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Transcranial-Doppler-Measured Vasospasm Severity is Associated with Delayed Cerebral Infarction After Subarachnoid Hemorrhage

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Abstract

Background

Angiographic vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is associated with delayed cerebral ischemia (DCI)-related cerebral infarction (radiological DCI) and worsened neurological outcome. Transcranial Doppler (TCD) measurements of cerebral blood flow velocity are commonly used after aSAH to screen for vasospasm; however, their association with cerebral infarction is not well characterized. We sought to determine whether time-varying TCD-measured vasospasm severity is associated with cerebral infarction and investigate the performance characteristics of different time/severity cutoffs for predicting cerebral infarction.

Methods

We conducted a retrospective single-center cohort study of consecutive adult patients with aSAH with at least one TCD study between 2011 and 2020. The primary outcome was radiological DCI, defined as a cerebral infarction develo** at least 2 days after any surgical or endovascular intervention without an alternative cause. Cox proportional hazards models were used to examine associations between time-varying vasospasm severity and radiological DCI. Optimal TCD-based time/severity thresholds for predicting radiological DCI were then determined.

Results

Of 262 patients with aSAH who underwent TCD studies, 27 (10%) developed radiological DCI. Patients with radiological DCI had higher modified Fisher scale scores and trended toward earlier onset of vasospasm. Adjusted for age, Hunt and Hess scores, and modified Fisher scale scores, the worst-vessel vasospasm severity was associated with radiological DCI (adjusted hazard ratio 1.7 [95% confidence interval 1.1–2.4]). Vasospasm severity within a specific vessel was associated with risk of delayed infarction in the territory supplied by that vessel. Optimal discrimination of patients with radiological DCI was achieved with thresholds of mild vasospasm on days 4–5 or moderate vasospasm on days 6–9, with negative predictive values greater than 90% and positive predictive values near 20%.

Conclusions

TCD-measured vasospasm severity is associated with radiological DCI after aSAH. An early, mild TCD-based vasospasm severity threshold had a high negative predictive value, supporting its role as a screening tool to identify at-risk patients.

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Funding

RWR was supported by a National Institutes of Health R25 (R25 NS065743) grant. SBS was supported by the American Academy of Neurology (CRTS 2020A013392).

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Author notes

  1. Samuel B. Snider and Ibrahim Migdady have contributed equally to this work.

Authors and Affiliations

  1. Division of Neurocritical Care, Department of Neurology, Brigham and Women’s Hospital, 60 Fenwood Road, Boston, MA, 02115, USA

    Samuel B. Snider, Ibrahim Migdady, Sarah L. LaRose & Morgan E. Mckeown

  2. Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston, MA, USA

    Robert W. Regenhardt

  3. Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA

    Pui Man Rosalind Lai & Rose Du

  4. Marinus Pharmaceuticals, Radnor, PA, USA

    Henrikas Vaitkevicius

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  1. Samuel B. Snider
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  2. Ibrahim Migdady
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Contributions

SBS: study conception/design, data cleaning and analysis, manuscript drafting and revision. IM: study conception/design, data cleaning, analysis, and interpretation, manuscript drafting and revision. SLL: data cleaning, analysis and interpretation, manuscript revision. MEM: data cleaning, analysis and interpretation, manuscript revision. RWR: data analysis and interpretation, manuscript revision. PMRL: study conception/design, manuscript revision. HV: study conception/design, manuscript revision. RD: study conception/design, data interpretation, manuscript drafting and revision. The final manuscript was approved by all authors.

Corresponding author

Correspondence to Samuel B. Snider.

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Conflicts of interest

SBS, IM, SLL, MEM, RWR, PMRL, and RD report no relevant disclosures. HV is employed by Marinus Pharmaceuticals.

Ethical approval/informed consent

This study was approved by the Mass General Brigham Institutional Review Board (protocol No. 2006P001829). Given that the data were deidentified, the requirement for patient consent was waived by the institutional review board.

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Snider, S.B., Migdady, I., LaRose, S.L. et al. Transcranial-Doppler-Measured Vasospasm Severity is Associated with Delayed Cerebral Infarction After Subarachnoid Hemorrhage. Neurocrit Care 36, 815–821 (2022). https://doi.org/10.1007/s12028-021-01382-2

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  • DOI: https://doi.org/10.1007/s12028-021-01382-2

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