Ultrasonografía doppler transcraneal urgente: utilidad predictiva del vasoespasmo sintomático en la hemorragia subaracnoidea espontánea en pacientes con buena situación neurológica

doi:10.1016/j.medin.2012.01.013

Medicina Intensiva

Volume 36, Issue 9, December 2012, Pages 611-618

https://doi.org/10.1016/j.medin.2012.01.013 Get rights and content

Resumen

Objetivo

Establecer el valor predictivo, para desarrollar deterioro neurológico tardío de origen isquémico (DNI), de un estudio doppler transcraneal (DTC) en pacientes con hemorragia subaracnoidea espontánea (HSA) en buena situación neurológica.

Diseño

Estudio descriptivo-observacional desarrollado durante 3 años.

Ámbito

Cuidados Críticos y Urgencias.

Pacientes

Se incluyeron de forma consecutiva aquellos pacientes con HSA en buena situación neurológica (Hunt-Hess I-III).

Variables de Interés

DNI (disminución en 2 puntos del GCS o déficit focal), velocidad media (VM) en arterias cerebrales medias, índice de Lindegaard (IL). Se consideró patrón sonográfico de vasoespasmo (PSV) cuando la VM fue > 120 cm/s y existía un IL > 3.

Resultados

La media de edad de los 122 pacientes fue de 54,1 ± 13,7 años. El 57,3% eran mujeres. Se detectaron 24 pacientes con PSV (19,7%) encontrándose VM elevadas en 38 pacientes (31,1%). 21 pacientes desarrollaron DNI (VM 183+/-49 cm/s), todos presentaron PSV. En los pacientes con DNI se detectó un aumento de VM de 22+/-5 cm/s/24 h durante los 3 primeros días. Al comparar aquellos pacientes que no presentaron VM elevadas (85 pacientes/VM 67+/-16,6 cm/s) con respecto a los que desarrollaron DNI encontramos diferencias en las VM (p < 0,001) y en el ΔVM/24 h (8,30+/-4,5 cm/s Vs 22+/-5 cm/s) durante los 3 primeros días (p = 0,009). Mediante curvas ROC, se fijó que el ΔVM/día de 21 cm/s (p < 0,001), era el que mejor predecía el DNI.

Conclusión

Durante los 3 primeros días un incremento en la VM de 21 cm/s/24 h se asoció con el desarrollo de vasoespamo sintomático. El DTC es una herramienta útil para la detección de aquellos pacientes con HSA en riesgo de desarrollar DNI.

Abstract

Purpose

To examine the predictive value of an early transcranial Doppler ultrasound (TCD) study performed in the emergency department in patients with spontaneous subarachoniod hemorrhage (SAH) in good neurological condition, in order to know which patients are at high risk of developing delayed cerebral ischemia (DCI).

Design

A descriptive observational study was carried out involving a period of 3 years.

Setting

Critical Care and Emergency Department.

Patients

The study consecutively included patients with SAH of grade I-III on the Hunt and Hess scale.

Variables of Interest

DCI (decrease of 2 points in GCS or focal deficit), Mean Velocity (MV) of middle cerebral arteries (MCA), Lindegaard Index (IL). Sonographic vasospasm pattern (SVP) was considered if MCA-MV > 120 cm/sc and IL > 3.

Results

The mean age of the 122 patients was 54.1 ± 13.7 years; 57.3% were women. SVP was detected in 24 patients (19.7%), although high velocities patterns (HVP) were present in 38 patients (31.1%). DCI developed in 21 patients (MV183+/-49 cm/sc), all with previous SVP. In this group MV increased 22+/-5 cm/sc/day during the first 3 days. The group without HVP (84 patients/MV of 67+/-16.6 cm/sc), compared with DCI group, showed differences in highest MV (p < 0.001), and also ΔMV/day (8.30+/-4,5 cm/sc Vs 22+/-5 cm/sc) during the first 3 days (p = 0.009). In our series, ROC analysis selected the best cut-off value for ΔMV/day as 21 cm/sc (p < 0.001).

Conclusion

During the first 3 days, an increase of 21 cm/s/24 h in MCA-MV was associated with the development of symptomatic vasospasm. TCD is a useful tool for the early detection of patients at risk of DCI after SAH.

