemorrhage after PED placement, suggesting the role of disrupted distal hemodynamics in delayed ipsilateral intraparenchymal hemorrhage.
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Affiliation(s)
- Sophia F Shakur
- Department of Neurosurgery, University of Illinois at Chicago, USA
| | - Victor A Aletich
- Department of Neurosurgery, University of Illinois at Chicago, USA
| | | | - Ahmed E Hussein
- Department of Neurosurgery, University of Illinois at Chicago, USA
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, USA
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D'Andrea A, Conte M, Cavallaro M, Scarafile R, Riegler L, Cocchia R, Pezzullo E, Carbone A, Natale F, Santoro G, Caso P, Russo MG, Bossone E, Calabrò R. Transcranial Doppler ultrasonography: From methodology to major clinical applications. World J Cardiol 2016; 8:383-400. [PMID: 27468332 PMCID: PMC4958690 DOI: 10.4330/wjc.v8.i7.383] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/29/2016] [Accepted: 05/17/2016] [Indexed: 02/06/2023] Open
Abstract
Non-invasive Doppler ultrasonographic study of cerebral arteries [transcranial Doppler (TCD)] has been extensively applied on both outpatient and inpatient settings. It is performed placing a low-frequency (≤ 2 MHz) transducer on the scalp of the patient over specific acoustic windows, in order to visualize the intracranial arterial vessels and to evaluate the cerebral blood flow velocity and its alteration in many different conditions. Nowadays the most widespread indication for TCD in outpatient setting is the research of right to left shunting, responsable of so called "paradoxical embolism", most often due to patency of foramen ovale which is responsable of the majority of cryptogenic strokes occuring in patients younger than 55 years old. TCD also allows to classify the grade of severity of such shunts using the so called "microembolic signal grading score". In addition TCD has found many useful applications in neurocritical care practice. It is useful on both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoidal haemorrhage (caused by aneurysm rupture or traumatic injury), traumatic brain injury, brain stem death. It is used also to evaluate cerebral hemodynamic changes after stroke. It also allows to investigate cerebral pressure autoregulation and for the clinical evaluation of cerebral autoregulatory reserve.
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Affiliation(s)
- Antonello D'Andrea
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Marianna Conte
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Massimo Cavallaro
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Raffaella Scarafile
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Lucia Riegler
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Rosangela Cocchia
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Enrica Pezzullo
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Andreina Carbone
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Francesco Natale
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Giuseppe Santoro
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Pio Caso
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Maria Giovanna Russo
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Eduardo Bossone
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Raffaele Calabrò
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
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D'Andrea A, Conte M, Scarafile R, Riegler L, Cocchia R, Pezzullo E, Cavallaro M, Carbone A, Natale F, Russo MG, Gregorio G, Calabrò R. Transcranial Doppler Ultrasound: Physical Principles and Principal Applications in Neurocritical Care Unit. J Cardiovasc Echogr 2016; 26:28-41. [PMID: 28465958 PMCID: PMC5224659 DOI: 10.4103/2211-4122.183746] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Transcranial Doppler (TCD) ultrasonography is a noninvasive ultrasound study, which has been extensively applied on both outpatient and inpatient settings. It involves the use of a low-frequency (≤2 MHz) transducer, placed on the scalp, to insonate the basal cerebral arteries through relatively thin bone windows and to measure the cerebral blood flow velocity and its alteration in many different conditions. In neurointensive care setting, TCD is useful for both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, and brain stem death. It also allows to investigate the cerebrovascular autoregulation in setting of carotid disease and syncope. In this review, we will describe physical principles underlying TCD, flow indices most frequently used in clinical practice and critical care applications in Neurocritical Unit care.
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Affiliation(s)
- Antonello D'Andrea
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Marianna Conte
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Raffaella Scarafile
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Lucia Riegler
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Rosangela Cocchia
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Enrica Pezzullo
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Massimo Cavallaro
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Andreina Carbone
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Francesco Natale
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Maria Giovanna Russo
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Giovanni Gregorio
- Department of Cardiology, San Luca Hospital, Vallo della Lucania, Salerno, Italy
| | - Raffaele Calabrò
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
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Amyot F, Arciniegas DB, Brazaitis MP, Curley KC, Diaz-Arrastia R, Gandjbakhche A, Herscovitch P, Hinds SR, Manley GT, Pacifico A, Razumovsky A, Riley J, Salzer W, Shih R, Smirniotopoulos JG, Stocker D. A Review of the Effectiveness of Neuroimaging Modalities for the Detection of Traumatic Brain Injury. J Neurotrauma 2015; 32:1693-721. [PMID: 26176603 PMCID: PMC4651019 DOI: 10.1089/neu.2013.3306] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The incidence of traumatic brain injury (TBI) in the United States was 3.5 million cases in 2009, according to the Centers for Disease Control and Prevention. It is a contributing factor in 30.5% of injury-related deaths among civilians. Additionally, since 2000, more than 260,000 service members were diagnosed with TBI, with the vast majority classified as mild or concussive (76%). The objective assessment of TBI via imaging is a critical research gap, both in the military and civilian communities. In 2011, the Department of Defense (DoD) prepared a congressional report summarizing the effectiveness of seven neuroimaging modalities (computed tomography [CT], magnetic resonance imaging [MRI], transcranial Doppler [TCD], positron emission tomography, single photon emission computed tomography, electrophysiologic techniques [magnetoencephalography and electroencephalography], and functional near-infrared spectroscopy) to assess the spectrum of TBI from concussion to coma. For this report, neuroimaging experts identified the most relevant peer-reviewed publications and assessed the quality of the literature for each of these imaging technique in the clinical and research settings. Although CT, MRI, and TCD were determined to be the most useful modalities in the clinical setting, no single imaging modality proved sufficient for all patients due to the heterogeneity of TBI. All imaging modalities reviewed demonstrated the potential to emerge as part of future clinical care. This paper describes and updates the results of the DoD report and also expands on the use of angiography in patients with TBI.
