Transcranial Doppler diagnosis of cerebral vasospasm following subarachnoid haemorrhage: correlation and analysis of results in relation to the age of patients

Treatment of octogenarians and nonagenarians with aneurysmal subarachnoid hemorrhage: a 17-year institutional analysis

BACKGROUND

Outcomes for octogenarians and nonagenarians after an aneurysmal subarachnoid hemorrhage (aSAH) are particularly ominous, with mortality rates well above 50%. The present analysis examines the neurologic outcomes of patients ≥ 80 years of age treated for aSAH.

METHOD

A retrospective review was performed of all aSAH patients treated at Barrow Neurological Institute from January 1, 2003, to July 31, 2019. Patients were placed in 2 groups by age, < 80 vs ≥ 80 years. The ≥ 80-year-old group of octogenarians and nonagenarians was subsequently analyzed to compare treatment modalities. Poor neurologic outcome was defined as a modified Rankin Scale (mRS) score of > 2.

RESULTS

During the study period, 1418 patients were treated for aSAH. The mean (standard deviation) age was 55.1 (13.6) years, the mean follow-up was 24.6 (40.0) months, and the rate of functional independence (mRS 0-2) at follow-up was 54% (751/1395). Logistic regression analysis found increasing age strongly associated with declining functional independence (R² = 0.929, p < 0.001). Forty-three patients ≥ 80 years old were significantly more likely to be managed endovascularly than with open microsurgery (67% [n = 29] vs 33% [n = 14], p < 0.001). Compared with younger patients, those ≥ 80 years old had an increased risk of mortality and poor neurologic outcomes at follow-up. In the ≥ 80-year-old group, only 4 patients had good outcomes; none of the 4 had preexisting comorbidities, and all 4 were treated endovascularly.

CONCLUSIONS

Age is a significant prognostic indicator of functional outcomes and mortality after aSAH. Most octogenarians and nonagenarians with aSAH will become severely disabled or die.

Effect of Age on Transcranial Doppler Velocities in Patients with Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

It is not well understood whether age impacts transcranial Doppler (TCD) mean flow velocities (MFVs) in patients with aneurysmal subarachnoid hemorrhage (SAH) with or without delayed cerebral ischemia (DCI). The aim of our study was to analyze the behavior of TCD MFV during the first 7 days after SAH in patients of different ages and correlate them with the occurrence of DCI.

METHODS

This study is a databank analysis of patients with SAH admitted between 2010 and 2012 in a single center. We analyzed mean MFV of bilateral middle cerebral arteries (MCAs) in all patients enrolled in the study on days 1, 3 and 7. The correlation between age and TCD MFV was analyzed using a univariate linear regression model.

RESULTS

Fifty-five patients were studied. Starting on the third day after the bleeding, increasing age was associated with slower MFVs. This trend was not affected by the interrogation of the right or left MCA. After correction to include only patients who developed DCI, the same findings persisted on days 3 and 7.

CONCLUSION

Older age was correlated with a significant decrease on TCD velocities in patients with SAH, even after correction for patients who developed DCI.

Difference in Transcranial Doppler Velocity and Patient Age between Proximal and Distal Middle Cerebral Artery Vasospasms after Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Transcranial Doppler (TCD) is used to monitor cerebral vasospasm after subarachnoid hemorrhage (SAH), but its diagnostic ability is reported to be limited. Therefore, the purpose of this study was to investigate the relationship between the diagnosability of TCD and the localization of the vasospasm.

METHODS

This retrospective study included 20 patients who presented with symptomatic vasospasm after SAH. All 20 patients underwent daily TCD examinations and cerebral angiography after the onset of delayed cerebral ischemia. We defined positive findings on TCD as a maximum flow velocity >200 cm/s or as a mean flow velocity >120 cm/s at the horizontal part of the middle cerebral artery (MCA). We also examined the site of vasospasm on cerebral angiography.

