Comparison Between Transcranial Color-Coded Duplex Doppler and Contrast Enhanced Transcranial Color-Coded Duplex Doppler After Subarachnoid Aneurysmal Hemorrhage.

BACKGROUND: Transcranial color-coded duplex Doppler (TCCD) is commonly used to detect and monitor vasospasm in subarachnoid aneurysmal hemorrhage (aSAH). However, contrast enhanced TCCD (CE-TCCD) may be more effective. The objective of this study was to compare the accuracy of TCCD and CE-TCCD in the detection of vasospasm. METHODS: This study was a prospective comparison of TCCD and CE-TCCD for the detection of vasospasm, using computed tomography angiography (CT Angio) as a reference examination. The setting was the Department of Anesthesiology and Intensive Care at the Bicêtre University Hospital in Le Kremlin Bicêtre, France. TCCD and CE-TCCD were performed in 47 patients admitted to the intensive care unit (ICU) following aSAH over a 7-month period. TCCD and CE-TCCD were performed at ICU admission and between days 7 and 10. We aimed to visualize the seven intracranial arteries of the circle of Willis. Vasospasm diagnosis was assessed by CT Angio  and graded as moderate when the percentage change in arterial diameter since admission was between 25 and 50% or as severe when the percentage change was greater than 50%. RESULTS: On ICU admission, TCCD allowed visualization of all intracranial arteries in 16 (34%) of 47 patients, whereas CE-TCCD allowed visualization of all vessels in 37 (79%) of 47 patients (p < 0.001). These results were consistent between days 7 and 10. The proportions of middle cerebral arteries (MCAs), anterior cerebral arteries (ACAs) and posterior cerebral arteries (PCAs) visualized were greater with CE-TCCD. There was no difference in the visualization of basilar arteries (BAs). We performed vasospasm analysis on 67 of 94 MCAs in 47 patients. Area under the curve (AUC) of mean flow velocity to detect MCA vasospasm (moderate and severe) was 0.86 (0.58-1.00) for TCCD and 0.90 (0.77-1.00) for CE-TCCD. AUC of mean velocity to detect severe MCA vasospasm was 0.86 (0.58-1.00) for TCCD and 0.90 (0.77-1.00) for CE-TCCD, without any significant difference between the two techniques. For other arteries, the accuracy of TCCD and CE-TCCD to diagnose vasospasm was poor. CONCLUSIONS: CE-TCCD allows better visualization of intracranial arteries in patients with aSAH. The accuracy of CE-TCCD to screen severe MCA vasospasm is similar to that of TCCD. CE-TCCD is an alternative tool for monitoring patients with aSAH without a temporal bone window for an ultrasound.

Spontaneous Regression of a Third Ventricle Colloid Cyst.

BACKGROUND: Colloid cysts represent 0.5%-1% of intracranial tumors and most commonly occur in the third ventricle near the Monro foramen. Although benign, if the lesion obstructs the foramen abruptly, sudden death may ensue. Evolution of these cysts is poorly understood. Spontaneous regression has been reported in only 2 other cases. Management of such cysts depends on whether the cyst continues to grow, its location, and clinical presentation. Incidental asymptomatic colloid cysts are typically followed with neuroimaging surveillance. CASE DESCRIPTION: We present a case of an incidental third ventricle colloid cyst in a 46-year-old patient who was managed conservatively with neuroimaging surveillance. Thereafter, she started developing some working memory deficits and intermittent headaches, with the cyst volume increasing, leading to the decision to perform a resection. However, the cyst underwent spontaneous regression before the scheduled surgery date, 3 years after initial diagnosis. CONCLUSIONS: This case confirms that some colloid cysts could regress spontaneously. Disappearance of the cyst is not necessarily accompanied by clinical worsening, as was reported by other investigators who noted deteriorating neurologic deficits as a result of worsening hydrocephalus. Assuming the cysts rupture, some patients tolerate the contents of the cyst leaking into the ventricular system, whereas others may mount an inflammatory reaction, causing a disruption in cerebrospinal fluid flow. In addition, it is still unclear what factors increase the likelihood of cysts to suddenly rupture.