A snapshot of European neurosurgery December 2019 vs. March 2020: just before and during the Covid-19 pandemic.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis. METHODS: We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days. RESULTS: We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs. CONCLUSION: Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

The increasing prevalence of Parkinson's disease in Estonia.

OBJECTIVES: A previous epidemiological study of Parkinson's disease (PD) in the county of Tartu, Estonia, found an adjusted prevalence rate of 152/100 000 persons. We aimed to determine PD prevalence almost 20 years later, as well as evaluate any dynamic changes in disease frequency compared to the first study. METHODS: A cross-sectional, community-based study was conducted over 2010-2016 in the county of Tartu, Estonia. Multiple case-finding sources, including information from neurologists, family doctors, the local PD Society, nursing institutions, and the database of the Estonian Health Insurance Fund were used to identify patients with PD of all ages. RESULTS: Total crude PD prevalence was 283 and age-adjusted prevalence (standardized to the 2014 age structure of the Estonian population) 314/100 000. No significant differences in age-adjusted prevalence rates were found between men and women, nor people living in urban and rural areas. After adjustment to the same standard population used in the previous prevalence study, the overall age-adjusted prevalence rate was 197/100 000. Patients in the current study were older and often had a more severe form of PD and a longer disease duration, compared to those reported in the first epidemiological study 20 years ago. CONCLUSIONS: The age-specific crude rates in oldest age-groups have risen substantially, and the age-adjusted prevalence has moderately increased compared to 20 years ago in Estonia. We hypothesize that the increased life expectancy of the Estonian population and improved diagnosis of PD contributed most to the increase in disease frequency.

Evolution of severe trauma in Estonia comparing early versus established independence of the state.

PURPOSE: Trauma mechanisms and patterns of severe injuries during the Estonian independence have not been evaluated. The aim of the study was to compare the incidence and outcomes of severe injuries between time periods of early independence from the Soviet Union and the present time. METHODS: After the ethics review board approval, all adult trauma admissions to major trauma facilities in 1993-1994 and 2013-2014 with Injury Severity Score >15 were identified. Data collection included demographics, injury severity variables, interventions, and in-hospital outcomes. Primary outcome was in-hospital mortality. Secondary outcomes included incidence of penetrating trauma, hospital length of stay (HLOS), and in-hospital complications. Primary outcome difference comparing the two time segments was determined using logistic regression analysis. RESULTS: A total of 1064 patients were included, 593 and 471 from 1993-1994 to 2013-2014, respectively. Incidence of penetrating trauma during 1993-1994 was 11.1 % and in 2013-2014 at 6.4 % (p = 0.007). Gunshot injuries constituted 62.1 and 23.3 % of all penetrating trauma in 1993-1994 and 2013-2014, respectively (p < 0.001). The overall mean HLOS was 15.5 ± 19.8 days and did not differ between the periods. The rate of adjusted complications showed a trend for a decreased incidence (adj. p = 0.064). Adjusted mortality rate was 50.3 and 16.4 % during 1993-1994 and 2013-2014, respectively (adj. OR 7.01; 95 % CI 4.69-10.47; p < 0.001). CONCLUSIONS: Effective law enforcement, gun control, evolution of trauma system, and reduction of interpersonal violence have all contributed to a significant decrease in penetrating trauma incidence and all-cause adjusted mortality during the 20 years of Estonian independence.

Brain activation in the chronic phase of traumatic spinal cord injury.

STUDY DESIGN: Cross-sectional clinical study. OBJECTIVES: Plastic changes within cortical areas occur after traumatic spinal cord injury (TSCI). The aim of the study was to assess cortical activation in the chronic phase of TSCI using functional magnetic resonance imaging (fMRI). SETTING: Tartu University Hospital, Tartu, Estonia. METHODS: Ten right-handed patients with paraplegia and 18 healthy controls were studied by fMRI. Individuals performed simple flexion/extension of the right hand fingers and the right ankle during fMRI. The activation volumes, maximum t values (T max) and centres of gravity (COG) were calculated. RESULTS: The mean time since trauma was 1848±1046 days (range 388-4459). During hand movements, the volume of activation (VOA) in the contralateral primary motor cortex was significantly larger among the TSCI patients who did not recover compared with the controls (4112 vs 2777, P=0.02). The VOA did not enlarge during the ankle movements (2420 vs 1114, P=0.08). There was a significant relationship between the VOA in Brodmann area 4 (BA4) and American Spinal Injury Association motor score during hand movements (r=-0.67, P=0.03). A positive correlation was found during hand movements in the VOA of BA4 and time since injury (r=0.62, P=0.05). CONCLUSIONS: We found increased cortical activation in the chronic phase of thoraco-lumbar TSCI that may be caused by increased use of upper limbs.