RESULTS

Fourteen patients had true-positive findings on TCD examination, and cerebral angiography showed diffuse vasospasm involving the horizontal segment of the MCA. However, 6 patients had false-negative findings on TCD examination, and cerebral angiography showed vasospasm localized at the distal part of the MCA (the insular and/or cortical segments). The patients with proximal vasospasm were significantly younger than those with distal vasospasm. Blood flow velocity at initial TCD and the increase in velocity at the onset of vasospasm were lower and smaller, respectively, in the distal vasospasm group.

CONCLUSIONS

In patients with cerebral vasospasm localized at the distal part of the MCA, flow velocity at the horizontal segment of the MCA did not increase to the level we defined as positive. To avoid such false negatives, a slight increase in velocity on TCD should be considered as positive in distal vasospasm cases, especially in older patients.

Current controversies in the prediction, diagnosis, and management of cerebral vasospasm: where do we stand?

Aneurysmal subarachnoid hemorrhage occurs in approximately 30,000 persons in the United States each year. Around 30 percent of patients with aneurysmal subarachnoid hemorrhage suffer from cerebral ischemia and infarction due to cerebral vasospasm, a leading cause of treatable death and disability following aneurysmal subarachnoid hemorrhage. Methods used to predict, diagnose, and manage vasospasm are the topic of recent active research. This paper utilizes a comprehensive review of the recent literature to address controversies surrounding these topics. Evidence regarding the effect of age, smoking, and cocaine use on the incidence and outcome of vasospasm is reviewed. The abilities of different computed tomography grading schemes to predict vasospasm in the aftermath of subarachnoid hemorrhage are presented. Additionally, the utility of different diagnostic methods for the detection and visualization of vasospasm, including transcranial Doppler ultrasonography, CT angiography, digital subtraction angiography, and CT perfusion imaging is discussed. Finally, the recent literature regarding interventions for the prophylaxis and treatment of vasospasm, including hyperdynamic therapy, albumin, calcium channel agonists, statins, magnesium sulfate, and endothelin antagonists is summarized. Recent studies regarding each topic were reviewed for consensus recommendations from the literature, which were then presented.

Lower Incidence of Transcranial Doppler and Symptomatic Vasospasm After Aneurysmal Subarachnoid Hemorrhage and Aneurysm Clipping in the Elderly Patient?

BACKGROUND:

Vasospasm is the major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. It is well known that the vasoreactivity decreases with advancing age, but it is not well investigated in a large patient cohort whether, as a consequence, the incidence of vasospasm is lower in elderly patients.

OBJECTIVE:

To investigate whether transcranial Doppler vasospasm, delayed ischemic neurological deficits, and vasospasm-associated ischemic lesions are less frequent in older patients.

METHODS:

Seven hundred fifty-eight patients who suffered from subarachnoid hemorrhage were included in this study. Clinical presentation, Hunt and Hess score, Fisher grade, incidence of vasospasm, neurological deficits and ischemic lesions on radiographic imaging, transcranial Doppler blood flow velocities, medical complications, and outcome were registered.

RESULTS:

Four hundred seventy-eight patients &lt; 60 years of age and 280 patients ≥ 60 years of age were identified; 55.2% of the younger and 25.7% of the older age group developed post-hemorrhagic vasospasm (P &lt; .001). Older patients developed less vasospasm (P = .00), fewer neurological deficits (P &lt; .001), and fewer ischemic lesions on computed tomography imaging (P = .06). On the other hand, older patients had significantly worse outcomes than younger patients (P = .01) and more frequently died of medical complications (P = .01).

CONCLUSION:

Vasospasm, delayed ischemic neurological deficits, and vasospasm-associated ischemic lesions are more likely to occur in patients &lt; 60 years of age than in older patients. The lower incidence of vasospasm and vasospasm-related ischemia in the elderly patient does not translate into better outcome because of the higher rate of fatal medical complications in patients ≥ 60 years of age.

