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Kim Y, Mehta A, Nair R, Felbaum DR, Mai JC, Armonda RA, Chang JJ. The TCD hyperemia index to detect vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. J Neuroimaging 2023; 33:725-730. [PMID: 37291461 DOI: 10.1111/jon.13132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/19/2023] [Accepted: 05/31/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND PURPOSE Elevated mean flow velocity (MFV) on transcranial Doppler (TCD) is used to predict vasospasm after aneurysmal subarachnoid hemorrhage (SAH). Hyperemia should be considered when observing elevated MFV. Lindegaard ratio (LR) is commonly used but does not enhance predictive values. We introduce a new marker, the hyperemia index (HI), calculated as bilateral extracranial internal carotid artery MFV divided by initial flow velocity. METHODS We evaluated SAH patients hospitalized ≥7 days between December 1, 2016 and June 30, 2022. We excluded patients with nonaneurysmal SAH, inadequate TCD windows, and baseline TCD obtained after 96 hours from onset. Logistic regression was conducted to assess the significant associations of HI, LR, and maximal MFV with vasospasm and delayed cerebral ischemia (DCI). Receiver operating characteristic analyses were employed to find the optimal cutoff value for HI. RESULTS Lower HI (odds ratio [OR] 0.10, 95% confidence interval [CI] 0.01-0.68), higher MFV (OR 1.03, 95% CI 1.01-1.05), and LR (OR 2.02, 95% CI 1.44-2.85) were associated with vasospasm and DCI. Area under the curve (AUC) for predicting vasospasm was 0.70 (95% CI 0.58-0.82) for HI, 0.87 (95% CI 0.81-0.94) for maximal MFV, and 0.87 (95% CI 0.79-0.94) for LR. The optimal cutoff value for HI was 1.2. Combining HI <1.2 with MFV improved positive predictive value without altering the AUC value. CONCLUSIONS Lower HI was associated with a higher likelihood of vasospasm and DCI. HI <1.2 may serve as a useful TCD parameter to indicate vasospasm and DCI when elevated MFV is observed, or when transtemporal windows are inadequate.
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Affiliation(s)
- Yongwoo Kim
- Comprehensive Stroke Center, MedStar Washington Hospital Center, Washington, DC, USA
- Department of Neurology, Georgetown University School of Medicine and MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amit Mehta
- Department of Neurology, Georgetown University School of Medicine and MedStar Georgetown University Hospital, Washington, DC, USA
| | - Reshmi Nair
- Center for Biostatistics, Informatics and Data Science, MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Jason J Chang
- Department of Neurology, Georgetown University School of Medicine and MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
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Pan Y, Wan W, Xiang M, Guan Y. Transcranial Doppler Ultrasonography as a Diagnostic Tool for Cerebrovascular Disorders. Front Hum Neurosci 2022; 16:841809. [PMID: 35572008 PMCID: PMC9101315 DOI: 10.3389/fnhum.2022.841809] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/04/2022] [Indexed: 01/08/2023] Open
Abstract
Imaging techniques including transcranial Doppler (TCD), magnetic resonance imaging (MRI), computed tomography (CT), and cerebral angiography are available for cerebrovascular disease diagnosis. TCD is a less expensive, non-invasive, and practically simpler approach to diagnosing cerebrovascular disorders than the others. TCD is a commonly available and inexpensive diagnostic tool. However, owing to its large operator dependency, it has a narrow application area. Cerebrovascular disease indicates a group of disorders that alter the flow of blood in the brain. The brain’s functions can be temporarily or permanently impaired as a result of this change in blood flow. Timely diagnosis and treatment can restore the brain-impaired functions, resulting in a much-improved prognosis for the patients. This review summarizes the basic principles underlying the TCD imaging technique and its utility as a diagnostic tool for cerebrovascular disease.
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Labak CM, Shammassian BH, Zhou X, Alkhachroum A. Multimodality Monitoring for Delayed Cerebral Ischemia in Subarachnoid Hemorrhage: A Mini Review. Front Neurol 2022; 13:869107. [PMID: 35493831 PMCID: PMC9043346 DOI: 10.3389/fneur.2022.869107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/14/2022] [Indexed: 12/13/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage is a disease with high mortality and morbidity due in large part to delayed effects of the hemorrhage, including vasospasm, and delayed cerebral ischemia. These two are now recognized as overlapping yet distinct entities, and supportive therapies for delayed cerebral ischemia are predicated on identifying DCI as quickly as possible. The purpose of this overview is to highlight diagnostic tools that are being used in the identification of DCI in the neurocritical care settings.