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Affiliation(s)
- Franck Amyot
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - David B. Arciniegas
- Beth K. and Stuart C. Yudofsky Division of Neuropsychiatry, Baylor College of Medicine, Houston, Texas
- Brain Injury Research, TIRR Memorial Hermann, Houston, Texas
| | | | - Kenneth C. Curley
- Combat Casualty Care Directorate (RAD2), U.S. Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Ramon Diaz-Arrastia
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Amir Gandjbakhche
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Peter Herscovitch
- Positron Emission Tomography Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Sidney R. Hinds
- Defense and Veterans Brain Injury Center, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Silver Spring, Maryland
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Anthony Pacifico
- Congressionally Directed Medical Research Programs, Fort Detrick, Maryland
| | | | - Jason Riley
- Queens University, Kingston, Ontario, Canada
- ArcheOptix Inc., Picton, Ontario, Canada
| | - Wanda Salzer
- Congressionally Directed Medical Research Programs, Fort Detrick, Maryland
| | - Robert Shih
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - James G. Smirniotopoulos
- Department of Radiology, Neurology, and Biomedical Informatics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Derek Stocker
- Walter Reed National Military Medical Center, Bethesda, Maryland
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Diffuse Patterns of Nonaneurysmal Subarachnoid Hemorrhage Originating from the Basal Cisterns Have Predictable Vasospasm Rates Similar to Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2015; 24:795-801. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/22/2014] [Accepted: 11/14/2014] [Indexed: 11/20/2022] Open
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Cho SY, Lee DH, Shin HS, Lee SH, Koh JS, Jung WS, Moon SK, Park JM, Ko CN, Kim H, Park SU. The efficacy and safety of acupuncture for cerebral vasospasm after subarachnoid hemorrhage: study protocol for a randomized controlled trial. Trials 2015; 16:68. [PMID: 25886483 PMCID: PMC4352281 DOI: 10.1186/s13063-015-0591-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 02/06/2015] [Indexed: 11/10/2022] Open
Abstract
Background Subarachnoid hemorrhage (SAH) is a neurological disease with a high mortality rate. Several serious complications frequently arise after successful surgery for this condition. Cerebral vasospasm, one such complication, occurs in 50 to 70% of SAH patients. These patients suffer neurological symptoms known as delayed ischemic neurological deficit (DIND); however, the effect of treatment of vasospasm is limited. The major pathogenesis of cerebral vasospasm is the reduction of nitric oxide (NO) and activation of vasoconstrictors. Acupuncture is known to increase the production and activity of vascular endothelial cell-derived NO and improve endothelium-dependent vasodilatation. A preliminary retrospective case study to investigate the ability of acupuncture to prevent the occurrence of cerebral vasospasm has been conducted. However, no randomized, controlled clinical trials have been carried out to evaluate the efficacy of acupuncture for cerebral vasospasm. Methods/Design This trial will be a single-center, randomized, placebo-controlled, parallel group, patient-assessor-blinded clinical trial. A total of 80 patients with SAH will be randomized into two groups: a study group given acupuncture, electroacupuncture, and intradermal acupuncture, and a control group given mock transcutaneous electrical nerve stimulation and sham intradermal acupuncture. Intervention will start within 96 h after SAH, and a total of 12 sessions will be performed during a 2-week period. The primary outcome measure will be the occurrence of DIND, and the secondary outcomes will be vasospasm as measured by cerebral angiography, transcranial Doppler, clinical symptoms, vasospasm-related infarcts, NO and endothelin-1 plasma levels, mortality, and modified Rankin Scale scores. Discussion This trial will examine the efficacy and safety of acupuncture for cerebral vasospasm after SAH. The placebo effect will be excluded and the mechanism of action of the treatments will be evaluated through blood testing. Trial registration ClinicalTrials.gov NCT02275949, Registration date: 26 October 2014.
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Affiliation(s)
- Seung-Yeon Cho
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Dong-Hyuk Lee
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Hee Sup Shin
- Department of Neurosurgery, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Seung Hwan Lee
- Department of Neurosurgery, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Jun Seok Koh
- Department of Neurosurgery, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Woo-Sang Jung
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Sang-Kwan Moon
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Jung-Mi Park
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Chang-Nam Ko
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea.
| | - Ho Kim
- Department of Epidemiology and Biostatistics, Graduate School of Public Health & Institute of Health and Environment, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 151-742, Republic of Korea.
| | - Seong-Uk Park
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, Republic of Korea. .,Stroke & Neurological Disorders Center, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul, 134-727, Republic of Korea.
