Uso complementario de Doppler transcraneal y tomografía por perfusión en la hemorragia subaracnoidea aneurismática: serie de 4 casos

CRITICAL CARE & EMERGENGY MEDICINE VOL. 5

Complementary use of transcranial Doppler and perfusion tomography in aneurysmal subarachnoid hemorrhage: a series of 4 cases

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www.doi.org/10.58281/ccem060126-cas-rep-01

Ruth Lissette Torres Vélez 1, Susy Arelis López Laaz 1, Oswaldo Bolaños Ladinez 1.

1 Departamento de Medicina Crítica, Clínica San Francisco, Guayaquil, Ecuador.

Editor
Manuel Alberto Guerrero Gutierrez , Diego Escarraman Martinez  .

Chair
Manuel Alberto Guerrero Gutierrez .

Abstract

Abstract: Aneurysmal subarachnoid hemorrhage (aSAH) accounts for about 5% of cerebrovascular events and is associated with high morbidity and mortality. Its complications include vasospasm and delayed cerebral ischemia (DCI). Transcranial Doppler (TCD) allows for the early detection of macrovasospasm, while cerebral perfusion computed tomography (CTP) provides information on perfusion status and areas at risk of ischemia. In this series of four cases of patients with aSAH treated with endovascular aneurysm exclusion, both methods were used as complementary diagnostic and monitoring tools. TCD allowed for the identification of elevated mean velocities (>120 cm/s) and increases in the Lindegaard index, while CTP showed patterns of hyperemia or hypoperfusion depending on the clinical scenario. Patients with symptomatic vasospasm were managed with targeted hyperdynamic therapy (norepinephrine 0.03–0.04 μg/kg/min; MAP > 90 mmHg), and all received prophylactic oral nimodipine according to the 2023 AHA/ASA guidelines (Class I; Level A); in one case with significant hypoperfusion, chemical and mechanical angioplasty with intra-arterial nimodipine was performed. Three patients were discharged with a modified Rankin Scale of 0 and one with 1, with no associated mortality. Case analysis demonstrates that the integration of TCD and CTP can provide complementary information for the timely detection and management of DCI, suggesting a potential future research direction for their combined use in patients with aSAH.

Resumen: La hemorragia subaracnoidea aneurismática (HSAa) representa cerca del 5 % de los eventos cerebrovasculares y se asocia con alta morbilidad y mortalidad. Entre sus complicaciones destacan el vasoespasmo y la isquemia cerebral tardía (ICT). El Doppler transcraneal (TCD) permite la detección temprana de macrovasoespasmo, mientras que la tomografía por perfusión cerebral (CTP) aporta información sobre los estados de perfusión y áreas en riesgo de isquemia. En esta serie de cuatro casos de pacientes con HSAa tratados mediante exclusión endovascular del aneurisma, se aplicaron ambos métodos como herramientas complementarias de diagnóstico y monitorización. El TCD permitió identificar velocidades medias elevadas (>120 cm/s) y aumentos en el índice de Lindegaard, mientras que la CTP evidenció patrones de hiperemia o hipoperfusión según el cuadro clínico. Los pacientes con vasoespasmo sintomático fueron manejados con terapia hiperdinámica dirigida (norepinefrina 0,03–0,04
μg/kg/min; TAM > 90 mmHg) y todos recibieron nimodipina oral profiláctica conforme a las guías AHA/ASA 2023 (Clase I; Nivel A); en un caso con hipoperfusión significativa se realizó angioplastia química y mecánica con nimodipino intraarterial.
Tres pacientes egresaron con escala de Rankin modificada 0 y uno con 1, sin mortalidad asociada. El análisis de los casos demuestra
que la integración del TCD y la CTP puede aportar información complementaria para la detección y el manejo oportuno de la ICT, planteando una posible línea de investigación futura sobre su uso combinado en pacientes con HSAa.

Middle Cerebral Artery, Ultrasonography Doppler Transcranial, Subarachnoid Hemorrhagen, Cerebral vasospasm.

Ruth Lissette Torres Vélez.
Departamento de Medicina Crítica, Clínica San Francisco, Guayaquil, Ecuador.

Susy Arelis López Laaz.
Departamento de Medicina Crítica, Clínica San Francisco, Guayaquil, Ecuador.

