Accuracy of transcranial Doppler sonography for predicting cerebral infarction in aneurysmal subarachnoid hemorrhage

PURPOSE: To evaluate the accuracy of transcranial Doppler (TCD) sonography using different criteria for predicting cerebral infarction due to symptomatic vasospasm. METHODS: We retrospectively evaluated the clinical and radiologic data of consecutive patients admitted with acute aneurysmal subarachnoid hemorrhage (SAH) in the anterior cerebral circulation between January 2001 and June 2002. TCD sonographic examinations were performed on alternate days up to 20 days after admission. Cerebral infarction was defined on CT as a new hypodensity in the vascular distribution with corresponding clinical symptoms. Vasospasm was diagnosed as mild or severe when TCD sonography revealed a mean blood flow velocity (MBFV) greater than 120 and 180 cm/s in the middle or anterior cerebral artery and in the intracranial part of the internal carotid artery, respectively. RESULTS: A total of 93 patients with aneurysmal SAH in the anterior cerebral circulation were included. Vasospasm was demonstrated by TCD sonography in 60 patients (64.5%) and was shown via multivariable logistic regression analysis to be predictive of cerebral infarction (OR 3.11, 95% CI 1.46-6.59), with an 82.6% and 69.6% sensitivity, a 41.4% and 77.1% specificity, a 31.7% and 50.0% positive predictive value, and an 87.9% and 88.5% negative predictive value when the MBFV was greater than 120 and 180 cm/s, respectively. CONCLUSIONS: Vasospasm on TCD was found to be predictive of symptomatic cerebral infarction on CT, but its positive predictive value remained low despite the adoption of restrictive TCD criteria for vasospasm.     

Assessment of middle cerebral artery diameter after aneurysmal subarachnoid hemorrhage by transcranial color-coded duplex sonography.

This study examined if vasospasm after aneurysmal subarachnoid hemorrhage could be visualized by middle cerebral artery (MCA) diameter changes in transcranial color-coded duplex sonography (TCCS). Comparative measurements between mean blood velocity (MBV) and MCA diameter were carried out in 17 patients in 76 instances. At two depth ranges (proximal, 60 55 mm: distal, 50-45 mm) two observers assessed the MCA diameter as indicated by the visualized blood flow column. At both points of measurement, the diameter differences between the two observers were within the ? 2 S.D. range of the mean difference indicating interobserver agreement. In 17 instances, MBV was > 120 cm/s indicating vasospasm but MBV did not correlate with absolute or relative diameter changes. MCA diameter assessment in TCCS seems reproducible. Because TCCS imaging is influenced by several factors comparative angiographic studies are necessary to clarify the TCCS findings.     

The accuracy of transcranial Doppler to detect vasospasm in patients with aneurysmal subarachnoid hemorrhage

OBJECTIVES. To examine the accuracy of transcranial Doppler to detect cerebral vasospasm in a patient population with aneurysmal subarachnoid hemorrhage. DESIGN. Prospective blind comparison of transcranial Doppler with cerebral angiography. Diagnostic accuracy of transcranial Doppler was assessed using receiver operating characteristic (ROC) analysis and likelihood ratios. Sensitivity and specificity were calculated using directly measured middle cerebral artery diameter as reference standard. SETTING. Intensive Care Unit of a large university teaching hospital. PATIENTS AND PARTICIPANTS. Twenty-two patients with subarachnoid hemorrhage were included. Patients underwent angiography on admission and after 8 days to diagnose vasospasm and were defined as having clinical vasospasm, angiographic vasospasm, or no vasospasm. MEASUREMENTS AND RESULTS. Sensitivity and specificity were 1.00 and 0.75 for angiographic vasospasm and both equal to 1.00 for clinical vasospasm diagnosis. A transcranial Doppler mean velocity threshold value of 100 cm/s for angiographic vasospasm and 160 cm/s for clinical vasospasm detection were chosen by ROC analysis. CONCLUSIONS. A Transcranial Doppler mean velocity threshold of 160 cm/s, calculated by the ROC analysis, accurately detects clinical vasospasm. A daily transcranial Doppler examination performed by a trained operator should be routinely used to provide early identification of patients at high risk and to orient therapeutic decisions.     

Vasospasm after aneurysmal subarachnoid hemorrhage

Despite every effort, 13% of patients with SAH still die or are permanently disabled as a consequence of vasospasm. Optimal outcome after aneurysmal SAH depends on careful assessment and management of patients throughout the course of hospitalization. Critical care nurses play a crucial role in this process. Efforts continue to understand the cascade of events that lead to cerebral vasospasm and to develop more effective treatments. Many therapies, both traditional and new, are being investigated to reduce the incidence of symptomatic vasospasm and improve the lives of patients who experience this devastating condition.     