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Affiliation(s)
- Collin M. Labak
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, United States
- Department of Neurosurgery, University Hospitals Cleveland Medicine Center, Cleveland, OH, United States
| | - Berje Haroutuon Shammassian
- Department of Neurology, Division of Neurocritical Care, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, United States
| | - Xiaofei Zhou
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, OH, United States
- Department of Neurosurgery, University Hospitals Cleveland Medicine Center, Cleveland, OH, United States
| | - Ayham Alkhachroum
- Department of Neurology, Division of Neurocritical Care, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, United States
- *Correspondence: Ayham Alkhachroum
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Ruhatiya RS, Adukia SA, Manjunath RB, Maheshwarappa HM. Current Status and Recommendations in Multimodal Neuromonitoring. Indian J Crit Care Med 2020; 24:353-360. [PMID: 32728329 PMCID: PMC7358870 DOI: 10.5005/jp-journals-10071-23431] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Every patient in neurocritical care evolves through two phases. Acute pathologies are addressed first. These include trauma, hemorrhagic or ischemic stroke, or neuroinfection. Soon after, the concentration shifts to identifying secondary pathologies like fever, seizures, and ischemia, which may exacerbate the brain injury. Frequent bedside examinations are not sufficient for timely detection and prevention of secondary brain injury (SBI) as per the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care. Multimodality monitoring (MMM) can help in tailoring treatment decisions to prevent such a brain injury. Multimodal neuromonitoring involves data-guided therapeutic interventions by employing various tools and data integration to understand brain physiology. Monitors provide real-time information on cerebral hemodynamics, oxygenation, metabolism, and electrophysiology. The monitors may be invasive/noninvasive and global/regional. We have reviewed such technologies in this write-up. Novel themes like bioinformatics, clinical research, and device development will also be discussed.
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Affiliation(s)
- Radhika S Ruhatiya
- Department of Critical Care Medicine, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
| | - Sachin A Adukia
- Department of Neurology, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
| | - Ramya B Manjunath
- Department of Anesthesia, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
| | - Harish M Maheshwarappa
- Department of Critical Care Medicine, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
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Campbell N, Verschuur C, Mitchell S, McCaffrey O, Deane L, Taylor H, Smith R, Foulkes L, Glazier J, Darekar A, Haacke ME, Bulters D, Galea I. Hearing impairment after subarachnoid hemorrhage. Ann Clin Transl Neurol 2019; 6:420-430. [PMID: 30911566 PMCID: PMC6414479 DOI: 10.1002/acn3.714] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 12/02/2018] [Indexed: 12/12/2022] Open
Abstract
Background Subarachnoid hemorrhage (SAH) survivors experience significant neurological disability, some of which is under-recognized by neurovascular clinical teams. We set out to objectively determine the occurrence of hearing impairment after SAH, characterize its peripheral and/or central origin, and investigate likely pathological correlates. Methods In a case-control study (n = 41), participants were asked about new onset hearing difficulty 3 months post-SAH, compared with pre-SAH. Formal audiological assessment included otoscopy, pure tone audiometry, a questionnaire identifying symptoms of peripheral hearing loss and/or auditory processing disorder, and a test of speech understanding in noise. A separate cohort (n = 21) underwent quantitative susceptibility mapping (QSM) of the auditory cortex 6 months after SAH, for correlation with hearing difficulty. Results Twenty three percent of SAH patients reported hearing difficulty that was new in onset post-SAH. SAH patients had poorer pure tone thresholds compared to controls. The proportion of patients with peripheral hearing loss as defined by the World Health Organization and British Audiological Society was however not increased, compared to controls. All SAH patients experienced symptoms of auditory processing disorder post-SAH, with speech-in-noise test scores significantly worse versus controls. Iron deposition in the auditory cortex was higher in patients reporting hearing difficulty versus those who did not. Conclusion This study firmly establishes hearing impairment as a frequent clinical feature after SAH. It primarily consists of an auditory processing disorder, mechanistically linked to iron deposition in the auditory cortex. Neurovascular teams should inquire about hearing, and refer SAH patients for audiological assessment and management.