Section snippets

Introducción

La patología cerebrovascular hemorrágica de origen aneurismático supone alrededor del 80% de todos los sangrados extravasados al espacio subaracnoideo de origen no traumático. La hemorragia subaracnoidea espontánea (HSA) supone entre el 5-10% de todos los ictus, presentando una incidencia media de 6-10/100.000 habitantes y es la causa más habitual de muerte súbita por ictus1, 2, 3, 4. Se ha detectado hasta un 20% de mortalidad evitable tras la HSA⁵. Una de las complicaciones principales,

Material y método

Estudio descriptivo longitudinal desarrollado siguiendo las directrices del Comité de Investigación de nuestro Hospital, en el Servicio de Cuidados Críticos y Urgencias del Hospital Universitario de Traumatología, Virgen del Rocío, en el período 2005-2007.

Se han incluido todas las HSA espontáneas de baja gravedad clínica - según la escala de Hunt y Hess (HH), grados i al iii - en el momento del ingreso en el hospital¹². Fueron excluidas las HSA traumáticas, los aneurismas incidentales, los

Resultados

Durante el periodo de realización de nuestro estudio, se registraron 123 episodios de HSA. Un paciente fue excluido del estudio al no presentar ventana sonográfica. Se estudiaron un total de 122 pacientes. La distribución por sexo fue de 70 mujeres (57,3%) y 52 hombres (42,6%), con una media de edad de 54,1 ±13,7 años.

El 70,4% de los pacientes acudieron al hospital, en las primeras 24 horas del sangrado y fueron diagnosticados de HSA, antes de transcurridas 24 horas de la aparición de los

Discusión

De nuestros resultados se infiere que un incremento de velocidad media de 21 cm/s/24 h en la ACM, en los 3 primeros días de evolución, se asocia de forma significativa con el desarrollo de vasoespasmo sintomático.

La VM máxima registrada en la ACM de nuestros pacientes con vasoespasmo sintomático superó en todos ellos 120 cm/s, de forma homogénea en todas las franjas de edad, excepto en uno con velocidad amortiguada por hidrocefalia. Por tanto, es innecesario utilizar otros puntos de corte más

Conclusiones

La anticipación al desarrollo de complicaciones isquémicas por vasoespasmo puede llevarse a cabo mediante el seguimiento evolutivo de la velocidad del flujo sanguíneo cerebral de los pacientes con HSA y buen grado neurológico. En este grupo de pacientes un incremento de VM en el registro DTC de 21 cm/s/24 h en la ACM durante los 3 primeros días de evolución o la detección de una VM> 120 cm/s con un IL > 3, nos permite identificar aquellos pacientes en riesgo de desarrollar vasoespasmo sintomático

Financiación

La realización de este estudio ha sido financiada mediante beca otorgada por la Consejería de Salud de Andalucía 2002. Número de Expediente 30/01.

Conflictos de intereses

Los autores declaran no tener ningún conflicto de intereses.

Bibliografía (40)

G. Teasdale et al.
Assessment of coma and impaired consciousness. A practical scale
Lancet
(1974)
T. Inagawa
Cerebral vasospasm in elderly patients with ruptured intracranial aneurysms
Surg Neurol
(1991)
J.M. Abadal et al.
Applications of transcranial color-coded duplex sonography in monitoring neurocritical patients
Med Intensiva
(2007)
J.A. Edlow et al.
Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage
N Engl J Med
(2000)
M.A. Muñoz-Sánchez et al.
Estudio de las hemorragias subaracnoideas espontáneas en Andalucía. Incidencia y resultados
Rev Neurol
(2003)
J.T King
Epidemiology of aneurysmal subarachnoid hemorrhage
Neuroimaging Clin N Am
(1997)
J. Van Gijn et al.
Subarachnoid haemorrhage: diagnosis, causes and management
Brain
(2001)
M.A. Muñoz-Sánchez et al.
Improving the outcomes in spontaneous subarachnoid haemorrhage: the EHSA project
Rev Neurol
(2009)
B. Weir
Epidemiology
N.F. Kassell et al.
The International Co-operative Study on the Timing of Aneurysm Surgery 1. Overall management results
J Neurosurg
(1990)

J.I. Suarez et al.

