Transcranial Doppler Ultrasonography for Diagnosis of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage: Mean Blood Flow Velocity Ratio of the Ipsilateral and Contralateral Middle Cerebral Arteries

Nakae, Ryuta; Yoshida, Daizo; Teramoto, Akira

doi:10.1227/neu.0b013e318222dc4c

Cited by 38 publications

(25 citation statements)

References 38 publications

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“…Seventeen studies (n = 2870 patients) met inclusion criteria. 3,13,15,16,22,27,29,30,33,34,[39][40][41]44,46,47,51 Study characteristics are summarized in Table 1. No studies addressed the comparative impact of TCD vasospasm on functional outcome and mortality.…”

Section: Resultsmentioning

confidence: 99%

Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Kumar¹,

Shahripour²,

Harrigan

2016

JNS

155

100

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C erebral vasospasm is a major cause of poor outcomes in aneurysmal subarachnoid hemorrhage (aSAH), resulting in cerebral ischemia, infarction, disability, and death. 20,25 Cerebral vasospasm is noted on angiography in as many as 70% of patients following aSAH and is predicted by high mean flow velocities (MFVs) on transcranial Doppler (TCD) ultrasonography. 19,24,26,35 Vasospasm is strongly associated with delayed cerebral ischemia (DCI) 12 and cerebral infarction, 11,39,49 although poor outcomes can still occur in its absence. Of the current techniques available for diagnosing cerebral vasospasm, catheter angiography and CT angiography are invasive, and require contrast-dye injection and radiation exposure, and therefore do not allow dynamic monitoring of vasospasm. 31The radiation exposure and invasive nature of angiography implies that it is not useful for identifying subclinical vasospasm prior to the onset of the condition, and that its use is frequently restricted to confirm prevalent vasospasm abbreviatioNs aSAH = aneurysmal subarachnoid hemorrhage; CI = confidence interval; DCI = delayed cerebral ischemia; df = degrees of freedom; MFV = mean flow velocity; MWE = mean weighted estimate; NPV = negative predictive value; PPV = positive predictive value; TCD = transcranial Doppler. obJective The impact of transcranial Doppler (TCD) ultrasonography evidence of vasospasm on patient-centered clinical outcomes following aneurysmal subarachnoid hemorrhage (aSAH) is unknown. Vasospasm is known to lead to delayed cerebral ischemia (DCI) and poor outcomes. This systematic review and meta-analysis evaluates the predictive value of vasospasm on DCI, as diagnosed on TCD. methods MEDLINE, Scopus, the Cochrane trial register, and clinicaltrials.gov were searched through September 2014 using key words and the terms "subarachnoid hemorrhage," "aneurysm," "aneurysmal," "cerebral vasospasm," "vasospasm," "transcranial Doppler," and "TCD." Sensitivities, specificities, and positive and negative predictive values were pooled by a DerSimonian and Laird random-effects model. results Seventeen studies (n = 2870 patients) met inclusion criteria. The amount of variance attributable to heterogeneity was significant (I 2 > 50%) for all syntheses. No studies reported the impact of TCD evidence of vasospasm on functional outcome or mortality. TCD evidence of vasospasm was found to be highly predictive of DCI. Pooled estimates for TCD diagnosis of vasospasm (for DCI) were sensitivity 90% (95% confidence interval [CI] 77%-96%), specificity 71% (95% CI 51%-84%), positive predictive value 57% (95% CI 38%-71%), and negative predictive value 92% (95% CI 83%-96%). coNclusioNs TCD evidence of vasospasm is predictive of DCI with high accuracy. Although high sensitivity and negative predictive value make TCD an ideal monitoring device, it is not a mandated standard of care in aSAH due to the paucity of evidence on clinically relevant outcomes, despite recommendation by national guidelines. High-quality randomized trials evaluating the impact ...

