Real-Time Detection of Cerebral Artery Rebleeding by Transcranial Doppler Ultrasound: Hemodynamic Changes and Response to Treatment
Year: 2017
Type: article
Abstract: Dear Editor,Aneurysmal rupture and subsequent subarachnoid hemorrhage (SAH) lead to multiple complications including vasospasm, delayed cerebral ischemia, cerebral edema, and cerebral herniation.[1][2][3] Transcranial Doppler ultrasound (TCD) is a noninvasive method for evaluating the blood flow velocities in intracranial vessels and the presence of vasospasm.3 An elevated intracranial pressure (ICP) leads to decreased mean and diastolic blood flow velocities and increased pulsatility index (PI), which can also be monitored in patients with SAH. 3 We present a case report of a patient with SAH and a clipped aneurysm who rebled while undergoing a TCD study, and provide unique images, vitals graphs, and a video of the TCD study before and during the bleeding as well as after applying emergency treatment.A 68-year-old Caucasian man presented for the evaluation of sudden-onset headache and neck pain.His blood pressure (BP) was initially elevated (240/117 mm Hg) and he had experienced a tonic-clonic seizure for which he received fosphenytoin and was subsequently intubated and started on a propofol drip.Brain computed tomography (CT) revealed SAH.Brain CT angiography showed an irregular anterior communicating artery aneurysm (2.5× 2×1.5 mm) and increased hemorrhage within the ventricles, septum pellucidum, and corpus callosum (Supplementary Fig. 1 in the online-only Data Supplement).An attempt to coil the aneurysm was unsuccessful, and so the patient underwent right frontotemporal craniotomy, clipping of the aneurysm, and placement of a ventriculostomy catheter (Supplementary Fig. 2 in the online-only Data Supplement).After surgery he was admitted to the neurointensive care unit (NICU), where an interval decrease in the subarachnoid blood was noticed in follow-up brain CT.Postoperatively he remained intubated, but was awake and followed commands briskly, and the results of neurological examination were normal except or a slight drift in the right upper extremity.The patient exhibited rebleeding at 8 days after the index event, secondary to clip dislocation (Supplementary Fig. 3 in the online-only Data Supplement).TCD waveforms were captured before and during the bleeding as well as after emergency treatment (Fig. 1) (Supplementary video 1 in the online-only Data Supplement) in parallel with NICU multimodal monitoring that captured minute-by-minute changes in the vital signs (Fig. 1).PI increased markedly during aneurysmal rebleeding (PI=1.7)compared to before the rebleeding (PI= 1.0) and following rebleeding treatment (PI=1.4) with propofol (two doses of 30 mg) and mannitol (75 g).The patient remained comatose (score on the Glasgow Coma Scale of 4 out of 15) throughout the following few weeks, and the family decided to withdraw life-support treatment at 40 days after admission.To the best of our knowledge, this is the first case in which the rebleeding of a cerebral aneurysm was detected in real time using TCD monitoring.This report highlights the poten-
Source: Journal of Clinical Neurology
Language: English
Subfield: Neurology
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W2549781011