Aneurysmal subarachnoid hemorrhage

N Engl J Med

(2006)

N.R. Gonzalez et al.

Vasospasm probability index: a combination of transcranial Doppler velocities, cerebral blood flow, and clinical risk factors to predict cerebral vasospasm after aneurysmal subarachnoid hemorrhage

J Neurosurg

(2007)

C.H. Tegeler et al.

Ultrasound in stroke

C.M. Fisher et al.

Relation of cerebral vasospasm to subarachnoid haemorrhage visualised by computerised tomographic scanning

Neurosurgery

(1980)

W.E. Hunt et al.

Surgical risk as related to time of intervention in the repair of intracranial aneurysms

J Neurosurg

(1968)

H.P. Adams et al.

Predicting cerebral ischemia after aneurysmal subarachnoid haemorrhage: Influence of clinical condition, CT results, and antifibrinolitic therapy. A report of the Co-operative Aneurysm Study

Neurology

(1987)

S.F. Ameriso et al.

Hematogenous factors and prediction of delayed ischemic deficit after subarachnoid haemorrhage

Stroke

(1992)

D.G. Grosset et al.

Use of transcraneal Doppler sonography to predict development of a delayed ischemic deficit after subarachnoid haemorrhage

J Neurosurg

(1993)

A.G. Harders et al.

Time course of blood velocity changes related to vasospasm in the circle of Willis measured by transcraneal Doppler ultrasound

J Neurosurg

(1987)

R.W. Seiler et al.

Cerebral vasospasm evaluated by transcraneal ultrasound correlated with clinical grade and CT visualised subarachnoid haemorrhage

J Neurosurg

(1986)