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Affiliation(s)
- Nicci Campbell
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Carl Verschuur
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Sophie Mitchell
- Clinical NeurosciencesClinical and Experimental SciencesFaculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Orlaith McCaffrey
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Lewis Deane
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Hannah Taylor
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Rory Smith
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Lesley Foulkes
- Wessex Neurological CentreUniversity Hospital Southampton NHS Foundation TrustUniversity of SouthamptonSouthamptonUnited Kingdom
| | - James Glazier
- Clinical NeurosciencesClinical and Experimental SciencesFaculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Angela Darekar
- Medical PhysicsUniversity Hospital Southampton NHS Foundation TrustSouthamptonUnited Kingdom
| | - Mark E. Haacke
- Department of RadiologyWayne State UniversityDetroitMichigan
| | - Diederik Bulters
- Wessex Neurological CentreUniversity Hospital Southampton NHS Foundation TrustUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Ian Galea
- Clinical NeurosciencesClinical and Experimental SciencesFaculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
- Wessex Neurological CentreUniversity Hospital Southampton NHS Foundation TrustUniversity of SouthamptonSouthamptonUnited Kingdom
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Brain Multimodality Monitoring: A New Tool in Neurocritical Care of Comatose Patients. Crit Care Res Pract 2017; 2017:6097265. [PMID: 28555164 PMCID: PMC5438832 DOI: 10.1155/2017/6097265] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 03/11/2017] [Accepted: 03/29/2017] [Indexed: 12/04/2022] Open
Abstract
Neurocritical care patients are at risk of developing secondary brain injury from inflammation, ischemia, and edema that follows the primary insult. Recognizing clinical deterioration due to secondary injury is frequently challenging in comatose patients. Multimodality monitoring (MMM) encompasses various tools to monitor cerebral metabolism, perfusion, and oxygenation aimed at detecting these changes to help modify therapies before irreversible injury sets in. These tools include intracranial pressure (ICP) monitors, transcranial Doppler (TCD), Hemedex™ (thermal diffusion probe used to measure regional cerebral blood flow), microdialysis catheter (used to measure cerebral metabolism), Licox™ (probe used to measure regional brain tissue oxygen tension), and continuous electroencephalography. Although further research is needed to demonstrate their impact on improving clinical outcomes, their contribution to illuminate the black box of the brain in comatose patients is indisputable. In this review, we further elaborate on commonly used MMM parameters, tools used to measure them, and the indications for monitoring per current consensus guidelines.
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Ryu J, Ko N, Hu X, Shadden SC. Numerical Investigation of Vasospasm Detection by Extracranial Blood Velocity Ratios. Cerebrovasc Dis 2017; 43:214-222. [PMID: 28241122 DOI: 10.1159/000454992] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/04/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Early diagnosis of vasospasm following subarachnoid hemorrhage can prevent cerebral ischemia and improve neurological outcomes. This study numerically evaluates the relevance of extracranial blood velocity indices to detect vasospasm. METHODS A numerical model of cerebral blood flow was used to evaluate the hemodynamics associated with anterior and posterior vasospasm under normal and impaired cerebral autoregulation conditions. Extracranial blood velocities at the carotid and vertebral arteries and their ratios between ipsilateral and contralateral, anterior and posterior, and downstream and upstream arteries were monitored during vasospasm progression. RESULTS For current clinical indices that track blood velocities at vasospastic arterial segments using transcranial Doppler (TCD), we observed that velocities increased initially and then decreased with vasospasm progression. This nonmonotonic behavior can lead to false-negative decisions in moderate to severe vasospasm. Alternatively, volumetric flow decreased monotonically at the affected arteries, leading to blood velocities upstream of the vasospastic artery also decreasing monotonically. Based on this principle, we demonstrate that velocity ratios between the carotid and vertebral arteries may better identify moderate to severe vasospasm and improve sensitivity and specificity of vasospasm detection. CONCLUSION The velocity indices proposed in this study may enable new or improved noninvasive diagnosis of vasospasm using extracranial Doppler ultrasound. Compared to current clinical indices, the new indices may improve the handling of (1) scenarios of severe vasospasm or impaired cerebral autoregulation, (2) systemic changes in blood pressure and cardiac output, (3) vasospasm occurring in arteries distal to the cerebral circle region, and (4) cases with insufficient acoustic bone window for TCD. The results provide a concrete basis for future clinical evaluation of extracranial indices for vasospasm detection.
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Affiliation(s)
- Jaiyoung Ryu
- School of Mechanical Engineering, Chung-Ang University, Seoul, Korea
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8
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Kumar G, Shahripour RB, Harrigan MR. Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Neurosurg 2015; 124:1257-64. [PMID: 26495942 DOI: 10.3171/2015.4.jns15428] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The impact of transcranial Doppler (TCD) ultrasonography evidence of vasospasm on patient-centered clinical outcomes following aneurysmal subarachnoid hemorrhage (aSAH) is unknown. Vasospasm is known to lead to delayed cerebral ischemia (DCI) and poor outcomes. This systematic review and meta-analysis evaluates the predictive value of vasospasm on DCI, as diagnosed on TCD. METHODS MEDLINE, Scopus, the Cochrane trial register, and clinicaltrials.gov were searched through September 2014 using key words and the terms "subarachnoid hemorrhage," "aneurysm," "aneurysmal," "cerebral vasospasm," "vasospasm," "transcranial Doppler," and "TCD." Sensitivities, specificities, and positive and negative predictive values were pooled by a DerSimonian and Laird random-effects model. RESULTS Seventeen studies (n = 2870 patients) met inclusion criteria. The amount of variance attributable to heterogeneity was significant (I(2) > 50%) for all syntheses. No studies reported the impact of TCD evidence of vasospasm on functional outcome or mortality. TCD evidence of vasospasm was found to be highly predictive of DCI. Pooled estimates for TCD diagnosis of vasospasm (for DCI) were sensitivity 90% (95% confidence interval [CI] 77%-96%), specificity 71% (95% CI 51%-84%), positive predictive value 57% (95% CI 38%-71%), and negative predictive value 92% (95% CI 83%-96%). CONCLUSIONS TCD evidence of vasospasm is predictive of DCI with high accuracy. Although high sensitivity and negative predictive value make TCD an ideal monitoring device, it is not a mandated standard of care in aSAH due to the paucity of evidence on clinically relevant outcomes, despite recommendation by national guidelines. High-quality randomized trials evaluating the impact of TCD monitoring on patient-centered and physician-relevant outcomes are needed.
