Summary
Introduced 15 years ago, transcranial Doppler (TCD) recordings of blood velocity in patients with recent subarachnoid haemorrhage (SAH) have two objectives: to detect elevated blood velocities suggesting cerebral vasospasm (VSP) and to identify patients at risk for delayed cerebral ischemic deficits (DID). The pathophysiological cascade causing DID is complex. Discrepancies between blood velocities and DID (presuming that there actually is an “ischemic threshold” for blood velocity in absolute terms, which seems most unlikely) have been demonstrated, particularly in patients with elevated intracranial pressure (ICP) levels. Furthermore, the vessel showing the highest blood velocity is not always the one perfusing the area where ischemic symptoms arise, nor does the site of the greatest subarachnoid blood clot always relate to the ischemic brain region. Moreover, it is probable that the complex haemodynamic changes following SAH and the subsequent development of VSP may be underestimated if only considering the crude intracranial artery blood velocities. Cerebral blood flow measurements combined with TCD to assess both flow and velocity have emphasised this point. Despite these findings and ignoring the basic principles of cerebral haemodynamics, cerebral vasospasm is still being assessed from the intracranial velocity measurement alone. The addition of at least a careful measurement from the extracranial internal carotid artery — using the same TCD equipment and taking only a few short minutes to perform — allows a much more accurate assessment of the degree and the effects of vasospasm.
This probably explains why the clinical value of TCD is still debated. There is still uncertainty as to the best method to prevent and to treat VSP, and the overall outcome after SAH depends on so many factors besides VSP. Conclusive evidence may therefore be hard to obtain, and it appears sound to conclude that even with advanced investigation technology available, proper selection, pre- peri- and postoperative care and timing of surgery remain cornerstones in the management of these patients,- equal in importance to their treatment in the operating room or in the interventional angiography suite.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsPreview
Unable to display preview. Download preview PDF.
References
Aaslid R (1987) Visually evoked dynamic blood flow response of the human cerebral circulation. Stroke 18: 771–775
Aaslid R (1999) Haemodynamics of cerebrovascular spasm. Acta Neurochir [Suppl] (Wien) 72: 47–57
Aaslid R, Lindegaard K-F (1986) Cerebral hemodynamics. In: Aaslid R (ed) Transcranial Doppler sonography. Springer, Wien New York 85
Aaslid R, Markwalder T-M, Nornes H (1982) Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 57: 769–774
Aaslid R, Huber P, Nornes H (1984) Evaluation of cerebrovascular spasm with transcranial Doppler ultrasound. J Neurosurg 60: 37–41
Aaslid R, Nornes H (1984) Musical murmurs from human basal cerebral arteries. J Neurosurg 60: 32–36
Aaslid R, Huber P, Nornes H (1986) A transcranial Doppler method in the evaluation of cerebrovascular spasm. Neuroradiology 28: 11–16
Adams RJ, Nichols FT, Hess DC (1992) Normal values and physiological variables. In: Newell DW, Aaslid R (eds) Transcranial Doppler. Raven Press, New York, pp 41–48
Benalcazar HE, Martin NA, Thomas-Lukes K, Rinsky BS (1994) How do transcranial Doppler velocities & the Lindegaard ratio change in hyperemia? A quantitative analysis. Stroke 25: 738
