Is routine transcranial Doppler ultrasound useful in the management of subarachnoid hemorrhage?

In this prospective observational study, the authors assess the impact of routine transcranial Doppler (TCD) ultrasound monitoring on the diagnosis, management, and outcome of delayed ischemic neurological deficit complicating subarachnoid hemorrhage (SAH). Over a 10-month period 186 patients admitted to a regional neurosciences center were included in the study. Three times a week, routine TCD examinations performed by neuroradiographers made an important positive contribution to the diagnosis of delayed ischemic neurological deficit in 72% of patients with this complication and altered management for the benefit of the patient in 43%. In 9% of patients with recent SAH, it was believed that the outcome might have been better if the TCD result had been acted upon appropriately. The TCD results did not adversely influence management or outcome and were accurate when compared with those obtained on angiography. The authors conclude that a routine TCD service provided by neuroradiographers is accurate and useful in diagnosing and managing elevated blood velocities and ischemic neurological deficit following SAH. In addition, it is possible that if the information gleened from TCD findings was used more often in patient management, outcome might be improved; however, a randomized controlled trial is necessary to assess this definitively.

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Is routine transcranial Doppler ultrasound monitoring useful in the management of subarachnoid hemorrhage?

Journal of Neurosurgery ◽

10.3171/jns.1998.88.2.0272 ◽

1998 ◽

Vol 88 (2) ◽

pp. 272-276 ◽

Cited By ~ 46

Author(s):

Joanna M. Wardlaw ◽

Ruth Offin ◽

Graham M. Teasdale ◽

Evelyn M. Teasdale

Keyword(s):

Subarachnoid Hemorrhage ◽

Neurological Deficit ◽

Transcranial Doppler ◽

Controlled Trial ◽

Positive Contribution ◽

Content Type ◽

Delayed Ischemic Neurological Deficit ◽

Ultrasound Monitoring ◽

The Impact ◽

Fine Print

Object. In this prospective observational study, the authors assess the impact of routine transcranial Doppler (TCD) ultrasound monitoring on the diagnosis, management, and outcome of delayed ischemic neurological deficit complicating subarachnoid hemorrhage (SAH). Methods. Over a 10-month period 186 patients admitted to a regional neurosciences center were included in the study. Three times a week, routine TCD examinations performed by neuroradiographers made an important positive contribution to the diagnosis of delayed ischemic neurological deficit in 72% of patients with this complication and led to altered management for the benefit of the patient in 43%. In 9% of patients with recent SAH, it was believed that the outcome might have been better if the TCD result had been acted upon appropriately. The TCD results did not adversely influence management or outcome and were generally accurate when compared with those obtained on angiography. Conclusions. A routine TCD service provided by neuroradiographers is accurate and useful in diagnosing and managing elevated blood velocities and ischemic neurological deficit following SAH. In addition, it is possible that if the information gleaned from TCD findings was used more often in patient management, outcome might be improved; however, a randomized controlled trial is necessary to assess both these points definitively.

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Transcranial Doppler Sonography Defined Vasospasm, Ischemic Brain Lesions, and Delayed Ischemic Neurological Deficit in Younger and Elderly Patients after Aneurysmal Subarachnoid Hemorrhage

World Neurosurgery ◽

10.1016/j.wneu.2020.03.051 ◽

2020 ◽

Vol 138 ◽

pp. e718-e724

Author(s):

Michael Bender ◽

Eva Richter ◽

Frank P. Schwarm ◽

Malgorzata A. Kolodziej ◽

Eberhard Uhl ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Elderly Patients ◽

Neurological Deficit ◽

Transcranial Doppler ◽

Doppler Sonography ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Transcranial Doppler Sonography ◽

Brain Lesions ◽

Ischemic Brain ◽

Delayed Ischemic Neurological Deficit

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Use of transcranial Doppler sonography to predict development of a delayed ischemic deficit after subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.1993.78.2.0183 ◽

1993 ◽

Vol 78 (2) ◽

pp. 183-187 ◽

Cited By ~ 97

Author(s):

Donald G. Ghosset ◽

John Straiton ◽

Isobel McDonald ◽

Muriel Cockburn ◽

Ross Bullock

Keyword(s):