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Affiliation(s)
| | | | - Mark R Harrigan
- Comprehensive Stroke Center, Department of Neurology, and.,Department of Neurosurgery, University of Alabama at Birmingham, Alabama
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9
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Intravenous flat-detector computed tomography angiography for symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage. ScientificWorldJournal 2014; 2014:315960. [PMID: 25383367 PMCID: PMC4212549 DOI: 10.1155/2014/315960] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 08/28/2014] [Accepted: 09/13/2014] [Indexed: 11/18/2022] Open
Abstract
The study evaluated the diagnostic accuracy of intravenous flat-detector computed tomography (IV FDCT) angiography in assessing hemodynamically significant cerebral vasospasm in patients with subarachnoid hemorrhage (SAH) with digital subtraction angiography (DSA) as the reference. DSA and IV FDCT were conducted concurrently in patients suspected of having symptomatic cerebral vasospasm postoperatively. The presence and severity of vasospasm were estimated according to location (proximal versus distal). Vasospasm >50% was defined as having hemodynamic significance. Vasospasms <30% were excluded from this analysis to avoid spectrum bias. Twenty-nine patients (311 vessel segments) were measured. The intra- and interobserver agreements were excellent for depicting vasospasm (k = 0.84 and 0.74, resp.). IV FDCT showed a sensitivity of 95.7%, specificity of 92.3%, positive predictive value of 93.6%, and negative predictive value of 94.7% for detecting vasospasm (>50%) with DSA as the reference. Bland-Altman plots revealed good agreement of assessing vasospasm between the two tests. The discrepancy of vasospasm severity was more noted in the distal location with high-severity. However, it was not statistically significant (Spearman's rank test; r = 0.15, P = 0.35). Therefore, IV FDCT could be a feasible noninvasive test to evaluate suspected significant vasospasm in SAH.
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Naqvi J, Yap KH, Ahmad G, Ghosh J. Transcranial Doppler ultrasound: a review of the physical principles and major applications in critical care. Int J Vasc Med 2013; 2013:629378. [PMID: 24455270 PMCID: PMC3876587 DOI: 10.1155/2013/629378] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 11/10/2013] [Indexed: 12/28/2022] Open
Abstract
Transcranial Doppler (TCD) is a noninvasive ultrasound (US) study used to measure cerebral blood flow velocity (CBF-V) in the major intracranial arteries. It involves use of low-frequency (≤2 MHz) US waves to insonate the basal cerebral arteries through relatively thin bone windows. TCD allows dynamic monitoring of CBF-V and vessel pulsatility, with a high temporal resolution. It is relatively inexpensive, repeatable, and portable. However, the performance of TCD is highly operator dependent and can be difficult, with approximately 10-20% of patients having inadequate transtemporal acoustic windows. Current applications of TCD include vasospasm in sickle cell disease, subarachnoid haemorrhage (SAH), and intra- and extracranial arterial stenosis and occlusion. TCD is also used in brain stem death, head injury, raised intracranial pressure (ICP), intraoperative monitoring, cerebral microembolism, and autoregulatory testing.
