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Indian J Crit Care Med
Indian J Crit Care Med
IJCCM
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
0972-5229
1998-359X
Jaypee Brothers Medical Publishers

10.5005/jp-journals-10071-24719
Letter to the Editor
Transient Cerebral Circulation Arrest in SAH
Salhotra Ripenmeet https://orcid.org/0000-0001-8987-6102

Department of Anaesthesiology and Critical Care, School of Medicine, Amrita Vishwa Vidyapeetham, Faridabad, Haryana, India
Ripenmeet Salhotra, Department of Anaesthesiology and Critical Care, School of Medicine, Amrita Vishwa Vidyapeetham, Faridabad, Haryana, India, Phone: +91 9810390927, e-mail: rippan.salhotra@gmail.com
6 2024
31 5 2024
28 6 620621
Copyright © 2024; The Author(s).
2024
https://creativecommons.org/licenses/by-nc/4.0/ © The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
How to cite this article: Salhotra R. Transient Cerebral Circulation Arrest in SAH. Indian J Crit Care Med 2024;28(6):620–621.

Keywords

Cerebral circulatory arrest
Neurocritical care
Subarachnoid haemorrhage
Transcranial Doppler
Transcranial ultrasound
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pmc Dear Editor,

Transcranial color doppler ultrasonography (TCCD), performed using point-of-care ultrasound machines, has been increasingly employed by intensivists at the bedside, to monitor changes in cerebral hemodynamics in patients with acute neurological conditions, including stroke, subarachnoid hemorrhage (SAH), raised intracranial pressures (ICP) and mid-line shift.1,2 It has been instrumental in detection of cerebral circulation arrest to aid in brain death determination.3 Subarachnoid hemorrhage is a life-threatening condition that has a high median case fatality of 27–44%.4 One of the major complications of SAH is rebleeding, which occurs in 10–20% of patients and is associated with poor outcomes.5 The occurrence of a transient cerebral circulatory arrest during rebleeding is rarely reported. In this letter, we report a case of a 44-year-old woman with SAH who experienced a transient cerebral circulatory arrest recorded on TCCD during a rebleed.

A 44-year-old woman was admitted to the intensive care unit with a diagnosis of World federation of Neurological Society grade IV (WFNS grade IV) SAH due to a rupture of internal carotid artery (ICA) aneurysm made at another hospital 2 days ago. The initial CT scan was suggestive of diffuse thin subarachnoid bleed (Fisher grade-II). She was on invasive mechanical ventilation and had a Glasgow coma scale (GCS) rating of 7. A definitive procedure (coiling of aneurysm) was planned. A few hours after admission, she suddenly had a fall in her GCS associated with dilated pupils-unreactive to light, and a surge in her blood pressure. A bedside TCCD was performed by the attending intensivist (Fig. 1). On insonation of the right middle cerebral artery (MCA), small, short systolic flow peaks (velocity less than 50 cm/sec) and absent diastolic flow were seen. These flow patterns on TCCD are referred to as: “systolic spikes”.1,3 The systolic spike pattern is highly characteristic for cerebral circulatory arrest.3 It is produced by a severe increase in ICP causing cessation of effective cerebrovascular blood flow. As a response to this TCCD finding, cerebral decongestants, namely mannitol and 3%-saline, were rapidly administered to reduce the ICP and improve cerebral perfusion. A repeat TCCD after 30 minutes showed a ‘normal’ looking right MCA flow waveform with the positive diastolic flow (Fig. 2) this was accompanied by the return of pupillary reactivity to light. A repeat CT scan of the brain performed subsequently confirmed the presence of a diffuse thick subarachnoid space bleed with intraventricular extension (Fisher grade-IV). Aneurysmal rebleeding was assumed to be the cause of catastrophic raised ICP.

Fig. 1 Short systolic spikes pattern seen on TCCD

Fig. 2 Normal TCCD flow waveform with restoration of positive diastolic flow after 30 minutes

Transcranial color doppler ultrasonography has been validated as a bedside tool to detect cerebral circulatory arrest and as an ancillary test to diagnose brain death.1,3 The presence of a systolic spike pattern, as seen in our patient, is highly suggestive of cerebral circulatory arrest. Systolic spikes are sharp unidirectional velocity signals in early systole of less than 200 milliseconds duration, less than 50 cm/s peak systolic velocity, and without a flow signal during the remaining cardiac cycle. These, along with the absence of previously recorded flow in intracerebral arteries, qualify as sonographic criteria of cerebral circulatory arrest.3 We postulate that transient a catastrophic increase in ICP caused by a rebleed in subarachnoid space caused this pattern which was reversed over time by a decrease in ICP. This phenomenon could have implications for the management of SAH patients, as it could indicate a high risk of brain injury and death. Transcranial color doppler ultrasonography could be a useful tool to detect and monitor this condition and guide therapeutic interventions. We hope that this case report will stimulate further research and discussion on this topic.

Orcid

Ripenmeet Salhotra https://orcid.org/0000-0001-8987-6102

Source of support: Nil

Conflict of interest:None
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References

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