CEREBRAL HEMODYNAMICS IN SUBARACHNOID HEMORRHAGE EVALUATED BY TRANSCRANIAL DOPPLER SONOGRAPHY .1. RELIABILITY OF FLOW VELOCITIES IN CLINICAL MANAGEMENT
R. Laumer et al., CEREBRAL HEMODYNAMICS IN SUBARACHNOID HEMORRHAGE EVALUATED BY TRANSCRANIAL DOPPLER SONOGRAPHY .1. RELIABILITY OF FLOW VELOCITIES IN CLINICAL MANAGEMENT, Neurosurgery, 33(1), 1993, pp. 1-9
DURING RECENT YEARS, the management of subarachnoid hemorrhage (SAH) h
as changed, resulting in an increase in early operations and routine a
dministration of nimodipine. Both influenced the indication for transc
ranial Doppler sonography (TCD). Furthermore, investigations detected
discrepancies between Doppler findings and neurological status. In a p
rospective study, the reliability of TCD was investigated in patients
with SAH treated with intravenously administered nimodipine. Patients
with large hematomas were excluded. Neurological deficits immediately
after surgery or within the first 48 hours were classified as not dela
yed, and therefore not necessarily due to vasospasm. The most remarkab
le points of this study are that there is no significant difference be
tween the flow velocities for Hunt and Hess Grades I and II when compa
red with those for Grade III, and that Grades IV and V seem to be affi
liated with the lowest velocities. When the flow velocities of 11 pati
ents who developed delayed ischemic deficits (DIDs) were compared with
those of patients with no deficit, no significant difference was seen
. A significant increase in velocity in the days before the onset of D
ID was found only in 3 of 11 cases. Eight patients showed either const
ant high or constant low velocities or even, in some cases, decreasing
time courses. High flow velocities did not necessarily mean impending
neurological deficits: 8 of 66 patients tolerated flow velocities ove
r 200 cm/s. Therefore, it no longer seems to be justified to proclaim
that TCD is able to predict neurological deficits, although it is doub
tless able to detect vasospasm. In an additional series of 97 normal s
ubjects, flow velocities were found to be higher than reported in the
literature, but this fact seems to explain only a minor proportion of
the discrepancies. The main difference between this series and older i
nvestigations is the routine administration of nimodipine. In patients
admitted within 48 hours after SAH (commonly no vasospasm) or with po
or grade SAHs (commonly low flow velocities) TCD seems to have no valu
e. Even in patients admitted later than 72 hours, the indication for T
CD depends on the local management. If surgery is to be performed even
in cases of asymptomatic vasospasm, the clinical value of TCD in case
s of SAH is questionable.