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Affiliation(s)
- Jawad Naqvi
- University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Kok Hooi Yap
- Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Gulraiz Ahmad
- Royal Oldham Hospital, Rochdale Road, Manchester OL1 2JH, UK
| | - Jonathan Ghosh
- University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
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11
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Chohan MO, Carlson AP, Hart BL, Yonas H. Lack of functional patency of the lamina terminalis after fenestration following clipping of anterior circulation aneurysms. J Neurosurg 2013; 119:629-33. [PMID: 23808534 DOI: 10.3171/2013.5.jns13251] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Fenestration of the lamina terminalis (FLT) during aneurysm surgery for subarachnoid hemorrhage can, in theory, improve CSF circulation from the lateral and third ventricles to the cortical subarachnoid space, which may, in turn, decrease the incidence of hydrocephalus and vasospasm. However, the actual effects of FLT on CSF circulation have been difficult to determine, due to confounding factors. In addition, it is unclear whether the lamina terminalis remains functionally patent when the brain resumes its normal position. The goal of this study was to assess the functional patency of the fenestrated lamina terminalis in patients who underwent surgery for ruptured aneurysms. METHODS This prospective study included 15 patients who underwent surgical clipping of ruptured anterior circulation aneurysms, with FLT performed during surgery. On postoperative Day 1, the external ventricular drain of each patient was closed, and 1 ml of Omnipaque 300, an iodine based contrast agent, was injected intraventricularly, accompanied by cranial maneuvering designed to position the contrast agent adjacent to the lamina terminalis. Three to 5 minutes after cranial maneuvering, the flow of contrast agent into the basal cisterns was assessed with CT imaging. Flow was verified by an increase in Hounsfield units in a prespecified "region of interest" within the basal cisterns on the CT scan. This procedure was performed using a standardized protocol designed in consultation with the Department of Radiology and approved by the institutional review board. One patient who underwent endoscopic third ventriculostomy was recruited as a positive control to validate the technique, and 1 patient who underwent aneurysm clipping but not FLT was recruited as a negative control. RESULTS Seventeen patients consented to study participation. In the 15 patients who underwent aneurysm clipping and FLT, and the negative control patient who underwent aneurysm clipping but not FLT, the contrast agent followed the normal ventricular pathway from the lateral ventricles into the fourth ventricle, and did not appear in the basal cisterns. In the positive control patient, the contrast agent robustly and immediately filled the basal cisterns. CONCLUSIONS Fenestration of the lamina terminalis did not result in functional patency of the lamina terminalis when performed as part of surgical clipping for ruptured aneurysms.
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Affiliation(s)
- Muhammad Omar Chohan
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico 87131, USA.
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12
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Advanced imaging modalities in the detection of cerebral vasospasm. Neurol Res Int 2013; 2013:415960. [PMID: 23476766 PMCID: PMC3580927 DOI: 10.1155/2013/415960] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 12/09/2012] [Indexed: 11/24/2022] Open
Abstract
The pathophysiology of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is complex and is not entirely understood. Mechanistic insights have been gained through advances in the capabilities of diagnostic imaging. Core techniques have focused on the assessment of vessel caliber, tissue metabolism, and/or regional perfusion parameters. Advances in imaging have provided clinicians with a multifaceted approach to assist in the detection of cerebral vasospasm and the diagnosis of delayed ischemic neurologic deficits (DIND). However, a single test or algorithm with broad efficacy remains elusive. This paper examines both anatomical and physiological imaging modalities applicable to post-SAH vasospasm and offers a historical background. We consider cerebral blood flow velocities measured by Transcranial Doppler Ultrasonography (TCD). Structural imaging techniques, including catheter-based Digital Subtraction Angiography (DSA), CT Angiography (CTA), and MR Angiography (MRA), are reviewed. We examine physiologic assessment by PET, HMPAO SPECT, 133Xe Clearance, Xenon-Enhanced CT (Xe/CT), Perfusion CT (PCT), and Diffusion-Weighted/MR Perfusion Imaging. Comparative advantages and limitations are discussed.
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13
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TOI H, MATSUMOTO N, YOKOSUKA K, MATSUBARA S, HIRANO K, UNO M. Prediction of Cerebral Vasospasm Using Early Stage Transcranial Doppler. Neurol Med Chir (Tokyo) 2013; 53:396-402. [DOI: 10.2176/nmc.53.396] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Hiroyuki TOI
- Department of Neurosurgery, Kawasaki Medical School
| | | | | | | | | | - Masaaki UNO
- Department of Neurosurgery, Kawasaki Medical School
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14
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Kronvall E, Undrén P, Romner B, Säveland H, Cronqvist M, Nilsson OG. Nimodipine in aneurysmal subarachnoid hemorrhage: a randomized study of intravenous or peroral administration. J Neurosurg 2009; 110:58-63. [DOI: 10.3171/2008.7.jns08178] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The calcium antagonist nimodipine has been shown to reduce the incidence of ischemic complications following aneurysmal subarachnoid hemorrhage (SAH). Although most randomized studies have been focused on the effect of the peroral administration of nimodipine, intravenous infusion is an alternative and the preferred mode of treatment in many centers. It is unknown whether the route of administration is of any importance for the clinical efficacy of the drug.
Methods
One hundred six patients with acute aneurysmal SAH were randomized to receive either peroral or intravenous nimodipine treatment. The patients were monitored for at least 10 days after bleeding in terms of delayed ischemic neurological deficits (DINDs) and with daily measurements of blood flow velocities in the middle cerebral arteries by using transcranial Doppler ultrasonography. Three months after SAH, clinical outcome and new cerebral infarctions according to MR imaging studies were recorded.
