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Evaluation of proximal-distal velocity gradient in spastic middle cerebral artery after aneurismal subarachnoid hemorrhage
Critical Care volume 17, Article number: P339 (2013)
Delayed cerebral ischemia (DCI) worsens neurological outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). DCI pathogenesis is multifactorial and not completely understood, but vasospasm plays a central role. Transcranial color-coded duplex sonography (TCCDS) is a non-invasive bedside tool to explore cerebral vessels, but specificity is still suboptimal. The aim of this study was to evaluate the proximal-distal gradient of mean cerebral blood flow velocity (CBF-V) in middle cerebral artery (MCA) as a possible indicator of critical vasospasm.
Consecutive aSAH patients (WFNS 1 to 5, age 18 to 80 years) admitted to NeuroICU between November 2011 and September 2012 were included in this study. TCCDS was used to assess CBF-V in MCA of both sides: we defined TCCDS vasospasm as CBF-V >120 cm/second. Magnetic resonance angiography (MRA, 3D TOF HR) was performed to evaluate vasospasm at early (<3 days) and delayed (7 to 10 days) time points. When patients underwent MRA, in the same clinical conditions, we recorded CBF-V with TCCDS at two levels: at the origin (proximal CBF-V) and at the end (distal CBF-V) of the MCA. Then we calculated the absolute value of proximal-distal CBF-V gradient for MCA of both sides. We defined clinical vasospasm as the appearance of a new neurological deficit confirmed by imaging. The relationships between the absolute value of TCCDS CBF-V gradient and (1) TCCDS vasospasm, (2) MRA vasospasm and (3) clinical vasospasm were explored.
We included 26 consecutive aSAH patients (WFNS 1 to 5, age 57 ± 12 years). The absolute value of MCA CBF-V gradient was higher in: (1) vessels affected by TCCDS vasospasm when compared with vessels not affected (63 cm/second, IR 23 to 85 and 15 cm/second IR 7 to 23 respectively, P < 0.001); (2) vessels affected by MRA vasospasm when compared with vessels not affected (43 cm/second, IR 18 to 78 and 13 cm/second IR 6 to 22, P < 0.001); and (3) in patients who developed clinical vasospasm than in patients who did not (56 cm/second IR 11 to 124 and 16 cm/second IR 8 to 30 respectively, P < 0.01). Considering only the subset of MCAs affected by MRA vasospasm, the CBF-V gradient was higher when clinical vasospasm was also present (75 cm/ second IR 56 to 124 and 23 cm/second IR 17 to 30 respectively, P < 0.05).
Proximal-distal CBF-V gradient of MCA might be a reliable indicator of critical vasospasm but further studies are warranted to define threshold values and specificity in aSAH patients.
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Gotti, M., Stretti, F., Pifferi, S. et al. Evaluation of proximal-distal velocity gradient in spastic middle cerebral artery after aneurismal subarachnoid hemorrhage. Crit Care 17, P339 (2013). https://doi.org/10.1186/cc12277
- Cerebral Ischemia
- Middle Cerebral Artery
- Magnetic Resonance Angiography
- Subarachnoid Hemorrhage
- Velocity Gradient