Keywords

Transcranial doppler; Vasospasm; Subarachnoid hemorrhage; Basilar artery; Vertebro-basilar

Abstract

Transcranial Doppler (TCD) is commonly used in the monitoring of neuro-critical patient. In the subarachnoid hemorrhage is used in the early diagnosis of cerebral vasospasm. We studied a 30 years old male patient, with severe traumatic brain injury, and right epidural parietal hematoma, right cerebellum hematoma and posttraumatic subarachnoid hemorrhage in posterior territory. The initial Glasgow Coma Score (GCS) was in 4 points. TCD was done one day 2, 3, 6, 14 y 21. We used as vasospasm diagnosis in basilar artery, the criteria of VmBA >95 cm/sec and VmBA /VmECVA > 2 referred to Soustiel Ratio (SI). The patient was diagnosed with early vasospasm of the basilar artery on day 3, based on a VmBA = 121 cm/ sec and SI = 3.36. The patient was treated with nimodipine immediately of vasospasm diagnosis. It also had neurosurgical treatment with evacuation of the epidural and cerebellum hematoma. Repeat TCD measurement was not done until day 6, the VmBA was 79 cm/sec and the IS was 2.29. It was transferred to another floor after 25 days in the ICU, with a GCS of 12. The TCD was used as a diagnosis kit in the vasospasm and show his usefulness in the develop tracing of traumatic subarachnoid hemorrhage in posterior territory. It showed the TCD value in the monitoring of neurocritical patient with severe brain injury and high suspicion of vasospasm develop.

Abstract

Transcranial Doppler (TCD) is commonly used in the monitoring of neuro-critical patient. In the subarachnoid hemorrhage is used in the early diagnosis of cerebral vasospasm.

We studied a 30 years old male patient, with severe traumatic brain injury, and right epidural parietal hematoma, right cerebellum hematoma and posttraumatic subarachnoid hemorrhage in posterior territory. The initial Glasgow Coma Score (GCS) was in 4 points.

TCD was done one day 2, 3, 6, 14 y 21. We used as vasospasm diagnosis in basilar artery, the criteria of VmBA >95 cm/sec and VmBA /VmECVA > 2 referred to Soustiel Ratio (SI).

The patient was diagnosed with early vasospasm of the basilar artery on day 3, based on a VmBA = 121 cm/ sec and SI = 3.36. The patient was treated with nimodipine immediately of vasospasm diagnosis. It also had neurosurgical treatment with evacuation of the epidural and cerebellum hematoma.

Repeat TCD measurement was not done until day 6, the VmBA was 79 cm/sec and the IS was 2.29.

It was transferred to another floor after 25 days in the ICU, with a GCS of 12.

The TCD was used as a diagnosis kit in the vasospasm and show his usefulness in the develop tracing of traumatic subarachnoid hemorrhage in posterior territory. It showed the TCD value in the monitoring of neurocritical patient with severe brain injury and high suspicion of vasospasm develop.

Keywords

Transcranial doppler; Vasospasm; Subarachnoid hemorrhage; Basilar artery; Vertebro-basilar

citation

Alexeis PO, Calixto MC, Elías GRA and Mario SMJ. Transcranial Doppler in Posttraumatic Vasospasm Diagnosis of Basilar Artery: Case Report. SM Emerg Med Crit Care. 2017; 1(1): 1001

Introduction

The Transcranial Doppler is commonly used in the monitoring of neuro-critical patient [1]. In the Subarachnoid Hemorrhage (SAH) is frequently used in the diagnosis of early cerebral vasospasm [2].

The TCD vasospasm diagnosis in SAH patients is validated in the Cerebral Middle Arteries (MCA’s) [3,5], but it’s poorly defined in the posterior territory [2,6].

Many years ago in SAH, the vasospasm diagnosis was only explored in the anterior circulation. In the posterior territory it was evaluated in some cases with traumatic subarachnoid hemorrhage [7].

During the last years, TCD was used to measure the cerebral flow arteries velocities as vasospasm rates suspected in the posterior territory [6].

Recently, the posterior rate or Soustiel Index (SI) is used in the vasospasm diagnosis of basilar artery [5,8,9].

We find the Soustiel Index to calculate the ratio between the Basilar Artery (BA) and Vertebral Artery (VA). We divided the last intensity value in the mean velocity of BA and the average of the Mean Velocity (Vm) in vertebral’s arteries. The normal value is 2 [5,8,9].

Case Report

We studied a 30 years old male patient, with severe brain injury by a sort of blunt trauma. T he initial GCS was in 4 points, with oro-tracheal intubation and artificial mechanic ventilation necessity. The cranial CT scan showed a patient with right parietal epidural hematoma, right cerebellum hematoma and posttraumatic subarachnoid hemorrhage in posterior territory, with no other significant lesions. The patient was evaluated by neurosurgery, with non-surgical yardstick.

It was admitted to Intensive Critical Care Unit (ICU) and we star with neuro-intensive treatment.