Severe Trauma in Estonia: 256 consecutive cases analysed and the impact on outcomes comparing two regions.

PURPOSE: The purpose of this study was to investigate epidemiology of severe injuries in Estonia while comparing outcomes at regional trauma facilities. METHODS: After the ethics review board approval, all consecutive trauma admissions with Injury Severity Score (ISS) > 15 to North Estonia Medical Center/Tallinn Children's Hospital (NEMC + TCH) and Tartu University Hospital (TUH) were identified between 1/1/2013 and 31/12/2013. Data collection included demographics, admission data, injury severity variables, interventions, and in-hospital outcomes. Primary outcome was in-hospital mortality. Secondary outcomes were complications per Clavien-Dindo and hospital length of stay (HLOS). Logistic regression analysis was used to compare adjusted mortality between the two regional hospitals. RESULTS: A total of 256 patients met inclusion criteria. The mean ISS for the cohort was 23.6 ± 7.8, 13.3 % were hypotensive on admission, and 44.1 % had a Glasgow Coma Scale < 9. Overall rate of complications was 40.2 % that did not differ between the facilities. The mean HLOS at the NEMC + TCH and the TUH were 20.1 ± 25.1 and 10.5 ± 11.2 days (p < 0.001), respectively. Overall mortality was 20.7 % (n = 53). Mortality was 25.4 and 14.9 % for the NEMC + TCH and the TUH, respectively (p = 0.04). Logistic regression analysis resulted in comparable mortality at the regional trauma facilities (adj. OR 1.38; 95 % CI 0.66-2.92; p value 0.39). CONCLUSIONS: The annual incidence of injuries with ISS > 15 was 256 cases with overall mortality at 20.7 % in Estonia. We observed comparable adjusted outcomes at the major regional trauma facilities. This study contains benchmarking data on severely injured patients in Estonia providing potential for future trauma care evaluation and regional outcome comparisons.

Impact of fatal cases on the epidemiology of traumatic spinal cord injury in Estonia.

BACKGROUND AND PURPOSE: Most epidemiological studies on traumatic spinal cord injury (TSCI) have not included patients who die before hospitalization. The aim of the research was to study the incidence of TSCI by including the individuals who die at the scene of the accident in addition to data retrieved from all hospitals in Estonia. METHODS: Medical records of patients with TSCI from all hospitals in Estonia from 2005 to 2007 were studied. With collaboration from the Estonian Forensic Science Institute the data of the victims of TSCI who died before hospitalization were included. RESULTS: From 2005 to 2007, 391 TSCI cases were identified: 183 patients were found retrospectively from medical records and 208 cases were detected from autopsy reports. Fifty-three per cent of patients died before hospitalization. The annual incidence rate was 97.0 per million population (95% confidence interval 87.4-106.6). The mean age at injury was 44.4 ± 18.7 years. Motor vehicle accidents were the leading cause of TSCI amongst the individuals who died before hospitalization (75%). Falls accounted for the highest number of TSCIs (43%) amongst the patients who reached hospital. CONCLUSIONS: Our study shows that, when the cases that die at the scene of the accident are included, the incidence of TSCI in Estonia rises from 39.7 to 97.0 per million population.

Health-related quality of life in patients with traumatic spinal cord injury in Estonia.

