Options for Continual Cerebral Blood Flow Monitoring to Detect Vasospasms in Patients after Severe Subarachnoid Haemorrhage

Czech version

Authors: A. Mrlian ¹; K. Ďuriš ^1,2; E. Neuman ¹; V. Vybíhal ¹; M. Smrčka ¹
Authors‘ workplace: Neurochirurgická klinika LF MU a FN Brno ¹; Ústav patologické fyziologie LF MU, Brno ²
Published in: Cesk Slov Neurol N 2014; 77/110(3): 326-332
Category: Original Paper

Práce byla sponzorována grantem IG MZ ČR č. NT 11092– 4.

Overview

Introduction:
Intensive care seems to be as important for prognosis after ruptured aneurysm and subarachnoid haemorrhage as early diagnosis and treatment of the aneurysm. Higher morbidity and mortality is typical in patients with clinical status corresponding to a higher Hunt and Hess grade. Multimodal monitoring would allow early detailed assessment of the patient’s actual clinical status and enable timely initiation of an appropriate therapy.

Material and methods:
A total number of 29 patients HH grade IV + V were monitored. Due to technical and procedural errors, 17 patients were finally analyzed. The objective was to measure the correlation between clinical status, outcome, tissue oxygen levels and TCD with respect to direct measurement of cerebral blood flow.

Results:
No statistically significant correlation was found between the mean values of CBF (for the entire monitoring period) and the HH grade, Fisher and GOS In the examined group. Correlation between CBF and PbtO₂ varied widely between patients (r = 0.16–0.65). There was not significant correlation in the research sample between CBF and flow parameters of the main vessels (PSV, EDV, Vmean, p = NS for all parameters). Furthermore, no significant correlation was found in the research sample between CBF and resistivity and pulsatility indices (PI, RI, p = NS) but there was a trend towards indirect correlation between CBF and RI (r = –0.3844, p = 0.0786).

Conclusion:
Comprehensive monitoring of patients after subarachnoid haemorrhage provides a broad picture of the processes running in the damaged brain tissue and improves intensive treatment. However, direct measurement of CBF has, according to our findings, inconsistent value for the diagnosis of vasospasm and patient evaluation. Therefore, this cannot be used as a basis for therapy choices in these patients.

Key words:
subarachnoid haemorrhage – multimodal monitoring – cerebral blood flow

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.

Sources

1. Beneš V, Netuka D, Kramář F, Charvát F. Současný stav péče o intrakraniální aneuryzmata. Cesk Slov Neurol N 2006; 69/ 102(3): 160– 174.

2. Allen GS, Ahn HS, Preziosi TJ, Battye TJ, Boone SC, Boone SC et al. Cerebral arterial spasm – a controlled trial of nimodipine in patients with subarachnoid hemorrhage. N Engl J Med 1983; 308(11): 619– 624.

3. Barker FG II, Ogilvy CS. Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: a metaanalysis. J Neurosurg 1996; 84(3): 405– 414.

4. Mehta V, Holness RO, Connolly K, Walling S, Hall R.Acute hydrocephalus following aneurysmal subarachnoid hemorrhage. Can J Neurol Sci 1996; 23(1): 40– 45.

5. Sheehan JP, Polin RS, Sheehan JM, Baskaya MK, Kassell NF. Factors associated with hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 1999; 45(5): 1120– 1127.

6. Jaeger M, Soehle M, Schuhmann MU, Winkler D, Meixensberger J. Correlation of continuously monitored regional cerebral blood flow and brain tissue oxygen. Acta Neurochir (Wien) 2005; 147(1): 51– 56.

7. Soukup J, Bramsiepe I, Brucke M, Sanchin L, Menzel M.Evaluation of a bedside monitor of regional CBF as a measure of CO₂ reactivity in neurosurgical intensive care patients. J Neurosurg Anesthesiol 2008; 20(4): 249– 255. doi: 10.1097/ ANA.0b013e31817ef487.

8. Valadka AB, Hlatky R, Furuya Y, Robertson CS. Brain tissue PO₂: correlation with cerebral blood flow. Acta Neurochir (Wien) 2000; 81: 299– 301.

9. Vajkoczy P, Roth H, Horn P, Lucke T, Thome C, Hubner U et al. Continuous monitoring of regional cerebral blood flow: experimental and clinical validation of a novel thermal diffusion microprobe. J Neurosurg 2000; 93(2): 265– 274.

