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Khawaja AM, McNulty J, Thakur UV, Chawla S, Devi S, Liew A, Mirshahi S, Du R, Mekary RA, Gormley W. Transcranial Doppler and computed tomography angiography for detecting cerebral vasospasm post-aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2022; 46:3. [PMID: 36471088 DOI: 10.1007/s10143-022-01913-1] [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] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Cerebral vasospasm is a life-threatening complication following aneurysmal subarachnoid hemorrhage (aSAH). While digital subtraction angiography (DSA) is the current gold standard for detection, the diagnostic performance of computed tomography angiography (CTA) and transcranial Doppler (TCD) remains controversial. We aimed to summarize the available evidence and provide recommendations for their use based on GRADE criteria. A literature search was conducted for studies comparing CTA or TCD to DSA for adults ≥ 18 years with aSAH for radiographic vasospasm detection. The DerSimonian-Laird random-effects model was used to pool sensitivity and specificity and their 95% confidence intervals (CI) and derive positive and negative pooled likelihood ratios (LR + /LR -). Out of 2070 studies, seven studies (1646 arterial segments) met inclusion criteria and were meta-analyzed. Compared to the gold standard (DSA), CTA had a pooled sensitivity of 82% (95%CI, 68-91%) and a specificity of 97% (95%CI, 93-98%), while TCD had lower sensitivity 38% (95%CI, 19-62%) and specificity of 91% (95%CI, 87-94%). Only the LR + for CTA (27.3) reached clinical significance to rule in diagnosis. LR - for CTA (0.19) and TCD (0.68) approached clinical significance (< 0.1) to rule out diagnosis. CTA showed higher LR + and lower LR - than TCD for diagnosing radiographic vasospasm, thereby achieving a strong recommendation for its use in ruling in or out vasospasm, based on the high quality of evidence. TCDs had very low LR + and a reasonably low LR - , thereby achieving a weak recommendation against its use in ruling in vasospasm and weak recommendation for its use in ruling out vasospasm.
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Affiliation(s)
- Ayaz M Khawaja
- Department of Neurology, Wayne State University, Detroit, MI, 48201, USA
| | - Jack McNulty
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
| | | | - Shreya Chawla
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Sharmila Devi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Aaron Liew
- Portiuncula University Hospital and National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shervin Mirshahi
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA.
- School of Pharmacy, MCPHS University, Boston, MA, USA.
| | - William Gormley
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
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Kawamura K, Tokugawa J, Watanabe M, Fujita N, Teramoto S, Kimura T, Ito Y, Nakao Y, Yamamoto T. Persistent Primitive Hypoglossal Artery with Ipsilateral Symptomatic Carotid Artery Stenosis and Cerebral Aneurysm. J Stroke Cerebrovasc Dis 2021; 30:106099. [PMID: 34536812 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/29/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE Persistent primitive hypoglossal artery (PPHA) is a rare type of persistent carotid-basilar anastomosis sometimes associated with other vascular lesions. We treated an extremely rare case of PPHA with concomitant ipsilateral symptomatic cervical internal carotid artery (ICA) stenosis and unruptured aneurysm. CASE PRESENTATION A 67-year-old woman visited our institution with acute onset of diplopia. Magnetic resonance imaging revealed multiple acute infarctions in the right anterior and posterior circulations. Digital subtraction angiography demonstrated the right PPHA concomitant with ipsilateral cervical ICA stenosis and an unruptured ICA aneurysm with maximum diameter of 8 mm. The multiple infarctions were considered to result from artery-to-artery embolism due to microthrombi from the ICA plaque passed along the PPHA, so carotid endarterectomy was performed as the first step with preoperative modified Rankin Scale (mRS) grade 1. During the operation, the patient had impaired ICA perfusion due to internal shunt catheter migration into the PPHA followed by acute infarction in the right hemisphere causing mild left hemiparesis. The patient was transferred to the rehabilitation hospital with mRS grade 3. After 3 months of rehabilitation, the patient recovered to mRS grade 1 and clipping surgery for the unruptured right ICA aneurysm was performed as the second step with uneventful postoperative course. CONCLUSION The treatment strategy should be carefully considered depending on the specific blood circulation for such cases of PPHA with unique vasculature.
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Affiliation(s)
- Kaito Kawamura
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan; Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan.
| | - Joji Tokugawa
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan.
| | - Mitsuya Watanabe
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan.
| | - Naohide Fujita
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan; Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan.
| | - Shinichiro Teramoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan; Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan.
| | - Takaoki Kimura
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan; Department of Neurosurgery, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa, Japan.
| | - Yoshitaka Ito
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan; Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Centre, Tokyo, Japan.
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan.
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan.
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