Carrera Emmanuel, Schmidt J Michael, Oddo Mauro, Fernandez Luis, Claassen Jan, Seder David, Lee Kiwon, Badjatia Neeraj, Connolly E Sander, Mayer Stephan A
Neurological Intensive Care Unit, Departments of Neurology and Neurosurgery, Columbia University, New York, New York 10032, USA.
Neurosurgery. 2009 Aug;65(2):316-23; discussion 323-4. doi: 10.1227/01.NEU.0000349209.69973.88.
Transcranial Doppler (TCD) is widely used to monitor the temporal course of vasospasm after subarachnoid hemorrhage (SAH), but its ability to predict clinical deterioration or infarction from delayed cerebral ischemia (DCI) remains controversial. We sought to determine the prognostic utility of serial TCD examination after SAH.
We analyzed 1877 TCD examinations in 441 aneurysmal SAH patients within 14 days of onset. The highest mean blood flow velocity (mBFV) value in any vessel before DCI onset was recorded. DCI was defined as clinical deterioration or computed tomographic evidence of infarction caused by vasospasm, with adjudication by consensus of the study team. Logistic regression was used to calculate adjusted odds ratios for DCI risk after controlling for other risk factors.
DCI occurred in 21% of patients (n = 92). Multivariate predictors of DCI included modified Fisher computed tomographic score (P = 0.001), poor clinical grade (P = 0.04), and female sex (P = 0.008). After controlling for these variables, all TCD mBFV thresholds between 120 and 180 cm/s added a modest degree of incremental predictive value for DCI at nearly all time points, with maximal sensitivity by SAH day 8. However, the sensitivity of any mBFV more than 120 cm/s for subsequent DCI was only 63%, with a positive predictive value of 22% among patients with Hunt and Hess grades I to III and 36% in patients with Hunt and Hess grades IV and V. Positive predictive value was only slightly higher if mBFV exceeded 180 cm/s.
Increased TCD flow velocities imply only a mild incremental risk of DCI after SAH, with maximal sensitivity by day 8. Nearly 40% of patients with DCI never attained an mBFV more than 120 cm/s during the course of monitoring. Given the poor overall sensitivity of TCD, improved methods for identifying patients at high risk for DCI after SAH are needed.
经颅多普勒（TCD）被广泛用于监测蛛网膜下腔出血（SAH）后血管痉挛的时间进程，但其预测延迟性脑缺血（DCI）导致临床恶化或梗死的能力仍存在争议。我们试图确定SAH后连续TCD检查的预后价值。
我们分析了441例动脉瘤性SAH患者发病14天内的1877次TCD检查。记录DCI发作前任何血管中的最高平均血流速度（mBFV）值。DCI被定义为血管痉挛导致的临床恶化或梗死的计算机断层扫描证据，由研究团队达成共识进行判定。在控制其他危险因素后，使用逻辑回归计算DCI风险的调整比值比。
21%的患者（n = 92）发生了DCI。DCI的多变量预测因素包括改良Fisher计算机断层扫描评分（P = 0.001）、临床分级差（P = 0.04）和女性性别（P = 0.008）。在控制这些变量后，120至180 cm/s之间的所有TCD mBFV阈值在几乎所有时间点都为DCI增加了适度的增量预测价值，在SAH第8天时敏感性最高。然而，任何mBFV超过120 cm/s对后续DCI的敏感性仅为63%，在Hunt和Hess分级I至III的患者中阳性预测值为22%，在Hunt和Hess分级IV和V的患者中为36%。如果mBFV超过180 cm/s，阳性预测值仅略高。
TCD血流速度增加仅意味着SAH后DCI的风险略有增加，在第8天时敏感性最高。近40%的DCI患者在监测过程中mBFV从未超过120 cm/s。鉴于TCD的总体敏感性较差，需要改进识别SAH后DCI高危患者的方法。