动脉瘤性蛛网膜下腔出血后再出血分析

目的 评估动脉瘤性蛛网膜下腔出血（aSAH）后再出血的临床特征及危险因素,为aSAH再出血的预防提供指导。方法 对12例再出血患者的临床特征、影像学资料、治疗及预后进行分析。结果 12例再出血患者首发症状表现为头痛10例（83％）,意识障碍8例（67％）;入院时Hunt Hess评分Ⅲ~Ⅳ级8例（67%）,改良Fisher Ⅲ~Ⅳ级10例（83%）。在SAH后的最初24小时内发生再出血7例（58％）。入院后再出血时平均动脉压显著增加。再出血患者责任动脉瘤位于大脑前动脉（ACA）及前交通动脉（AComA）4例（33％）,多发动脉瘤5例（42％）,所有患者均对动脉瘤进行处理。SAH后并发急性脑积水9例（75％）,行脑室外引流6例（50%）,减压颅骨切除术1例（8%）,最终死亡5例（42％）。结论 SAH后院内再出血死亡率高、预后差,积极干预危险因素,从而减少残疾率及病死率。     

Plasma gelsolin levels and outcomes after aneurysmal subarachnoid hemorrhage

Introduction

Lower gelsolin levels have been associated with the severity and poor outcome of critical illness. Nevertheless, their link with clinical outcomes of aneurysmal subarachnoid hemorrhage is unknown. Therefore, we aimed to investigate the relationship between plasma gelsolin levels and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage.

Methods

A total of 262 consecutive patients and 150 healthy subjects were included. Plasma gelsolin levels were measured by enzyme-linked immunosorbent assay. Mortality and poor long-term outcome (Glasgow Outcome Scale score of 1-3) at 6 months were recorded.

Results

Plasma gelsolin levels on admission were substantially lower in patients than in healthy controls (66.9 (26.4) mg/L vs. 126.4 (35.4) mg/L, P < 0.001), and negatively associated with World Federation of Neurological Surgeons score (r = -0.554, P < 0.001) and Fisher score (r = -0.538, P < 0.001), and identified as an independent predictor of poor functional outcome (odds ratio, 0.957; 95% confidence interval (CI), 0.933-0.983; P = 0.001) and death (odds ratio, 0.953; 95% CI, 0.917-0.990; P = 0.003) after 6 months. The areas under the ROC curve of gelsolin for functional outcome and mortality were similar to those of World Federation of Neurological Surgeons score and Fisher score (all P > 0.05). Gelsolin improved the predictive values of World Federation of Neurological Surgeons score and Fisher score for functional outcome (both P < 0.05), but not for mortality (both P > 0.05).

Conclusions

Gelsolin levels are a useful, complementary tool to predict functional outcome and mortality 6 months after aneurysmal subarachnoid hemorrhage.     

Vasospasm after head injury studied by transcranial Doppler sonography

During the past 2 years cerebral blood flow velocity was measured serially first of all in the middle cerebral arteries and in the bifurcation of the carotid arteries, less frequently in the other basal arteries by transcranial Doppler sonography in 36 head injured patients selected from 87 cerebral contusions and intracranial haematomas. Raised flow velocity referring to cerebral vasospasm was observed in 14 (40%) of 36 cases. Vasospasm developed between the 2nd and 8th days in the basal arteries, never on the first day. It was classified as slight (over 120 cm/sec) and sever (over 160 cm/sec) in the case of vasospasm lasting for several days. Development of vasospasm could be justified in 6 from 14 control angiographies. Authors' observations are compared with some literary data of traumatic vasospasm. The theoretical significance and practical usefulness of transcranial Doppler sonography in the study and follow up of the blood flow of the injured brain, especially in traumatic vasospasm, are emphasized.     

Case studies in cardiac dysfunction after acute aneurysmal subarachnoid hemorrhage

Patients with acute aneurysmal subarachnoid hemorrhage (SAH) often present with more than just neurological compromise. A wide spectrum of complicating cardiopulmonary abnormalities have been documented in patients with acute SAH, presenting additional challenges to the healthcare providers who attempt to treat and stabilize these patients. The patients described in this article presented with both acute aneurysmal SAH and cardiopulmonary compromise. Education and further research on this connection is needed to provide optimal care and outcomes for this vulnerable population. Nurses play a key role in balancing the critical and diverse needs of patients presenting with these symptoms.     

