title: Predicting delayed ischemic deficits after aneurysmal subarachnoid hemorrhage using a transient hyperemic response test of cerebral autoregulation.
abstract: OBJECTIVE
  To assess whether the development of delayed ischemic deficits (DIDs) after aneurysmal subarachnoid hemorrhage can be predicted using transcranial Doppler ultrasonography and the transient hyperemic response test (THRT).
  
  
  METHODS
  An increase in the middle cerebral artery peak flow velocity (FV) of more than 9% of baseline values after 5 to 9 seconds of carotid artery compression was defined as a normal THRT result, indicating good autoregulatory reserve. The transcranial Doppler criteria for vasospasm were a FV of more than 120 cm/s and a Lindegaard ratio of more than 3. Twenty patients with no immediate postoperative neurological deficits were studied. The FVs at all of the major cerebral arteries were measured daily after surgery, and the THRT results were assessed bilaterally.
  
  
  RESULTS
  Five of six patients with abnormal THRT results in the first examination after surgery (primary THRT impairment) developed DIDs; none of the remaining patients developed DIDs (Fisher exact test, P = 0.0004). All five patients with DIDs initially exhibited low FVs but all subsequently developed increases in FVs to values of more than 150 cm/s and four exhibited FVs of more than 200 cm/s. The time of onset of DIDs corresponded to the time of onset of moderate vasospasm (FV > 150 cm/s). None of the patients with initially normal THRT results developed DIDs, although four patients did exhibit late (secondary) THRT impairment, which was associated with FVs of more than 120 cm/s.
  
  
  CONCLUSIONS
  When the effects of primarily impaired (after surgery) autoregulation are magnified by vasospasm, the risk of DIDs seems to be very high. Vasospasm alone does not seem to cause DIDs. The development of DIDs could therefore be predicted using the THRT for patients after aneurysm clipping.
authors.affiliation: Wolfson Brain Imaging Centre, and Academic Neurosurgical Unit, Addenbrooke's Hospital, Cambridge, England.
authors.forename: J M
authors.initials: JM
authors.lastname: Lam
authors.forename: P
authors.initials: P
authors.lastname: Smielewski
authors.forename: M
authors.initials: M
authors.lastname: Czosnyka
authors.forename: J D
authors.initials: JD
authors.lastname: Pickard
authors.forename: P J
authors.initials: PJ
authors.lastname: Kirkpatrick
mesh_terms: D000328:Adult; D000368:Aged; D001783:Blood Flow Velocity; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology*; D002560:Cerebrovascular Circulation; D005260:Female; D006706:Homeostasis; D006801:Humans; D006940:Hyperemia / Q000503:physiopathology; D002532:Intracranial Aneurysm / Q000150:complications* / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D013345:Subarachnoid Hemorrhage / Q000150:complications* / Q000503:physiopathology*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D020301:Vasospasm, Intracranial / Q000209:etiology