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Carpenter KLH, Czosnyka M, Jalloh I, Newcombe VFJ, Helmy A, Shannon RJ, Budohoski KP, Kolias AG, Kirkpatrick PJ, Carpenter TA, Menon DK, Hutchinson PJ. Systemic, local, and imaging biomarkers of brain injury: more needed, and better use of those already established? Front Neurol 2015; 6:26. [PMID: 25741315 PMCID: PMC4332345 DOI: 10.3389/fneur.2015.00026] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 01/30/2015] [Indexed: 02/02/2023] Open
Abstract
Much progress has been made over the past two decades in the treatment of severe acute brain injury, including traumatic brain injury and subarachnoid hemorrhage, resulting in a higher proportion of patients surviving with better outcomes. This has arisen from a combination of factors. These include improvements in procedures at the scene (pre-hospital) and in the hospital emergency department, advances in neuromonitoring in the intensive care unit, both continuously at the bedside and intermittently in scans, evolution and refinement of protocol-driven therapy for better management of patients, and advances in surgical procedures and rehabilitation. Nevertheless, many patients still experience varying degrees of long-term disabilities post-injury with consequent demands on carers and resources, and there is room for improvement. Biomarkers are a key aspect of neuromonitoring. A broad definition of a biomarker is any observable feature that can be used to inform on the state of the patient, e.g., a molecular species, a feature on a scan, or a monitoring characteristic, e.g., cerebrovascular pressure reactivity index. Biomarkers are usually quantitative measures, which can be utilized in diagnosis and monitoring of response to treatment. They are thus crucial to the development of therapies and may be utilized as surrogate endpoints in Phase II clinical trials. To date, there is no specific drug treatment for acute brain injury, and many seemingly promising agents emerging from pre-clinical animal models have failed in clinical trials. Large Phase III studies of clinical outcomes are costly, consuming time and resources. It is therefore important that adequate Phase II clinical studies with informative surrogate endpoints are performed employing appropriate biomarkers. In this article, we review some of the available systemic, local, and imaging biomarkers and technologies relevant in acute brain injury patients, and highlight gaps in the current state of knowledge.
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Affiliation(s)
- Keri L. H. Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,*Correspondence: Keri L. H. Carpenter, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK e-mail:
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Ibrahim Jalloh
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Virginia F. J. Newcombe
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Richard J. Shannon
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Karol P. Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter J. Kirkpatrick
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Thomas Adrian Carpenter
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - David K. Menon
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Westermaier T, Pham M, Stetter C, Willner N, Solymosi L, Ernestus RI, Vince GH, Kunze E. Value of transcranial Doppler, perfusion-CT and neurological evaluation to forecast secondary ischemia after aneurysmal SAH. Neurocrit Care 2015; 20:406-12. [PMID: 23982597 DOI: 10.1007/s12028-013-9896-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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.
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Affiliation(s)
- Thomas Westermaier
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany,
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Walcott BP, Patel AP, Stapleton CJ, Trivedi RA, Young AM, Ogilvy CS. Multiplexed protein profiling after aneurysmal subarachnoid hemorrhage: characterization of differential expression patterns in cerebral vasospasm. J Clin Neurosci 2014; 21:2135-2139. [PMID: 25082408 PMCID: PMC4250356 DOI: 10.1016/j.jocn.2014.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/14/2014] [Indexed: 11/19/2022]
Abstract
Cerebral vasospasm is a major contributor to delayed morbidity following aneurysmal subarachnoid hemorrhage. We sought to evaluate differential plasma protein levels across time in patients with aneurysmal subarachnoid hemorrhage to identify potential biomarkers and to better understand the pathogenesis of cerebral vasospasm. Nine female patients with aneurysmal subarachnoid hemorrhage underwent serial analysis of 239 different serum protein levels using quantitative, multiplexed immunoassays (DiscoveryMAP 250+ v2.0, Myriad RBM, Austin, TX, USA) on post-hemorrhage days 0 and 5. A repeated measures analysis of variance determined that mean protein concentration decreased significantly in patients who developed vasospasm versus those who did not for alpha-2-macroglobulin (F [1.00,7.00]=16.33, p=0.005), angiogenin (F [1.00,7.00]=7.65, p=0.028), apolipoprotein A-IV (F [1.00,7.00]=6.308, p=0.040), granulocyte colony-stimulating factor (F [1.00,7.00]=9.08, p=0.020), macrophage-stimulating protein (F [1.00,7.00]=24.21, p=0.002), tetranectin (F [1.00,7.00]=5.46, p<0.039), vascular endothelial growth factor receptor 3 (F [1.00,7.00]=6.94, p=0.034), and significantly increased for vitronectin (F [1.00,7.00]=5.79, p=0.047). These biomarkers may be of value in detecting cerebral vasospasm, possibly aiding in the identification of patients at high-risk prior to neurological deterioration.
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Affiliation(s)
- Brian P. Walcott
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA
| | - Anoop P. Patel
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA
| | - Christopher J. Stapleton
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA
| | - Rikin A. Trivedi
- Department of Neurosurgery, Addenbrooke’s Hospital and the University of Cambridge, Cambridge, UK
| | - Adam M.H. Young
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA
- Department of Neurosurgery, Addenbrooke’s Hospital and the University of Cambridge, Cambridge, UK
| | - Christopher S. Ogilvy
- Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW To present the practical aspects of transcranial Doppler (TCD) and provide evidence supporting its use for the management of traumatic brain injury (TBI) patients. RECENT FINDINGS TCD measures systolic, mean, and diastolic cerebral blood flow (CBF) velocities and calculates the pulsatility index from basal intracranial arteries. These variables reflect the brain circulation, provided there is control of potential confounding factors. TCD can be useful in patients with severe TBI to detect low CBF, for example, during intracranial hypertension, and to assess cerebral autoregulation. In the emergency room, TCD might complement brain computed tomography (CT) scan and clinical examination to screen patients at risk for further neurological deterioration after mild-to-moderate TBI. SUMMARY The diagnostic value of TCD should be incorporated into other findings from multimodal brain monitoring and CT scan to optimize the bedside management of patients with TBI and help guide the choice of appropriate therapies.
