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Middle Cerebral Artery Spasm after Subarachnoid Hemorrhage: Detection with Transcranial Color-coded Duplex US¹

¹ From the Department of Radiology (J. Krejza, E.R.M.), University of Pennsylvania, Science Building, Suite 370, 3600 Market St, Philadelphia, PA 19104; and Departments of Radiology (J. Krejza) and Neurosurgery (J. Kochanowicz, Z.M., J.L.), Bialystok University School of Medicine, Bialystok, Poland. Received October 13, 2003; revision requested January 5, 2004; final revision received August 13; accepted October 1. Supported in part by American Heart Association Established Investigator Award grant 044099N. J. Krejza supported by NATO fellowship program. Address correspondence to J. Krejza (e-mail: Jaroslaw.Krejza{at}uphs.upenn.edu).

PURPOSE: To prospectively determine the accuracy of transcranial color-coded duplex ultrasonography (US) used alone and in conjunction with carotid artery US for diagnosis of middle cerebral artery (MCA) spasm, with intraarterial digital subtraction angiography (DSA) used as the reference standard.

MATERIALS AND METHODS: The institutional ethics committee approved the study. Each patient, or members of the patient's family, gave informed consent. One hundred twenty consecutive patients (64 women, 56 men; mean age, 45.5 years ± 13.6 [standard deviation]) were routinely referred for DSA after subarachnoid hemorrhage. Vasospasm was graded as mild (25% reduction in vessel diameter), moderate (>25% to 50% reduction), or severe (>50% reduction). US was performed 2 hours or less before angiography. The ratio of flow velocity in the middle cerebral artery (V_MCA) to flow velocity in the ipsilateral extracranial internal carotid artery (V_ICA) was calculated. Diagnostic accuracy was evaluated by calculating the area under the receiver operating characteristic curve (A_z). The significance of the difference between the two A_z values (for US vs DSA) was determined by using the z test with correction for correlated data.

RESULTS: Nine of 120 patients were excluded because of inadequacy of acoustic windows in the squama of temporal bones. Spasm was mild in 17, moderate in 16, and severe in only nine of 222 arteries studied. Arteries with moderate or severe vasospasm were combined in one group. The best-performing parameters were peak systolic velocity and V_MCA/V_ICA ratio. A_z values for these two parameters in diagnosis of moderate-to-severe vasospasm were 0.93 and 0.95, and in diagnosis of mild vasospasm, 0.90 and 0.91. Accuracy of the V_MCA/V_ICA ratio calculated on the basis of end-diastolic velocity for diagnosis of mild MCA narrowing was significantly better than that of end-diastolic MCA velocity alone (A_z = 0.88 vs 0.84, P < .05). The stepwise approach with use of the V_MCA/V_ICA ratio after flow velocity measurements in the MCA resulted in a decreased number of false-negative findings in both vasospasm subgroups. The thresholds of highest efficiency were at a mean velocity of 94 and 108 cm/sec and a peak systolic V_MCA/V_ICA ratio of 3.6 and 3.9 for diagnosis of mild and moderate-to-severe vasospasm, respectively.

CONCLUSION: Transcranial color-coded duplex US alone or in conjunction with carotid artery US has excellent accuracy for angiographic detection of vasospasm. Use of MCA velocity measurements and V_MCA/V_ICA ratio can increase the accuracy of Doppler US.

© RSNA, 2005

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