Impaired cerebral autoregulation is associated with vasospasm and delayed cerebral ischemia in subarachnoid hemorrhage

Abstract

Background and purpose: Cerebral autoregulation may be impaired in the early days after subarachnoid hemorrhage (SAH). The purpose of this study was to examine the relationship between cerebral autoregulation and angiographic vasospasm (aVSP) and radiographic delayed cerebral ischemia (DCI) in patients with SAH.

Methods: Sixty-eight patients (54±13 years) with a diagnosis of nontraumatic SAH were studied. Dynamic cerebral autoregulation was assessed using transfer function analysis (phase and gain) of the spontaneous blood pressure and blood flow velocity oscillations on days 2 to 4 post-SAH. aVSP was diagnosed using a 4-vessel conventional angiogram. DCI was diagnosed from CT. Decision tree models were used to identify optimal cut-off points for clinical and physiological predictors of aVSP and DCI. Multivariate logistic regression models were used to develop and validate a risk scoring tool for each outcome.

Results: Sixty-two percent of patients developed aVSP, and 19% developed DCI. Patients with aVSP had higher transfer function gain (1.06±0.33 versus 0.89±0.30; P=0.04) and patients with DCI had lower transfer function phase (17.5±39.6 versus 38.3±18.2; P=0.03) compared with those who did not develop either. Multivariable scoring tools using transfer function gain>0.98 and phase<12.5 were strongly predictive of aVSP (92% positive predictive value; 77% negative predictive value; area under the receiver operating characteristic curve, 0.92) and DCI (80% positive predictive value; 91% negative predictive value; area under the curve, 0.94), respectively.

Conclusions: Dynamic cerebral autoregulation is impaired in the early days after SAH. Including autoregulation as part of the initial clinical and radiographic assessment may enhance our ability to identify patients at a high risk for developing secondary complications after SAH.

Keywords: cerebrovascular circulation; subarachnoid hemorrhage; ultrasonography, Doppler.

Figures

Figure 1

Transfer function phase (A), gain (B), and mean ow velocity (C) in patients with and without angiographic vasospasm. Average transfer function phase, gain, and mean flow velocity across days 2 to 4 in the low frequency (LF; 0.03–0.15 Hz) and high frequency (HF; 0.15–0.5 Hz) ranges for patients with and without angiographic vasospasm. *P<0.05.

Figure 2

Transfer function phase (A), gain (B), and mean flow velocity (C) in patients with and without delayed cerebral ischemia (DCI). Average transfer function phase, gain, and mean flow velocity across days 2 to 4 in the low frequency (LF; 0.03–0.15 Hz) and high frequency (HF; 0.15–0.5 Hz) ranges for patients with and without DCI. *P<0.05.