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Naqvi J, Yap KH, Ahmad G, Ghosh J. Transcranial Doppler ultrasound: a review of the physical principles and major applications in critical care. Int J Vasc Med 2013; 2013:629378. [PMID: 24455270 PMCID: PMC3876587 DOI: 10.1155/2013/629378] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 11/10/2013] [Indexed: 12/28/2022] Open
Abstract
Transcranial Doppler (TCD) is a noninvasive ultrasound (US) study used to measure cerebral blood flow velocity (CBF-V) in the major intracranial arteries. It involves use of low-frequency (≤2 MHz) US waves to insonate the basal cerebral arteries through relatively thin bone windows. TCD allows dynamic monitoring of CBF-V and vessel pulsatility, with a high temporal resolution. It is relatively inexpensive, repeatable, and portable. However, the performance of TCD is highly operator dependent and can be difficult, with approximately 10-20% of patients having inadequate transtemporal acoustic windows. Current applications of TCD include vasospasm in sickle cell disease, subarachnoid haemorrhage (SAH), and intra- and extracranial arterial stenosis and occlusion. TCD is also used in brain stem death, head injury, raised intracranial pressure (ICP), intraoperative monitoring, cerebral microembolism, and autoregulatory testing.
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Affiliation(s)
- Jawad Naqvi
- University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Kok Hooi Yap
- Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Gulraiz Ahmad
- Royal Oldham Hospital, Rochdale Road, Manchester OL1 2JH, UK
| | - Jonathan Ghosh
- University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
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Inflammation, cerebral vasospasm, and evolving theories of delayed cerebral ischemia. Neurol Res Int 2013; 2013:506584. [PMID: 24058736 PMCID: PMC3766617 DOI: 10.1155/2013/506584] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 06/26/2013] [Accepted: 06/26/2013] [Indexed: 11/23/2022] Open
Abstract
Cerebral vasospasm (CVS) is a potentially lethal complication of aneurysmal subarachnoid hemorrhage (aSAH). Recently, the symptomatic presentation of CVS has been termed delayed cerebral ischemia (DCI), occurring as early as 3-4 days after the sentinel bleed. For the past 5-6 decades, scientific research has promulgated the theory that cerebral vasospasm plays a primary role in the pathology of DCI and subsequently delayed ischemic neurological decline (DIND). Approximately 70% of patients develop CVS after aSAH with 50% long-term morbidity rates. The exact etiology of CVS is unknown; however, a well-described theory involves an antecedent inflammatory cascade with alterations of intracellular calcium dynamics and nitric oxide fluxes, though the intricacies of this inflammatory theory are currently unknown. Consequently, there have been few advances in the clinical treatment of this patient cohort, and morbidity remains high. Identification of intermediaries in the inflammatory cascade can provide insight into newer clinical interventions in the prevention and management of cerebral vasospasm and will hopefully prevent neurological decline. In this review, we discuss current theories implicating the inflammatory cascade in the development of CVS and potential treatment targets.
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Abstract
Transcranial Doppler (TCD) is a portable device that uses a handheld 2-MHz transducer. It is most commonly used in subarachnoid hemorrhage where cerebral blood flow velocities in major intracranial blood vessels are measured to detect vasospasm in the first 2 to 3 weeks. TCD is used to detect vasospasm in traumatic brain injury and post-tumor resection, measurement of cerebral autoregulation and cerebrovascular reactivity, diagnosis of acute arterial occlusions in stroke, screening for patent foramen ovale and monitoring of emboli. It can be used to detect abnormally high intracranial pressure and for confirmation of total cerebral circulatory arrest in brain death.
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Abstract
Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular disease. Outcome after SAH is mainly determined by the initial severity of the hemorrhage. Neuroimaging, in particular computed tomography, and aneurysm repair techniques, such as coiling and clipping, as well as neurocritical care management, have improved during the last few years. The management of a patient with SAH should have an interdisciplinary approach with case discussions between the neurointensivist, interventionalist and the neurosurgeon. The patient should be treated in a specialized neurointensive care unit of a center with sufficient SAH case volume. Poor-grade patients can be observed for complications and delayed cerebral ischemia through continuous monitoring techniques in addition to transcranial Doppler ultrasonography such as continuous electroencephalography, brain tissue oxygenation, cerebral metabolism, cerebral blood flow and serial vascular imaging. Neurocritical care should focus on neuromonitoring for delayed cerebral ischemia, management of hydrocephalus, seizures and intracranial hypertension, as well as of medical complications such as hyperglycemia, fever and anemia.
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Affiliation(s)
- Katja E Wartenberg
- Neurocritical Care Unit, Department of Neurology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120 Halle (Saale), Germany
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Yang TC, Chang CH, Liu YT, Chen YL, Tu PH, Chen HC. Predictors of shunt-dependent chronic hydrocephalus after aneurysmal subarachnoid haemorrhage. Eur Neurol 2013; 69:296-303. [PMID: 23445755 DOI: 10.1159/000346119] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 11/24/2012] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Chronic hydrocephalus is a common complication that can occur after aneurysmal subarachnoid haemorrhage (SAH). The purpose of this study was to investigate clinical risk factors that could predict the occurrence of shunt-dependent chronic hydrocephalus after aneurysmal SAH. METHODS Eighty-eight consecutive patients who underwent either surgery or transarterial endovascular embolization as a treatment for cerebral aneurysm within 72 h -after experiencing SAH from March 2005 to July 2006 were studied retrospectively to assess the risk factors that might predict shunt-dependent chronic hydrocephalus. Clinical and demographic factors were examined, including age, sex, initial admission mean arterial blood pressure (MABP), blood sugar level at admission, fever frequency, initial external ventricular drainage (EVD), Fisher grade, Hunt and Hess grade, intraventricular haemorrhage (IVH) and treatment methods to define predictors of shunt-dependent hydrocephalus. The length of hospital stay and modified Rankin scale recorded 6 months after SAH were also evaluated; these parameters were compared between the shunt-dependent and non-shunt-dependent groups. RESULTS Of the 88 patients, 22 (25%) underwent shunt placement to treat their chronic hydrocephalus. The average length of hospital stay was 33.9 days for the shunt-treated group and 14 days for the non-shunt-treated group. The non-shunt-treated group scored an average of 1.05 on the modified Rankin scale compared with 2.77 for the shunt-treated group. A univariate analysis revealed that several admission variables were associated with long-term shunt-dependent hydrocephalus: (1) increased age (p = 0.023); (2) initial admission MABP (p = 0.027); (3) a high Fisher grade (p = 0.031); (4) a poor admission Hunt and Hess grade (p = 0.030); (5) the presence of IVH (p = 0.029), and (6) initial EVD (p < 0.0001). The factor most commonly associated with shunt-dependent hydrocephalus over the course of hospital days was fever frequency (p < 0.0001). CONCLUSIONS Chronic hydrocephalus after aneurysmal SAH has a multifactorial aetiology. Understanding the risk factors that predict the occurrence of chronic hydrocephalus may help neurosurgeons to expedite permanent cerebrospinal fluid diversion, which could decrease both the cost and length of hospital stay and prevent further complications.
