Posttraumatic vasospasm: the epidemiology, severity, and time course of an underestimated phenomenon: a prospective study performed in 299 patients

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Object. The purpose of this prospective study was to evaluate the cumulative incidence, duration, and time course of cerebral vasospasm after traumatic brain injury (TBI) in a cohort of 299 patients.

Methods. Transcranial Doppler (TCD) ultrasonography studies of blood flow velocity in the middle cerebral and basilar arteries (VMCA and VBA, respectively) were performed at regular intervals during the first 2 weeks posttrauma in association with 133Xe cerebral blood flow (CBF) measurements. According to current definitions of vasospasm, five different criteria were used to classify the patients: A (VMCA > 120 cm/second); B (VMCA > 120 cm/second and a Lindegaard ratio [LR] > 3); C (spasm index [SI] in the anterior circulation > 3.4); D (VBA > 90 cm/second); and E (SI in the posterior circulation > 2.5). Criteria C and E were considered to represent hemodynamically significant vasospasm. Mixed-effects spline models were used to analyze the data of multiple measurements with an inconsistent sampling rate.

Overall 45.2% of the patients demonstrated at least one criterion for vasospasm. The patients in whom vasospasm developed were significantly younger and had lower Glasgow Coma Scale scores on admission. The normalized cumulative incidences were 36.9 and 36.2% for patients with Criteria A and B, respectively. Hemodynamically significant vasospasm in the anterior circulation (Criterion C) was found in 44.6% of the patients, whereas vasospasm in the BA—Criterion D or E—was found in only 19 and 22.5% of the patients, respectively. The most common day of onset for Criteria A, B, D, and E was postinjury Day 2. The highest risk of developing hemodynamically significant vasospasm in the anterior circulation was found on Day 3. The daily prevalence of vasospasm in patients in the intensive care unit was 30% from postinjury Day 2 to Day 13. Vasospasm resolved after a duration of 5 days in 50% of the patients with Criterion A or B and after a period of 3.5 days in 50% of those patients with Criterion D or E. Hemodynamically significant vasospasm in the anterior circulation resolved after 2.5 days in 50% of the patients. The time course of that vasospasm was primarily determined by a decrease in CBF.

Conclusions. The incidence of vasospasm after TBI is similar to that following aneurysmal subarachnoid hemorrhage. Because vasospasm is a significant event in a high proportion of patients after severe head injury, close TCD and CBF monitoring is recommended for the treatment of such patients.

Article Information

Address reprint requests to: Thomas C. Glenn, Ph.D., David Geffen School of Medicine at University of California at Los Angeles, Box 957039, 10833 Le Conte Avenue, Los Angeles, California 90095–7039. email: tglenn@mednet.ucla.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Upper: Graph showing the cumulative incidence of vasospasm in the anterior circulation (Criteria A–C) plotted against the postinjury day. The total incidence is highest for an SI greater than 3.4 including the cases with a VMCA less than 120 cm/second. Lower: Graph depicting the cumulative incidence of vasospasm in the posterior circulation (Criteria D and E).

  • View in gallery

    Bar graphs showing the daily probability of entering a phase of vasospasm for each of the five criteria. The highest probability is on postinjury Day 2 for Criteria A and B; however, hemodynamically significant vasospasm (Criterion C) does not develop until postinjury Day 3. Note that the overall occurrence of vasospasm is lower in the posterior circulation (Criteria D and E).

  • View in gallery

    Graphs depicting the proportion of patients remaining in a state of vasospasm plotted against the days after onset. For VMCA measurements (Criteria A and B), 50% of patients experienced resolution of vasospasm in 5 days. For hemodynamically significant vasospasm (SI > 3.4), 50% of patients experienced resolution in 2.5 days. Note that the duration of vasospasm is shorter in the posterior circulation (lower) than in the anterior circulation (upper).

  • View in gallery

    Bar graphs showing the daily prevalence of vasospasm in the ICU plotted against the days postinjury. Those patients who left the ICU because they improved or died are not represented. Starting with postinjury Day 2, the daily prevalence is approximately 30% for vasospasm in the anterior circulation (upper) and 20% or less for vasospasm in the posterior circulation (lower).

  • View in gallery

    Bar graphs demonstrating the distribution of SI, VMCA, and CBF values in patients with hemodynamically significant vasospasm, expressed as a percentage of total studies for each variable. In more than 50% of the studies, the SI was greater than 4, the VMCA higher than 120 cm/second, and the CBF lower than 30 ml/100 g/min. Nevertheless, a VMCA less than 120 cm/second was present in 42% of the studies.

  • View in gallery

    Graphs showing the time course of the VMCA, CBF, and SI in patients who experienced hemodynamically significant vasospasm in the anterior circulation (SI > 3.4). The mean (solid black line) and the 95% confidence limits (dotted lines) for each variable are displayed. Time 0 indicates the onset of hemodynamically significant vasospasm. These graphs were generated using a mixed-effects spline model. Note that the decrease in CBF was primarily responsible for the increase in the SI.

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