Computed Tomography Angiography Compared with Computed Tomography Perfusion in the Diagnosis of Cerebral Vasospasm: A Systematic Review and Meta-Analysis

Emergent Management of Spontaneous Subarachnoid Hemorrhage

OBJECTIVE

Spontaneous subarachnoid hemorrhage (SAH) carries high morbidity and mortality rates, and the emergent management of this disease can make a large impact on patient outcome. The purpose of this article is to provide a pragmatic overview of the emergent management of SAH.

LATEST DEVELOPMENTS

Recent trials have influenced practice around the use of antifibrinolytics, the timing of aneurysm securement, the recognition of cerebral edema and focus on avoiding a lower limit of perfusion, and the detection and prevention of delayed cerebral ischemia. Much of the acute management of SAH can be protocolized, as demonstrated by two updated guidelines published by the American Heart Association/American Stroke Association and the Neurocritical Care Society in 2023. However, the gaps in evidence lead to clinical equipoise in some aspects of critical care management.

ESSENTIAL POINTS

In acute management, there is an urgency to differentiate the etiology of SAH and take key emergent actions including blood pressure management and coagulopathy reversal. The critical care management of SAH is similar to that of other acute brain injuries, with the addition of detecting and treating delayed cerebral ischemia. Strategies for the detection and treatment of delayed cerebral ischemia are limited by disordered consciousness and may be augmented by monitoring and imaging technology.

Intracranial dynamics biomarkers at traumatic cerebral vasospasm

Introduction

Patients who suffer severe traumatic brain injury (sTBI) and cerebral vasospasm (CVS) frequently have posttraumatic cerebral ischemia (PCI).

The research question

was to study changes in cerebral microcirculatory bed parameters in sTBI patients with CVS and with or without PCI.

Material and methods

A total of 136 severe TBI patients were recruited in the study. All patients underwent perfusion computed tomography, intracranial pressure monitoring, and transcranial Doppler. The levels of cerebrovascular resistance (CVR), cerebral arterial compliance (CAC), cerebrovascular time constant (CTC), and critical closing pressure (CCP) were measured using the neuromonitoring complex. Statistical analysis was performed using parametric and nonparametric methods and factor analysis. The patients were dichotomized into PCI-positive (n = 114) and PCI-negative (n = 22) groups. Data are presented as mean values (standard deviations).

Results

CVR was significantly increased, whereas CAC, CTC, and CCP were significantly decreased in sTBI patients with CVS and PCI development (p < 0.05). Factor analyses revealed that all studied microcirculatory bed parameters were significantly associated with the development of PCI (p < 0.05).

Discussion and conclusion

The changes in all studied microcirculatory bed parameters in TBI patients with CVS were significantly associated with PCI development, which enables us to regard them as the biomarkers of CVS and PCI development. The causes of the described microcirculatory bed parameters changes might include complex (cytotoxic and vasogenic) brain edema development, regional microvascular spasm, and dysfunction of pericytes. A further prospective study is warranted.