Question 2

College Answer

Techniques that have proven or demonstrated potential in the diagnosis and monitoring of 
vasospasm include: 

Clinical: 

In the conscious patient, may be detected clinically by new focal neurology or a drop in GCS. Advantages: No additional costs and readily available, can be repeated easily, non-invasive (usually), has to be performed at the bedside. Major disadvantage is lack of specificity often necessitating CT/angiography. Also lacks sensitivity, vasospasm can occur without a clinical correlate, early in the disease. Operator dependent.

Conventional 4 vessel DSA angiography: 

 Remains the gold standard for diagnosis of vasospasm. 
 May allow therapeutic intervention (angioplasty) at the time. 

Disadvantages: invasive, risks of bleeding, embolism, radiation/contrast exposure and transport. Requires skilled interventional radiology, and therefore resource heavy. Risk of stroke (quoted about 1%, but probably a little lower) just from the angio, plus the dissections etc. that occur as well. 

Detects vessel narrowing, not necessarily poor flow to distal tissue in all cases (either increased flow rate through narrow vessel or collateral supply. May lead to over treatment. 

Transcranial Doppler (TCD): 

 It is low risk, performed at the bedside, non-invasive and able to be repeated daily enabling trend analysis. 
 Disadvantages:

• The technique is however operator dependent and there is high inter- observer variability. 
• Debate exists regarding correlation of flow velocity and vasospasm and although high velocities (> 200cm/sec) are predictive, lower velocity may not be as good.
• The technique may be more accurate when MCA velocity is indexed to the ipsilateral extracranial carotid artery (Lindegaard index, >3 strongly predictive). 
• Colour coded TCD may offer greater accuracy than plain TCD alone. 
   

CTA/MRI:

• May be combined with perfusion allowing characterisation of both vascular anatomy and associated perfusion abnormalities. 
   
• MR diffusion weighted imaging accurately identifies brain tissue at high risk of infarction; perfusion weighted imaging reveals asymmetries in regional perfusion. 
   
• Both methods show correlation with delayed ischaemic neurological deficit (DIND). 
   
• Disadvantages:
  • Image clarity will be affected by clip/coil and contrast related issues need consideration. The overall diagnostic capability of this modality however remains unclear until further prospective studies are performed. Similar disadvantages as per angiography with respect to transport, radiation (for CT), contrast exposure, interpretation by experts. 
     

SPECT/PET

• Can be used to obtain a picture of brain perfusion and metabolism and have 
  shown variable correlation with vasospasm as assessed by more conventional 
  methods.
• Disadvantages: They are resource heavy not easily available, radiation exposure, patient 
  transport are issues.

EEG:

• May provide prognostic information, focal areas of slowing correlate with angiographic vasospasm and a decrease in alpha to delta ratio strongly correlates with ischaemia. Sensitivity and specificity for detecting vasospasm is high. 
  
  Disadvantage: Not readily available however and their may be issues with interpretation. 

Tissue sensors:

• The use of measures of tissue oxygenation using parenchymal sensors and microdialysis for 
  monitoring biochemical indices of ischaemia are largely research tools.

Salient points

• Clinical examination
• DSA
• CTA
• EEG
• Transcranial doppler
• Parenchymal sensors
• SPECT

Discussion

This answer lends itself well to a table format.

Technique	Advantages	Disadvantages
Clinical examination	Cheap Available at the bedside Easily sequentialised	Inaccurate Operator-dependent Many episodes of vasospasm are not associated with physical signs
DSA	Gold standard Offers a means of treating the vasospasm	May overtreat by picking up narrowing which is not associated with a decreased flow Radiation exposure Contrast exposure Need for transport Need for skilled personnel invasive 1% risk of stroke or dissection
CTA	Reasonable sensitivity and specificity Non-invasive	Radiation exposure Contrast exposure Need for transport Need for skilled personnel Frustrated by the presence of coils and clips (artifact is generated)
Transcranial Doppler	High (100%) specificity; non invasive Easily sequentialised	Operator-dependent Mediocre sensitivity
EEG	Highly sensitive and specific Can pick up features of ischaemia and vasospasm earlier than the development of obvious signs or radiological features Non invasive	Requires skilled operator and interpreter; may not be available Ideally, EEG monitoring should be continuous.
SPECT	potentially very useful in detecting ischaemia and cerebral hypoperfusion	Not validated, and mainly a tool of research

Apocryphal notes on the diagnosis and management of SAH are also available.

Oh's Intensive Care manual

Chapter   51   (pp. 568)  Acute  cerebrovascular  complications by Bernard  Riley  and  Thearina  de  Beer

Marshall, Scott A., Paul Nyquist, and Wendy C. Ziai. "The role of transcranial Doppler ultrasonography in the diagnosis and management of vasospasm after aneurysmal subarachnoid hemorrhage." Neurosurgery Clinics of North America21.2 (2010): 291-303.

Greenberg, E. D., et al. "Diagnostic accuracy of CT angiography and CT perfusion for cerebral vasospasm: a meta-analysis." American Journal of Neuroradiology 31.10 (2010): 1853-1860.

Sloan, M. A., et al. "Sensitivity and specificity of transcranial Doppler ultrasonography in the diagnosis of vasospasm following subarachnoid hemorrhage." Neurology 39.11 (1989): 1514-1514.

Rivierez, M., et al. "Value of electroencephalogram in prediction and diagnosis of vasospasm after intracranial aneurysm rupture." Acta neurochirurgica 110.1-2 (1991): 17-23.