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Safety and efficacy of a novel robotic transcranial doppler system in subarachnoid hemorrhage. Sci Rep 2022; 12:2266. [PMID: 35145104 PMCID: PMC8831519 DOI: 10.1038/s41598-021-04751-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/23/2021] [Indexed: 12/25/2022] Open
Abstract
Delayed cerebral ischemia (DCI) secondary to vasospasm is a determinate of outcomes following non-traumatic subarachnoid hemorrhage (SAH). SAH patients are monitored using transcranial doppler (TCD) to measure cerebral blood flow velocities (CBFv). However, the accuracy and precision of manually acquired TCD can be operator dependent. The NovaGuide robotic TCD system attempts to standardize acquisition. This investigation evaluated the safety and efficacy of the NovaGuide system in SAH patients in a Neuro ICU. We retrospectively identified 48 NovaGuide scans conducted on SAH patients. Mean and maximum middle cerebral artery (MCA) CBFv were obtained from the NovaGuide and the level of agreement between CBFv and computed tomography angiography (CTA) for vasospasm was determined. Safety of NovaGuide acquisition of CBFv was evaluated based on number of complications with central venous lines (CVL) and external ventricular drains (EVD). There was significant agreement between the NovaGuide and CTA (Cohen’s Kappa = 0.74) when maximum MCA CBFv ≥ 120 cm/s was the threshold for vasospasm. 27/48 scans were carried out with CVLs and EVDs present without negative outcomes. The lack of adverse events associated with EVDs/CVLs and the strong congruence between maximal MCA CBFv and CTA illustrates the diagnostic utility of the NovaGuide.
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Neulen A, Stein M, Pantel T, Berres M, Brockmann C, Giese A, Kantelhardt SR. Image-Guided Transcranial Doppler Ultrasound for Monitoring Posthemorrhagic Vasospasms of Infratentorial Arteries: A Feasibility Study. World Neurosurg 2019; 134:284-291. [PMID: 31678314 DOI: 10.1016/j.wneu.2019.10.144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND A considerable number of patients with subarachnoid hemorrhage (SAH) develop vasospasms of the infratentorial arteries. Transcranial Doppler sonography (TCD) is used to screen for vasospasm. In this study, we used a technical modification that combines TCD with an image guidance device that the operator can use to navigate to the ultrasonic window and to predefined intracranial vascular targets. Our aim was to analyze the feasibility, spatial precision, and spatial reproducibility of serial image-guided TCD of infratentorial and-for comparison-supratentorial arteries in the clinical setting of monitoring for vasospasm after SAH. METHODS The study included 10 SAH patients, who each received 5 serial image-guided TCD examinations. Using computed tomography angiography data, trajectories to the infratentorial and supratentorial cerebral arteries were planned and loaded into an image guidance device tracking the Doppler probe. As a measure of spatial precision and spatial reproducibility, we analyzed the distances between the positions of preplanned vascular targets and optimal Doppler signals. RESULTS The mean distance between preplanned and optimal target points was 4.8 ± 2.1 mm (first exam), indicating high spatial precision. The spatial precision decreased with increasing depth of the vascular target. In all patients, image-guided TCD detected all predefined supratentorial and infratentorial vascular segments. There were no significant changes in spatial precision in serial exams, indicating high reproducibility. CONCLUSIONS Image-guided TCD is feasible for supratentorial and infratentorial arteries. It shows high spatial precision and reproducibility. This study provides a basis for future clinical studies on image-guided TCD for post-SAH vasospasm screening.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Maximilian Stein
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Manfred Berres
- Institute of Medical Biometry, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany; Department of Mathematics and Technology, University of Applied Sciences Koblenz, Remagen, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Alf Giese
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany; Orthocentrum Hamburg, Hamburg, Germany
| | - Sven R Kantelhardt
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany.
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Robba C, Goffi A, Geeraerts T, Cardim D, Via G, Czosnyka M, Park S, Sarwal A, Padayachy L, Rasulo F, Citerio G. Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review. Intensive Care Med 2019; 45:913-927. [PMID: 31025061 DOI: 10.1007/s00134-019-05610-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/26/2019] [Indexed: 12/20/2022]
Abstract
Brain ultrasonography can be used to evaluate cerebral anatomy and pathology, as well as cerebral circulation through analysis of blood flow velocities. Transcranial colour-coded duplex sonography is a generally safe, repeatable, non-invasive, bedside technique that has a strong potential in neurocritical care patients in many clinical scenarios, including traumatic brain injury, aneurysmal subarachnoid haemorrhage, hydrocephalus, and the diagnosis of cerebral circulatory arrest. Furthermore, the clinical applications of this technique may extend to different settings, including the general intensive care unit and the emergency department. Its increasing use reflects a growing interest in non-invasive cerebral and systemic assessment. The aim of this manuscript is to provide an overview of the basic and advanced principles underlying brain ultrasonography, and to review the different techniques and different clinical applications of this approach in the monitoring and treatment of critically ill patients.
