Introduction: Cerebral vasospasm is frequently encountered in patients suffering from aneurysmal subarachnoid hemorrhage (SAH) leading to significant morbidity and mortality. Identifying vasospasm is an important part of management in these patients, and while diagnostic tests exist to assist in this, none are infallible. Arterial stiffness has been shown to have correlations with global vascular risk factors, and our study examines its measurement using the ankle-brachial index (ABI) as a predictor of vasospasm.

Methods: We performed a prospective cohort study, enrolling 18 patients with diagnosed aneurysmal SAH at a single center. ABIs were performed on days 2, 5, 7, 9, 11 and 13 after SAH. Diagnostic cerebral angiograms were performed during the study period to evaluate for spasm. TCD values were also obtained to evaluate for correlations between ABI, TCD and angiographic spasm.

Results: A significant difference in age (61±13.6 vs. 48.1±9.6 years, p=0.035) and incidence of hyperlipidemia (5 vs. 1, p=0.046) was seen between non-vasospasm and vasospasm patients. Other demographic (gender, medical comorbidities) and aneurysm characteristics (Hunt & Hess grade, Modified Fisher grade, treatment modality, aneurysm size, location, and family history) were not significantly different. Mean TCD values showed a significant difference between non-vasospasm and vasospasm patients in the right anterior cerebral artery distribution at day 3, left middle cerebral artery distribution at days 5 through 13, and right middle cerebral artery distribution at days 5 through 11 (p<0.05). ABI in the vasospasm group was significantly lower on post bleed day 7, 13, and on average between day 2 to 7 and day 2 to 13 (p<0.05).

Conclusions: A drop in the ABI correlated well with SAH induced vasospasm in our study. ABI may be a simple and effective tool in the management of vasospasm in aneurysmal SAH.

Patient Care: Ankle-brachial index is a low-cost, simple, and rapid bedside tool that can be used to identify patients at risk for vasospasm and help guide therapy to minimize the risk of death and disability from untreated spasm after subarachnoid hemorrhage.

Learning Objectives: By the conclusion of this session participants should be able to: 1) Describe the importance of arterial stiffness as a global vascular risk factor. 2) Discuss the effect of vascular reactivity on vasospasm risk. 3) Identify ways to use the ankle-brachial index in settings where transcranial doppler and diagnostic cerebral angiogram may not be feasible.