Patient Age and Vasospasm After Subarachnoid Hemorrhage

BACKGROUND:

Subarachnoid hemorrhage (SAH) from a ruptured intracranial aneurysm is a devastating disease with high mortality and morbidity. The incidence of SAH increases with advancing age.

OBJECTIVE:

To determine whether age is an independent predictor of angiographic vasospasm, delayed ischemic neurological deficits (DINDs), or abnormal transcranial Doppler (TCD) measurements in patients with aneurysmal subarachnoid hemorrhage.

METHODS:

Data from CONSCIOUS-1 (Clazosentan to Overcome Neurological Ischemia and Infarct Occurring After Subarachnoid Hemorrhage study), a dose-finding study of clazosentan, were used. Data on angiographic vasospasm, DINDs, and TCD abnormalities were prospectively recorded as well as baseline characteristics and treatment data. Patient age was considered in 3 ways: as a continuous variable, dichotomized at age 65 years, and categorized by decade. Age was investigated as the main variable, whereas other possible confounding variables were adjusted for in the multiple logistic regression modeling with each of 3 dichotomized vasospasm outcome measures, presence or absence of angiographic vasospasm, DINDs, and TCD abnormalities as the dependent variable.

RESULTS:

The proportions of patients with angiographic vasospasm, DINDs, and TCD abnormalities were 45%, 19%, and 81%, respectively. Age, whether considered as a continuous, dichotomous, or a categorical variable, was not significantly associated with angiographic vasospasm, DINDs, or abnormal TCD measurements.

CONCLUSION:

Age does not seem to be a significant predictor for cerebral vasospasm after subarachnoid hemorrhage.

Association of a younger age with an increased risk of angiographic and symptomatic vasospasms following subarachnoid hemorrhage

Object

Vasospasm is a leading cause of morbidity and death following aneurysmal subarachnoid hemorrhage (SAH). It is important to predict which patients are at risk for vasospasm so that interventions can be made. There are several potential risk factors for vasospasm, one of which is age. However, the effect of age on vasospasm, particularly symptomatic vasospasm, remains controversial.

Methods

Three hundred ninety-one patients were retrospectively identified from a prospective observational database of patients with SAH who had been admitted to a single center. Demographic and clinical data were recorded, and cerebral angiograms obtained at admission and between 5 and 10 days later were compared. The relationship between age and angiographic and symptomatic vasospasms was examined using logistic regression techniques.

Results

Mild (86 patients), moderate (69 patients), severe (56 patients), and no angiographic vasospasms (180 patients) were documented by comparing admission and follow-up angiograms in each patient. Symptomatic vasospasm was identified in 69 patients (17.6%). Angiographic vasospasm was more frequent as age decreased. Except in patients < 30 years old, the frequency of symptomatic vasospasm also increased with decreasing age (p = 0.0001). After adjusting for variables known to be associated with vasospasm, an advanced age was associated with a reduced incidence of any angiographic vasospasm (OR 0.96, 95% CI 0.94–0.97), severe angiographic vasospasm (OR 0.96, 95% CI 0.95–0.98), and symptomatic vasospasm (OR 0.98, 95% CI 0.96–0.99).

Conclusions

Results in this study show that a younger age is associated with an increased incidence of angiographic and symptomatic vasospasm.

Transcranial Doppler for predicting delayed cerebral ischemia after subarachnoid hemorrhage

OBJECTIVE

Transcranial Doppler (TCD) is widely used to monitor the temporal course of vasospasm after subarachnoid hemorrhage (SAH), but its ability to predict clinical deterioration or infarction from delayed cerebral ischemia (DCI) remains controversial. We sought to determine the prognostic utility of serial TCD examination after SAH.