OBJECTIVES: To describe health-related quality of life (HRQoL) in persons with traumatic spinal cord injury (TSCI) and to assess factors that affect HRQoL. STUDY DESIGN: Cross-sectional. METHODS: Eighty Estonian-speaking TSCI patients from the Estonian TSCI database were included in the study. The RAND-36 questionnaire, the Life Orientation Test, the Emotional State Questionnaire and the Brief Social Support Questionnaire were used. RESULTS: There were 66 men and 14 women; the mean age was 38.9±14.8 years. The mean time that had elapsed since injury was 4.2 years. According to the RAND-36 scales, the lowest scores were given for physical health-related domains, followed by the energy/fatigue and the general health domains. The regression analysis adjusted to age and gender revealed that age, employment and category of the American Spinal Injury Association (ASIA) Impairment Scale during the acute phase of injury were significant factors in predicting physical functioning (P<0.001). Age, depression and general anxiety were significant predictors of emotional well-being (P<0.001). Age and depression were independently associated with general health (P<0.001). CONCLUSION: As expected, physical functioning and physical role limitation were the most pronounced deficits in HRQoL. Compared with data from other countries, all scores for the RAND-36 scales are lower in Estonian TSCI patients. The HRQoL following TSCI is affected by severity of injury, depression, age and employment status.

Brain activation in the acute phase of traumatic spinal cord injury.

STUDY DESIGN: Prospective clinical study. BACKGROUND: The aim of the study was to investigate cortical reorganisation after traumatic spinal cord injury (TSCI) using functional magnetic resonance imaging (fMRI). SETTING: Tartu University Hospital, Tartu, Estonia. METHODS: We studied six right-handed tetraplegic TSCI patients at 1, 3 and 12 months after the injury and 12 age- and gender-matched healthy controls. Individuals performed simple test-rest cycles of flexion/extension of the right-hand fingers and flexion/extension of the right ankle during fMRI. The volumes of activation (VOA), maximum t-values, centres of gravity (COG) and weighted laterality indexes were calculated. RESULTS: There was no recovery of neurologic function in three patients and, according to the American Spinal Injury Association (ASIA) Impairment Scale the remaining three recovered. A positive correlation between the VOA in the primary motor cortex and the ASIA impairment scale (1 month: r=0.82, P=0.002; 3 Month: r=0.63, P=0.03; 12 Month: r=0.23, P=0.52) was found. The study also revealed a pattern of cortical activation that was increased among the patients who recovered (in Brodmann area 4 (BA 4), P=0.06; BA 1-2-3-5, P=0.08; BA 6, P=0.05). During the hand task there was an expansion of COG laterally, anteriorly and inferiorly among the patients who recovered. During the hand movement the cortical activation was less lateralised among the patients compared with the controls (P<0.05). CONCLUSION: Our study has found broadening of cortical activation and shift of COG during the first year after TSCI, depending on the recovery.

Thiopurine metabolite measurement leads to changes in management of inflammatory bowel disease.

BACKGROUND: The thiopurines azathioprine and 6-mercaptopurine are recommended for maintenance of remission in inflammatory bowel disease (IBD). Measurement of concentrations of the metabolites 6-thioguanine nucleotide and 6-methylmercaptopurine helps delineate interindividual variation in metabolism that may underlie variability in efficacy and toxicity. AIMS: We aimed to perform a retrospective observational study to determine the utility of thiopurine metabolite testing following its introduction into South Australia. METHODS: All patients having thiopurine metabolite tests done at Flinders Medical Centre between November 2008 and January 2010 were identified. Case notes of patients with testing done in the context of treatment for IBD were interrogated to determine the reason for testing, clinical context and outcome. RESULTS: One hundred and fifty-one patients were identified with thiopurine metabolite testing for IBD with 157 testing episodes. Eighty (51.0%) had testing done for flare or inefficacy, 18 (11.5%) for adverse effects, 5 (3.2%) for a combination of inefficacy and adverse effects, and 54 (34.4%) for routine or other reasons. Testing was followed by improved outcomes of increased efficacy, reduced toxicity or change to alternative therapy in 55.0% of the inefficacy/flare group, 27.8% of the suspected adverse reaction group, 60.0% of the combination group, and 13.0% of the routine/other group. Allopurinol was used as cotherapy in 16 patients and led to marked improvements in metabolite concentrations. CONCLUSIONS: Thiopurine metabolite testing has quickly become established in South Australia. When used for inefficacy or adverse effects, it often leads to improved outcomes. Prospective studies are needed to determine whether routine testing to guide dosing is of benefit.

Traumatic spinal cord injury in two European countries: why the differences?

