Routine Utilization of the Transient Hyperaemic Response Test after Aneurysmal Subarachnoid Haemorrhage

Rätsep, Tõnu; Eelmäe, J.; Asser, Toomas

doi:10.1007/978-3-7091-6738-0_31

Cited by 5 publications

(6 citation statements)

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“…CA was impaired in those who developed vasospasm and delayed ischemia compared to those who did not, and was highly predictive of these adverse conditions. Indeed, consistent evidence indicates that dynamic CA is impaired post-SAH (38–40, 73–75), which is thought to play a role in delayed cerebral ischemia (76) and infarction after SAH (77–79). Loss of cerebral protection is clinically significant as vasospasm is a leading cause of morbidity and mortality after SAH and ischemia may occur when autoregulation does not compensate.…”

Section: Peripheral and Cerebral Circulatory Considerations For Exercmentioning

confidence: 98%

Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

Marzolini

Robertson

et al. 2019

Front. Neurol.

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Knowledge gaps exist in how we implement aerobic exercise programs during the early phases post-stroke. Therefore, the objective of this review was to provide evidence-based guidelines for pre-participation screening, mobilization, and aerobic exercise training in the hyper-acute and acute phases post-stroke. In reviewing the literature to determine safe timelines of when to initiate exercise and mobilization we considered the following factors: arterial blood pressure dysregulation, cardiac complications, blood-brain barrier disruption, hemorrhagic stroke transformation, and ischemic penumbra viability. These stroke-related impairments could intensify with inappropriate mobilization/aerobic exercise, hence we deemed the integrity of cerebral autoregulation to be an essential physiological consideration to protect the brain when progressing exercise intensity. Pre-participation screening criteria are proposed and countermeasures to protect the brain from potentially adverse circulatory effects before, during, and following mobilization/exercise sessions are introduced. For example, prolonged periods of standing and static postures before and after mobilization/aerobic exercise may elicit blood pooling and/or trigger coagulation cascades and/or cerebral hypoperfusion. Countermeasures such as avoiding prolonged standing or incorporating periodic lower limb movement to activate the venous muscle pump could counteract blood pooling after an exercise session, minimize activation of the coagulation cascade, and mitigate potential cerebral hypoperfusion. We discuss patient safety in light of the complex nature of stroke presentations (i.e., type, severity, and etiology), medical history, comorbidities such as diabetes, cardiac manifestations, medications, and complications such as anemia and dehydration. The guidelines are easily incorporated into the care model, are low-risk, and use minimal resources. These and other strategies represent opportunities for improving the safety of the activity regimen offered to those in the early phases post-stroke. The timeline for initiating and progressing exercise/mobilization parameters are contingent on recovery stages both from neurobiological and cardiovascular perspectives, which to this point have not been specifically considered in practice. This review includes tailored exercise and mobilization prescription strategies and precautions that are not resource intensive and prioritize safety in stroke recovery.

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Section: Peripheral and Cerebral Circulatory Considerations For Exercmentioning

confidence: 98%

Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

Marzolini

Robertson

et al. 2019

Front. Neurol.

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“…In brief, middle cerebral artery (MCA) BFV is continuously measured by TCD. Autoregulatory responses are then measured following an alteration in CPP (the transmural pressure sensed by myogenic mechanisms): this is typically achieved in SAH patients by compressing the carotid artery ipsilateral to the insonified MCA (126)(127)(128)(129)(130)(131), although in some cases, a bilateral thigh cuff is utilized (132,133). Compression of the carotid artery (tailored to yield ∼30% reduction in MCA BFV) decreases CPP: after a brief period (usually 3-5 s), the compression is released.…”

Section: Dynamic Autoregulation Measurementmentioning

confidence: 99%

“…SAH patients frequently display abnormal THRT results (Table 3) (126)(127)(128)(129)(130)(131). Two studies show a timeline following SAH ictus, based on the proportion of patients with negative/abnormal THRT results: while these studies show variable proportions of negative results early after ictus (0-3 days post-SAH), there is a clear peak between days 7-10, after which point the proportion of negative THRT results declines (128,129). This peak fits well with the timeline for development of DCI.…”