METHODS

We analyzed 1877 TCD examinations in 441 aneurysmal SAH patients within 14 days of onset. The highest mean blood flow velocity (mBFV) value in any vessel before DCI onset was recorded. DCI was defined as clinical deterioration or computed tomographic evidence of infarction caused by vasospasm, with adjudication by consensus of the study team. Logistic regression was used to calculate adjusted odds ratios for DCI risk after controlling for other risk factors.

RESULTS

DCI occurred in 21% of patients (n = 92). Multivariate predictors of DCI included modified Fisher computed tomographic score (P = 0.001), poor clinical grade (P = 0.04), and female sex (P = 0.008). After controlling for these variables, all TCD mBFV thresholds between 120 and 180 cm/s added a modest degree of incremental predictive value for DCI at nearly all time points, with maximal sensitivity by SAH day 8. However, the sensitivity of any mBFV more than 120 cm/s for subsequent DCI was only 63%, with a positive predictive value of 22% among patients with Hunt and Hess grades I to III and 36% in patients with Hunt and Hess grades IV and V. Positive predictive value was only slightly higher if mBFV exceeded 180 cm/s.

CONCLUSION

Increased TCD flow velocities imply only a mild incremental risk of DCI after SAH, with maximal sensitivity by day 8. Nearly 40% of patients with DCI never attained an mBFV more than 120 cm/s during the course of monitoring. Given the poor overall sensitivity of TCD, improved methods for identifying patients at high risk for DCI after SAH are needed.

The influence of ethanol on blood flow velocity in major cerebral vessels. A prospective and controlled study

Cerebral vasospasm secondary to subarachnoid hemorrhage leads to increased cerebrovascular resistance and may cause ischemia in the affected vascular territories. The currently available therapeutic options for treating vasospasm are limited. The effect of ethanol at a concentration of 0.75 g/kg body weight on blood flow velocity in the major cerebral arteries was studied. In 31 healthy persons, the major extra- and intracranial cerebral vessels were examined by Doppler ultrasonography before and following oral ingestion of 0.75 g/kg body weight of ethanol. An additional 20 healthy subjects served as a control group. Ethanol in the applied concentration significantly increased the systolic, diastolic, and mean blood flow velocities and significantly decreased the pulsatility indices in the middle cerebral artery (MCA). It may reduce vascular resistance and may increase cerebral blood flow in the area supplied by the MCA in healthy persons.

Standardization of flow velocities with respect to age and sex improves the accuracy of transcranial color Doppler sonography of middle cerebral artery spasm

OBJECTIVE

The overall accuracy of transcranial Doppler sonography in the diagnosis of middle cerebral artery spasm has not been established. Moreover, the factors of age and sex have not been addressed in most studies. In this article, we present receiver operating characteristic (ROC) curve analysis of the accuracy of transcranial color Doppler sonography in diagnosing middle cerebral artery spasm on the basis of flow velocities standardized for age and sex. SUBJECTS AND METHODS. We prospectively studied 214 consecutive patients (110 male, 104 female; age range, 12-77 years) who were routinely referred for cerebral angiography. Middle cerebral artery spasm was graded as mild (</= 25% of vessel caliber reduction) and moderate to severe (> 25% reduction). Angle-corrected blood velocity measurements were obtained using a 2.5-MHz probe. The velocity values were reexpressed as a percentage of the mean of normal reference values for the relevant age, for subjects younger than 40 years, and for sex.

RESULTS

The prevalence of spasm among 335 arteries studied was 8.1% for mild and 12.8% for moderate to severe middle cerebral artery narrowing. For distinguishing all or moderate to severe vasospasm from lesser grades of vasospasm, peak systolic velocity was the best parameter. Areas under ROC curves for all and moderate to severe middle cerebral artery spasms were 0.83 and 0.92, respectively. After standardization, the ROC areas increased significantly (p < 0.05) for all, to 0.86, and only slightly, to 0.93, for moderate to severe spasms. For all grades of middle cerebral artery spasm, the best efficiencies were found at standardized velocity value of 170%.