BACKGROUND AND PURPOSE: The aim of the study was to compare the incidence, causes, severity and mortality of traumatic spinal cord injury (TSCI) in Western Norway and Estonia from 1997 to 2001. METHODS: The patients were identified from hospital records. All patients were followed until death or 14 October 2011. Analysed data included demographic data, causes of injury, neurological level, American Spinal Injury Association Impairment Scale and mortality. RESULTS: A total of 71 patients in Western Norway and 244 in Estonia were included. The standardized incidence rate per million was 24.9 (CI 95%, 19.4-31.7) for Western Norway and 37.4 (CI 95%, 32.8-42.5) for Estonia. Falls was the most frequent cause of TSCI in both countries. The incidence of TSCI was highest among men in their 20s in Estonia and men in their 70s in Western Norway. The median survival time among the deceased was 4.0 (95% CI, 1.50-6.50) years in Norway and 2.8 (95% CI, 1.54-4.04) in Estonia. The mean standardized mortality ratio (SMR) was 5.00 (95% CI, 4.00-6.20) in Estonia and 1.89 (95% CI, 1.23-2.77) in Western Norway. CONCLUSION: Although the two cohorts had similar demographic, injury and clinical characteristics, the age profile of the victims was different. The incidence rate was 1.5 times higher and SMR was 2.7 times higher in Estonia. Probable explanations for the different outcomes of the two European countries are socioeconomic differences, lower physical activity level, lower life expectancy and insufficient injury prevention programmes in Estonia.

Functional MRI of the cortical sensorimotor system in patients with hereditary spastic paraplegia.

OBJECTIVES: The study aimed to use functional magnetic resonance imaging to ascertain changes in sensorimotor system function in patients with hereditary spastic paraplegia and to correlate it with severity of spasticity and paresis. SETTING: Tartu University Hospital, Tartu, Estonia. METHODS: Nine patients with autosomal-dominant pure HSP and 14 age- and sex-matched healthy controls were investigated with a 1.5T fMRI scanner during flexion/extension of the right-hand fingers and right ankle. Images were analysed with a general linear model and Statistical Parametrical Mapping software. Highest Z-scores were identified from probability maps, and weighted laterality indices were calculated using combined bootstrap/histogram analysis; these were correlated with clinical severity of spasticity and paresis. RESULTS: During hand movements, clusters located in contralateral primary sensorimotor and premotor areas activated in both controls and patients. Bilateral activation occurred in the supplementary motor area, parietal operculum and cerebellum (predominantly ipsilateral). During the ankle task, bilateral activation was noted in the primary sensorimotor area, supplementary motor area and cerebellum. Activation clusters in HSP patients were smaller than those in controls in the sensorimotor area, especially during the ankle task, and more pronounced ipsilaterally in cerebellum both during hand and ankle motor tasks. Spasticity was significantly associated with contralateral activation in the sensory area and correlated negatively with the highest Z-scores in Brodmann areas 1-2-3 and 4. CONCLUSION: Our results suggest changes in cortical sensorimotor network function in patients with HSP compared with healthy subjects. Lower activation in patients might reflect damage to the corticospinal tract, be influenced by compensatory mechanisms, and/or be a reflection of neurorehabilitation.

High incidence of traumatic spinal cord injury in Estonia.

STUDY DESIGN: Retrospective population-based cohort study. OBJECTIVES: To provide national data on epidemiology of traumatic spinal cord injury (TSCI) among the population of Estonia from 1997 to 2007. SETTING: All Estonian hospitals. METHODS: Medical records of patients with TSCI from all regional, central, general and rehabilitation hospitals in Estonia were retrospectively reviewed. Epidemiological characteristics, etiology, neurological level and severity of injury, concomitant injuries were analyzed. RESULTS: A total of 595 patients with TSCI from 1 January 1997 to 31 December 2007 were identified. The male to female ratio was 5.5:1. The mean age at injury was 39.0 years. The crude incidence rate was 39.7 (95% confidence interval: 36.6-43.0) per million population. The most frequent cause of TSCI was falls (41%), followed by traffic accidents (29%). Alcohol consumption preceded 43% of injuries. The lesion level was cervical in 59.4%, thoracic in 18.3% and lumbar/sacral in 22.3%. CONCLUSION: Compared to recent studies from Europe, where the incidence of TSCI is between 15 and 30 per million population, the incidence of TSCI in Estonia is among the highest. The rates are significantly higher in men compared with women and especially among the youngest men. The leading cause of TSCI is falls. A significant proportion of injuries are related to alcohol consumption before trauma in Estonia.

