Cerebral vasospasm evaluated by transcranial ultrasound correlated with clinical grade and CT-visualized subarachnoid hemorrhage

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✓ In 39 patients with a proven subarachnoid hemorrhage (SAH), the clinical status, the amount of subarachnoid blood on a computerized tomography scan obtained within 5 days after SAH, and the flow velocities (FV's) in both middle cerebral arteries (MCA's) measured by transcranial Doppler sonography were recorded daily and correlated. All patients had pathological FV's over 80 cm/sec between Day 4 and Day 10 after SAH. The side of the ruptured aneurysm showed higher FV's than did the unaffected side in cases of laterally localized aneurysms. Increase in FV preceded clinical manifestation of ischemia. A steep early increase of FV's portended severe ischemia and impending infarction. Maximum FV's in the range of 120 to 140 cm/sec were not critical and in no case led to brain infarction. Maximum FV's over 200 cm/sec were associated with a tendency for ischemia, but the patients may remain clinically asymptomatic. In cases of no or only a little blood in the basal cisterns, mean FV's in both MCA's increased only moderately whereas, with thick clots of subarachnoid blood, there was a steeper and higher increase of mean FV's.

Article Information

Address reprint requests to: Rolf W. Seiler, M.D., Neurochirurgische Klinik, Universitätspital, CH-3010 Bern, Switzerland.

Present address for Dr. Aaslid: Institute for Applied Physiology and Medicine, 70, 16 Avenue, Seattle, Washington 98122.

Present address for Dr. Nornes: Department of Neurosurgery, Rikshospitalet, Oslo 1, Norway.

© AANS, except where prohibited by US copyright law.

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Figures

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    Mean flow velocity (FV, in cm/sec) curves of the side with the higher FV's (continuous line) and the side with the lower FV's (dotted line) correlated with the mean clinical status according to the classification of Hunt and Hess (H & H) over a 28-day time course after subarachnoid hemorrhage (SAH). Upper Left: Data for 20 patients with no neurological symptoms (Clinical Group 1). Because the 13 patients operated on before Day 10 generally showed an increase in FV postoperatively, the curve has an irregular form. This postoperative increase of the FV was never critical and was clinically asymptomatic. Upper Right: Data for 11 patients with transient neurological symptoms (Clinical Group 2). The initial curve shows the natural time course of mild symptomatic vasospasm, because no patient underwent surgery before Day 11. Lower Left: Data for five patients with permanent neurological deficits due to cerebral infarction (Clinical Group 3a). The curve shows the time course of severe symptomatic vasospasm. The early increase in FV precedes clinical deterioration. Lower Right: Data for three patients who died from cerebral infarction (Clinical Group 3b). There is already a steep increase of FV on the 2nd and 3rd day after SAH.

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    Mean flow velocity (FV, in cm/sec) curves of 18 patients with laterally localized aneurysms (arising from the internal carotid and middle cerebral arteries). The side of the ruptured aneurysm (continuous line) shows a higher FV than the unaffected side (dotted line). SAH = subarachnoid hemorrhage.

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    Distribution of patients with maximum flow velocities (FV's) for the three clinical groups (CL 1, 2, and 3). Maximum FV's over 200 cm/sec have a tendency for ischemia, but may remain asymptomatic. For a definition of the clinical groups see text. v = flow velocity.

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    Mean flow velocity (FV, in cm/sec) curves from the side with the higher FV (continuous line) and the side with the lower FV (dotted line) recorded over 28 days after subarachnoid hemorrhage (SAH). Upper Left: Data for nine patients with a normal computerized tomography (CT) scan (CT Group 1). There is only a slow increase to about 140 cm/sec on Day 7. The peaks on Days 11 and 15 are due to increased FV's postoperatively. Upper Right: Data for 11 patients with diffuse deposition or thin layers of subarachnoid blood (CT Group 2). There is a slow increase of FV to about 150 cm/sec during the 2nd week. Lower: Data for 15 patients with localized cisternal clots or diffuse thick layers of blood (CT Group 3). There is a steep increase of FV's on the afflicted side to about 190 cm/sec on Day 7. No influence of early operation is seen because no patient underwent surgery before Day 10 post-SAH.

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    Distribution of patients within the three computerized tomography groups with their maximum flow velocities (FV's). There is remarkably positive correlation between the amount of subarachnoid blood and the increase of FV. v = flow velocity.

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