M. De Lima Oliveira, S. Paulo Brasil Lima, M. Kranyk De Azevedo, E. Santos Junior, L. Peraza, F. Lacerda Brambilla, M. Jacobsen Teixeira, E. Bor-Seng-Shu
Department of Neurology, University Hospital, University of São Paulo – São Paulo, Brazil
Objective: Intracranial vasospasm is an important cause of brain ischemia when associated to subarachnoid hemorrhage. Multimodal monitoring can detect brain flow decrease and patients with high risk to develop brain ischemic lesions. TCD can detect and measure vasospasm intensity in the large intracranial arteries. Usually the oximetry catheter is implanted in the area most likely to occur vasospasm, which is near of brain bleeding. It can measure brain tissue oxygen (PtiO2) in areas with oligoemia associated to vasospasm. They give support to plane treatment to improve brain blood flow in patients suffering brain vasospasm.
Case Report: A 48 years old woman with subarachnoid hemorrhage (Hess IV) and intracranial brain hemorrhage at right side in cranial tomography (CT)(Fisher IV). She was underwent a middle cerebral artery aneurism clipping, intracranial pressure (ICP) catheter implantation and catheter to measure brain parenchyma PtiO2 close to the bleeding area. Serial TCD exams disclosed diffuse brain vasospasm, which were more intense at left side. Despite treatment with 3H therapy, we noted ischemic areas in brain CT at opposite side of bleeding (left side), when PtiO2 values maintained in normal range close to the hemorrhage area (right side), nine days after the hemorrhage. At this time ICP was normal. Unfortunately, after 14 days, the patient developed refractory ICP and circulatory arrest.
Discussion: Brain vasospasm can be focal or diffuse. In this case TCD suggested more intensity vasospasm at opposite side of bleeding; ischemic areas were disclosed by CT exam in this side, confirming TCD findings. Brain oxymetry catheter can monitor a small area of brain tissue so it is not reliable as a isolated monitor method in patients with subarachnoid hemorrhage and diffuse vasospasm.
Key words: brain ischemia, brain oximetry, diffuse vasospasm, subarachnoid hemorrhage.