Irreversible motor impairment in young addicts--ephedrone, manganism or both?

BACKGROUND: Parkinsonian syndrome related to intravenous use of a "designer" psychostimulant, derived from pseudoephedrine using potassium permanganate as the oxidant, has been observed in drug addicts in Estonia. OBJECTIVE: To describe the symptomatology of four young patients, history of drug administration and chemical analysis of a drug batch. METHODS: Mental and motor function and quality of life were scored and ephedrone was analyzed using electrospray mass spectrometry. Manganese content of the final synthetic mixture was analyzed using Inductively Coupled Plasma-Atomic Emission Spectrometry. RESULTS: None of the four cases scored below the dementia threshold in MMSE, while other ratings (UPDRS, H&Y, PDQ-39) corresponded to disabilities seen in relatively advanced Parkinson's disease. The ephedrone yield of the reaction was approximately 44% and the mixture was found to contain 0.6 g/l of manganese. CONCLUSIONS: The cases were exposed to extreme manganese load. Their symptomatology is probably identical to manganism. The role of ephedrone is presently unknown. Physicians must be aware of early signs of manganism in patients within social risk groups.

[Health telematics/telemedicine in the republic of Estonia]. / Gesundheitstelematik/Telemedizin in der Republik Estland.

The people of Estonia, who until their independence had been systematically deprived of all forms of information, have shown a ready acceptance of the use of information technology in all areas of life. This environment and an excellent IT infrastructure have since the beginning of the new century provided favourable conditions for developing various individual projects in telemedicine. At the core of current telemedical applications in Estonia is the BITNET Project (in neurology, general medicine), built up with Swedish cooperation, and three German-Estonian projects (in telecardiology and telepathology). These projects are accompanied by studies of their cost-effectiveness. They constitute the basis for the plan that routine telemedical services be taken over by the Estonian health insurance. Differing from the situation in the Scandinavian countries, which have had an effective national telemedical service for over ten years, the special feature of telematrics in Estonia is its international networking with foreign centres of excellence. This has its origin in the aim of Estonian health policy to ensure medical services within its own country in all branches of medicine.

Routine utilization of the transient hyperaemic response test after aneurysmal subarachnoid haemorrhage.

In order to explore the applicability of daily cerebral autoregulation monitoring through routine utilization of the transient hyperaemic response (THR) test in patients after aneurysmal subarachnoid haemorrhage (SAH), we performed THR tests daily in 50 consecutive patients with verified SAH. Out of 1167 studies, the test results were acceptable during 954 procedures (81.5%). 310 negative (32.5%; range 0.75-1.099; mean 1.03) and 644 positive (67.5%; range 1.10-1.77; mean 1.19) test results were obtained. Multiple logistic regression analysis revealed that the registration of negative THR in a middle cerebral artery (MCA) during the period of critical care was related to the patients' poor clinical grade (p-0.02) and Fisher CT-grade (p-0.04) on admission, to the development of vasospasm (p-0.003) and to the detection of ipsilateral intracerebral haemorrhage and/or cerebral infarction (p-0.01). The frequent registration of negative THR tests (negative results in > 30% of all the tests in an MCA) was independently related to the detection of ipsilateral intracerebral haemorrhage and/or cerebral infarction (p-0.0001). THR tests provide information about intracranial alterations and can be safely performed as a routine monitoring tool after SAH.

Tissue plasminogen activator as a key effector in neurobiology and neuropathology.

Tissue plasminogen activator (tPA) is expressed by many types of neurons in the developing and adult rodent brain. We have now mapped tPA transcripts and protein in the human central nervous system using tissue arrays and find widespread expression, in particular in neocortical mantle, thalamus, amygdala, and hippocampal pyramidal neurons. The abundant presence of tPA protein in cellular vesicles implies that its acute release, e.g. upon ischaemic stroke or trauma, could play a role in neuronal damage. We also found in patients with multiple sclerosis (MS), and to a lesser extent patients with leukaemia and encephalitis, prominently elevated tPA activity in the cerebrospinal fluid and in MS in neurons in the proximity of areas of demyelination elevated tPA mRNA and antigen levels. In addition, we observed up-regulation of tPA expression in a mouse model of MS, experimental autoimmune encephalomyelitis. Accumulating evidence implies roles for tPA in normal neural function, as well as in neurodestructive processes in humans, such as occur in MS and brain tumours and warrant further studies on expression of tPA and its regulatory molecules in neurodegenerative diseases.