CONCLUSION

The accuracy of transcranial color Doppler sonography is high in the identification of middle cerebral artery spasm. Standardization of velocities with respect to age and sex increases the accuracy of the method in diagnosing mild middle cerebral artery spasms.

Effect of age on cerebral blood flow velocity and incidence of vasospasm after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Current transcranial Doppler criteria for vasospasm after aneurysmal subarachnoid hemorrhage are not age specific. We analyzed the effect of age on cerebral blood flow velocity changes after subarachnoid hemorrhage and constructed an age-adjusted predictive model of cerebral blood flow velocity in subarachnoid hemorrhage patients.

METHODS

We identified patients with aneurysmal subarachnoid hemorrhage admitted between 1991 and 1999 with a prospective transcranial Doppler database. Eighty-one patients, with complete medical records and transcranial Doppler examinations of the vessels of interest, were included. Patients were subdivided into 2 groups by age: younger, <68 years of age (n=47) and older, >/=68 years of age (n=34). Maximum mean flow velocity and incidence of symptomatic vasospasm were reported. Linear and nonlinear regression analyses were performed.

RESULTS

Middle cerebral artery and internal carotid artery mean flow velocity were lower in older patients (median 76 versus 114 cm/s and 76 versus 126 cm/s, respectively; P<0.003). Incidence of symptomatic vasospasm was lower in older patients (44% versus 66%; P=0.05). Older patients developed symptomatic vasospasm at lower middle cerebral artery (median 57 versus 103 cm/s; P=0.04) and internal carotid artery (median 54 versus 81 cm/s, P=0.02) mean flow velocity. Relationship between middle cerebral artery and internal carotid artery mean flow velocity and age was quadratic (ANOVA, P<0.0001).

CONCLUSIONS

Older patients have a lower incidence of symptomatic vasospasm, and such vasospasm develops at lower cerebral blood flow velocity than younger patients. A quadratic relationship was found between age and cerebral blood flow velocity. This model could be used to create an age-adjusted nomogram that might improve diagnostic capabilities of transcranial Doppler.

Effects of aging on cerebral vasospasm after subarachnoid hemorrhage in rabbits

BACKGROUND AND PURPOSE

The effects of aging on cerebral vasospasm after subarachnoid hemorrhage (SAH) remain to be elucidated. The aim of this study was to clarify age-related differences of vasospasm and of papaverine reactivity in the responses of basilar arteries after SAH in rabbits.

METHODS

Rabbits receiving a single injection of arterial blood into the cisterna magna were divided into 3 groups: young (2 to 3 months old), adult (6 to 9 months old), and old (20 to 40 months old). Vertebrobasilar angiograms were obtained before SAH and 1, 2, 4, and 7 days after SAH. Papaverine was administrated selectively via the vertebral artery on day 2, and serial angiography was performed for up to 2 hours. Vessel structures were assessed with light microscopy on days 1, 2, 4, and 7 after SAH and at 10, 30, and 60 minutes after papaverine infusion.

RESULTS

Mortality from SAH in old rabbits was 40%, whereas that of young and adult rabbits was 0%. Angiograms revealed that SAH induced maximal constriction of the basilar arteries on day 2 in all age groups, and the constrictions were significantly increased with age at all time points investigated. The degree of dilatation of spastic basilar arteries after intra-arterial papaverine administration significantly decreased with age. Duration of the efficacy of papaverine became significantly shorter with age. Vessel diameter returned to the preinfusion value approximately 120, 60, and 30 minutes after infusion in young, adult, and old rabbits, respectively. Light microscopy in old rabbits showed luminal narrowing and corrugation of the internal elastic lamina not only in the basilar arteries but also in small arteries and intraparenchymal arterioles.

CONCLUSIONS

This study suggests that aging increases the degree of vasospasm in rabbits. The impaired reactivity to papaverine with aging might imply the early transition of the aged vessel to the papaverine-resistant chronic stage.

