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Morris NA, Manning N, Marshall RS, Connolly ES, Claassen J, Agarwal S, Roh DJ, Schmidt JM, Park S. Transcranial Doppler Waveforms During Intra-aortic Balloon Pump Counterpulsation for Vasospasm Detection After Subarachnoid Hemorrhage. Neurosurgery 2018; 83:416-421. [PMID: 28973669 DOI: 10.1093/neuros/nyx405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 06/20/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Transcranial Doppler ultrasound is a standard screening tool for vasospasm after subarachnoid hemorrhage. Prevention of vasospasm-induced delayed cerebral ischemia after subarachnoid hemorrhage depends on optimization of cerebral perfusion pressure, which can be challenged by neurogenic stress cardiomyopathy. Intra-aortic balloon pumps have been utilized to augment cerebral perfusion, but they change the transcranial Doppler waveform, altering its interpretability for vasospasm screening. OBJECTIVE To assess the features of the transcranial Doppler waveform that correlate with vasospasm. METHODS We retrospectively reviewed cases of subarachnoid hemorrhage that underwent same-day transcranial Doppler ultrasound and angiography. Transcranial Doppler waveforms were assessed for mean velocity, peak systolic velocity, balloon pump-augmented diastolic velocity, and a novel feature, "delta velocity" (balloon pump-augmented velocity - systolic velocity). Relationship of flow velocity features to vasospasm was estimated by generalized estimating equation models using a Gaussian distribution and an exchangeable correlation structure. RESULTS There were 31 transcranial Doppler and angiography pairings (12 CT angiography/19 digital subtraction angiography) from 4 patients. Fourteen pairings had proximal vasospasm by angiography. Delta velocity was associated with proximal vasospasm (coefficient -6.8 [95% CI -9.8 to -3.8], P < .001). There was no significant correlation with proximal vasospasm for mean velocity (coefficient -13.0 [95% CI -29.3 to 3.4], P = .12), systolic velocity (coefficient -8.7 [95% CI -24.8 to 7.3], P = .29), or balloon pump-augmented velocity (coefficient -15.3 [95% CI -31.3 to 0.71], P = .06). CONCLUSION Delta velocity, a novel transcranial Doppler flow velocity feature, may reflect vasospasm in patients with subarachnoid hemorrhage and intra-aortic balloon pumps.
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Affiliation(s)
- Nicholas A Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan Manning
- Department of Neurosurgery, Columbia University Medical Center, New York, New York.,Department of Radiology, Columbia University Medical Center, New York, New York.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Randolph S Marshall
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - E Sander Connolly
- Department of Neurosurgery, Columbia University Medical Center, New York, New York
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - David J Roh
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - J Michael Schmidt
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, New York, New York
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Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJB, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870-947. [PMID: 23370205 DOI: 10.1161/str.0b013e318284056a] [Citation(s) in RCA: 3186] [Impact Index Per Article: 289.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.
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Saqqur M, Ibrahim M, Butcher K, Khan K, Emery D, Manawadu D, Derksen C, Schwindt B, Shuaib A. Transcranial Doppler and Cerebral Augmentation in Acute Ischemic Stroke. J Neuroimaging 2012; 23:460-5. [DOI: 10.1111/j.1552-6569.2011.00674.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Emery DJ, Schellinger PD, Selchen D, Douen AG, Chan R, Shuaib A, Butcher KS. Safety and feasibility of collateral blood flow augmentation after intravenous thrombolysis. Stroke 2011; 42:1135-7. [PMID: 21350210 DOI: 10.1161/strokeaha.110.607846] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Collateral flow augmentation using partial aortic occlusion may improve cerebral perfusion in acute stroke. We assessed the safety and feasibility of partial aortic occlusion immediately after intravenous tissue plasminogen activator. METHODS We conducted an open-label pilot study of partial aortic occlusion after thrombolysis. The primary end point was all serious adverse events within 30 days of treatment. RESULTS None of the 22 patients enrolled developed symptomatic parenchymal hemorrhages. Asymptomatic hemorrhagic transformation occurred in 9 patients. Procedure-related adverse events were limited to groin complications (n=13). Seventy-seven percent of patients experienced neurological improvement (≥4-point improvement of the National Institutes of Health Stroke Scale score). CONCLUSIONS Partial aortic occlusion as an adjunct to thrombolysis in the treatment of acute stroke appears safe. Studies aimed at determining the efficacy of this therapeutic approach are warranted. CLINICAL TRIAL REGISTRATION INFORMATION URL: http://www.clinicaltrials.gov. Unique Identifier: NCT01006993.