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Transcranial sonography in the critical patient
2024, Medicina Intensiva
La ultrasonografía transcraneal es una técnica no invasiva y disponible a pie de cama que se ha convertido en una herramienta accesible y consolidada en la evaluación y el manejo clínico de los pacientes neurocríticos. Se trata de una técnica en continuo crecimiento cuyos fundamentos (y sus limitaciones) deben ser conocidos por el intensivista. Esta revisión aporta un enfoque práctico para el intensivista, incluyendo las diferentes ventanas y planos de insonación y su papel en la patología específica propia de los pacientes neurocríticos y en los pacientes críticos de otras etiologías.
Transcranial ultrasonography is a non-invasive, bedside technique that has become a widely implemented tool in the evaluation and management of neurocritically ill patients. It constitutes a technique in continuous growth whose fundamentals (and limitations) must be known by the intensivist. This review provides a practical approach for the intensivist, including the different sonographic windows and planes of insonation and its role in different conditions of the neurocritical patients and in critical care patients of other etiologies.
Cerebrospinal fluid lumbar drainage in reducing vasospasm following aneurysmal subarachnoid hemorrhage in Vietnam: A single-center prospective study
2021, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
Citation Excerpt :
The introduction of 3-H therapy in early 1980s [4], angioplasty in late 1980s [5] and routinely clinical use of Nimodipine in 1985 [6] have played a vital role in vasospasm management. However, the impact remains devastating and it contributes to poor outcomes in approximately 10–40% of aSAH patients [7–9]. This indicates the need to have an effective mean to prevent vasospasm in clinical practice.
Vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) aggravates outcome of patients through a cascade of complications and harsh consequences. This study was conducted to evaluate the effect of cerebrospinal fluid (CSF) lumbar drainage in aSAH management and in the prevention of vasospasm at a university hospital in Vietnam.
A single-center, prospective case series of aSAH treatment with CSF lumbar drainage was conducted from June 2018 to July 2019. Outcomes measured were clinical vasospasm, vasospasm-induced infarction, shunt-dependent rate, duration of treatment in hospital and Glasgow Outcome Scale (GOS) at 3 months and 1 year after discharge.
Among 43 patients with aSAH admitted to the clinic, thirty-two aSAH patients (71.8% female, mean age 58.8 ± 11.5 years) received lumbar drainage. The incidence of clinical vasospasm and vasospasm-induced infarction on CT scan/MRI (including asymptomatic cerebral infarction) was 21.9% and 56.3%, respectively. Four patients (12.5%) underwent another CSF shunting operation. The mean duration of hospital stay was 27.8 ± 16.9 days. Nearly 70% of aSAH patients were discharged and were able to return to normal life with no or minor neurological deficits (GOS 4–5) at 3-month and 1-year follow-ups. No serious complication of CSF lumbar drainage was observed, except for one major setback, which was meningitis during treatment (53.1%).
CSF lumbar drainage may reduce the incidence of clinical vasospasm, shorten hospital stays, and possibly improve patient outcomes following aSAH. Our findings suggest that the selective use of CSF lumbar drainage, in addition to standard strategies, can be beneficial in preventing vasospasm and offers more choice in aSAH management.
Incorporation of Transcranial Doppler into the ED for the neurocritical care patient
2019, American Journal of Emergency Medicine
In the catastrophic neurologic emergency, a complete neurological exam is not always possible or feasible given the time-sensitive nature of the underlying disease process, or if emergent airway management is indicated. As the neurologic exam may be limited in some patients, the emergency physician is reliant on the assessment of brainstem structures to determine neurological function. Physicians thus routinely depend on advanced imaging modalities to further investigate for potential catastrophic diagnoses. Acquiring these tests introduces the risks of transport as well as delays in managing time-sensitive neurologic processes. A more immediate, non-invasive bedside approach complementing these modalities has evolved: Transcranial Doppler (TCD).
This narrative review will provide a description of scenarios in which TCD may be applicable. It will summarize the sonographic findings and associated underlying pathophysiology in such neurocritical care patients. An illustrated tutorial, along with pearls and pitfalls, is provided.
Although there are numerous formalized TCD protocols utilizing four views (transtemporal, submandibular, suboccipital, and transorbital), point-of-care TCD is best accomplished through the transtemporal window. The core applications include the evaluation of midline shift, vasospasm after subarachnoid hemorrhage, acute ischemic stroke, and elevated intracranial pressure. An illustrative tutorial is provided.
With the wide dissemination of bedside ultrasound within the emergency department, there is a unique opportunity for the emergency physician to utilize TCD for a variety of conditions. While barriers to training exist, emergency physician performance of limited point-of-care TCD is feasible and may provide rapid and reliable clinical information with high temporal resolution.
Bias in the interpretation of the transcranial color-coded duplex sonography register
2019, Medicina Intensiva
Urotensinergic system genes in experimental subarachnoid hemorrhage
2017, Medicina Intensiva
Citation Excerpt :
Of those who survive, 40% present disabling sequelae.5,6 It is estimated that cerebral vasospasm (CVS) is responsible for neurological deterioration, and even death, in 15–20% of patients with SAH.5,7 CVS is characterized by diffuse and long-lasting arterial constriction.
Cerebral vasospasm, one of the main complications of subarachnoid hemorrhage (SAH), is characterized by arterial constriction and mainly occurs from day 4 until the second week after the event. Urotensin-II (U-II) has been described as the most potent vasoconstrictor peptide in mammals. An analysis is made of the serum U-II concentrations and mRNA expression levels of U-II, urotensin related peptide (URP) and urotensin receptor (UT) genes in an experimental murine model of SAH.
An experimental study was carried out.
Experimental operating room of the Biomedicine Institute of Seville (IBiS), Virgen del Rocío University Hospital (Seville, Spain).