10. Wolf S, Vajkoczy P, Dengler J, Schürer L, Horn P. Drift of the Bowman Hemedex® cerebral blood flow monitor between calibration cycles. Acta Neurochir Suppl 2012; 14: 187– 190. doi: 10.1007/ 978– 3– 7091- 0956- 4_36.

11. Skjoth‑ Rasmussen J, Schulz M, Kristensen SR, Bjerre P. Delayed neurological deficits detected by an ischemic pattern in the extracellular cerebral metabolites in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 2004; 100(1): 8– 15.

12. Purkayastha S, Sorond F. Transcranial Doppler ultrasound: technique and application. Semin Neurol 2012; 32(4): 411– 420. doi: 10.1055/ s‑ 0032-1331812.

13. Alexandrov AV, Sloan MA, Wong LK, Douville C, Razumovsky AY, Koroshetz WJ et al. Practice standards for transcranial Doppler ultrasound. J Neuroimaging 2007; 17(1): 11– 18.

14. Meixensberger J, Vath A, Jaeger M, Kunze E, Dings J, Roosen K. Monitoring of brain tissue oxygenation following severe subarachnoid hemorrhage. Neurol Res 2003; 25(5): 445– 450.

15. Lam JM, Smielewski P, Czosnyka M, Pickard JD, Kirkpatrick PJ. Predicting delayed ischemic deficits after aneurysmal subarachnoid hemorrhage using a transient hyperemic response test of cerebral autoregulation. Neurosurgery 2000; 47(4): 819– 825.

16. Ramakrishna R, Stiefel M, Udoetuk J, Spiotta A, Levine JM, Kofke WA et al. Brain oxygen tension and outcome in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 2008; 109(6): 1075– 1082. doi: 10.3171/ JNS.2008.109.12.1075.

17. Smrčka M. Monitoring pacientů s těžkým poraněním mozku. Cesk Slov Neurol N 2011; 74/ 107(1): 9– 21.

18. Mrlian A, Smrčka M, Duba M, Gál R, Ševčík P. Využití kontinuálního monitoringu průtoku krve mozkem po těžkém mozkovém poranění. Cesk Slov Neurol N 2010; 73/ 106(6): 711– 715.

19. Bhatia A, Gupta AK. Neuromonitoring in the intensive care unit. I. Intracranial pressure and cerebral blood flow monitoring. Intensive Care Med 2007; 33(7): 1263– 1271.

20. Hejčl A, Bolcha M, Procházka J, Sameš M. Multimodální monitorování mozku u pacientů s těžkým kraniocerebrálním traumatem a subarachnoidálním krvácením v neurointenzivní péči. Cesk Slov Neurol N 2009; 72/ 105(4): 383– 387.

21. Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 1980; 6(1): 1– 9.

22. Heuer GG, Smith MJ, Elliott JP, Winn HR, LeRoux PD. Relationship between intracranial pressure and other clinical variables in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 2004; 101(3): 408– 416.

23. Chen HI, Stiefel MF, Oddo M, Milby AH, Maloney‑ Wilensky E, Frangos S et al. Detection of cerebral compromise with multimodality monitoring in patients with subarachnoid hemorrhage. Neurosurgery 2011; 69(1): 53– 63. doi: 10.1227/ NEU.0b013e3182191451.

24. Dunn IF, Ellegala DB, Kim DH, Litvack ZN. Brigham and Women‘s Hospital Neurosurgery Group. Neuromonitoring in neurological critical care. Neurocrit Care 2006; 4(1): 83– 92.

25. Budohoski KP, Czosnyka M, Kirkpatrick PJ, Smielewski P, Steiner LA, Pickard JD. Clinical relevance of cerebral autoregulation following subarachnoid haemorrhage. Nat Rev Neurol 2013; 9(3): 152– 163. doi: 10.1038/ nrneurol.2013.11.

26. Kamp MA, Dibué M, Etminan N, Steiger HJ, Schneider T, Hänggi D. Evidence for direct impairment of neuronal function by subarachnoid metabolites following SAH. Acta Neurochir (Wien) 2013; 155(2): 255– 260. doi: 10.1007/ s00701- 012-- 1559- y.

27. Keyrouz SG, Diringer MN. Clinical review: Prevention and therapy of vasospasm in subarachnoid hemorrhage. Crit Care 2007; 11(4):220.

28. Clyde BL, Resnick DK, Yonas H, Smith HA, Kaufmann AM. The relationship of blood velocity as measured by transcranial doppler ultrasonography to cerebral blood flow as determined by stable xenon computed tomographic studies after aneurysmal subarachnoid hemorrhage. Neurosurgery 1996; 38(5): 896– 904.