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

  • Carla B. RynkowskiEmail author
  • Airton Leonardo de Oliveira Manoel
  • Marcelo Martins dos Reis
  • Corina Puppo
  • Paulo Valdeci Worm
  • Diego Zambonin
  • Marino Muxfeldt Bianchin
Original Work



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.


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.


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.


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


Subarachnoid hemorrhage Cerebral circulation Transcranial Doppler Cerebral autoregulation Transient hyperemic response test 



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).

Authors’ 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.

Source of Support


Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from each participant in the study.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2019

Authors and Affiliations

  • Carla B. Rynkowski
    • 1
    • 2
    Email author
  • Airton Leonardo de Oliveira Manoel
    • 3
    • 4
  • Marcelo Martins dos Reis
    • 5
  • Corina Puppo
    • 6
  • Paulo Valdeci Worm
    • 5
  • Diego Zambonin
    • 5
  • Marino Muxfeldt Bianchin
    • 1
    • 7
  1. 1.Graduate Program in Medical ScienceUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
  2. 2.Adult Critical Care UnitHospital Cristo RedentorPorto AlegreBrazil
  3. 3.Critical Care UnitHospital Paulistano, UnitedHealth Group BrazilSão PauloBrazil
  4. 4.Keenan Research Centre for Biomedical Science, St. Michael’s HospitalUniversity of TorontoTorontoCanada
  5. 5.Department of NeurosurgeryHospital Cristo RedentorPorto AlegreBrazil
  6. 6.Hospital de Clínicas Dr. Manuel QuintelaUniversidad de la RepublicaMontevideoUruguay
  7. 7.Division of NeurologyHospital de Clínicas de Porto Alegre – B.R.A.I.NPorto AlegreBrazil

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