Brint SU, Yoon WB, Hier DB, Ausman JI, Charbel F (1997) Normalization of transcranial Doppler middle cerebral artery velocities after aneurysm clipping. Surg Neurol 47: 541–546
Brouwers PJAM, Wijdicks EFM, van Gijn J (1992) Infarction after aneurysm rupture does not depend on distribution or clearance rate of blood. Stroke 23: 374–379
Chyatte D, Sundt TM Jr (1984) Cerebral vasospasm after subarachnoid hemorrhage. Mayo Clin Proc 59: 498–505
Clyde BL, Resnick DK, Yonas H, Smith HA, Kaufmann AM (1996) The relationship of blood velocity as measured by transcranial doppler ultrasonography to cerebral blood flow as determined by stable xenon computed tomographic studies after aneurysmal subarachnoid hemorrhage. Neurosurgery 38: 896–904
Compton JS, Redmond S, Symon L (1987) Cerebral blood velocity in subarachnoid haemorrhage: a transcranial Doppler study. J Neurol Neurosurg Psychiatry 50: 1499–1503
Creissard P, Proust F, Langlois O (1995) Vasospasm diagnosis: theoretical and real transcranial Doppler sensitivity. Acta Neurochir (Wien) 136: 181–185
Dahl A, Russel D, Nyberg-Hansen R, Rootwelt K (1989) Effect of nitroglycerin on cerebral circulation measured by transcranial Doppler and SPECT. Stroke 20: 1733–1736
Darby JM, Yones H, Marks EC, Durham S, Snyder RW, Nemoto EM (1994) Acute cerebral blood flow response to dopamine-induced hypertension after subarachnoid hemorrhage. J Neurosurg 80: 857–864
du Boulay GH (1980) Angiography — the radiologist’s view. In: Boullin DJ (ed) Cerebral vasospasm. Wiley, Chichester, pp 47–80
Ecker A, Riemenschneider PA (1951) Arteriographic demonstration of spasm of the intracranial arteries with special reference to saccular aneurysms. J Neurosurg 8: 660–667
Ekelund A, Säveland H, Romner B, Brandt L (1996) Is transcranial Doppler sonography useful in detecting late cerebral ischemia after aneurysmal subarachnoid haemorrhage? Br J Neurosurg 10: 19–25
Eskesen V, Karle A, Kruse A, Kruse-Larsen C, Prstholm J, Schmidt K (1987) Observer variability in assessment of angiographic vasospasm after aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 87: 54–57
Fisher CM, Kistler JP, Davis JM (1980) Relation of cerebral vasospasm to subarachnoid hemorrhage visualised by computerized tomographic scanning. Neurosurgery 6: 1–9
Fujioka KA, Douville CM (1992) Anatomy and freehand examination techniques. In: Newell DW, Aaslid R (eds) Transcranial Doppler. Raven Press, New York, pp 9–32
Gabrielsen TO, Greitz T (1970) Normal size of the internal carotid, middle cerebral and anterior cerebral arteries. Acta Radiol (Diagn) 10: 1–10
Giller CA, Hatab MR, Griller AM (1998) Estimation of vessel flow and diameter during cerebral vasospasm using transcranial Doppler indices. Neurosurgery 42: 1076–1082
Gosling RG, King DH (1974) Arterial assessment by Doppler-shift ultrasound. Proc R Soc Med 67: 447–449
Grolimund P, Seiler RW, Aaslid R, Huber P, Zurbruegg H (1987) Evaluation of cerebrovascular disease by combined extracranial and transcranial Doppler sonography. Experience in 1039 patients. Stroke 18: 1018–1024
Grolimund P, Seiler W (1988) Age dependence of the flow velocity in the basal cerebral arteries — a transcranial Doppler ultrasound study. Ultrasound Med Biol 14: 191–198
Grosset DG, Straiton J, du Trevou M, Bullock R (1992) Prediction of symptomatic vasospasm after subarachnoid hemorrhage by rapidly increasing transcranial Doppler velocity and cerebral blood flow changes. Stroke 23: 674–679