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Section: Resultsmentioning

confidence: 99%

Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Kumar¹,

Shahripour²,

Harrigan

2016

JNS

155

100

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“…However, this may not represent a clinically significant deficit, as multiple studies have now demonstrated that using the Lindegaard ratio is less predictive than using absolute velocity values in identifying angiographic vasospasm [12,13]. In addition, using the absolute flow velocity values of the MCA alone appears to allow diagnosis of angiographic vasospasm with high sensitivity and specificity [14–16]. The Presto system also has the added benefit of simultaneous bilateral monitoring.…”

Section: Discussionmentioning

confidence: 99%

The Presto 1000: A novel automated transcranial Doppler ultrasound system

Han¹,

Rutledge²,

Englot³

et al. 2015

Journal of Clinical Neuroscience

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We examined the reliability and ease of use of a novel automated transcranial Doppler (TCD) system in comparison to a conventional TCD system. TCD ultrasound allows non-invasive monitoring of cerebral blood flow, and can predict arterial vasospasm after a subarachnoid hemorrhage (SAH). The Presto 1000 TCD system (PhysioSonics, Bellevue, WA, USA) is designed for monitoring flow through the M1 segment of the middle cerebral artery (MCA) via temporal windows. The Presto 1000 system was tested across multiple preclinical and clinical settings in parallel with a control predicate TCD system. In a phantom flow generating device, both the Presto 1000 and Spencer system (Spencer Technologies, Redmond, WA, USA) were able to detect velocities with high accuracy. In nine volunteer patients, the Presto system was able to locate the MCA in 14 out of 18 temporal windows, in an average of 12.5 s. In the SAH cohort of five patients with a total of 25 paired measurements, the mean absolute difference in flow velocities of the M1 segment, as measured by the two systems, was 17.5 cm/s. These data suggest that the Presto system offers an automated TCD that can reliably localize and detect flow of the MCA, with relative ease of use. The system carries the additional benefit of requiring minimal training for the operator, and can be used by many providers across multiple bedside settings. The mean velocities that were generated warrant further validation across an extended group of patients, and the predictive value for vasospasm should be checked against the current standard of angiography.

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“…The Lindegaard ratio (LR) between the middle cerebral artery and external carotid artery velocities can help differentiate between vasospasm and hyperemia. LR values greater than 3 have been accurate in differentiating clinical and radiographic vasospasm from hyperemia [69, 70] (see Table 2). However, this data cannot be used in isolation as not all vasospasm leads to ischemic injury, and a significant proportion of ischemic injury can occur with (normal) TCD velocities <120 cm/s [71].…”

Section: Cerebral Blood Flowmentioning

confidence: 99%

Brain Multimodality Monitoring: Updated Perspectives

Roh

Park

2016

Curr Neurol Neurosci Rep

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The challenges posed by acute brain injury (ABI) involve the management of the initial insult in addition to downstream inflammation, edema, and ischemia that can result in secondary brain injury (SBI). SBI is often subclinical, but can be detected through physiologic changes. These changes serve as a surrogate for tissue injury/cell death and are captured by parameters measured by various monitors that measure intracranial pressure (ICP), cerebral blood flow (CBF), brain tissue oxygenation (PbtO2), cerebral metabolism, and electrocortical activity. In the ideal setting, multimodality monitoring (MMM) integrates these neurological monitoring parameters with traditional hemodynamic monitoring and the physical exam, presenting the information needed to clinicians who can intervene before irreversible damage occurs. There are now consensus guidelines on the utilization of MMM, and there continue to be new advances and questions regarding its use. In this review, we examine these recommendations, recent evidence for MMM, and future directions for MMM.

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Transcranial Doppler Ultrasonography for Diagnosis of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage: Mean Blood Flow Velocity Ratio of the Ipsilateral and Contralateral Middle Cerebral Arteries

Abstract: In patients with SAH, the I/C mBFV demonstrated a more significant correlation to vasospasm than the absolute mean flow velocity.

Cited by 38 publications

References 38 publications

Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

The Presto 1000: A novel automated transcranial Doppler ultrasound system

Brain Multimodality Monitoring: Updated Perspectives

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