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Affiliation(s)
- Tao-Chieh Yang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Keelung, Taiwan, ROC. jade5048 @ yahoo.com.tw
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Razumovsky A, Tigno T, Hochheimer SM, Stephens FL, Bell R, Vo AH, Severson MA, Marshall SA, Oppenheimer SM, Ecker R, Armonda RA. Cerebral hemodynamic changes after wartime traumatic brain injury. ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 115:87-90. [PMID: 22890651 DOI: 10.1007/978-3-7091-1192-5_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Traumatic brain injury (TBI) is associated with the severest casualties from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). From October 1, 2008, the U.S. Army Medical Department initiated a transcranial Doppler (TCD) ultrasound service for TBI; included patients were retrospectively evaluated for TCD-determined incidence of post-traumatic cerebral vasospasm and intracranial hypertension after wartime TBI. Ninety patients were investigated with daily TCD studies and a comprehensive TCD protocol, and published diagnostic criteria for vasospasm and increased intracranial pressure (ICP) were applied. TCD signs of mild, moderate, and severe vasospasms were observed in 37%, 22%, and 12% of patients, respectively. TCD signs of intracranial hypertension were recorded in 62.2%; 5 patients (4.5%) underwent transluminal angioplasty for post-traumatic clinical vasospasm treatment, and 16 (14.4%) had cranioplasty. These findings demonstrate that cerebral arterial spasm and intracranial hypertension are frequent and significant complications of combat TBI; therefore, daily TCD monitoring is recommended for their recognition and subsequent management.
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Topcuoglu MA. Transcranial Doppler ultrasound in neurovascular diseases: diagnostic and therapeutic aspects. J Neurochem 2012; 123 Suppl 2:39-51. [PMID: 23050641 DOI: 10.1111/j.1471-4159.2012.07942.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Albeit no direct anatomical information can be obtained, neurosonological methods provide real-time determination of velocity, and spectral waveform of blood flow in basal intracranial arteries adds significant benefit to the care of the patients with neurovascular diseases. Several features, such as relative simplicity in terms of interpretation and performance, significantly low cost, totally non-invasiveness, portability, and excellent temporal resolution, make neurosonology increasingly popular tool for evaluation, planning, and monitoring of treatment, and for determining prognosis in various neurovascular diseases. Usefulness of transcranial Doppler in diagnosing/monitoring subarachnoid hemorrhage related vasospasm and sickle cell vasculopathy is already well known. Utility in diagnosis of intracranial arterial stenosis, acute occlusion and recanalization, intracranial hemodynamic effect of the cervical arterial pathologies, intracranial pressure increase, and cerebral circulatory arrest are also well established. Neurosonological determination of vasomotor reactivity, cerebral autoregulation, neurovascular coupling, and micro-embolic signals detection are useful in the assessment of stroke risk, diagnosis of right-to-left shunting, and monitoring during surgery and interventional procedures. Transcranial Doppler is also an evolving ultrasound method with a therapeutic potential such as augmentation of clot lysis and cerebral delivery of thrombolytic or neuroprotective agent loaded nanobubbles in neurovascular diseases. The aim of this study is to give an overview of current usage of the different ultrasound modalities in different neurovascular diseases.
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Affiliation(s)
- M Akif Topcuoglu
- Hacettepe University Hospitals, Department of Neurology, Neurosonology Laboratory, Neurological Intensive Care Unit, Ankara, Turkey.
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[Sonographic diagnostics in neurological emergency and intensive care medicine]. Med Klin Intensivmed Notfmed 2012; 108:131-8. [PMID: 23070330 DOI: 10.1007/s00063-012-0146-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 05/14/2012] [Accepted: 07/03/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND This article gives an up-to-date overview of neurosonographic emergency and intensive care diagnostics. METHODS Selective literature research from 1984 with critical appraisal and including national and international guidelines. RESULTS Fast and valid diagnostics in acute stroke is the main field of application of neurosonography. Specific monitoring methods bear great advantages for intensive care patients, especially "as-often-as-wanted" repetitive imaging under real-time conditions. A number of new developments make neurosonography an interesting area of research. CONCLUSIONS Neurosonography has played a key role in neurological emergency and intensive care medicine for many years. It remains important to continuously support dissemination of the method.