Subarachnoid Hemorrhage ◽

Neurological Deficit ◽

Transcranial Doppler ◽

Doppler Sonography ◽

Peak Velocity ◽

Transcranial Doppler Sonography ◽

Early Period ◽

Delayed Ischemic Neurological Deficit ◽

Rate Of Increase ◽

Significant Difference

✓ Blood flow velocity was recorded from the middle or anterior cerebral and extracranial internal carotid arteries using transcranial Doppler sonography (TCD) in 121 unselected consecutive patients with acute aneurysmal subarachnoid hemorrhage (SAH). Recordings were made daily or every 2nd day after SAH for a 14-day period. The highest recorded velocity was greater in the 47 patients who developed a delayed ischemic neurological deficit (186 ± 6 cm sec−1; mean ± standard error of the mean) than in the 74 patients who did not develop a neurological deficit (149 ± 5 cm sec−1) (p < 0.001, Mann-Whitney test). Peak velocity recordings can thus assist in the diagnosis of delayed ischemic neurological deficit; however, peak velocity was often recorded only after the onset of neurological deficit. When only those readings made before the onset of neurological deficit were considered, there was no significant difference in peak velocity between the groups (157 ± 8 cm sec−1 vs. 149 ± 5 cm sec−1, respectively). Alternative TCD parameters for predicting delayed neurological deficit were therefore sought. The rate of increase in TCD velocity, recorded during the first few days after SAH, was significantly higher in the patients who later developed a neurological deficit. A maximum velocity increase of 65 ± 5 cm sec−1 per 24-hour period was recorded in patients who later developed a neurological deficit, compared to 47 ± 3 cm sec−1 24 hrs−1 in patients who did not develop a delayed neurological deficit (p = 0.003). A rise of more than 50 cm sec−1 24 hrs−1 identifies those patients who are most likely to develop a delayed ischemic neurological deficit after SAH. This can be applied prospectively to individual cases. Serial TCD studies in the early period after SAH are thus of value to identify patients who can be selected for prophylactic therapy, which may prevent or ameliorate development of delayed ischemic neurological deficits.

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A randomized trial of nicardipine in subarachnoid hemorrhage: angiographic and transcranial Doppler ultrasound results

Journal of Neurosurgery ◽

10.3171/jns.1993.78.4.0548 ◽

1993 ◽

Vol 78 (4) ◽

pp. 548-553 ◽

Cited By ~ 111

Author(s):

E. Clarke Haley ◽

Neal F. Kassell ◽

James C. Torner ◽

_ _

Keyword(s):

Subarachnoid Hemorrhage ◽

Doppler Ultrasound ◽

Transcranial Doppler ◽

Transcranial Doppler Ultrasound ◽

High Dose ◽

Content Type ◽

Central Registry ◽

Significant Difference ◽

Fine Print ◽

Flow Velocities

✓ Calcium antagonist drugs were proposed for use in patients with recent aneurysmal subarachnoid hemorrhage (SAH) because of their ability to block the effects of a wide variety of vasoconstrictor substances on cerebral arteries in vitro. It was suggested that these agents might, therefore, be useful in ameliorating cerebral vasospasm and its ischemic consequences which frequently complicate SAH. This hypothesis was tested in an arm of a randomized double-blind placebo-controlled trial of high-dose intravenous nicardipine in patients with recently ruptured aneurysms. Participating investigators were required to send selected copies of all admission and follow-up angiograms obtained between Days 7 and 11 following hemorrhage (the peak period of risk for vasospasm) to the Central Registry of the Cooperative Aneurysm Study for blinded interpretation and review for the presence and severity of angiographic vasospasm. In centers with transcranial Doppler ultrasound (TCD) capabilities, middle cerebral artery (MCA) mean flow velocities were measured and recorded. Angiograms obtained between Days 7 and 11 were available for 103 (23%) of 449 patients receiving nicardipine and 121 (26%) of 457 receiving placebo. There was a balance of prognostic factors for vasospasm between the groups. Fifty-one percent of placebo-treated patients had moderate or severe vasospasm on “Day 7–11 angiograms” compared to 33% of nicardipine-treated patients. This difference is statistically significant (p < 0.01). Sixty-seven (49%) of 137 placebo-treated patients examined with TCD between Days 7 and 11 had mean MCA flow velocities exceeding 120 cm/sec compared to 26 (23%) of 112 nicardipine-treated patients (significant difference, p < 0.001). These data suggest that high-dose intravenous nicardipine reduces the incidence and severity of delayed cerebral arterial narrowing in patients following aneurysmal SAH.

