Predictive value of TCD and MFV for Early detection of cerebral vasospasm in aneurysmal subarachnoid hemorrhage

1. Predictive Value of The Transcranial Doppler
and Mean Arterial Flow Velocity for Early
Detection of Cerebral Vasospasm in
Aneurysmal Subarachnoid Hemorrhage
Presentan
dr. Lailatul Fadhila
Pembimbing
dr. Farida, Sp. S (K)

3. Introduction
o Aneurysmal subarachnoid hemorrhage (aSAH) carries a risk for cerebral vasospasm
(CV), which causes reduced cerebral blood flow and delayed ischemic injury.
o Around 5.5 per 100,000 persons/year experience aSAH. 20% to 30% of patients with
aSAH develop delayed cerebral ischemia (DCI) caused by CV.
o CV is one of the main causes of poor outcome and prognosis for aSAH.
o CV is characterized by narrowing of a cerebral blood vessel significant to cause a
decrease in the distal blood flow.
o Approximately 70% of aSAH patients show angiographic vasospasm.

4. Introduction
Standard tests used to determine
the source of bleeding and
diagnose CV include CTA or DSA.
but cannot be readily performed
at the bedside and expose to
radiation.
Transcranial Doppler (TCD) is a
noninvasive tool for assessment
of the cerebral blood vessel and
predict CV.
TCD is inexpensive, repeatable,
and allows continuous bedside
monitoring of cerebral blood flow
velocity (CBFV)
Ability TCD to detect the cutoff
values of the mean flow velocity to
predict CV has not been fully
assessed. This study aimed to to
determine the cut-off values that
predict the development of CV.
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5. Patients and Methods
1
2
3
Study sample
• Prospective study on 45 patients aSAH in department
neuropsychiatry, Mataria Teaching Hospital, Cairo, Egypt.
• 1 year period initiated on 1 January 2018.
• aSAH divided into groups: 26 cases with vasospasm and 14 cases
without vasospasm.
Inclusion criteria
• Adult patient (30-65 years old), both sexes, diagnosed spontaneous
aSAH by noncontrast brain CT scan at the onset and confirmed by CT
angiography within 72h onset
Exclusion criteria
• Previous history of disabling brain injuries causing focal neurological
sign
• A poor temporal TCD window
• Decompensated systemic illness
• Deep coma (GCS<6)

7. Clinical Assessment and Radiological Diagnosis of SAH
1. Full history including factors
that have an impact on
vasospasm such as the age, sex
and history of hypertension,
diabetes, dyslipidemia, smoking
2. General clinical
examination (blood
pressure and full
neurological examination)
4. Initial laboratory
investigations
3. Admission
Glasgow Coma
Scale (GCS) score
and Hunt–Hess scale
5. SAH was
diagnosed on
admission by
noncontrast brain
CT scan, within 24 h
the patients had
cerebral artery CT
angiography and
DSA

8. Clinical and Radiological Scales for Assessment of SAH

9. Monitoring for Detection of Vasospasm
TCD was performed using a
DWL-EZ-Dop unit, use low
frequency 2 MHz for
measurement MFV in the
middle, anterior, and posterior
cerebral artery
MFV is calculated
by
(systolic+diastolic)
/3 + diastolic
velocities. Follow
up TCD were done
on the 1st, 3rd , 5th,
7th. and 10th
This study compares:
• Full TCD examination includes
bilateral evaluation of cerebral
vessels and usage of the four cranial
insonation windows.
• The transtemporal technique can
determine the flow signals from the
MCA, ACA, and PCA.
• During TCD examination: Follow the
course of blood flow in each major
branch, identify and store spectral
waveforms at a minimum of two key
points per artery.
• CT brain and/or MRI brain was
performed in patients with suspected
vasospasm to detect vasospasm-
associated DCI

10. Statistical Analysis
Analysis of data by SPSS
version 22. Statisticsl
analysis was performed
using X2 and Fisher
extract. P<0,05 were
significant.
Pearson correlation
was used to estimate
relationship between
TCD findings and
vasospasm.
Odd ratio (OR) was
calculated and 95%
confidence interval (CI)
was estimated.
ROC curve was
performed to
determine the cut off
points for MFV.

11. Discussion
• This study showed TCD was capable of prediction of CV, made a contribution to the
diagnosis of vasospasm in 26 (65%) patients.
• The evaluation of cerebrovascular hemodynamics mostly depends on the measurement of
CBFV, but these estimates may not fully explain changes in cerebrovascular properties.
• The alterations in end-tidal PCO2 have been used to further describe cerebral hemodynamic
alterations.
• DM increases the risk of vasospasm following aSAH independent of glycemic control.
• Systolic and diastolic blood pressures were significantly higher in the vasospasm groups.
History of hypertension was associated with radiological vasospasm, symptomatic
vasospasm, and cerebral infarction.
• Higher admission GCS score was significantly associated with vasospasm.
• CV following aSAH is more prevalent in patients with higher HHS, indicates an excessive
amount of blood in the subarachnoid space.

12. Discussion
Association between TCD findings
and vasospasm
• In TCD left side, correlation only the 10th
day ACA, 7th day MCA, and 3rd, 5th, and
7th day PCA readings significantly
• In TCD right side, only MCA on the 10th
day, and PCA on the 3rd day readings
significantly
• Wozniak et al. reported that patients who
developed vasospasm had MFV >120 cm/s
in MCA, MFV > 90 cm/s in ACA, >60 cm/s
in PCA.

13. Discussion
(a) The average MFVs of the cerebral arteries
measured within the first 10 days of aSAH in
patients with vasospasm and aSAH patients
without vasospasm
(b) Receiver Operating Characteristic (ROC) curve
for prediction of CV according to MFV in
cerebral arteries in aSAH

14. Discussion
Prediction of the development of CV and
MFV cut-off points within the first 10 days
after aSAH

15. Conclusions
• TCD is a useful tool in early detection, monitoring, and prediction of post
subarachnoid vasospasm
• Subsequently may become a regularly employed tool in neurocritical care and
perioperative settings
• Facilitating early therapeutic intervention before irreversible ischemic neurological
deficits occur

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