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Value of Perfusion CT, Transcranial Doppler Sonography, and Neurological Examination to Detect Delayed Vasospasm after Aneurysmal Subarachnoid Hemorrhage. Radiol Res Pract 2012; 2012:231206. [PMID: 23050146 PMCID: PMC3462401 DOI: 10.1155/2012/231206] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Accepted: 08/16/2012] [Indexed: 11/23/2022] Open
Abstract
Background. If detected in time, delayed cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) may be treated by balloon angioplasty or chemical vasospasmolysis in order to enhance cerebral blood flow (CBF) and protect the brain from ischemic damage. This study was conceived to compare the diagnostic accuracy of detailed neurological examination, Transcranial Doppler Sonography (TCD), and Perfusion-CT (PCT) to detect angiographic vasospasm. Methods. The sensitivity, specificity, positive and negative predictive values of delayed ischemic neurological deterioration (DIND), pathological findings on PCT-maps, and accelerations of the mean flow velocity (MVF) were calculated. Results. The accuracy of DIND to predict angiographic vasospasm was 0.88. An acceleration of MFV in TCD (>140 cm/s) had an accuracy of 0.64, positive PCT-findings of 0.69 with a higher sensitivity, and negative predictive value than TCD. Interpretation. Neurological assessment at close intervals is the most sensitive and specific parameter for cerebral vasospasm. PCT has a higher accuracy, sensitivity and negative predictive value than TCD. If detailed neurological evaluation is possible, it should be the leading parameter in the management and treatment decisions. If patients are not amenable to detailed neurological examination, PCT at regular intervals is a helpful tool to diagnose secondary vasospasm after aneurysmal SAH.
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Malhotra K, Conners JJ, Lee VH, Prabhakaran S. Relative changes in transcranial Doppler velocities are inferior to absolute thresholds in prediction of symptomatic vasospasm after subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2012; 23:31-6. [PMID: 22959107 DOI: 10.1016/j.jstrokecerebrovasdis.2012.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 07/25/2012] [Accepted: 08/05/2012] [Indexed: 10/27/2022] Open
Abstract
The absolute transcranial Doppler (TCD) velocity threshold has been validated as a screening tool for vasospasm after subarchnoid hemorrhage (SAH). We assessed whether relative changes in velocity were superior to absolute TCD thresholds in the detection of symptomatic vasospasm. We reviewed consecutive patients with aneurysmal SAH who underwent serial TCD monitoring and survived at least 7 days. We recorded initial flow velocity (IFV) and maximal flow velocity (MFV) of the middle cerebral artery (MCA) serially up to 14 days from admission. We calculated relative flow velocity changes (MFV/IFV) and maximum change in mean flow velocity (FVmean) over any consecutive 2 days in addition to standard absolute measures of Lindegaard ratio (LR) and FVmean. We calculated receiver operating characteristic curve and area under curve (AUC) values, sensitivity, specificity, and positive predictive and negative predictive values for these parameters, optimal cutpoints, and various combinations. Forty-eight of 211 patients (23%) developed symptomatic MCA vasospasm. AUC values for various TCD parameters were 0.80 for MCA MFV >175 cm/s, 0.71 for LR >6, 0.64 for MFV/IFV >2, and 0.64 for >70% change in MFV over 2 days. The best characteristics were observed for the combination of MFV >175 cm/s and/or maximal LR >6 (AUC 0.81). Our data suggest that absolute thresholds of TCD FVmean provide the most accurate prediction of symptomatic MCA vasospasm after SAH. Other thresholds, including relative change from baseline and day-to-day changes, are inferior to established absolute thresholds.
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Affiliation(s)
- Konark Malhotra
- Department of Neurological Sciences, Allegheny General Hospital, Pittsburgh, Pennsylvania.
| | - James J Conners
- Section of Cerebrovascular Disease and Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois
| | - Vivien H Lee
- Section of Cerebrovascular Disease and Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois
| | - Shyam Prabhakaran
- Division of Stroke, Department of Neurology, Northwestern University-Feinberg School of Medicine, Chicago, Illinois
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Chhor V, Le Manach Y, Clarençon F, Nouet A, Daban JL, Abdennour L, Puybasset L, Lescot T. Admission risk factors for cerebral vasospasm in ruptured brain arteriovenous malformations: an observational study. Crit Care 2011; 15:R190. [PMID: 21831293 PMCID: PMC3387632 DOI: 10.1186/cc10345] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Revised: 06/25/2011] [Accepted: 08/10/2011] [Indexed: 11/10/2022] Open
Abstract
Introduction Cerebral vasospasm is a well-documented complication of aneurismal subarachnoid hemorrhage but has not been extensively studied in brain arteriovenous malformations (BAVMs). Here, our purpose was to identify risk factors for cerebral vasospasm after BAVM rupture in patients requiring intensive care unit (ICU) admission. Methods Patients admitted to our ICU from January 2003 to May 2010 for BAVM rupture were included in this observational study. Clinical, laboratory and radiological features from admission to ICU discharge were recorded. The primary endpoint was cerebral vasospasm by transcranial Doppler (TCD-VS) or cerebral infarction (CI) associated with vasospasm. Secondary endpoints included the Glasgow Outcome Scale (GOS) at ICU discharge. Results Of 2,734 patients admitted to our ICU during the study period, 72 (2.6%) with ruptured BAVM were included. TCD-VS occurred in 12 (17%) and CI in 6 (8%) patients. All patients with CI had a previous diagnosis of TCD-VS. A Glasgow Coma Scale score <8 was a risk factor for both TCD-VS (relative risk (RR), 4.7; 95% confidence interval (95% CI), 1.6 to 26) and CI (RR, 7.8; 95% CI, 0.1 to 63). Independent risk factors for TCD-VS by multivariate analysis were lower Glasgow Coma Scale score (odds ratio (OR) per unit decrease, 1.38; 95% CI, 1.13 to 1.80), female gender (OR, 4.86; 95% CI, 1.09 to 25.85), and younger age (OR per decade decrease, 1.39; 95% CI, 1.05 to 1.82). The risk of a poor outcome (GOS <4) at ICU discharge was non-significantly increased in the patients with TCD-VS (RR, 4.9; 95% CI, 0.7 to 35; P = 0.09). All six patients with CI had poor outcomes. Conclusions This is the first cohort study describing the incidence and risk factors for cerebral vasospasm after BAVM rupture. Larger studies are needed to investigate the significance of TCD-vasospasm and CI in these patients.