Oswaldo Bolaños Ladinez.
Departamento de Medicina Crítica, Clínica San Francisco, Guayaquil, Ecuador.

  1. Thilak S, Brown P, Whitehouse T, Gautam N, Lawrence E, Ahmed Z, Veenith T. Diagnosis and management of subarachnoid haemorrhage. Nat Commun. 2024 Feb 29;15(1):1850. doi:10.1038/s41467-024-46015-2.
  2. Dodd WS, Laurent D, Dumont AS, Hasan DM, Jabbour PM, et al. Pathophysiology of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: A Review. J Am Heart Assoc. 2021 Aug
  3. 10(15):e021845. doi: 10.1161/JAHA.121.021845. 3. Fragata I, Canhão P. Imaging predictors of outcome in acute spontaneous subarachnoid hemorrhage: a review of the literature. Acta Radiol. 2019 Feb;60(2):247-259. doi: 10.1177/0284185118778877.
  1. Lolli VE, Guenego A, Sadeghi N, Jodaitis L, Lubicz B, Taccone FS, Gouvea Bogossian E. CT perfusion imaging in aneurysmal subarachnoid hemorrhage. State of the art. Front Radiol. 2024 Oct 7;4:1445676. doi: 10.3389/fradi.2024.1445676.
  2. Hoh BL, Ko NU, Amin-Hanjani S, Chou SH-Y, Cruz-Flores S, et al. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2023 Jul;54(7):e314-e370. doi: 10.1161/STR.0000000000000436.
  3. Haggenmüller B, Kreiser K, Sollmann N, Huber M, Vogele D, et al. Pictorial Review on Imaging Findings in Cerebral CTP in Patients with Acute Stroke and Its Mimics: A Primer for General Radiologists. Diagnostics (Basel). 2023 Jan 26;13(3):447. doi: 10.3390/diagnostics13030447.
  4. Robba C, Busl KM, Claassen J, Diringer MN, Helbok R, et al. Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist. Intensive Care Med. 2024 May;50(5):646-664. doi: 10.1007/s00134-024-07387-7.
  5. Kumar G, Shahripour RB, Harrigan MR. Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Neurosurg. 2016 May;124(5):1257-64. doi: 10.3171/2015.4.JNS15428.
  6. Hollingworth M, Jamjoom AAB, Bulters D, Patel HC. How is vasospasm screening using transcranial Doppler associated with delayed cerebral ischemia and outcomes in aneurysmal subarachnoid hemorrhage? Acta Neurochir (Wien). 2019 Feb; 161(2):385-392. doi: 10.1007/s00701-018-3765-8.
  7. van der Harst JJ, Elting JWJ, Hijlkema J, Veeger NJGM, van Donkelaar CE, et al. Diagnostic value of transcranial doppler to predict delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage : To predict delayed cerebral ischemia. Acta Neurochir (Wien). 2024 Jun 29;166(1):278. doi: 10.1007/s00701-024-06164-1. Mir D, et al. CT Perfusion for Detection of Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2014, 35 (5) 866-871. https://doi.org/10.3174/ajnr.A3787
  1. Mitchelle A, Gorolay VV, Aitken M, Hanneman K, Huo YR, et al. CTP for the Screening of Vasospasm and Delayed Cerebral Ischemia in Aneurysmal SAH: A Systematic Review and Metaanalysis. AJNR Am J Neuroradiol. 2024 Jul 8;45(7):871-878. doi: 10.3174/ajnr.A8249.
[1]
Ruth Lissette Torres Vélez, Susy Arelis López Laaz, and Oswaldo Bolaños Ladinez. 2026. Uso complementario de Doppler transcraneal y tomografía por perfusión en la hemorragia subaracnoidea aneurismática: serie de 4 casos. CRITICAL CARE & EMERGENGY MEDICINE 5, (January 2026), 70–78. https://doi.org/10.58281/ccem060126-cas-rep-01
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Licencia

© 2025 Critical Care & Emergency Medicine by Ediciones Prado. This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) .

Licencia Creative Commons CC BY 4.0

The copyrights of the articles published in Critical Care & Emergency Medicine belong to Ediciones Prado. The contents of the articles that appear in the Journal are exclusively the responsibility of the authors and do not necessarily reflect the opinions of the Editorial Committee of the Journal. It is allowed to reproduce the material published in Critical Care & Emergency Medicine without prior authorization for non-commercial use.