Grosset DG, Straiton J, McDonald I, Cockburn M, Bullock R (1993) Use of transcranial Doppler sonography to predict development of a delayed ischemic deficit after subarachnoid hemorrhage. J Neurosurg 78: 183–187
Grote E, Hassler W (1988) The critical first minutes after subarachnoid hemorrhage. Neurosurgery 22: 654–661
Grubb RL, Raichle ME, Eichling JO, Gado MH (1977) Effects of subarachnoid hemorrhage on cerebral blood volume, blood flow and oxygen utilization in humans. J Neurosurg 46: 446–453
Guglielmi G, Vinuela F, Dion J et al (1991) Electrothrombosis of saccular aneurysms via endovascular approach, part 2: preliminary clinical experience. J Neurosurg 75: 8–14
Haley EC Jr, Kassell NF, Torner JC et al (1993) A randomized controlled trial of high-dose intravenous nicardipine in aneurysmal subarachnoid hemorrhage. A report of the cooperative aneurysm study. J Neurosurg 76: 537–547
Harders AG, Gilsbach JM (1987) Time course of blood velocity changes related to vasospasm in the circle of Willis measured by transcranial Doppler ultrasound. J Neurosurg 66: 718–728
Hassler W (1986) Hemodynamic aspects of cerebral angiomas. Acta Neurochir (Wien) [Suppl] 37: 1–136
Hassler W, Steinmetz H, Gawlowski J (1988) Transcranial Doppler ultrasonography in raised intracranial pressure and in intracranial circulatory arrest. J Neurosurg 68: 745–751
Hatab MR, Giller CA, Clarke GD (1997) Evaluation of cerebral arterial flow with transcranial Doppler ultrasound. Theoretical development and phantom studies. Ultrasound Med Biol 23: 1025–1031
Hunt WE, Hess RM (1968) Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28: 14–19
Hutchinson K, Weir B (1989) Transcranial Doppler studies in aneurysm patients. Can J Neurol Sci 16: 411–416
Ishii (1979) Regional cerebral blood flow in patients with ruptured intracranial aneurysms. J Neurosurg 50: 587–594
Jakobsen M, Hansen M, Enevoldsen E (1989) Time course study of AVDO-2 in man following SAH: a prognostic evaluation. J Cereb Blood Flow Metab 9 [Suppl] 1: 458
Jakobsen M, Enevoldsen E, Bjerre P (1990a) Cerebral blood flow and metabolism following subarachnoid haemorrhage: Cerebral oxygen uptake and global blood flow during the acute period in patients with SAH. Acta Neurol Scand 82: 174–182
Jakobsen M, Enevoldsen E, Dalager T (1990b) Spasm index in subarachnoid haemorrhage: consequences of vasospasm upon cerebral blood flow and oxygen extraction. Acta Neurol Scand 82:311–320
Kassell NF, Torner JC (1984) The international cooperative study on timing of aneurysm surgery — an update. Stroke 15: 566–570
Kawakami Y, Shimamura Y (1987) Cisternal drainage after early operation of ruptured aneurysm. Neurosurg 20: 8–14
Kiliç T, Pamir MN, Özek MM, Zirh T, Erzen C (1996) A new, more dependable methodology for the use of transcranial Doppler ultrasonography in the management of subarachnoid haemorrhage. Acta Neurochir (Wien) 138: 1070–1078
Klingelhöfer J, Sander D, Holzgraefe M, Bischoff C, Conrad B (1991) Cerebral vasospasm evaluated by transcranial Doppler ultrasonography at different intracranial pressures. J Neurosurg 75: 752–758
Klingelhöfer J, Sander D, Hakk K, Schwarze J, Dressnand J, Bischoff C (1996) Relationships between delayed ischemic dysfunctions and intracranial hemodynamics following subarachnoid hemorrhage. J Neurol Sci 143: 72–78
Kwak R, Niizuma H, Ohi T, Suzuki J (1979) Angiographic study of cerebral vasospasm following rupture of intracranial aneurysms, part 1: time of the appearance. Surg Neurol 11: 257–262
