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(Stroke. 2009;40:1963.)
© 2009 American Heart Association, Inc.

Original Contributions

Defining Vasospasm After Subarachnoid Hemorrhage

What Is the Most Clinically Relevant Definition?

Jennifer A. Frontera, MD; Andres Fernandez, MD; J. Michael Schmidt, PhD; Jan Claassen, MD; Katja E. Wartenberg, MD; Neeraj Badjatia, MD; E. Sander Connolly, MD Stephan A. Mayer, MD

From the Neurological Intensive Care Unit, Departments of Neurosurgery and Neurology (J.A.F.), Mount Sinai School of Medicine, New York, NY; Departments of Neurology (A.F., J.C., M.S., K.E.W., N.B., K.L., S.A.M.) and Neurosurgery (N.B., E.S.C., S.A.M.), Columbia University College of Physicians and Surgeons, New York, NY.

Correspondence to Jennifer A. Frontera, Mount Sinai School of Medicine, Departments of Neurosurgery and Neurology, One Gustave Levy Place, Box 1136, New York, NY 10029. E-mail Jennifer.Frontera{at}mountsinai.org

Background and Purpose— Vasospasm is an important complication of subarachnoid hemorrhage, but is variably defined in the literature.

Methods— We studied 580 patients with subarachnoid hemorrhage and identified those with: (1) symptomatic vasospasm, defined as clinical deterioration deemed secondary to vasospasm after other causes were eliminated; (2) delayed cerebral ischemia (DCI), defined as symptomatic vasospasm, or infarction on CT attributable to vasospasm; (3) angiographic spasm, as seen on digital subtraction angiography; and (4) transcranial Doppler (TCD) spasm, defined as any mean flow velocity >120 cm/sec. Logistic regression analysis was performed to test the association of each definition of vasospasm with various hospital complications, and 3-month quality of life (sickness impact profile), cognitive status (telephone interview of cognitive status), instrumental activities of daily living (Lawton score), and death or severe disability at 3 months (modified Rankin scale score 4–6), after adjustment for covariates.

Results— Symptomatic vasospasm occurred in 16%, DCI in 21%, angiographic vasospasm in 31%, and TCD spasm in 45% of patients. DCI was statistically associated with more hospital complications (N=7; all P<0.05) than symptomatic spasm (N=4), angiographic spasm (N=1), or TCD vasospasm (N=1). Angiographic and TCD vasospasm were not related to any aspect of clinical outcome. Both symptomatic vasospasm and DCI were related to reduced instrumental activities of daily living, cognitive impairment, and poor quality of life (all P<0.05). However, only DCI was associated with death or severe disability at 3 months (adjusted OR, 2.2; 95% CI, 1.2–3.9; P=0.007).

Conclusions— DCI is a more clinically meaningful definition than either symptomatic deterioration alone or the presence of arterial spasm by angiography or TCD.

Key Words: angiography • delayed cerebral ischemia • outcome • subarachnoid hemorrhage • transcranial Doppler • vasospasm