Samuel Snider, MD
Dr.
Brigham and Women's Hospital, United States
Disclosure information not submitted.
Robert Regenhardt, MD, PhD
Dr.
Massachusetts General Hospital
Boston, Massachusetts, United States
Disclosure information not submitted.
Pui Man Rosalind Lai, MD
Dr
Brigham and Women's Hospital, United States
Disclosure information not submitted.
Henrikas Vaitkevicius, MD
Dr.
Marinus Pharmaceuticals, United States
Disclosure information not submitted.
Rose Du, MD, PhD
Dr.
Brigham and Women's Hospital, United States
Disclosure information not submitted.
Title: TCD-Measured Vasospasm Severity is Associated with Cerebral Infarction After Subarachnoid Hemorrhage
Objective: Angiographic vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is associated with delayed cerebral ischemia (DCI)-related cerebral infarction and worsened neurological outcome. Transcranial doppler (TCD) measurements of cerebral blood 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 aSAH patients with at least one TCD study between 2011 and 2020. The primary outcome was DCI-related cerebral infarction, defined as an infarction developing at least 2 days after any surgical intervention without an alternative cause. Cox proportional-hazards models were used to examine associations between time-varying vasospasm severity and infarction. Optimal TCD-based time/severity thresholds for predicting infarction were then determined.
Results: Of 262 aSAH patients who underwent TCDs, 27 (10%) developed DCI-related infarction. As compared to those without infarction, patients with infarction had higher modified Fisher scale scores, and an earlier onset of vasospasm. Adjusted for age and Hunt and Hess and modified Fisher Scale scores, the worst-vessel vasospasm severity was associated with infarction (aHR 1.7, 95% CI: 1.2-2.5). Vasospasm severity within a specific vessel was associated with risk of infarction in the territory supplied by that vessel. A threshold of at least mild vasospasm severity on hospital day 4 had a negative predictive value of 94% for the development of infarction, but a positive predictive value of 19%.
Conclusion: TCD-measured vasospasm severity is associated with DCI-related infarction after aSAH. A TCD-based threshold for predicting infarction had a high negative predictive value, supporting its role as a screening tool to identify at-risk patients.