Laumer R, Steinmeier R, Gönner R, Vogtmann T, Priem R, Fahlbush R (1993) Cerebral hemodynamics in subarachnoid hemorrhage evaluated by transcranial Doppler sonography, part 1. Reliability of flow velocities in clinical management. Neurosurgery 33: 1–9
Lennihan, L, Petty GW, Fink ME, Solomon RA, Mohr JP (1993) Transcranial Doppler detection of anterior cerebral artery vasospasm. J Neurol Neurosurg Psychiatry 56: 906–909
Lewis DH, Newell DW, Winn HR (1997) Delayed ischemia due to cerebral vasospasm occult to transcranial Doppler. An important role for cerebral perfusion SPECT. Clin Nucl Med 22: 238–240
Lindegaard K-F (1992) Pulsatility indices. In: Newell DW, Aaslid R (eds) Transcranial Doppler. Raven Press, New York, pp 67–82
Lindegaard K-F, Bakke SJ, Grolimund P, Aaslid R, Huber P, Nornes H (1985) Assessment of intracranial hemodynamics in carotid artery disease by transcranial Doppler ultrasound. J Neurosurg 63: 890–898
Lindegaard K-F, Bakke SJ, Aaslid R, Nornes H (1986) Doppler diagnosis of intracranial artery occlusive disorders. J Neurol Neurosurg Psychiatry 49: 510–518
Lindegaard K-F, Grolimund P, Aaslid R, Nornes H (1986a) Evaluation of cerebral AVM’s using transcranial Doppler ultrasound. J Neurosurg 65: 335–344
Lindegaard K-F, Bakke SJ, Sorteberg W, Nakstad P, Nornes H (1986b) A non-invasive Doppler ultrasound method for the evaluation of patients with subarachnoid hemorrhage. Acta Radiol [Suppl] 369: 96–98
Lindegaard K-F, Nornes H, Bakke SJ, Sorteberg W, Nakstad P (1989) Cerebral vasospasm diagnosis by means of angiography and blood velocity measurements. Acta Neurochir (Wien) 100: 12–24
Macdonald RL, Weir B (1996) Cerebral vasospasm: prevention and treatment. In: Batjer HH et al (eds) Cerebrovascular disease. Lippingcott Raven, Philadelphia, pp 1111–1121
Martin NA, Doberstein C, Zane C, Caron MJ, Thomas K, Becker DP (1992) Posttraumatic cerebral arterial spasm: transcranial Doppler ultrasound, cerebral blood flow, and angiographic findings. J Neurosurg 77: 575–583
Martin NA, Patwardhan RV, Alexander MJ, Africk CZ, Lee JH, Shalmon E, Hovda DA Becker DP (1997) Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm. J Neuro-surg 87:9–19
Matsuda, M, Shiino A, Handa J (1990) Sequential changes of cerebral blood flow after aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 105: 98–106
Meixensberger J, Hamelbeck B, Dings J, Ernemann U, Roosen K (1996) Critical increase of blood flow velocities after subarachnoid haemorrhage: vasospasm versus hyperaemia. Zen-tralbl Neurochir 57: 70–75
Meyer CHA, Lowe D, Meyer M, Richardson PL, Neil-Dwyer G (1983) Progressive change in cerebral blood flow during the first three weeks after subarachnoid hemorrhage. Neurosurgery 12: 58–76
Mickey B, Vorstrup S, Lindewald H, Harmsen A, Lassen NA (1984) Serial measurement of regional cerebral blood flow in patients with SAH using 133Xe inhalation and emission computerized tomography. J Neurosurg 60: 916–922
Miller JD, Smith RR (1994) Transcranial Doppler sonography in aneurysmal subarachnoid hemorrhage. Cerebrovasc Brain Metab Rev 6:31–46
Mizuno M, Nakajima S, Sampei T, Nishimura H, Hadeishi H, Suzuki A, Yasui N, Nathal-Vera E (1994) Serial transcranial Doppler flow velocity and cerebral blood flow measurements for evaluation of cerebral vasospasm after subarachnoid hemorrhage. Neurol Med Chir (Tokyo) 34: 164–171
Murayama Y, Malisch T, Guglielmi G, Mawad ME, Vinuela F, Duckwiler GR, Gobin YP, Klucznik RP, Martin NA, Frazer J (1997) Incidence of cerebral vasospasm after endo-vascular treatment of acutely ruptured aneurysms: report on 69 cases. J Neurosurg 87: 830–835