Extracerebral organ dysfunction and neurologic outcome after aneurysmal subarachnoid hemorrhage

OBJECTIVE: To analyze the influence of extracerebral organ system dysfunction after aneurysmal subarachnoid hemorrhage (SAH) on mortality and neurologic outcome. DESIGN: Observational study with retrospective data extraction. SETTING: Neurosurgical intensive care unit (NICU) at a primary level university hospital, supervised and staffed by both members of the Clinic of Neurosurgery and the Clinic of Anesthesiology and General Intensive Care. PATIENTS: Two hundred forty-two patients treated for intracranial aneurysm rupture within 7 days of the most recent SAH. INTERVENTIONS: Routine neurosurgical interventions for obliteration of the ruptured aneurysm (microsurgery, Guglielmi Detachable Coils embolization) and for treatment of posthemorrhagic hydrocephalus (ventriculostomy, cerebrospinal fluid shunt implantation). MEASUREMENTS AND MAIN RESULTS: Respiratory, renal, hepatic, cardiovascular, and hematologic organ system functions were evaluated both individually and in aggregate by using a modified version of the Multiple Organ Dysfunction (mMOD) score. Of 1,452 organ system functions assessed in 242 patients during their NICU stay, 714 organ system functions were intact (cerebral: 0, extracerebral: 714), 556 organ systems had mild-to-moderate dysfunctions (mMOD scoremax 1-2 for the affected organ system; cerebral: 153, extracerebral: 403), and 182 organ systems failed (mMOD scoremax 3 for the affected organ system; cerebral: 89, extracerebral: 93). Severity of extracerebral organ system dysfunctions correlated with the degree of neurologic impairment (Hunt and Hess [H&H] score) in a graded fashion. Similarly, the chance to develop systemic inflammatory response syndrome (SIRS) during the NICU stay increased with increasing admission H&H grade. The incidence of SIRS and septic shock was 29% and 10.3%, respectively. The mortality rate was 40.2% in patients with SIRS and 80% for patients suffering septic shock. Seventy-seven percent of extracerebral organ system failures (OSFs) occurred in conjunction with SIRS: 51% of respiratory OSFs, 97% of renal OSFs, 100% of hepatic OSFs, 96% of cardiovascular OSFs, and 73% of hematopoietic OSFs. Both CNS dysfunction and extracerebral organ system dysfunctions were significantly related to neurologic outcome. The probability of unfavorable neurologic outcome significantly increased with both decreasing cerebral perfusion pressure (CPP) and increasing severity of extracerebral organ dysfunction. CONCLUSION: Aneurysmal SAH and its neurologic sequelae accounted for the principal morbidity and mortality in the current series. Development of extracerebral organ system dysfunction was associated with a higher probability of unfavorable neurologic outcome. Systemic inflammation (SIRS) and secondary organ dysfunction were the principal non-neurologic causes of death.     

Impact of pattern of admission on outcomes after aneurysmal subarachnoid hemorrhage

Objective

Patients with aneurysmal subarachnoid hemorrhage (aSAH) require management in centers with neurosurgical expertise necessitating emergent interhospital transfer (IHT). Our objective was to compare outcomes in aSAH IHTs to our institution with aSAH admissions from our institutional emergency department (ED).

Methods

Data for consecutive patients with aSAH admitted to Johns Hopkins Medical Institutions between 1991 and 2009 were analyzed from a prospectively obtained database. We compared in-hospital mortality and functional outcomes at first clinical appointment post-aSAH (30-120 days) using dichotomized Glasgow Outcome Scale (good outcome: Glasgow Outcome Scale 4-5) in ED admissions with IHTs.

Results

A total of 1134 consecutive patients with aSAH were included in analysis (ED 40.1%, IHT 59.9%). Direct ED admissions had a higher incidence of poor Hunt and Hess grade (4/5) and major medical comorbidities, with no significant differences between the 2 groups in age, intraventricular hemorrhage, and hydrocephalus. In-hospital mortality for ED admissions (14.9%) was significantly lower than that for IHTs (20.5%), with 1.8 times greater adjusted odds of survival after multivariate analysis (P = .001). Emergency department admissions had nearly 2-fold greater odds of good outcomes (odds ratio, 1.89; P < .001) after multivariate analysis.

Conclusions

Our institutional ED SAH admissions had significantly better outcomes than did IHTs, suggesting that delays in optimizing care before transfer could deleteriously impact outcomes.     