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Affiliation(s)
- Vibol Chhor
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie- Paris 6, 47-83 boulevard de l'hôpital, Paris 75651, France
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Cho WS, Kang HS, Kim JE, Kwon OK, Oh CW, Son YJ, Know BJ, Jung C, Hang MH. Intra-arterial nimodipine infusion for cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. Interv Neuroradiol 2011; 17:169-78. [PMID: 21696654 DOI: 10.1177/159101991101700205] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 01/31/2011] [Indexed: 11/15/2022] Open
Abstract
This study evaluated the efficacy of intra-arterial nimodipine infusion for symptomatic vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). Clinical data collected from 42 consecutive patients with symptomatic vasospasm after aSAH were retrospectively reviewed. Forty-two patients underwent 101 sessions of intra-arterial nimodipine infusion. Angiographic response, immediate clinical response, and clinical outcome were evaluated at discharge and six months later. Angiographic improvement was achieved in 82.2% of patients. The immediate clinical improvement rate was 68.3%, while the deterioration rate was 5.0%. A favorable clinical outcome was achieved in 76.2% at discharge and 84.6% six months. Vasospasm-related infarction occurred in 21.4%. There was no drug-related complication. The nimodipine group showed satisfactory outcomes. Nimodipine can be recommended as an effective and safe intra-arterial agent for the treatment of symptomatic vasospasm after aSAH.
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Affiliation(s)
- W-S Cho
- Department of Neurosurgery, Kangwon National University Hospital, School of Medicine, Chuncheon, Gangwon-do, Korea
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Eggers C, Liu W, Brinker G, Fink GR, Burghaus L. Do negative CCT and CSF findings exclude a subarachnoid haemorrhage? A retrospective analysis of 220 patients with subarachnoid haemorrhage. Eur J Neurol 2011; 18:300-305. [DOI: 10.1111/j.1468-1331.2010.03168.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- C. Eggers
- Department of Neurology, University Hospital Cologne, Cologne
| | - W. Liu
- Department of Neurology, University Hospital Cologne, Cologne
| | - G. Brinker
- Department of Neurosurgery, University Hospital Cologne, Cologne, Germany
| | - G. R. Fink
- Department of Neurology, University Hospital Cologne, Cologne
| | - L. Burghaus
- Department of Neurology, University Hospital Cologne, Cologne
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Vasospasm after subarachnoid hemorrhage: a 3D rotational angiography study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 110:221-5. [PMID: 21125475 DOI: 10.1007/978-3-7091-0356-2_40] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE the purpose of this study was to investigate the clinical value of 3D rotational angiography (3DRA) for evaluation of cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage (SAH) by comparison with 2D digital subtraction angiography (DSA). METHODS forty-six patients who had undergone 2D DSA and 3DRA for evaluation of cerebral vasospasm following SAH were retrospectively analyzed. 3DRA was routinely performed after standard 2D DSA. 3D volume rendering images were created from 3DRA dataset and compared with DSA for the detection and characterization of vasospasm. RESULTS Of the 46 patients investigated, 25 had vasospasm on 2D DSA images. No vasospasm was observed in 21 patients with aneurysmal SAH. According to the reference standard of DSA, 46 spastic segments were found in 25 patients with vasospasms. A total of 51 spastic segments were found on 3DRA volume rendering angiograms. The sensitivity, specificity, positive and negative predictive values of 3DRA for detecting vasospasm were 100, 76, 90, 100%, respectively. CONCLUSION the pseudo-spasm phenomenon was frequently observed on 3DRA volume rendering images. 3DRA was less useful than 2D DSA for evaluation of vasospasm after SAH.
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Alexandrov AV, Sloan MA, Tegeler CH, Newell DN, Lumsden A, Garami Z, Levy CR, Wong LK, Douville C, Kaps M, Tsivgoulis G. Practice Standards for Transcranial Doppler (TCD) Ultrasound. Part II. Clinical Indications and Expected Outcomes. J Neuroimaging 2010; 22:215-24. [DOI: 10.1111/j.1552-6569.2010.00523.x] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Milrinone as a rescue therapy for symptomatic refractory cerebral vasospasm in aneurysmal subarachnoid hemorrhage. Neurocrit Care 2010; 11:165-71. [PMID: 18202923 DOI: 10.1007/s12028-008-9048-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Delayed ischemic neurological deficit associated to cerebral vasospasm is the most common cause of sequelae and death that follows the rupture of an aneurysm. The objective of this study was to evaluate the safety and efficacy of intra-arterial Milrinone in patients with symptomatic refractory cerebral vasospasm. PATIENTS AND METHOD Eight patients diagnosed with aneurysmal subarachnoid hemorrhage who developed symptomatic cerebral vasospasm refractory to conventional medical therapy were enrolled. They received an intra-arterial infusion of Milrinone at a rate of 0.25 mg/min, with a total dose of 10-15 mg. Qualitative evaluation of angiographic response, neurological and systemic complications as well as functional outcome at 3 months were documented. RESULTS All patients had a significant angiographic response. This was evidenced by a pre-treatment vessel stenosis greater than 70%, that improved to less than 50% after the intra-arterial Milrinone infusion. Three patients developed recurrent vasospasm that improved after a second intra-arterial Milrinone infusion. None of the patients developed neurologic or systemic complications attributed to the intervention. At 3 months follow-up all patients were alive and had a mean modified Rankin scale of 2 +/- 1 and a Barthel index of 83 +/- 10. CONCLUSION Intra-arterial Milrinone infusion seems to be a safe and effective treatment for patients who develop refractory symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage.