Results
Baseline characteristics (age, sex distribution, clinical status on admission, radiological findings, and aneurysm treatment) did not differ between the treatment groups. There was no significant difference in the incidence of DINDs (28 vs 30% in the peroral and intravenous groups, respectively) or middle cerebral artery blood flow velocities (> 120 cm/second, 50 vs 45%, respectively). Clinical outcome according to the Glasgow Outcome Scale was the same in both groups, and there was no difference in the number of patients with new infarctions on MR imaging.
Conclusions
The results suggest that there is no clinically relevant difference in efficacy between peroral and intravenous administration of nimodipine in preventing DINDs or cerebral vasospasm following SAH.
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Affiliation(s)
| | - Per Undrén
- 2Neuroradiology, Lund University Hospital, Lund, Sweden
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15
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Gonzalez NR, Boscardin WJ, Glenn T, Vinuela F, Martin NA. 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 2008; 107:1101-12. [PMID: 18077946 DOI: 10.3171/jns-07/12/1101] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECT The goal in this study was to create an index (vasospasm probability index [VPI]) to improve diagnostic accuracy for vasospasm after subarachnoid hemorrhage (SAH). METHODS Seven hundred ninety-five patients in whom aneurysmal SAH was demonstrated by computed tomography, and in whom one or more intracranial aneurysms had been diagnosed, underwent transcranial Doppler (TCD) studies between April 1998 and January 2000. In 154 patients angiography was performed within 24 hours of the TCD examination, and in 75 133Xe cerebral blood flow (CBF) studies were obtained the same day. Seven cases were excluded because of a limited sonographic window. Forty-one women (60.3%) and 27 men (39.7%) between the ages of 35 and 84 years (58.0 +/- 13.2 years [mean +/- standard deviation]) were included. Clinical characteristics analyzed included age, sex, Hunt and Hess grade, Fisher grade, days after SAH, day of treatment, type of treatment (coil embolization, surgical clip occlusion, or conservative treatment), smoking history, and hypertension history. Lindegaard ratios and spasm indexes (TCD velocities/hemispheric CBF) were calculated bilaterally. Digital subtraction angiography images were measured at specific points of interest. Sensitivity, specificity, predictive values, and global accuracy of the different tests were calculated. Logistic regression was used to evaluate the possible predictive factors, and the coefficients of the logistic regression were integrated to create the VPI. RESULTS In 18 patients (26.5%) symptomatic vasospasm was diagnosed, and 33 (48.5%) had angiographic evidence of vasospasm. For TCD velocities above 120 cm/second at the middle cerebral artery, the global accuracy was 81.1% for the diagnosis of clinical vasospasm and 77.2% for angiographic vasospasm. For a Lindegaard ratio higher than 3.0, the accuracy was 85% for clinical vasospasm and 83.2% for angiographic vasospasm. A spasm index higher than 3.5 had an accuracy of 82.0% for the diagnosis of clinical vasospasm and 81.6% for angiographic vasospasm. The selected model for estimation of clinical vasospasm included Fisher grade, Hunt and Hess grade, and spasm index. The VPI had a global accuracy of 92.9% for clinical vasospasm detection. For diagnosis of angiographic vasospasm, the model included Fisher grade, Hunt and Hess grade, and Lindegaard ratio. The VPI achieved a global accuracy of 89.9% for angiographic vasospasm detection. CONCLUSIONS The use of TCD velocities, Lindegaard ratio, and spasm index independently is of limited value for the diagnosis of clinical and angiographic vasospasm. The combination of predictive factors associated with the development of vasospasm in the new index reported here has a significantly superior accuracy compared with the independent tests and may become a valuable tool for the clinician to evaluate the individual probability of cerebral vasospasm after aneurysmal SAH.
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Affiliation(s)
- Nestor R Gonzalez
- Division of Neurosurgery, David Geffen School of Medicine, University of California at Los Angeles, California 90025-7039, USA.
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McGirt MJ, Blessing R, Alexander MJ, Nimjee SM, Woodworth GF, Friedman AH, Graffagnino C, Laskowitz DT, Lynch JR. Risk of cerebral vasopasm after subarachnoid hemorrhage reduced by statin therapy: a multivariate analysis of an institutional experience. J Neurosurg 2006; 105:671-4. [PMID: 17121126 DOI: 10.3171/jns.2006.105.5.671] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Object
Impairment of endothelial nitric oxide synthase (eNOS), endothelium-dependent relaxation, and cerebrovascular autoregulation all occur in vasospastic cerebral arteries following subarachnoid hemorrhage (SAH). The 3-hy-droxy-3-methylglutaryl coenzyme A reductase inhibitors, or statins, both improve endothelial function and increase eNOS messenger RNA, protein, and enzymatic activity threefold. Increasing experimental evidence in animal models of SAH suggests that statins may ameliorate cerebral vasospasm. The authors hypothesized that patients chronically treated with statins would have a decreased risk of symptomatic vasospasm after SAH.