Section: Dynamic Autoregulation Measurementmentioning

confidence: 99%

“…This peak fits well with the timeline for development of DCI. Negative THRT results are frequently, but not always, a good predictor for the emergence of angiographic vasospasm (126,127,129,130) and poor THRT results are clearly more prevalent in patients who develop cerebral infarction (129,131), have poor neurological status (e.g., WFNS Score >2 or Glasgow Coma Score <6) (126)(127)(128)(129)131) and ultimately have poor outcomes (e.g., Glasgow Outcome Score ≤3 or modified Rankin Scale ≥4 at 6 months) (126,128,131). Likewise, the thigh cuff/ARI approach appears capable of segregating patients who will develop angiographic vasospasm, rapid neurological deterioration, and suffer poor outcome (132,133).…”

Section: Dynamic Autoregulation Measurementmentioning

confidence: 99%

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Cerebral Autoregulation in Subarachnoid Hemorrhage

2021

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Subarachnoid hemorrhage (SAH) is a devastating stroke subtype with a high rate of mortality and morbidity. The poor clinical outcome can be attributed to the biphasic course of the disease: even if the patient survives the initial bleeding emergency, delayed cerebral ischemia (DCI) frequently follows within 2 weeks time and levies additional serious brain injury. Current therapeutic interventions do not specifically target the microvascular dysfunction underlying the ischemic event and as a consequence, provide only modest improvement in clinical outcome. SAH perturbs an extensive number of microvascular processes, including the “automated” control of cerebral perfusion, termed “cerebral autoregulation.” Recent evidence suggests that disrupted cerebral autoregulation is an important aspect of SAH-induced brain injury. This review presents the key clinical aspects of cerebral autoregulation and its disruption in SAH: it provides a mechanistic overview of cerebral autoregulation, describes current clinical methods for measuring autoregulation in SAH patients and reviews current and emerging therapeutic options for SAH patients. Recent advancements should fuel optimism that microvascular dysfunction and cerebral autoregulation can be rectified in SAH patients.

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“…Disturbance of CA over the early course of aneurysmal SAH is increasingly known to cause VS, cerebral infarction, and poor neurological outcome. [ 19 , 20 , 27 ] Various studies have focused on TCD as a tool for prediction of VS and it has been recommended as Class II level of evidence to monitor cerebral VS following aSAH. [ 5 , 17 , 26 ] In our study, 51% of patients developed VS.…”

Section: Discussionmentioning

confidence: 99%

Assessment of impaired cerebral autoregulation and its correlation with neurological outcome in aneurysmal subarachnoid hemorrhage: A prospective and observational study

Kataria,

Panda,

Luthra

et al. 2023

Surgical Neurology International

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Background: Cerebral autoregulation (CA) is crucial for the maintenance of cerebral homeostasis. It can be assessed by measuring transient hyperemic response ratio (THRR) using transcranial Doppler (TCD). We aimed at assessing the incidence of impaired CA (ICA) and its correlation with the neurological outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods: One hundred consecutive patients with aSAH scheduled for aneurysmal clipping were enrolled in this prospective and observational study. Preoperative and consecutive 5-day postoperative THRR measurements were taken. Primary objective of the study was to detect the incidence of ICA and its correlation with vasospasm (VS) postclipping, and neurological outcome at discharge and 1, 3, and 12 months was secondary objectives. Results: ICA (THRR < 1.09) was observed in 69 patients preoperatively, 74 patients on the 1st and 2nd postoperative day, 76 patients on 3rd postoperative day, and 78 patients on 4th and 5th postoperative day. Significant VS was seen in 13.4% and 61.5% of patients with intact THRR and deranged THRR, respectively (P < 0.000). Out of 78 patients who had ICA, 42 patients (53.8%) at discharge, 60 patients (76.9%) at 1 month, 54 patients (69.2%) at 3 month, and 55 patients (70.5%) at 12 months had unfavorable neurological outcome significantly more than those with preserved CA. Conclusion: Incidence of ICA assessed in aSAH patients varies from 69% to 78% in the perioperative period. The deranged CA was associated with significantly poor neurological outcome. Therefore, CA assessment using TCD-based THRR provides a simple, noninvasive bedside approach for predicting neurological outcome in aSAH.

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Routine Utilization of the Transient Hyperaemic Response Test after Aneurysmal Subarachnoid Haemorrhage

Cited by 5 publications

References 10 publications

Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

Cerebral Autoregulation in Subarachnoid Hemorrhage

Assessment of impaired cerebral autoregulation and its correlation with neurological outcome in aneurysmal subarachnoid hemorrhage: A prospective and observational study

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