ISSN

2992-6785

eISSN: 2992-6785
DOI: 10.3989/ccem

Indexación

Patrocinadores

www.doi.org/10.58281/ccem060126-cas-rep-01

Ruth Lissette Torres Vélez 1, Susy Arelis López Laaz 1, Oswaldo Bolaños Ladinez 1.

1 Departamento de Medicina Crítica, Clínica San Francisco, Guayaquil, Ecuador.

Editor
Manuel Alberto Guerrero Gutierrez , Diego Escarraman Martinez  .

Chair
Manuel Alberto Guerrero Gutierrez .

Abstract

Abstract: Aneurysmal subarachnoid hemorrhage (aSAH) accounts for about 5% of cerebrovascular events and is associated with high morbidity and mortality. Its complications include vasospasm
and delayed cerebral ischemia (DCI). Transcranial Doppler (TCD) allows for the early detection of macrovasospasm, while cerebral perfusion computed tomography (CTP) provides information on perfusion status and areas at risk of ischemia. In this series of four cases of patients with aSAH treated with endovascular aneurysm exclusion, both methods were used as complementary diagnostic and monitoring tools. TCD allowed for the identification of elevated mean velocities (>120 cm/s) and increases in the Lindegaard index, while CTP showed patterns of hyperemia or hypoperfusion depending on the clinical scenario. Patients with symptomatic vasospasm were managed with targeted hyperdynamic therapy (norepinephrine 0.03–0.04 μg/kg/min; MAP > 90 mmHg), and all received prophylactic oral nimodipine according to the 2023 AHA/ASA guidelines (Class I; Level A); in one case with significant hypoperfusion, chemical and mechanical angioplasty with intra-arterial nimodipine was performed. Three patients were discharged with a modified Rankin Scale of 0 and one with 1, with no associated mortality. Case analysis demonstrates that the integration of TCD
and CTP can provide complementary information for the timely detection and management of DCI, suggesting a potential future research direction for their combined use in patients with aSAH.

Resumen: La hemorragia subaracnoidea aneurismática (HSAa) representa cerca del 5 % de los eventos cerebrovasculares y se asocia con alta morbilidad y mortalidad. Entre sus complicaciones destacan el vasoespasmo y la isquemia cerebral tardía (ICT). El Doppler transcraneal (TCD) permite la detección temprana de macrovasoespasmo, mientras que la tomografía por perfusión cerebral (CTP) aporta información sobre los estados de perfusión y áreas en riesgo de isquemia. En esta serie de cuatro casos de pacientes con HSAa tratados mediante exclusión endovascular del aneurisma, se aplicaron ambos métodos como herramientas complementarias de diagnóstico y monitorización. El TCD permitió identificar velocidades medias elevadas (>120 cm/s) y aumentos en el índice de Lindegaard, mientras que la CTP evidenció patrones de hiperemia o hipoperfusión según el cuadro clínico. Los pacientes con vasoespasmo sintomático fueron manejados con terapia hiperdinámica dirigida (norepinefrina 0,03–0,04
μg/kg/min; TAM > 90 mmHg) y todos recibieron nimodipina oral profiláctica conforme a las guías AHA/ASA 2023 (Clase I; Nivel A); en un caso con hipoperfusión significativa se realizó angioplastia química y mecánica con nimodipino intraarterial.
Tres pacientes egresaron con escala de Rankin modificada 0 y uno con 1, sin mortalidad asociada. El análisis de los casos demuestra
que la integración del TCD y la CTP puede aportar información complementaria para la detección y el manejo oportuno de la ICT, planteando una posible línea de investigación futura sobre su uso combinado en pacientes con HSAa.

Middle Cerebral Artery, Ultrasonography Doppler Transcranial, Subarachnoid Hemorrhagen, Cerebral vasospasm.

Ruth Lissette Torres Vélez.
Departamento de Medicina Crítica, Clínica San Francisco, Guayaquil, Ecuador.

Susy Arelis López Laaz.
Departamento de Medicina Crítica, Clínica San Francisco, Guayaquil, Ecuador.

Oswaldo Bolaños Ladinez.
Departamento de Medicina Crítica, Clínica San Francisco, Guayaquil, Ecuador.