We performed TCD with a Doppler EZ - DOP equipment and 2 MHz transductor. All exams were realized by the same explorer. The TCD was done one day 2, 3, 6, 14 y 21.

On day 2, the test showed high velocities pattern in CMA’s and Cerebral Anterior Arteries (CAA’s) in both hemispheres, associated to high resistance pattern, in right Cerebral Posterior Artery (CPA) (Table 1)

The Vm in both CMA’s were over 120 cm/sec, but the Lindergard Rate (LI) in both cases were<3 (Generally in vasospasm cases the LI≥3) [7]. This vasospasm is associated to low values of IP and IR.

In this patient the anterior vasospasm criteria’s were absent. We consider as cerebral hyperemia pattern and it were present in the 4 arteries of the anterior territory.

We used as vasospasm diagnosis in basilar artery, the criteria of VmBA>95 cm/sec and VmBA/VmECVA>2 referred to Soustiel ratio.

We explored the vertebro-basilar system, and we found BA with Vm: 99 cm/sec and the Soustiel Rate (SI): 1.82 with a high suspicion of BA vasospasm because the patient had a high Vm value in AB, but the Soustiel rate was normal.

The patient was diagnosed with an early vasospasm of the basilar artery on hospital day 3, based on a Vm BA = 121 cm/sec and a (SI) VmBA/VmECVA = 3.36 (Table 2).

The patient had a neurologic deterioration with GCS in 3 points. We began the treatment with calcio-antagonistic (nimodipine 60 mg/4 hrs).

The neuro-surgical physicians return to evaluate the patient and recognized a neurosurgical intervention necessity. The epidural hematoma and cerebellum hematoma were evacuated. The patient remained with similar neurologic state during 72 hrs with GCS in 3 points.

The TCD measurement was not done until day 6. The VmBA was 79 cm/sec and the SI = 2.29. We find a normal pattern bilateral in CMA’s and CAA’s, with Vm decrease in vertebro-basilar territory. The patient moves the GCS to 6 points.

In the next day’s the TCD showed slow and progressive decrease of the VM BA velocities with a clinical and neurologic patient recovery (Table 2).

The patient was transferred to another floor after 25 days in the ICU, with a neurologic state and GCS 12 points

Discussion

We report a 30 years old patient with severe traumatic brain injuries and early vasospasm apparition in posterior circulation before 72 hrs. It was a rapid progression to severe vasospasm. We used the criteria of VmBA>95 cm/sec and Soustiel rate (VmBA/VmECVA>2) as vasospasm diagnosis of BA.

According to studies performed in patients with cerebral vasospasm after a traumatic brain injury, using criteria of a VmBA >90 cm/sec, the basilar artery vasospasm was in 19%; it was recorded from post-injury between days 2nd and 12th.

The literature describe in these case as values of Vm>90 cm/sec in BA, showing a vasospasm diagnosis in posterior territory arteries with angiographic correlation performed [2,10].

The traumatic vasospasm AB was present in younger patients with a low score in GCS at the hospital admission [10]. These results are according with our findings.

Orthel et al. used Vm>90 cm/sec and the Soustiel rate (SI>2.5) in BA as vasospasm criteria. In 102 patient was performed the SI and it was positive in 23 patient (22.5%), this criteria represented a significant risk of vasospasm development [10].

When the Soustiel rate is about >2, the diagnosis of vasospasm is about 95% of specificity [6,7,9].

The SI>2.5 is associated to moderate vasospasm and when the SI > 3 and with Vm in BA > 95 cm/sec, the diagnosis of severe vasospasm have a specificity and sensibility near to 100% [7-9].

In our case since the first TCD with Vm in BA of 99 cm/sec, we had a high suspicion of vasospasm. The second TCD showed a severe vasospasm in BA based on a VmBA of 121 cm/sec and a SI of 3.36 (Figures 1 and 2 and Table 2).

The beneficial effect showed by nimodipine in some studies, in a subgroup of brain injury patients with subarachnoid hemorrhage make suggest this drug use in the treatment of the patient. The nimodipine was included in our institutional guide by treat the ASH, although we should be very careful, because it can increase the risk of adverse reactions in someone patient.

Next to 6th day, the patient began with progressive decrease in BA velocities associated to a better clinical condition. These findings showed a close relationship between vasospasm resolution and the neurologic recovery.

Conclusions

The TCD was used as a diagnosis kit in the vasospasm and show his usefulness in the develop tracing of traumatic subarachnoid hemorrhage in the posterior territory. It showed the TCD value in the  monitoring of neurocritical patient with severe brain injury and high suspicion of vasospasm develop.

References

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Citation

Alexeis PO, Calixto MC, Elías GRA and Mario SMJ. Transcranial Doppler in Posttraumatic Vasospasm Diagnosis of Basilar Artery: Case Report. SM Emerg Med Crit Care. 2017; 1(1): 1001.