Vasospasm diagnosis strategies
Early detection of cerebral vasospasm may lead to effective prevention and treatment strategies. This is however hampered by the poor conditions of SAH patients and lack of tools to make early diagnosis. This review summarized most technologies on cerebra
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Vasospasm diagnosis strategies P. Vajkoczy1, E. Mu¨nch2 1 2
Department of Neurosurgery, Charite, University Clinic, Berlin, Germany Anesthesiology, Klinikum Mannheim, University of Heidelberg, Mannheim, Germany
Summary Early detection of cerebral vasospasm may lead to effective prevention and treatment strategies. This is however hampered by the poor conditions of SAH patients and lack of tools to make early diagnosis. This review summarized most technologies on cerebral perfusion monitoring including direct regional CBF, PET, SPECT, Ve-CT, MRI, and TCD. Cerebral perfusion monitoring may assist early detection of vasospasm. Keywords: Vasospasm; subarchnoid hemorrhage; diagnosis; cerebral blood flow; cerebral perfusion monitoring.
Introduction A prompt and correct diagnosis of vasospasm is the first step in the management of SAH patients, but guidelines for diagnostic algorithms have not been established so far. Currently, the major limitation in detecting a vasospasm-associated ischemic deficit is the fact that a reliable diagnosis is impossible in patients who have to remain sedated and ventilated or who are comatous. Furthermore, clinical monitoring of the neurological condition allows recognition of neurological deterioration only when it has already occurred, therefore lacking the possibility of detecting an early development of hemodynamically relevant, but still asymptomatic, vasospasm. Thus, current diagnostic approaches to the SAH patient should focus on an early and reliable detection of hemodynamically relevant vasospasm. However, the specificity of the gold standard in detecting vasospasm, i.e. angiography, has recently been calculated to be only 50% in the diagnosis of hemodynamically relevant vasospasm [4]. On this account, monitoring techniques that enable a direct or indirect assessment of cerebral perfuCorrespondence: Peter Vajkoczy, Neurochirurgische Klinik – CBF, Campus Benjamin Franklin, Charite – Universita¨tsmedizin Berlin, Hindenburgdamm 30, 12200 Berlin, Germany. e-mail: peter.vajkoczy@ charite.de
sion may allow for a more reliable and earlier detection of symptomatic vasospasm. Various techniques to monitor cerebral perfusion directly or indirectly have been devised in the past years. However, recent experiences have taught us that each monitoring technology also has its limitations in clinical practice. Diagnostic techniques to assess rCBF can be summarized into the following catagories: – – – –
direct, non-invasive CBF measurements indirect, non-invasive CBF measurements indirect, invasive CBF measurements direct, invasive CBF measurements
Direct non-invasive regional CBF (rCBF) measurement techniques encompass positron emission tomography (PET), single photon emission computed tomography (SPECT), 133Xe washout, stable xenon-enhanced computed tomography (sXe-CT), computed tomographic (CT) perfusion imaging and magnetic resonance imaging (MRI). Besides their individual drawbacks, all these rCBF measurement techniques have several further limitations in common. First, they only provide
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