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Affiliation(s)
- Derek J Emery
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
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Lazaridis C, Pradilla G, Nyquist PA, Tamargo RJ. Intra-Aortic Balloon Pump Counterpulsation in the Setting of Subarachnoid Hemorrhage, Cerebral Vasospasm, and Neurogenic Stress Cardiomyopathy. Case Report and Review of the Literature. Neurocrit Care 2010; 13:101-8. [DOI: 10.1007/s12028-010-9358-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Taccone FS, Lubicz B, Piagnerelli M, Van Nuffelen M, Vincent J, De Backer D. Cardiogenic Shock with Stunned Myocardium during Triple-H Therapy Treated with Intra-aortic Balloon Pump Counterpulsation. Neurocrit Care 2009; 10:76-82. [DOI: 10.1007/s12028-008-9135-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Accepted: 08/06/2008] [Indexed: 10/21/2022]
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Abstract
Postprocedural hypotension following endovascular stent placement of carotid artery disease (CAS) predicts increased in-hospital complications and long-term risk of death. Intra-aortic balloon counterpulsation (IABP) both increases mean arterial pressure and cerebral blood flow and therefore possibly reduces complications due to hemodynamic instability during and after CAS. In this study, we describe the use of IABP in a patient with severe depression of left ventricular function due to diffuse coronary artery disease undergoing CAS. Controlled studies are necessary to demonstrate a potentially protective role of IABP in high-risk CAS patients.
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Affiliation(s)
- B Hennen
- Medizinische Klinik III (Kardiologie/Angiologie), Universitätskliniken des Saarlandes, Homburg/Saar, Germany.
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Affiliation(s)
- M Montessuit
- Clinique et Policlinique de Chirurgie Cardio-vasculaire et Thoracique, Hôpital Universitaire de Genève, Switzerland
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Abstract
BACKGROUND The intraaortic balloon pump has been shown to improve cardiac output and diastolic coronary flow. Animal studies with balloon counterpulsation have shown variable effects on carotid and cerebral blood flow. We investigated the effects of counterpulsation with the intraaortic balloon pump on blood flow in the common carotid artery in human beings. METHODS AND RESULTS We studied 14 patients who had an intraaortic balloon pump placed for clinical indications; 9 were hypotensive (4 in the setting of an acute myocardial infarction and 5 immediately after cardiac surgery). Five patients required counterpulsation after undergoing complicated coronary angioplasty. Common carotid artery blood flow was assessed with carotid Duplex scanning both with and without 1:1 balloon augmentation. We found no net increase in the total blood flow in the common carotid artery with intraaortic balloon counterpulsation. This result occurred despite a significant mean increase in both the peak flow velocity and flow velocity integral of the augmented diastolic flows by 160% and 78%, respectively. Total flow did not change because an early systolic reversal of blood flow was seen only with balloon augmentation, which negated the augmented diastolic flow. CONCLUSION Despite a significant augmentation in diastolic blood flow with balloon counterpulsation, no increase occurred in total carotid artery blood flow. This appeared to be caused by improper timing of balloon deflation. This could result in no improvement in cerebral blood flow with intraaortic balloon pump counterpulsation in critically ill patients.
