NEUROIMAGING / NEUROSONOLOGY

TCD/TCCD vasospasm monitoring

Updated on 28/10/2023, published on 31/03/2021

  • vasospasm is a contraction of the muscular wall of an artery, resulting in its stenosis and reduced flow
  • the prevalence of vasospasms (VSP) following SAH is 50-70%
  • vasospasms in SAH patients occur around day 3-5 and last up to 3-4 weeks
  • approx. 30% of patients with aneurysmal SAH develop delayed ischemic deficit (DID) (Yamaki, 2019)

    • DID is the leading preventable cause of poor outcome
  • increased risk of VSP is associated with:
  • the risk of complications increases with the number of arteries involved and with hemodynamically significant spasms

Methods for Vasospasms Detection and Monitoring

  • transcranial Doppler ultrasound (TCCD/TCD)
    • optimal bedside, cost-effective, and non-invasive method
  • CT angiography
  • MR angiography
    • low sensitivity for detection of distal vasospasms
    • MR perfusion may help predict DID
  • digital subtraction angiography (DSA)
    • reserved for local endovascular treatment

TCCD Criteria

  • it is recommended to start the examination on days 2-3 to obtain baseline velocities and then repeat every 24 hours to assess the dynamics
  • examine:
    • PSV, EDV, Vmean
    • PI and RI  → more here
    • to exclude the effect of hyperemia, determine the ACM/ACI ratio (Lindegaard Ratio – LR); a value of LR >3 indicates spasm
  • a significant increase in velocity indicates vasospasm  [Vora, 1999] [Lindegaard,1988]
    • Vmean ≥ 120 cm/s ( ACM, ACA) + LR >3
    • Vmean ≥ 80 cm/s (AV)
    • Vmean ≥ 85-95 cm/s (AB) + LR > 2.5-3
  • critical value is ↑ Vmean > 50 cm/s/24 h or > 25%/24 h

Vmean = 1/3 (PSV-EDV)+ EDV

  • there is no correlation between the severity of vasospasm detected by ultrasound and the clinical course; the development of DID cannot be reliably predicted
  • a sudden increase in peripheral resistance (PI > 1.5) indicates either distal VSP or decompensated intracranial hypertension if detected in multiple vessels
Vessel
Vmean
Sensitivity/specificity
MCA, ACA
≥ 120 cm/s
≥ 200 cm/s (severe spasm)
88% / 78%
27% / 98%
ICA
≥ 90 cm/s
25 % / 93%
VA
BA
≥ 60-80 cm/s
≥ 85-95 cm/s
44% / 79% (60cm/s)
77% / 79% (60 cm/s)
  • the positive predictive value of angiographic vasospasm in MCA is 87% with Vmean > 200 cm/s
  • the negative predictive value of angiographic vasospasm in MCA is 94% with Vmean < 120 cm/s  [Vora, 1999]
Lindegaard Ratio vasospasm on DSA
< 3 no VSP
3-4.5 mild VSP
4.5-6 moderate VSP
> 6 sever VSP
MCA vasospasm on TCD

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TCD/TCCD vasospasm monitoring
link: https://www.stroke-manual.com/tccd-vasospasm-monitoring/