96 Wistar rats: 74 SAH and 22 sham intervention animals.
Day 1: blood sampling, followed by the percutaneous injection of 100 μl saline (sham) or blood (SAH) into the subarachnoid space. Day 5: blood sampling, followed by sacrifice of the animals.
Weight, early mortality, serum U-II levels, mRNA values for U-II, URP and UT.
Serum U-II levels increased in the SAH group from day 1 (0.62 pg/mL [IQR 0.36–1.08]) to day 5 (0.74 pg/mL [IQR 0.39–1.43]) (p < 0.05), though not in the sham group (0.56 pg/mL [IQR 0.06–0.83] day 1; 0.37 pg/mL [IQR 0.23–0.62] day 5; p = 0.959). Between-group differences were found on day 5 (p < 0.05). The ROC analysis showed that the day 5 serum U-II levels (AUC = 0.691), URP mRNA (AUC = 0.706) and UT mRNA (AUC = 0.713) could discriminate between sham and SAH rats. The normal serum U-II concentration range in rats was 0.56 pg/mL (IQR 0.06–0.83).
The urotensinergic system is upregulated on day 5 in an experimental model of SAH.
El vasoespasmo cerebral, una de las principales complicaciones secundarias a hemorragia subaracnoidea (HSA), se caracteriza por una constricción arterial que tiene lugar principalmente entre el día 4 y la segunda semana. La urotensina-II (U-II) ha sido definida como el péptido con mayor capacidad vasoconstrictora en mamíferos. Quisimos analizar los niveles séricos de U-II, así como los niveles de expresión de los genes de U-II, péptido relacionado con urotensina y receptor de urotensina, en un modelo murino experimental de HSA.
Estudio experimental.
Quirófano experimental del Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío.
Noventa y seis ratas Wistar: 74 con inyección percutánea de sangre (HSA), 22 con inyección percutánea de 100 μL de salino (Sham).
Día 1: extracción de muestras de sangre. Posteriormente, inyección percutánea de 100 μL de salino (Sham) o de sangre (HSA) en el espacio subaracnoideo. Día 5: extracción de muestras de sangre y sacrificio del animal.
Peso, mortalidad precoz, niveles séricos de U-II, valores de ARNm de U-II, péptido relacionado con urotensina y receptor de urotensina.
Observamos un incremento en los niveles de U-II sérica en el grupo HSA desde el día 1 (0,62 pg/mL [RI 0,36-1,08]) al día 5 (0,74 pg/mL [RI 0,39-1,43]) (p < 0,05); pero no observamos tal diferencia en el grupo Sham (0,56 pg/mL [RI 0,06-0,83] día 1; 0,37 pg/mL [RI 0,23-0,62] día 5) (p = 0,959). Se encontraron diferencias en los niveles de U-II entre ambos grupos al quinto día (p < 0,05). El análisis de curvas ROC demostró que la U-II sérica al quinto día (AUC = 0,691), ARNm de péptido relacionado con urotensina (AUC = 0,706) y ARNm de receptor de urotensina (AUC = 0,713) podían discriminar entre ratas Sham y HSA. Además, definimos un rango de normalidad para los niveles de U-II séricos en ratas: 0,56 pg/mL (RI 0,06-0,83).
Este estudio demuestra por primera vez que el sistema urotensinérgico ve incrementada su expresión en el quinto día en un modelo de HSA.
External lumbar cerebrospinal fluid drainage in patients with aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis of controlled trials
2016, Neurologia
El drenaje lumbar externo de líquido cefalorraquídeo es una medida promisoria para la prevención de las complicaciones de la isquemia cerebral tardía asociada a la hemorragia subaracnoidea espontánea de origen aneurismático.
Se incluyeron los estudios controlados que evaluaran los efectos del drenaje lumbar externo en pacientes con hemorragia subaracnoidea aneurismática. Los desenlaces primarios fueron: nuevos infartos cerebrales y discapacidad grave. Los desenlaces secundarios fueron: deterioro clínico causado por isquemia cerebral tardía, mortalidad y necesidad de derivación ventricular definitiva. Los resultados se presentaron en riesgos relativos combinados, con un intervalo de confianza del 95% (IC 95%).
Fueron incluidos un total de 6 estudios controlados. Los riesgos relativos combinados fueron: nuevos infartos cerebrales, 0,48 (IC 95%: 0,32-0,72); discapacidad grave, 0,5 (IC 95%: 0,29-0,85); deterioro clínico causado por isquemia cerebral tardía, 0,46 (IC 95%: 0,34-0,63); mortalidad, 0,71 (IC 95%: 0,24-2,06) y necesidad de derivación ventricular definitiva, 0,80 (IC 95%: 0,51-1,24). La evaluación de la heterogeneidad demostró índices estadísticamente significativos únicamente en el análisis de discapacidad grave (I² = 70% y p = 0,01).
El drenaje lumbar externo se asoció con una reducción estadísticamente significativa del riesgo de complicaciones causadas por la isquemia cerebral tardía (infartos cerebrales y deterioro clínico), así como del riesgo de discapacidad grave; sin embargo, esto no se tradujo en una menor mortalidad. No obstante, no es prudente emitir recomendaciones definitivas debido a la heterogeneidad cualitativa y cuantitativa entre los estudios. Son necesarios más ensayos clínicos con definiciones homogéneas de sus desenlaces para aclarar sus efectos en los pacientes con hemorragia subaracnoidea aneurismática.
External lumbar drainage is a promising measure for the prevention of delayed aneurysmal subarachnoid hemorrhage-related ischemic complications.
Controlled studies evaluating the effects of external lumbar drainage in patients with aneurysmal subarachnoid hemorrhage were included. Primary outcomes were: new cerebral infarctions and severe disability. Secondary outcomes were: clinical deterioration due to delayed cerebral ischemia, mortality, and the need of definitive ventricular shunting. Results were presented as pooled relative risks, with their 95% confidence intervals (95% CI).
A total of 6 controlled studies were included. Pooled relative risks were: new cerebral infarctions, 0.48 (95% CI: 0.32-0.72); severe disability, 0.5 (95% CI: 0.29-0.85); delayed cerebral ischemia-related clinical deterioration, 0.46 (95% CI: 0.34-0.63); mortality, 0.71 (95% CI: 0.24-2.06), and need of definitive ventricular shunting, 0.80 (95% CI: 0.51-1.24). Assessment of heterogeneity only revealed statistically significant indexes for the analysis of severe disability (I² = 70% and P = .01).
External lumbar drainage was associated with a statistically significant decrease in the risk of delayed cerebral ischemia-related complications (cerebral infarctions and clinical deterioration), as well as the risk of severe disability; however, it was not translated in a lower mortality. Nevertheless, it is not prudent to provide definitive recommendations at this time because of the qualitative and quantitative heterogeneity among included studies. More randomized controlled trials with more homogeneous outcomes and definitions are needed to clarify its impact in patients with aneurysmal subarachnoid hemorrhage.