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The impact of surgical site infections on hospital contribution margin—a European prospective observational cohort study

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.273 ◽

2019 ◽

Vol 40 (12) ◽

pp. 1374-1379

Author(s):

Marco von Strauss ◽

Walter R. Marti ◽

Edin Mujagic ◽

Michael Coslovsky ◽

Katharina Diernberger ◽

...

Keyword(s):

Financial Incentives ◽

Diagnosis Related Groups ◽

Controlled Trial ◽

Private Insurance ◽

Surgical Site Infections ◽

Positive Contribution ◽

Contribution Margin ◽

Multicenter Randomized Controlled Trial ◽

Preoperative Antibiotic Prophylaxis ◽

The Impact

AbstractBackground:Surgical site infections (SSIs) are common surgical complications that lead to increased costs. Depending on payer type, however, they do not necessarily translate into deficits for every hospital.Objective:We investigated how surgical site infections (SSIs) influence the contribution margin in 2 reimbursement systems based on diagnosis-related groups (DRGs).Methods:This preplanned observational health cost analysis was nested within a Swiss multicenter randomized controlled trial on the timing of preoperative antibiotic prophylaxis in general surgery between February 2013 and August 2015. A simulation of cost and income in the National Health Service (NHS) England reimbursement system was conducted.Results:Of 5,175 patients initially enrolled, 4,556 had complete cost and income data as well as SSI status available for analysis. SSI occurred in 228 of 4,556 of patients (5%). Patients with SSIs were older, more often male, had higher BMIs, compulsory insurance, longer operations, and more frequent ICU admissions. SSIs led to higher hospital cost and income. The median contribution margin was negative in cases of SSI. In SSI cases, median contribution margin was Swiss francs (CHF) −2045 (IQR, −12,800 to 4,848) versus CHF 895 (IQR, −2,190 to 4,158) in non-SSI cases. Higher ASA class and private insurance were associated with higher contribution margins in SSI cases, and ICU admission led to greater deficits. Private insurance had a strong increasing effect on contribution margin at the 10th, 50th (median), and 90th percentiles of its distribution, leading to overall positive contribution margins for SSIs in Switzerland. The NHS England simulation with 3,893 patients revealed similar but less pronounced effects of SSI on contribution margin.Conclusions:Depending on payer type, reimbursement systems with DRGs offer only minor financial incentives to the prevention of SSI.

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Effect of Nimodipine on Cerebrovascular Response to CO2 in Asymptomatic Individuals and Patients with Subarachnoid Hemorrhage: A Transcranial Doppler Ultrasound Study

Neurosurgery ◽

10.1227/00006123-199008000-00013 ◽

1990 ◽

Vol 27 (2) ◽

pp. 247-251 ◽

Cited By ~ 20

Author(s):

Rolf W. Seiler ◽

Arto C. Nirkko

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Transcranial Doppler ◽

Doppler Ultrasonography ◽

Transcranial Doppler Ultrasound ◽

Initial Value ◽

Ruptured Aneurysms ◽

Ultrasound Study ◽

Asymptomatic Individuals

Abstract The cerebrovascular response to CO2was evaluated by measuring relative changes in blood flow velocity within the middle cerebral artery by transcranial Doppler ultrasonography during normo-, hypo-, and hypercapnia. In seven patients without subarachnoid hemorrhage (five with unruptured arteriovenous malformations and two with aneurysms), the CO2vasoreactivity was tested on the side of the middle cerebral artery with normal flow velocities opposite the lesion. A baseline CO2reactivity test was obtained in each patient and then repeated under constant intravenous infusion of nimodipine, 2 mg/hr. Nine patients with ruptured aneurysms who were rated at Hunt and Hess Grades 1 or 2 were operated on within 1 to 3 days after the hemorrhage and treated with nimodipine, 2 mg/hr, given intravenously. In these patients. CO2vasoreactivity was tested during the second week after the hemorrhage, when the middle cerebral artery velocity was increased by at least 50% of the initial value or more. Nimodipine was then discontinued and, 48 hours later, when the middle cerebral artery velocity was still in the same range, CO2vasoreactivity was tested again. Two months later, after full recovery from the subarachnoid hemorrhage and normalization of the velocities, a third measurement of CO2reactivity was obtained as a baseline control. No significant effect of nimodipine on CO2vasoreactivity could be demonstrated in any of the test periods. In the second week after a subarachnoid hemorrhage, a significant reduction of the cerebrovascular response to CO2was found (P < 0.005).

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