Early identification of patients at risk for symptomatic vasospasm after aneurysmal subarachnoid hemorrhage

OBJECTIVE

To develop a scheme for early identification of individuals at risk for symptomatic vasospasm after subarachnoid hemorrhage (SAH).

DESIGN

Analysis of prospectively collected data from the placebo-treated group in a multicenter clinical trial.

SETTINGS

Fifty-four neurosurgical centers in North America.

MEASUREMENTS AND MAIN RESULTS

We identified independent predictors of symptomatic vasospasm using stepwise logistic regression analysis from demographic, clinical, laboratory, and neuroimaging characteristics of the participants. We developed a scoring system (symptomatic vasospasm risk index) based on a combination of these predictors. Out of 283 patients in the analysis (all treated with oral nimodipine), 93 (33%) developed symptomatic vasospasm within 14 days after SAH. There were four independent predictors of symptomatic vasospasm: thickness of subarachnoid clot on computed tomographic scan (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.8-10.0); early rise in middle cerebral artery mean flow velocity (MCA-MFV), defined as a value > or =110 cm/sec recorded on or before post-SAH day 5 (OR, 1.9; 95% CI, 1.1-3.3), Glasgow Coma Scale score <14 (OR, 1.8; 95% CI, 1.1-3.1); and rupture of anterior cerebral or internal carotid artery aneurysm (OR, 1.9; 95% CI, 1.0-3.4). The probability of identifying patients who would develop symptomatic vasospasm (percentage of area under receiver operating characteristics curve +/- SEM) was higher with symptomatic vasospasm risk index (68%+/-8%) compared with thickness of clot (62%+/-8%; p = .08) or MCA-MFV (45%+/-7%, p < .05) criteria alone.

CONCLUSIONS

Patients at high risk for symptomatic vasospasm can be identified early in the course of SAH using a risk index. A risk index based on a combination of variables may represent a predictive paradigm superior to conventionally used criteria based on clot thickness or MCA-MFV criteria.

Cerebral aneurysms in the elderly in Yamaguchi, Japan. Analysis of the Yamaguchi Data Bank of Cerebral Aneurysm from 1985 to 1995

BACKGROUND AND PURPOSE

The number of elderly people is markedly increasing in Japan. We have investigated the epidemiology and management outcome of cerebral aneurysms in elderly patients aged > or = 70 years.

METHODS

A total of 3100 patients were enrolled in the Yamaguchi Data Bank of Cerebral Aneurysm between 1985 and 1995. Of these, 598 with ruptured cerebral aneurysms and 120 with unruptured cerebral aneurysms were elderly (ie, aged > or = 70 years).

RESULTS

The number of elderly patients with cerebral aneurysms has markedly increased since 1991, and in 1995 approximately 30% of all patients with cerebral aneurysms were elderly. In cases of ruptured cerebral aneurysms, the proportion of patients with severe neurological grade did not change and that with an unfavourable outcome did not decrease throughout the 11 years. The proportion of patients with severe neurological grade in the elderly group was higher than in the younger group (< 70 years), and the management outcome of elderly patients for each neurological grade on admission was worse than that of younger patients (P < .01). However, the incidence rate of symptomatic cerebral vasospasm and rebleeding was the same for the two age groups. Eventually, 60.4% of all elderly patients with ruptured cerebral aneurysms had an unfavorable outcome. In cases of unruptured cerebral aneurysms, 63.3% of the selected elderly patients were surgically treated, and the surgical morbidity and mortality rates were 26.3% and 4.0%, respectively. These rates were nonsignificantly higher than those for younger patients.

CONCLUSIONS

The number of elderly patients with cerebral aneurysms has markedly increased in Yamaguchi. Because of the unsatisfactory management outcome of ruptured cerebral aneurysms and surgical outcome of unruptured cerebral aneurysms in elderly patients during the 11-year period, we propose the treatment of unruptured cerebral aneurysms at a younger age and the use of a screening system to detect these subjects.