Methods
The authors retrospectively reviewed the charts of 115 patients with SAH who were consecutively admitted to the Neuroscience Intensive Care Unit of Duke University between 1998 and 2001. The independent association of statin therapy to symptomatic vasospasm was assessed using multivariate logistic regression analysis. Fifteen patients (13%) admitted with SAH were receiving statin therapy for at least 1 month before admission. Forty-nine patients (43%) experienced symptomatic vasospasm a mean of 5.8 ± 3 days after onset of SAH. Current statin therapy on admission (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.01–0.77) was independently associated with an 11-fold reduction in the risk of symptomatic vasospasm. Fisher Grade 3 SAH (OR 2.82, 95% CI 1.50–5.71) and rupture of anterior cerebral or internal carotid artery aneurysm (OR 3.77, 95% CI 1.29–10.91) were independently associated with an increased risk of symptomatic vasospasm.
Conclusions
In this retrospective case series, patients who received statin therapy for at least 1 month demonstrated an 11-fold decrease in the risk of developing symptomatic vasospasm after SAH.
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Affiliation(s)
- Matthew J McGirt
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
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Tseng MY, Czosnyka M, Richards H, Pickard JD, Kirkpatrick PJ. Effects of acute treatment with statins on cerebral autoregulation in patients after aneurysmal subarachnoid hemorrhage. Neurosurg Focus 2006; 21:E10. [PMID: 17029334 DOI: 10.3171/foc.2006.21.3.10] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors previously have demonstrated that acute treatment with pravastatin after aneurysmal subarachnoid hemorrhage (SAH) can ameliorate vasospasm-related delayed ischemic neurological deficits (DINDs). In the current study, they test the hypothesis that these effects are associated with improvement in indices describing autoregulation of cerebral blood flow. METHODS In this double-blind study, 80 patients between the ages of 18 and 84 years who had aneurysmal SAH were randomized equally to receive either 40 mg of oral pravastatin or placebo once daily for up to 14 days (medication was started 1.8 x 1.3 days after ictus). Autoregulation was measured using a daily transient hyperemic response test (THRT) on transcranial Doppler ultrasonography (800 measurements in 80 patients), and data were compared between the pravastatin and placebo groups and between patients with or without vasospasm, DINDs, or unfavorable outcome. Measurement of autoregulation also was performed using the pressure-reactivity index, a moving correlation coefficient between mean arterial and intracranial pressures (Days 0-5, 132 measurements in 32 patients). There was no difference in baseline autoregulation indices between the trial groups. The members of the pravastatin group not only had a shorter duration of impaired autoregulation but also had stronger transient hyperemic response ratios (THRRs) bilaterally. A negative correlation existed between the mean flow velocity in the middle cerebral artery and THRRs. Onset of DINDs occurred when bilateral autoregulation failed. On Days 3, 4, and 5, the pressure-reactivity index correlated significantly with ipsilateral impaired autoregulation. CONCLUSIONS The neuroprotective effects of acute treatment with pravastatin following aneurysmal SAH are associated with enhancement of autoregulation. A routine and daily assessment of cerebral autoregulation by using the THRT may help identify patients at high risk of DINDs.
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Affiliation(s)
- Ming-Yuan Tseng
- Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, United Kingdom.
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Moftakhar R, Rowley HA, Turk A, Niemann DB, Kienitz BA, Van Gomple J, Başkaya MK. Utility of computed tomography perfusion in detection of cerebral vasospasm in patients with subarachnoid hemorrhage. Neurosurg Focus 2006; 21:E6. [PMID: 17029345 DOI: 10.3171/foc.2006.21.3.6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Digital subtraction (DS) angiography is the gold standard for detecting cerebral vasospasm after subarachnoid hemorrhage (SAH). Computed tomography (CT) perfusion is a recently developed modality for the evaluation of cerebral hemodynamics. This study was conducted to evaluate the potential of using CT perfusion to detect vasospasm in patients with SAH. METHODS Fourteen patients between the ages of 41 and 66 years with aneurysmal SAH underwent 23 CT perfusion scans for suspected vasospasm. All patients underwent DS angiography within 12 hours of the CT perfusion scans. The presence of vasospasm on CT perfusion images was determined based on qualitative reading using color maps of mean transit time, cerebral blood flow, and cerebral blood volume as criteria. The presence or absence of vasospasm as retrospectively determined using CT perfusion was compared with DS angiography findings. Of the 23 CT perfusion scans performed, 21 (91%) were concordant with angiography findings in predicting the presence or absence of vasospasm. In 15 of 23 scans, the presence of vasospasm was detected on CT perfusion scans and confirmed on DS angiography studies. In two cases, vasospasm was revealed on DS angiography but was not confirmed on CT perfusion. The degree of agreement between CT perfusion and DS angiography for detection of vasospasm was high (K = 0.8, p , 0.0001). CONCLUSIONS Computed tomography perfusion is an accurate, reliable, and noninvasive method to detect the presence or absence of vasospasm. It can be used as a tool to help guide the decision to pursue DS angiography with the intent to treat vasospasm.