References: 1. Kassell NF, Torner JC, Haley EC Jr. Jane JA, Adams HP, Kongable GL and participants (1990) The international cooperative study for the timing of aneurysm surgery. Part 1: overall management results. J Neurosurg 73:18-36. 2. Macdonald RL (2014) Delayed neurological deterioration after subarachnoid hemorrhage. Nat Rev Neurol 10(1):44-58. 3. Charpentier C, Audibert G, Guillemin F, Civit T, Ducrocq X, Bracard S, Hepner H, Picard L, Laxenaire MC (1999) Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage. Stroke 30:1402-1408. 4. Rinkel GJ, Feigin VL, Algra A, van den Bergh WM, Vermeulen M, van Gijn J (2005) Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 1:CD000277. 5. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P (2012) American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 43(6):1711-1737. 6. Mortimer AM, Steinfort B, Faulder K, Bradford C, Finfer S, Assaad N, Harrington T (2015) The detrimental clinical impact of severe angiographic vasospasm may be diminished by maximal medical therapy and intensive endovascular treatment. J Neurointervent Surg 0:1-7. 7. Scheglov DV, Polischuk ME, Scheglov VI, Mamonova MY, Monsein LH (2015) Endovascular treatment of vasospasm related to subarachnoid hemorrhage from ruptured aneurysms. Acta Neurochir Suppl 120:223-229. 8. Rosenwasser RH, Armonda RA, Thomas JE, Benitez RP, Gannon PM, Harrop J (1999) Therapeutic modalities for the management of cerebral vasospasm: timing of endovascular options. Neurosurgery 44:975-980. 9. Hayashi K, Hirao T, Sakai N, Nagata I; JR-NET2 Study Group (2014) Current status of endovascular treatment for vasospasm following subarachnoid hemorrhage: analysis of JR-NET 2. Neurol Med Chir (Tokyo) 54:107-112. 10. Dusick JR, Gonzalez NR (2013) Management of arterial vasospasm following aneurysmal subarachnoid hemorrhage. Semin Neurol 33:488-497. 11. Mayberg MR, Batjer HH, Dacey R, Diringer M, Haley C, Heros RC, Sternau LL, Torner J, Adams HP, Feinberg W, Thies W (1994) Guidelines for the management of aneurysmal subarachnoid hemorrhage. Stroke 25:2315-2328. 12. Cloft HJ, Joseph GJ, Dion JE (1999) Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a meta-analysis. Stroke 30:317-320. 13. Yundt KD, Dacey RG Jr, Diringer MN (1996) Hospital resource utilization in the treatment of cerebral aneurysms. J Neurosurg 85(3):403-409. 14. Aaslid R, Markwalder TM, Nornes H (1982) Noninvasive transcranial doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 57(6):769-774. 15. Sloan MA, Haley EC, Kassell NF, Henry ML, Stewart SR, Beskin RR, Sevilla EA, Torner JC (1989) Sensitivity and specificity of transcranial doppler ultrasonography in the diagnosis of vasospasm following subarachnoid haemorrhage. Neurology 39:1514–1518. 16. Vora YY, Suarez-Almazor M, Steinke DE, Martin ML, Findlay JM (1999) Role of transcranial doppler monitoring in the diagnosis of cerebral vasospasm after subarachnoid hemorrhage. Neurosurgery 44:1237–1247 ?. 17. Lysakowski C, Walder B, Costanza MC, Tramer MR (2001) Transcranial doppler versus angiography in patients with vasospasm due to a ruptured cerebral aneurysm: a systematic review. Stroke 32:2292–2298. 18. Shen Q, Stuart J, Venkatesh B, Wallace J, Lipman J (1999) Interobserver vari- ability of the transcranial doppler ultrasound technique. Impact of lack of practice on the accuracy of measurement. J Clin Monit Comp 15:179–184. 19. Itoh T, Matsumoto M, Handa N, Maeda H, Hougaku H, Hashimoto H, Etani H, Tsukamoto Y, Kamada T (1993) Rate of successful recording of blood flow signals in the middle cerebral artery using transcranial doppler sonography. Stroke 24:1192–1195. 20. Newell DW, Grady MS, Eskridge JM, Winn HR (1990) Distribution of angio- graphic vasospasm after subarachnoid hemorrhage: implications for diagnosis by transcranial doppler ultrasonography. Neurosurgery 27:574–577. 21. Nagasawa S, Handa H, Naruo Y, Watanabe H, Moritake K, Hayashi K (1983) Experimental cerebral vasospasm. Part 2. Contractility of spastic arterial wall. Stroke 14(4):579-584. 22. Mattace-Raso FU, van der Cammen TJ, Hofman A, van Popele NM, Bos ML, Schalekamp MA, Asmar R, Reneman RS, Hoeks AP, Breteler MM, Witteman JC (2006) Arterial stiffness and risk of coronary heart disease and stroke: the Rotterdam study. Circulation 113:657-663. 23. Sutton-Tyrrell K, Najjar SS, Boudreau RM, Venkitachalam L, Kupelian V, Simonsick EM, Havlik R, Lakatta EG, Spurgeon H, Kritchevsky S, Pahor M, Bauer D, Newman A; Health ABC Study (2005) Elevated aortic pulse wave velocity, a marker of arterial stiffness, predicts cardiovascular events in well-functioning older adults. Circulation 111:3384-3390. 24. Creager MA, Belkin M, Bluth EI, Casey DE Jr, Chaturvedi S, Dake MD, Fleg JL, Hirsch AT, Jaff MR, Kern JA, Malenka DJ, Martin ET, Mohler ER 3rd, Murphy T, Olin JW, Regensteiner JG, Rosenwasser RH, Sheehan P, Stewart KJ, Treat-Jacobson D, Upchurch GR Jr, White CJ, Ziffer JA (2012) 2012 ACCF/AHA/ACR/SCAI/SIR/STS/SVM/SVN/SVS Key data elements and definitions for peripheral atherosclerotic vascular disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards (Writing Committee to develop Clinical Data Standards for peripheral atherosclerotic vascular disease). J Am Coll Cardiol 59(3):294-357. 25. Ix JH, Miller RG, Criqui MH, Orchard TJ (2012) Test characteristics of the ankle brachial index and ankle brachial difference for medial arterial calcification on x-ray in type 1 diabetes. J Vasc Surg 56(3):721-727. 26. Rabkin SW, Chan SH, Sweeney C (2011) Ankle-brachial index as an indicator of arterial stiffness in patients without peripheral artery disease. Angiology 63(2):150-154. 27. Hunt WE, Hess RM (1968) Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28(1):14-20. 28. Fisher CM, Kistler JP, Davis JM (1980) Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6(1):1-9. 29. Frontera JA, Claasen J, Schmidt JM, Wartenberg KE, Temes R, Connolly ES, Macdonald RL, Mayer SA (2006) Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified fisher scale. Neurosurgery 58(7):21-27. 30. Aboyans V, Criqui MH, Abraham P, Allison MA, Creager MA, Diehm C, Fowkes FG, Hiatt WR, Jönsson B, Lacroix P, Marin B, McDermott MM, Norgren L, Pande RL, Preux PM, Stoffers HE, Treat-Jacobson D; American Heart Association Council on Peripheral Vascular Disease; Council on Epidemiology and Prevention; Council on Clinical Cardiology; Council on Cardiovascular Nursing; Council on Cardiovascular Radiology and Intervention, and Council on Cardiovascular Surgery and Anesthesia (2012) Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation 126:2890-2909. 31. Mariëlle M.F. Poels, Kèren Zaccai, Germaine C. Verwoert, Meike W. Vernooij, Albert Hofman, Aad van der Lugt, Jacqueline C.M. Witteman, Monique M.B. Breteler, Francesco U.S. Mattace-Raso and M. Arfan Ikram (2012) Arterial stiffness and cerebral small vessel disease: the Rotterdam scan study. Stroke 43:2637-2642. 32. Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, Golzarian J, Gornik HL, Halperin JL, Jaff MR, Moneta GL, Olin JW, Stanley JC, White CJ, White JV, Zierler RE; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society for Vascular Medicine; Society for Vascular Surgery (2011) 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 58(19):2020-2045. 33. Espeland MA, Regensteiner JG, Jaramillo SA, Gregg E, Knowler WC, Wagenknecht LE, Bahnson J, Haffner S, Hill J, Hiatt WR (2008) Look AHEAD Study Group. Measurement characteristics of the ankle- brachial index: results from the Action for Health in Diabetes study. Vasc Med 13:225–233.