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Nogueira RG, Bodock MJ, Koroshetz WJ, Topcuoglu MA, Carter BS, Ogilvy CS, Pryor JC, Buonanno FS. High-dose bosentan in the prevention and treatment of subarachnoid hemorrhage-induced cerebral vasospasm: an open-label feasibility study. Neurocrit Care 2008; 7:194-202. [PMID: 17901934 DOI: 10.1007/s12028-007-0070-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the safety of high-dosages of the endothelin ET(A/B )receptor antagonist bosentan in SAH patients at high-vasospasm risk. METHODS Ten Fisher group-3 SAH patients, enrolled within 96 h of ictus, received bosentan in a dose-escalation manner (20, 30, 40 mg/kg/day orally every 4 hours on treatment days 1, 2, and 3 respectively, to a maximum dose of 4000 mg/day), followed by maintenance of the maximum tolerated dose until 14 days post-SAH or vasospasm resolution. Further management followed standard protocols: nimodipine in all patients; daily transcranial Doppler (TCD); "triple-H"/endovascular treatment, as indicated. RESULTS Two of the ten patients never developed any clinical or TCD signs of vasospasm; the other eight patients exhibited some elevation of TCD velocities during the vasospasm watch period. Four of the eight patients remained asymptomatic; of them, one had only mild elevation on peak systolic velocities, thought to represent hyperemia. The other three were further assessed with CT-angiography; this revealed moderate vasospasm (asymptomatic) in only one patient. The remaining four patients developed symptomatic vasospasm requiring endovascular treatment; two developed cerebral infarction; both had started bosentan relatively later than the other subjects. The most common adverse drug effects were flushing and transient liver enzyme elevations, reversible in all. Two patients had ALT/AST elevations >3x normal limit, requiring bosentan-dose reduction or discontinuation (one case each). CONCLUSION High-dose bosentan (up to 40 mg/kg/day) appears to be safe in SAH patients at high risk of developing vasospasm. Further studies are required to properly investigate the efficacy of this regimen in the prevention and treatment of SAH-induced vasospasm.
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Affiliation(s)
- Raul G Nogueira
- Neurocritical Care and Vascular Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Abstract
Perhaps the greatest recent controversy in the medical management of complex neurologic and neurosurgical patients has been the defining of the optimal care arena. Despite some early skepticism and measured recognition by the ICU community, neurosciences critical care has grown into a well-recognized subspecialty. Within this environment, the diverse expertise of surgeons, neurologists, and anesthesiologists come together to define best therapeutic strategies. Two neurologic disease states that, in particular, continue to elicit expansive interdisciplinary debate are spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- J Ricardo Carhuapoma
- Neurosciences Critical Care Division, Department of Neurology, The Johns Hopkins Hospital, 600 North Wolfe Street, Mayer 8-140, Baltimore, MD 21287, USA
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Cattivelli FS, Sayed AH, Hu X, Lee D, Vespa P. Mathematical models of cerebral hemodynamics for detection of vasospasm in major cerebral arteries. ACTA NEUROCHIRURGICA. SUPPLEMENT 2008; 102:63-9. [PMID: 19388290 PMCID: PMC2673531 DOI: 10.1007/978-3-211-85578-2_13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Vasospasm is a common complication of aneurismal subarachnoid hemorrhage (SAH) that may lead to cerebral ischemia and death. The standard method for detection of vasospasm is conventional cerebral angiography, which is invasive and does not allow continuous monitoring of arterial radius. Monitoring of vasospasm is typically performed by measuring Cerebral Blood Flow Velocity (CBFV) in the major cerebral arteries and calculating the Lindegaard ratio. We describe an alternative approach to estimate intracranial arterial radius, which is based on modeling and state-estimation techniques. The objective is to obtain a better estimation than that offered by the Lindegaard ratio, that might allow for continuous monitoring and possibly vasospam prediction without the need for angiography. METHODS We propose two new models of cerebral hemodynamics. Model 1 is a more general version of Ursino's 1991 model that includes the effects of vasospasm, and Model 2 is a simplified version of Model 1. We use Model 1 to generate Intracranial Pressure (ICP) and CBFV signals for different vasospasm conditions, where CBFV is measured at the middle cerebral artery (MCA). Then we use Model 2 to estimate the arterial radii from these signals. FINDINGS Simulations show that Model 2 is capable of providing good estimates for the radius of the MCA, allowing the detection of the vasospasm. These changes in arterial radius are being estimated from measurements of CBFV, and CBF is never being measured directly. This is the main advantage of the model-based approach where several interrelations between CBFV, ABP and ICP are taken into account by the differential equations of the model. CONCLUSIONS Our results indicate that arterial radius may be estimated using measurements of ABP, ICP and CBFV, allowing the detection of vasospasm.
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Affiliation(s)
- Federico S Cattivelli
- Electrical Engineering Department, University of California Los Angeles, 44-123 Engineering IV Building, Los Angeles, CA 90095, USA.
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Aplicaciones del dúplex transcraneal codificado en color en la monitorización del enfermo neurocrítico. Med Intensiva 2007; 31:510-7. [DOI: 10.1016/s0210-5691(07)74858-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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