Newell DW, Eskridge JM, Mayberg MR, Grady MS, Winn HR (1989) Angioplasty for the treatment of symptomatic vasospasm following subarachnoid hemorrhage. J Neurosurg 71: 654–660
Newell DW, Grady MS, Eskridge JM, Winn R (1990) Distribution of angiographic vasospasm after subarachnoid hemorrhage: implications for diagnosis by transcranial Doppler ultrasonography. Neurosurgery 27: 574–577
Nornes H (1973) The role of intracranial pressure in the arrest of hemorrhage in patients with ruptured intracranial aneurysm. J Neurosurg 39: 226–234
Nornes H (1978) Cerebral arterial flow dynamics during subarachnoid hemorrhage. Acta Neurochir (Wien) 41: 39–48
Nornes H, Magnæs B (1972) Intracranial pressure in patients with ruptured saccular aneurysm. J Neurosurg 36: 537–547
Nornes H, Wikeby P (1979) Results of microsurgical management of intracranial aneurysms. J Neurosurg 51: 608–614
Nornes H, Grip A, Wikeby P (1979) Intraoperative evaluation of cerebral hemodynamics using directional Doppler technique, part 2: saccular aneurysms. J Neurosurg 50: 570–577
Parkinson D, Bachers G (1980) Arteriovenous malformations. Summary of 100 consecutive cases. J Neurosurg 53: 285–299
Powers WJ, Grubb RL, Baker RP, Mintun MA, Raichle ME (1985) Regional cerebral blood flow and metabolism in reversible ischemia due to vasospasm. J Neurosurg 62: 539–546
Proust F, Hannequin D, Do Marcolia C, Auzou P, Rabehe-noina Ch, Fréger P, Creissard P (1995) Vasospasme après rupture des anévrismes de l’artère communicante antérieure. Sensibilité et spécificité du Doppler transcrânien. Neurochirurgie 41:385–390
Pucher RK, Auer LM (1988) Effects of vasospasm in the middle cerebral artery territory on flow velocity and volume flow. A computer simulation. Acta Neurochir (Wien) 93: 123–128
Rinkel GJE, Wijdicks EFM, Hasan D, Kienstra GEM, Franke CL, Hageman LM, Vermeulen M, van Gijn J (1991) Outcome in patients with subarachnoid haemorrhage and negative angiography according to pattern of haemorrhage on computed tomography. Lancet 338: 964–968
Robertson EG (1948) Cerebral lesions due to intracranial aneurysms. Brain 72: 150–182
Romner B, Ljunggren B, Brandt L, Säveland H (1989) Transcranial Doppler sonography within 12 hours after subarachnoid hemorrhage. J Neurosurg 70: 732–736
Romner B, Ljunggren B, Brandt L, Säveland H (1990) Correlation of transcranial Doppler sonography findings with timing of aneurysm surgery. J Neurosurg 73: 72–762
Romner B, Bellner J, Kongstad P, Sjöholm H (1996) Elevated transcranial Doppler flow velocities after severe head injury: cerebral vasospasm or hyperemia? J Neurosurg 85: 90–97
Schaller C, Rohde V, Meyer B, Hassler W (1995) Amount of subarachnoid blood and vasospasm: Current aspects. Acta Neurochir (Wien) 136: 67–71
Schaller C, Raueiser B, Rohde V, Hassler W (1996) Cerebral vasospasm after subarachnoid haemorrhage of unknown aetiology. A clinical and transcranial Doppler study. Acta Neurochir (Wien) 138: 560–569
Schwartz A, Hennerici M (1986) Noninvasive transcranial Doppler ultrasound in intracranial angiomas. Neurology 36: 626–635
Seiler RW, Grolimund P, Aaslid R, Huber P, Nornes H (1986) Cerebral vasospasm evaluated by transcranial ultrasound correlated with clinical grade and CT-visualized subarachnoid hemorrhage. J Neurosurg 64: 594–600
Seiler RW, Reulen HJ, Huber P, Grolimund P, Ebeling U, Steiger HJ (1988) Outcome of aneurysmal subarachnoid hemorrhage in a hospital population: a prospective study including early operation, intravenous nimodipine, and transcranial Doppler ultrasound. Neurosurgery 23: 598–604
