Rebleeding of a Cerebral Aneurysm During Transcranial Doppler: Hemodynamic Changes and Response to Treatment (P5.126)

Objective: To present a case study of TCD capturing the dynamics of a real-time intracranial bleed. Background: Transcranial Doppler is a common method used to measure cerebral blood flow velocities and estimate flow resistance related to intracranial pressure (ICP). We present the case of a patient with subarachnoid hemorrhage and clipped aneurysm, who, while undergoing TCDs, rebled. Methods: A 68 year old man presented with sudden-onset severe headache. CT of the head showed a subarachnoid hemorrhage (SAH) with intraventricular extension and obstructive hydrocephalus. An anterior communicating artery (ACOM) aneurysm was found and clipped and a ventriculostomy was placed. After surgery there was an interval decrease in the SAH. Eight days after the original event the patient re-bled during a TCD test because of clip failure. Results: TCD waveforms were captured before, during the bleed and post treatment with Mannitol and CSF drainage from the ventriculostomy. Prior to the bleed, ICP was 8mm Hg, the Left MCA flow velocity was 62cm/sec and the Pulsatility index (PI) 1.0. During the bleed the ICP increased to 54 and PI to 1.7-2.0, with the waveform showing a narrow peak and decreased diastolic and mean velocity. 75g of Mannitol was given and the ventriculostomy was opened to drain. Within 5 minutes the ICP decreased to 14, the PI improved to 1.4, the waveform widened and the velocities returned to previous levels ( video will be provided showing the TCD changes ). Repeat CT of the head showed increased SA blood, extensive new intraventricular hemorrhage and in the angiogram a malpositioned clip. The ACOM aneurysm was coiled successfully. Conclusion: We present this unique case of TCD capturing the dynamics of a real-time intracranial bleed with significantly elevated ICP. Our data demonstrated the TCD PI, flow velocities and waveforms changed dramatically during the rebleeding and improved quickly with treatment. Disclosure: Dr. Marrotte has nothing to disclose. Dr. Abdelhak has nothing to disclose. Dr. Melvin has nothing to disclose. Dr. Varelas has received personal compensation for activities with UCB Pharma as an advisory board member. Dr. Varelas has held stock and/or stock options in The Medicines Company.