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Resumen

Objetivo

Diseño

Ámbito

Pacientes

Variables de Interés

Resultados

Conclusión

Abstract

Purpose

Design

Setting

Patients

Variables of Interest

Results

Conclusion

Section snippets

Introducción

Material y método

Resultados

Discusión

Conclusiones

Financiación

Conflictos de intereses

Lancet

Surg Neurol

Med Intensiva

Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage

N Engl J Med

Estudio de las hemorragias subaracnoideas espontáneas en Andalucía. Incidencia y resultados

Rev Neurol

Epidemiology of aneurysmal subarachnoid hemorrhage

Neuroimaging Clin N Am

Subarachnoid haemorrhage: diagnosis, causes and management

Brain

Improving the outcomes in spontaneous subarachnoid haemorrhage: the EHSA project

Rev Neurol

Epidemiology

The International Co-operative Study on the Timing of Aneurysm Surgery 1. Overall management results

J Neurosurg

Aneurysmal subarachnoid hemorrhage

N Engl J Med

Vasospasm probability index: a combination of transcranial Doppler velocities, cerebral blood flow, and clinical risk factors to predict cerebral vasospasm after aneurysmal subarachnoid hemorrhage

J Neurosurg

Ultrasound in stroke

Relation of cerebral vasospasm to subarachnoid haemorrhage visualised by computerised tomographic scanning

Neurosurgery

Surgical risk as related to time of intervention in the repair of intracranial aneurysms

J Neurosurg

Predicting cerebral ischemia after aneurysmal subarachnoid haemorrhage: Influence of clinical condition, CT results, and antifibrinolitic therapy. A report of the Co-operative Aneurysm Study

Neurology

Hematogenous factors and prediction of delayed ischemic deficit after subarachnoid haemorrhage

Stroke

Use of transcraneal Doppler sonography to predict development of a delayed ischemic deficit after subarachnoid haemorrhage

J Neurosurg

Time course of blood velocity changes related to vasospasm in the circle of Willis measured by transcraneal Doppler ultrasound

J Neurosurg

Cerebral vasospasm evaluated by transcraneal ultrasound correlated with clinical grade and CT visualised subarachnoid haemorrhage

J Neurosurg