连续腰椎穿刺引流在动脉瘤性蛛网膜下腔出血栓塞术后的作用

目的探讨连续腰椎穿刺引流对动脉瘤性蛛网膜下腔出血（a SAH）患者血管栓塞治疗后的作用。方法 42例a SAH患者接受颅内动脉栓塞治疗后,根据是否采取连续腰椎穿刺分为观察组20人和对照组22人。观察2组患者迟发性缺血性神经功能缺陷（DIDN）、头痛缓解和Rankin评分差异。结果观察组患者头痛缓解天数短于对照组（P〈0.05）;治疗期内,观察组患者DIDN发生率低于对照组（P〈00.05）,14 d时Rankin评分低于对照组（P〈0.05）。结论 a SAH患者栓塞治疗后行早期连续腰椎穿刺引流,能降低DIND发生风险,促进神经和认知功能早期恢复。     

Controversies in the management of aneurysmal subarachnoid hemorrhage

BACKGROUND: The care of patients with aneurysmal subarachnoid hemorrhage has evolved significantly with the advent of new diagnostic and therapeutic modalities. Although it is believed that these advances have contributed to improved outcomes, considerable uncertainty persists regarding key areas of management. OBJECTIVE: To review selected controversies in the management of aneurysmal subarachnoid hemorrhage, with a special emphasis on endovascular vs. surgical techniques for securing aneurysms, the diagnosis and therapy of cerebral vasospasm, neuroprotection, antithrombotic and anticonvulsant agents, cerebral salt wasting, and myocardial dysfunction, and to suggest venues for further clinical investigation. DATA SOURCE: Search of MEDLINE and Cochrane databases and manual review of article bibliographies. DATA SYNTHESIS AND CONCLUSIONS: Many aspects of care in patients with aneurysmal subarachnoid hemorrhage remain highly controversial and warrant further resolution with hypothesis-driven clinical or translational research. It is anticipated that the rigorous evaluation and implementation of such data will provide a basis for improvements in short- and long-term outcomes.     

Take care when taking care of fever after aneurysmal subarachnoid hemorrhage

Fever is prevalent in the majority of patients after aneurysmal subarachnoid hemorrhage and is associated with worse outcome. Treatment of fever is highly recommended, but with low-grade evidence in current guidelines. The analysis by Schiefecker and colleagues reveals that the situation may be more complicated than at first glance and careless treatment may introduce further harm. The importance of this study lies in analyzing real-world multimodal neuromonitoring data, showing a pitfall in incautiously applied treatment paradigms.     

高血糖对动脉瘤出血后症状性脑血管痉挛的影响

目的探讨动脉瘤性蛛网膜下腔出血后血糖水平与症状性脑血管痉挛的发生及预后的关系。方法回顾性分析175例动脉瘤性蛛网膜下腔出血患者的临床特征和血糖水平。用Cox回归来分析入院时血糖的平均值、住院期间血糖的平均值、胰岛素用量、糖尿病病史、Hunt-Hess分级、Fisher分级。结果在175例患者中,53例(30.4%)发生症状性血管痉挛。入院时血糖为(9.7±2.2)mmol/L和住院期间血糖值(9.2±1.4)mmol/L相比,显著升高。多因素分析显示,住院期间血糖值[RR=1.02,95%可信区间(CI)1.02~1.04],Hunt-Hess≥3级[RR=2.22,95%可信区间(CI)1.20~3.98],FisherⅢ级[RR=1.26,95%可信区间(CI)1.14~3.0]是影响症状性血管痉挛发生的危险因素。结论高血糖是症状性脑血管痉挛发生的相关因素,控制高血糖可减少症状性脑血管痉挛的发生,改善临床预后。     

Role of transcranial Doppler in optimizing treatment of cerebral vasospasm in subarachnoid hemorrhage

This study was undertaken to evaluate the role of transcranial Doppler ultrasonography in arterial blood pressure management during hypervolemia/hypertension/ hemodilution therapy in patients with vasospasm from subarachnoid hemorrhage and correlate this data with neurologic outcome. The study included 18 adult patients, Hunt and Hess grades III-IV. Complete neurologic assessment was performed. Transcranial Doppler indices were calculated by standard formulas. On the basis of our results, resistance area product can be used to estimate the optimal arterial blood pressure in hypervolemia/hypertension/hemodilution therapy. An increase in the cerebral blood flow index was associated with better performance on neurologic examination. Estimated cerebral perfusion pressure from transcranial Doppler data analysis showed poor correlation with cerebral perfusion pressure derived from direct measurement of intracranial pressure in patients with cerebral vasospasm (rho = 0.15; 95% CI, 0.11-0.39; P = .2590).