  1. Thilak S, Brown P, Whitehouse T, Gautam N, Lawrence E, Ahmed Z, Veenith T. Diagnosis and management of subarachnoid haemorrhage. Nat Commun. 2024 Feb 29;15(1):1850. doi:10.1038/s41467-024-46015-2.
  2. Dodd WS, Laurent D, Dumont AS, Hasan DM, Jabbour PM, et al. Pathophysiology of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: A Review. J Am Heart Assoc. 2021 Aug
  3. 10(15):e021845. doi: 10.1161/JAHA.121.021845. 3. Fragata I, Canhão P. Imaging predictors of outcome in acute spontaneous subarachnoid hemorrhage: a review of the literature. Acta Radiol. 2019 Feb;60(2):247-259. doi: 10.1177/0284185118778877.
  1. Lolli VE, Guenego A, Sadeghi N, Jodaitis L, Lubicz B, Taccone FS, Gouvea Bogossian E. CT perfusion imaging in aneurysmal subarachnoid hemorrhage. State of the art. Front Radiol. 2024 Oct 7;4:1445676. doi: 10.3389/fradi.2024.1445676.
  2. Hoh BL, Ko NU, Amin-Hanjani S, Chou SH-Y, Cruz-Flores S, et al. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2023 Jul;54(7):e314-e370. doi: 10.1161/STR.0000000000000436.
  3. Haggenmüller B, Kreiser K, Sollmann N, Huber M, Vogele D, et al. Pictorial Review on Imaging Findings in Cerebral CTP in Patients with Acute Stroke and Its Mimics: A Primer for General Radiologists. Diagnostics (Basel). 2023 Jan 26;13(3):447. doi: 10.3390/diagnostics13030447.
  4. Robba C, Busl KM, Claassen J, Diringer MN, Helbok R, et al. Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist. Intensive Care Med. 2024 May;50(5):646-664. doi: 10.1007/s00134-024-07387-7.
  5. Kumar G, Shahripour RB, Harrigan MR. Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Neurosurg. 2016 May;124(5):1257-64. doi: 10.3171/2015.4.JNS15428.
  6. Hollingworth M, Jamjoom AAB, Bulters D, Patel HC. How is vasospasm screening using transcranial Doppler associated with delayed cerebral ischemia and outcomes in aneurysmal subarachnoid hemorrhage? Acta Neurochir (Wien). 2019 Feb; 161(2):385-392. doi: 10.1007/s00701-018-3765-8.
  7. van der Harst JJ, Elting JWJ, Hijlkema J, Veeger NJGM, van Donkelaar CE, et al. Diagnostic value of transcranial doppler to predict delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage : To predict delayed cerebral ischemia. Acta Neurochir (Wien). 2024 Jun 29;166(1):278. doi: 10.1007/s00701-024-06164-1. Mir D, et al. CT Perfusion for Detection of Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2014, 35 (5) 866-871. https://doi.org/10.3174/ajnr.A3787
  1. Mitchelle A, Gorolay VV, Aitken M, Hanneman K, Huo YR, et al. CTP for the Screening of Vasospasm and Delayed Cerebral Ischemia in Aneurysmal SAH: A Systematic Review and Metaanalysis. AJNR Am J Neuroradiol. 2024 Jul 8;45(7):871-878. doi: 10.3174/ajnr.A8249.
[1]
Ruth Lissette Torres Vélez, Susy Arelis López Laaz, and Oswaldo Bolaños Ladinez. 2026. Uso complementario de Doppler transcraneal y tomografía por perfusión en la hemorragia subaracnoidea aneurismática: serie de 4 casos. CRITICAL CARE & EMERGENGY MEDICINE 5, (January 2026), 70–78. https://doi.org/10.58281/ccem060126-cas-rep-01
PDF
HTML

Licencia

© 2025 Critical Care & Emergency Medicine by Ediciones Prado. This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) .

Licencia Creative Commons CC BY 4.0

The copyrights of the articles published in Critical Care & Emergency Medicine belong to Ediciones Prado. The contents of the articles that appear in the Journal are exclusively the responsibility of the authors and do not necessarily reflect the opinions of the Editorial Committee of the Journal. It is allowed to reproduce the material published in Critical Care & Emergency Medicine without prior authorization for non-commercial use.

ISSN

2992-6785

eISSN: 2992-6785
DOI: 10.3989/ccem

Indexación

Patrocinadores

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