Coping strategies in patients following subarachnoid haemorrhage.

OBJECTIVES: To assess psychological coping strategies and their relationship with outcome in patients after primary subarachnoid haemorrhage (SAH). PATIENTS AND METHODS: In 51 unselected patients (24 males, 27 females; mean age 46 years) in an average 15.7+/-12.0 months after SAH usage of coping strategies were assessed by means of Estonian COPE-D test with 15 four-items scales and compared to those obtained from 51 age-, sex- and education-matched healthy persons. The data were analysed according to age, sex and education of the patients, initial severity of disease, localization of aneurysm and outcome characteristics. RESULTS: Patients after SAH reported using social support strategy less than control persons (P<0.05) with a tendency of using acceptance-oriented strategy. Task-oriented coping styles were less used (P<0.05) by patients with severe initial state, who had more marked late disability and dependence in daily living. Healthy women used social support more than men; patients and control persons 50 years or older used task-oriented strategies less than younger persons (P<0.05). CONCLUSION: The structure of coping strategies used by patients after SAH differs compared to healthy persons. The differences in using coping strategies are related to age of the patients, functional state and degree of adaptation after SAH.

Survival of patients with primary CNS tumours in Estonia.

We studied a population-based survey that included 1417 patients with a primary central nervous system (CNS) tumour diagnosed in Estonia between 1986 and 1996. Survival rates at 1 and 5 years and median survival by histology and patient's age at diagnosis were estimated. Median survival time for all tumours was 33.2 months and 1- and 5-year survival rates were 59.3 and 46.0%, respectively. In multivariate analysis, younger age, better clinical condition (i.e. a Karnofsky Performance Status (KPS) score of 60 and more) and tumour histology were all dependent prognostic factors for better survival. Risk of death was more than 8 times greater for glioblastoma (Risk Ratio (RR) 8.31) and approximately seven times greater for anaplastic astrocytoma (RR 7.22) and other gliomas (RR 5.74) compared with meningiomas. Comparing the first (1986-1989) and the third (1994-1996) time periods, statistically significant improvements in survival occurred for all tumours and astrocytomas. Declines in survival during the second period (1990-1993) were statistically significant for all the tumour groups, but the most striking decrease took place in patients with glioblastoma. Age-specific rates showed that the increase in survival was more evident for patients aged between 45 and 64 years.

Cerebral hemodynamic impairment after aneurysmal subarachnoid hemorrhage as evaluated using transcranial doppler ultrasonography: relationship to delayed cerebral ischemia and clinical outcome.

OBJECT: In this study the authors evaluated the relative role of cerebral hemodynamic impairment (HDI) in the pathogenesis of delayed cerebral ischemia and poor clinical outcome after aneurysmal subarachnoid hemorrhage (SAH). METHODS: Cerebral hemodynamics were assessed daily with transcranial Doppler (TCD) ultrasonography in 55 consecutive patients with verified SAH. Hemodynamic impairment was defined as blood flow velocity (BFV) values consistent with vasospasm in conjunction with impaired autoregulatory vasodilation as evaluated using the transient hyperemic response tests in the middle cerebral arteries. A total of 1344 TCD examinations were performed, in which the evaluation of HDI was feasible during 80.9% and HDI was registered during 12% of the examinations. It was found that HDI occurred in 60% of patients and was frequently recorded in conjunction with severe vasospasm (p < 0.05) and a rapid increase of BFV values (p < 0.05). Detection of HDI was closely associated with the development of delayed ischemic brain damage after SAH (p < 0.05). Furthermore, because delayed ischemia was never observed in cases in which vasospasm had not led to the development of HDI, its occurrence increased significantly the likelihood of subsequent cerebral ischemia among the patients with vasospasm (p < 0.05). Detection of HDI was independently related to unfavorable clinical outcome according to Glasgow Outcome Scale at 6 months after SAH (p < 0.05). CONCLUSIONS: The results showed that HDI is common after SAH and can be evaluated with TCD ultrasonography in routine clinical practice. Detection of HDI could be useful for identifying patients at high or low risk for delayed ischemic complications and unfavorable clinical outcome after SAH.