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Early Transcranial Doppler Evaluation of Cerebral Autoregulation Independently Predicts Functional Outcome After Aneurysmal Subarachnoid Hemorrhage

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An Invited Editorial Commentary to this article was published on 10 July 2019

Abstract

Background

Cerebral autoregulation (CA) impairment after aneurysmal subarachnoid hemorrhage (SAH) has been associated with delayed cerebral ischemia and an unfavorable outcome. We investigated whether the early transient hyperemic response test (THRT), a transcranial Doppler (TCD)-based CA evaluation method, can predict functional outcome 6 months after aneurysmal SAH.

Methods

This is a prospective observational study of all aneurysmal SAH patients consecutively admitted to a single center between January 2016 and February 2017. CA was evaluated within 72 h of hemorrhage by THRT, which describes the changes in cerebral blood flow velocity after a brief compression of the ipsilateral common carotid artery. CA was considered to be preserved when an increase ≥ 9% of baseline systolic velocity was present. According to the modified Rankin Scale (mRS: 4–6), the primary outcome was unfavorable 6 months after hemorrhage. Secondary outcomes included cerebral infarction, vasospasm on TCD, and an unfavorable outcome at hospital discharge.

Results

Forty patients were included (mean age = 54 ± 12 years, 70% females). CA was impaired in 19 patients (47.5%) and preserved in 21 (52.5%). Impaired CA patients were older (59 ± 13 vs. 50 ± 9, p = 0.012), showed worse neurological conditions (Hunt&Hess 4 or 5–47.4% vs. 9.5%, p = 0.012), and clinical initial condition (APACHE II physiological score—12 [5.57–13] vs. 3.5 [3,4,5], p = 0.001). Fourteen patients in the impaired CA group and one patient in the preserved CA group progressed to an unfavorable outcome (73.7% vs. 4.7%, p = 0.0001). The impaired CA group more frequently developed cerebral infarction than the preserved CA group (36.8% vs. 0%, p = 0.003, respectively). After multivariate analysis, impaired CA (OR 5.15 95% CI 1.43–51.99, p = 0.033) and the APACHE II physiological score (OR 1.67, 95% CI 1.01–2.76, p = 0.046) were independently associated with an unfavorable outcome.

Conclusions

Early CA impairment detected by TCD and admission APACHE II physiological score independently predicted an unfavorable outcome after SAH.

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Acknowledgements

We thank Vânia Naomi Hirakata for assistance with statistical analyzes, the laboratory team of Hospital Cristo Redentor for assistance with blood collection and Neurosurgery residents of Hospital Cristo Redentor for helping with the acquisition of some data. MMB is supported by Brazilian National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico—CNPq) (Grants #485423/2012-0, #307084/2014-0, #438548/2018-3 #312683/2018-9).

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Authors and Affiliations

  1. Graduate Program in Medical Science, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

    Carla B. Rynkowski & Marino Muxfeldt Bianchin

  2. Adult Critical Care Unit, Hospital Cristo Redentor, Rua Domingos Rubbo, 20, Porto Alegre, Rio Grande do Sul, CEP: 91040-000, Brazil

    Carla B. Rynkowski

  3. Critical Care Unit, Hospital Paulistano, UnitedHealth Group Brazil, São Paulo, SP, Brazil

    Airton Leonardo de Oliveira Manoel

  4. Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, University of Toronto, Toronto, Canada

    Airton Leonardo de Oliveira Manoel

  5. Department of Neurosurgery, Hospital Cristo Redentor, Porto Alegre, Rio Grande do Sul, Brazil

    Marcelo Martins dos Reis, Paulo Valdeci Worm & Diego Zambonin

  6. Hospital de Clínicas Dr. Manuel Quintela, Universidad de la Republica, Montevideo, Uruguay

    Corina Puppo

  7. Division of Neurology, Hospital de Clínicas de Porto Alegre – B.R.A.I.N, Porto Alegre, Rio Grande do Sul, Brazil

    Marino Muxfeldt Bianchin

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Contributions

CBR contributed to the conception and design, acquisition, analysis and interpretation of data, drafting the article. ALOM contributed to statistical analysis, critically revising and drafting the article. MMR contributed to the design, acquisition, and analysis of data. CP contributed to conception and design, analysis and interpretation of data, critically revising the article. PVW contributed to acquisition, analysis, and interpretation of data. DZ contributed to acquisition and analysis of data. MMB contributed to conception and design, analysis, and interpretation of data, critically revising the article and supervising the study.

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Correspondence to Carla B. Rynkowski.

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Rynkowski, C.B., de Oliveira Manoel, A.L., dos Reis, M.M. et al. Early Transcranial Doppler Evaluation of Cerebral Autoregulation Independently Predicts Functional Outcome After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 31, 253–262 (2019). https://doi.org/10.1007/s12028-019-00732-5

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