Utility of Screening for Cerebral Vasospasm Using Digital Subtraction Angiography Eric

Abstract

Aneurysmal subarachnoid hemorrhage (aSAH) is a serious cerebrovascular disease, affecting ≈30 000 Americans a year and leading to significant neurological disability, with much of this morbidity related to delayed cerebral ischemia (DCI) and cerebral infarction. Cerebral arterial vasospasm (CVS) is a common complication of aSAH, seen in as many as 70% of patients, and has been strongly associated with neurological deterioration and DCI. Most patients developing DCI harbor significant CVS, with both typically occurring 4 to 14 days after hemorrhage (peak 7–10 days). The association between the 2 phenomena, coupled with the more objective quantifiable nature of CVS, has led to the widespread practice of screening for CVS in patients with aSAH as a means of detecting DCI early and intervening before infarction can occur. However, because less than half of those with CVS ultimately develop DCI, definitive prognostic and therapeutic decisions based on CVS screening can be problematic. The gold standard for the diagnosis of CVS is digital subtraction angiography (DSA), which allows accurate quantitative assessment of CVS severity in each intracranial artery, as well as therapeutic endovascular interventions, if needed. However, because of limited availability of DSA, many centers use transcranial Doppler (TCD) ultrasound or computed tomographic angiography (CTA) as alternatives, even though these tests have a lower sensitivity and specificity for CVS detection. Therefore, most studies evaluating the utility of screening for CVS (as a surrogate or predictor of DCI) have used these suboptimal diagnostic tools and often only in those who are symptomatic or at high risk for DCI. Our institution has a long history of safely using DSA in the evaluation and management of CVS after aSAH. This led to the evolution of our standard practice to a protocol whereby Background and Purpose—Cerebral arterial vasospasm (CVS) is a common complication of aneurysmal subarachnoid hemorrhage strongly associated with neurological deterioration and delayed cerebral ischemia (DCI). The utility of screening for CVS as a surrogate for early detection of DCI, especially in patients without clinical signs of DCI, remains uncertain. Methods—We performed a retrospective analysis of 116 aneurysmal subarachnoid hemorrhage patients who underwent screening digital subtraction angiography to determine the association of significant CVS and subsequent development of DCI. Patients were stratified into 3 groups: (1) no symptoms of DCI before screening, (2) ≥1 episodes of suspected DCI symptoms before screening, and (3) unable to detect symptoms because of poor examination. Results—Patients asymptomatic before screening had significantly lower rates of CVS (18%) compared with those with transient symptoms of DCI (60%; P<0.0001). None of the 79 asymptomatic patients developed DCI after screening, regardless of digital subtraction angiography findings, compared with 56% of those with symptoms (P<0.0001). Presence of CVS was significantly associated with DCI in those with transient symptoms and in those whose examinations did not permit clear assessment (odds ratio 16.0, 95% confidence interval 2.2–118.3, P=0.003). Conclusions—Patients asymptomatic before screening have low rates of CVS and seem to be at negligible risk of developing DCI. Routine screening of asymptomatic patients seems to have little utility. Screening may still be considered in patients with possible symptoms of DCI or those with examinations too poor to clinically detect symptoms because finding CVS may be useful for risk stratification and guiding management. (Stroke. 2015;46:3137-3141. DOI: 10.1161/ STROKEAHA.115.010081.)

Cite this paper

@inproceedings{Arias2015UtilityOS, title={Utility of Screening for Cerebral Vasospasm Using Digital Subtraction Angiography Eric}, author={Jes{\'u}s Arias and Sravya Vajapey and Matthew R. Reynolds and Michael R . Chicoine and Keith M . Rich and G . Dacey and Ian G . Dorward and Colin P Derdeyn and C. J. Moran and Dewitte T Cross and Gregory Joseph Zipfel and Rajat Dhar}, year={2015} }