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Affiliation(s)
- R M Applebaum
- Department of Medicine, New York University School of Medicine, NY, USA
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Nussbaum ES, Sebring LA, Ganz WF, Madison MT. Intra-aortic balloon counterpulsation augments cerebral blood flow in the patient with cerebral vasospasm: a xenon-enhanced computed tomography study. Neurosurgery 1998; 42:206-13; discussion 213-4. [PMID: 9442527 DOI: 10.1097/00006123-199801000-00048] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE We previously established the ability of intra-aortic balloon counterpulsation (IABC) to improve cerebral blood flow (CBF) significantly in a canine model of cerebral vasospasm. This study was performed to assess the efficacy of IABC in a patient with cardiac dysfunction and severe cerebral vasospasm that was refractory to traditional treatment measures. METHODS We report our experience with the clinical use of IABC to treat cerebral vasospasm in a patient who suffered subarachnoid hemorrhage and concomitant myocardial infarction. Hypertensive, hypervolemic, hemodilution therapy was ineffective, and IABC was instituted. Xenon-enhanced computed tomography (Xe-CT) was utilized to obtain serial measurements of CBF with and without IABC over a 4-day period. RESULTS IABC dramatically improved cardiac function in this patient, and Xe-CT demonstrated significant improvement in CBF with IABC. The average global CBF was 20.5 +/- 4.4 ml/100g/min before versus 34.7 +/- 3.8 ml/100g/min after IABC (p < 0.0001, paired student's t-test). The lower the CBF before IABC, the greater the improvement with IABC (correlation coefficient r = 0.83, p = 0.0007). CBF improvement ranged from 33% to 161% above baseline, average 69.3%. No complications of IABC were observed. CONCLUSIONS This is the first report demonstrating the ability of IABC to improve CBF in a patient with vasospasm. We suggest that IABC is a rational treatment option in select patients with refractory cerebral vasospasm who do not respond to traditional treatment measures.
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Affiliation(s)
- E S Nussbaum
- Department of Neurological Surgery, University of Minnesota Hospital and Clinic, Minneapolis, USA
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Apostolides PJ, Greene KA, Zabramski JM, Fitzgerald JW, Spetzler RF. Intra-aortic balloon pump counterpulsation in the management of concomitant cerebral vasospasm and cardiac failure after subarachnoid hemorrhage: technical case report. Neurosurgery 1996; 38:1056-9; discussion 1059-60. [PMID: 8727836 DOI: 10.1097/00006123-199605000-00042] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
We report two patients who had symptomatic cerebral vasospasm and cardiac failure after aneurysmal subarachnoid hemorrhage and who were treated successfully with intra-aortic balloon pump counterpulsation therapy. Both patients developed congestive heart failure and pulmonary edema while receiving postoperative hypertensive, hypervolemic, hemodilutional (Triple-H) therapy for symptomatic cerebral vasospasm. Both cases of cardiac failure were refractory to maximum pressor and inotropic infusions. Intra-aortic balloon pump counterpulsation was used to optimize cardiac performance to allow continuation of Triple-H therapy and to maintain adequate cerebral perfusion in an attempt to decrease the risk of cerebral ischemic complications. Both patients have had good long-term outcomes. These two cases illustrate the potential usefulness of the intra-aortic balloon pump as an adjunct to Triple-H therapy in patients with symptomatic cerebral vasospasm and cardiac failure. To our knowledge, this report documents the first clinical application of this adjunctive therapy for vasospasm after aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- P J Apostolides
- Division of Neurological Surgery, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Simeone FA. Intra-aortic Balloon Counterpulsation Augments Cerebral Blood Flow in a Canine Model of Subarachnoid Hemorrhage-induced Cerebrovasospasm. Neurosurgery 1995; 37:1233???1234. [DOI: 10.1097/00006123-199512000-00040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Nussbaum ES, Heros RC. Intra-aortic Balloon Counterpulsation Augments Cerebral Blood Flow in a Canine Model of Subarachnoid Hemorrhage-induced Cerebrovasospasm: . Neurosurgery 1995; 37:1234. [DOI: 10.1097/00006123-199512000-00041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abraham J, Ott EO, Aoyagi M, Tagashira Y, Achari AN, Meyer JS. Regional cerebral blood flow changes after bilateral external carotid artery ligation in acute experimental infarction. J Neurol Neurosurg Psychiatry 1975; 38:78-88. [PMID: 1117303 PMCID: PMC491863 DOI: 10.1136/jnnp.38.1.78] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Regional cerebral blood flow (rCBF) was measured in baboons by intracarotid injection of 133Xe and a gamma camera after acute cerebral infarction was induced by occlusion of the middle cerebral artery (MCA). A steady state of rCBF was measured four hour after MCA occlusion and was followed by bilateral ligation of the external cartoid arteries (ECA). Subsequent rCBF measurements were obtained at 30, 60, and 120 minutes. After bilateral ECA ligation, flow in ischaemic and non-ischaemic areas was greatly enhanced and flow in the hyperaemic areas significantly reduced, presumably since they had provided collateral circulation to the ischaemic zone with a favourable redistribution.
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