Sekhar LN, Wechsler LR, Yonas H, Luyckx K, Obrist W (1988) Value of transcranial Doppler examination in the diagnosis of cerebral vasospasm after subarachnoid hemorrhage. Neurosurgery 22: 813–821
Sloan MA, Haley EC, Kasell NF, Henry ML, Stewart SR, Beskin RR, Seville EA, Torner JC (1989) Sensitivity and specificity of transcranial Doppler ultrasonography in the diagnosis of vasospasm following subarachnoid hemorrhage. Neurology 39: 1514–1518
Song JK, Elliott JP, Eskridge JM (1997) Neuroradiologic diagnosis and treatment of vasospasm. Neuroimaging Clin N Am 7: 819–835
Sorteberg W (1992) Cerebral artery blood velocity and cerebral blood flow. In: Newell DW, Aaslid R (eds) Transcranial Doppler. Raven Press, New York, pp 57–66
Sorteberg W, Lindegaard K-F, Rootwelt K, Dahl A, Russell D, Nyberg-Hansen R, Nornes H (1989a) Blood velocity and regional blood flow in defined cerebral artery systems. Acta Neurochir (Wien) 97: 47–52
Sorteberg W, Lindegaard K-F, Rootwelt K, Dahl A, Nyberg-Hansen R, Russell D, Nornes H (1989b) Effect of acetazola-mide on cerebral artery blood velocity and regional cerebral blood flow in normal subjects. Acta Neurochir (Wien) 97:139–145
Steinmeier R, Laumer R, Bondár I, Priem R, Fahlbush R (1993) Cerebral hemodynamics in subarachnoid hemorrhage evaluated by transcranial Doppler sonography, part 2, pulsa-tility indices: normal reference values and characteristics in subarachnoid hemorrhage. Neurosurgery 33: 10–19
Symon L (1980) The incidence and onset of vasospasm after subarachnoid hemorrhage. In: Wilkins RH (ed) Cerebral arterial spasm. Willians & Wilkins, Baltimore, pp 306–307
Talacchi A (1993) Sequential measurements of cerebral blood flow in the acute phase of subarachnoid hemorrhage. J Neuro-surg Sci 37:9–18
Tranquart F, Ades PE, Groussin P, Rieant JF, Jan M, Baulieu JL (1993) Postoperative assessment of cerebral blood flow in subarachnoid haemorrhage by means of 99mTC-HMPAO tomography. Eur J Nucl Med 20: 53–58
Wardlaw JM, Offin R, Teasdale GM, Teasdale EM (1998) Is routine transcranial Doppler ultrasound monitoring useful in the management of subarachnoid hemorrhage? J Neurosurg 88: 272–276
Weber M, Grolimund P, Seiler RW (1990) Evaluation of posttraumatic cerebral blood flow velocities by transcranial Doppler ultrasonography. Neurosurgery 27: 106–112
Weir B, Grace N, Hansen J, Rothberg C (1978) Time course of vasospasm in man. J Neurosurg 48: 173–178
Wilkins RH (1976) Aneurysm rupture during angiography: does acute vasospasm occur? Surg Neurol 5: 299–302
Wrantze-Bielefeld E, Dauch WA, Bauer BL (1990) Discrepancy between the results of TCD and the clinical status of patients after SAH. Adv Neurosurg 18: 276–280
Dorsch NWC (1995) Cerebral arterial spasm — a clinical review. Br J Neurosurg 9: 403–412
Weir B (1995) The pathophysiology of cerebral vasospasm. Br J Neurosurg 9: 375–390
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 1999 Springer-Verlag Wien
About this chapter
Cite this chapter
Lindegaard, KF. (1999). The Role of Transcranial Doppler in the Management of Patients with Subarachnoid Haemorrhage — a Review. In: Langmoen, I.A., Lundar, T., Aaslid, R., Reulen, HJ. (eds) Neurosurgical Management of Aneurysmal Subarachnoid Haemorrhage. Acta Neurochirurgica Supplements, vol 72. Springer, Vienna. https://doi.org/10.1007/978-3-7091-6377-1_5
Download citation
DOI: https://doi.org/10.1007/978-3-7091-6377-1_5
Publisher Name: Springer, Vienna
Print ISBN: 978-3-7091-7309-1
Online ISBN: 978-3-7091-6377-1
eBook Packages: Springer Book Archive