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Affiliation(s)
- Roham Moftakhar
- Department of Neurosurgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
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Keller E, Krayenbühl N, Bjeljac M, Yonekawa Y. Cerebral vasospasm: results of a structured multimodal treatment. ACTA NEUROCHIRURGICA. SUPPLEMENT 2005; 94:65-73. [PMID: 16060243 DOI: 10.1007/3-211-27911-3_11] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Symptomatic cerebral vasospasm (CVS) with delayed ischemic neurologic deficits affects about one third of the patients after aneurysmal subarachnoid hemorrhage (SAH). In spite of the lack of definite evidence of large clinical trials, the devastating outcome of the natural history of symptomatic CVS demands an aggressive CVS treatment in a practically oriented, structured multimodal treatment regimen. With our treatment protocol good functional outcome could be reached in 66% of the patients with symptomatic CVS. This policy requires close and fast multidisciplinary collaboration between neurosurgeons, neuroradiologists, competent in endovascular interventions, and specialists for neurointensive care. We report on our experience with 79 cases with symptomatic CVS and delayed ischemic neurologic deficit (DIND) after aneurysmal SAH. The different treatment options with CVS are reviewed and practical guidelines for a step by step treatment are given.
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Affiliation(s)
- E Keller
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.
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Krejza J, Mariak Z, Lewko J. Standardization of flow velocities with respect to age and sex improves the accuracy of transcranial color Doppler sonography of middle cerebral artery spasm. AJR Am J Roentgenol 2003; 181:245-52. [PMID: 12818868 DOI: 10.2214/ajr.181.1.1810245] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The overall accuracy of transcranial Doppler sonography in the diagnosis of middle cerebral artery spasm has not been established. Moreover, the factors of age and sex have not been addressed in most studies. In this article, we present receiver operating characteristic (ROC) curve analysis of the accuracy of transcranial color Doppler sonography in diagnosing middle cerebral artery spasm on the basis of flow velocities standardized for age and sex. SUBJECTS AND METHODS. We prospectively studied 214 consecutive patients (110 male, 104 female; age range, 12-77 years) who were routinely referred for cerebral angiography. Middle cerebral artery spasm was graded as mild (</= 25% of vessel caliber reduction) and moderate to severe (> 25% reduction). Angle-corrected blood velocity measurements were obtained using a 2.5-MHz probe. The velocity values were reexpressed as a percentage of the mean of normal reference values for the relevant age, for subjects younger than 40 years, and for sex. RESULTS The prevalence of spasm among 335 arteries studied was 8.1% for mild and 12.8% for moderate to severe middle cerebral artery narrowing. For distinguishing all or moderate to severe vasospasm from lesser grades of vasospasm, peak systolic velocity was the best parameter. Areas under ROC curves for all and moderate to severe middle cerebral artery spasms were 0.83 and 0.92, respectively. After standardization, the ROC areas increased significantly (p < 0.05) for all, to 0.86, and only slightly, to 0.93, for moderate to severe spasms. For all grades of middle cerebral artery spasm, the best efficiencies were found at standardized velocity value of 170%. CONCLUSION The accuracy of transcranial color Doppler sonography is high in the identification of middle cerebral artery spasm. Standardization of velocities with respect to age and sex increases the accuracy of the method in diagnosing mild middle cerebral artery spasms.
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Affiliation(s)
- Jaroslaw Krejza
- Department of Radiology, Bialystok Medical Academy, Sklodowskiej-Curie 24A, 15-279 Bialystok, Poland
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Egge A, Waterloo K, Sjøholm H, Solberg T, Ingebrigtsen T, Romner B. Prophylactic Hyperdynamic Postoperative Fluid Therapy after Aneurysmal Subarachnoid Hemorrhage: A Clinical, Prospective, Randomized, Controlled Study. Neurosurgery 2001. [DOI: 10.1227/00006123-200109000-00012] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Treggiari-Venzi MM, Suter PM, Romand JA. Review of Medical Prevention of Vasospasm after Aneurysmal Subarachnoid Hemorrhage: A Problem of Neurointensive Care. Neurosurgery 2001. [DOI: 10.1227/00006123-200102000-00001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Boet R, Mee E. Magnesium Sulfate in the Management of Patients with Fisher Grade 3 Subarachnoid Hemorrhage: A Pilot Study. Neurosurgery 2000. [DOI: 10.1227/00006123-200009000-00014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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