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Affiliation(s)
- Chiara Robba
- Department of Anaesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Geeraerts
- Department of Anaesthesia and Intensive Care, University Hospital of Toulouse, Toulouse NeuroImaging Center (ToNIC), Inserm-UPS, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Soojin Park
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University, New York, USA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Llewellyn Padayachy
- Department of Neurosurgery, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Frank Rasulo
- Department of Anaesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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Neulen A, Pantel T, Dieter A, Kosterhon M, Berres M, Thal SC, Brockmann MA, Kantelhardt SR. Volumetric analysis of intracranial vessels: a novel tool for evaluation of cerebral vasospasm. Int J Comput Assist Radiol Surg 2018; 14:157-167. [PMID: 30097958 DOI: 10.1007/s11548-018-1844-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 07/31/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Together with other diagnostic modalities, computed tomography angiography (CTA) is commonly used to indicate endovascular vasospasm treatment after subarachnoid hemorrhage (SAH), despite the fact that objective, user-independent parameters for evaluation of CTA are lacking. This exploratory study was designed to investigate whether quantification of vasospasm by automated volumetric analysis of the middle cerebral artery M1 segment from CTA data could be used as an objective parameter to indicate endovascular vasospasm treatment. METHODS We retrospectively identified SAH patients who underwent transcranial Doppler sonography (TCD), CTA, and CT perfusion (CTP), with or without subsequent endovascular treatment. We determined vessel volume/vessel length of the M1 segments from CTA data and used receiver operating characteristic curve analysis to determine the optimal threshold of vessel volume to predict vasospasm requiring endovascular treatment. In addition, blinded investigators independently analyzed TCD, CTA, and CTP data. RESULTS Of 45 CTA examinations with corresponding CTP and TCD examinations (24 SAH patients), nine indicated the need for endovascular vasospasm treatment during examination. In our patients, vessel volume < 5.8 µL/mm was moderately sensitive but fairly specific to detect vasospasm requiring endovascular treatment (sensitivity, 67%; specificity, 78%; negative predictive value (NPV), 89%; positive predictive value (PPV), 46%). For CTA, CTP, and TCD, we found NPVs of 96%, 92%, and 89%, PPVs of 40%, 35%, and 35%, sensitivities of 89%, 78%, and 67%, and specificities of 67%, 64%, and 69%, respectively. CONCLUSION Vessel volumes could provide a new objective parameter for the interpretation of CTA data and could thereby improve multimodal assessment of vasospasm in SAH patients.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Anna Dieter
- Department of Neuroradiology, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Manfred Berres
- Institute of Medical Biometry, Epidemiology and Informatics, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.,Department of Mathematics and Technology, University of Applied Sciences Koblenz, Joseph-Rovan-Allee 2, 53424, Remagen, Germany
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Sven R Kantelhardt
- Department of Neurosurgery, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
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Cerebral Blood Flow in Polytrauma: Transcranial Doppler Analysis in a Nonhuman Primate Shock Model. J Surg Res 2018; 232:146-153. [PMID: 30463710 DOI: 10.1016/j.jss.2018.05.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/05/2018] [Accepted: 05/24/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND In combat-related trauma, resuscitation goals are to attenuate tissue hypoxia and maintain circulation. During hemorrhagic shock, compensatory and autoregulatory mechanisms are activated to preserve cerebral blood flow. Transcranial Doppler (TCD) ultrasonography may be an ideal noninvasive modality to monitor cerebral hemodynamics. Using a nonhuman primate (NHP) model, we attempted to characterize cerebral hemodynamics during polytraumatic hemorrhagic shock using TCD ultrasonography. MATERIALS AND METHODS The ophthalmic artery was insonated at multiple time points during varying stages of shock. Hemorrhage was controlled and pressure targeted to 20 mmHg to initiate and maintain the shock period. Mean flow velocity (MFV), peak systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) were recorded. Results represent mean ± standard deviation; statistical significance is P < 0.05; n = 12. RESULTS Compared to baseline, MFV, PSV, EDV, and RI show significant changes after 60 min of hemorrhagic shock, (9.81 ± 3.60 cm/s; P < 0.01), (21.15 ± 8.59 cm/s; P < 0.01), (5.15 ± 0.21 cm/s; P < 0.01), (0.70 ± 0.11; P < 0.05), respectively. PI did not change during hemorrhagic shock. At end of prehospital care (T30), cerebral flow recovers for MFV, PSV, and RI while EDV remained decreased at T30 (6.15 ± 1.13 cm/s; P < 0.01) and 1 h of simulated transport (T90) (5.87 ± 0.62 cm/s; P < 0.01). Changes in PI at T30 and T90 were not significant. MFV diminished (16.45 ± 3.85 cm/s; P < 0.05) at T90. CONCLUSIONS This study establishes baseline and hemorrhagic shock values for NHP cerebral blood flow velocities and cerebrovascular indices. TCD ultrasonography may represent an important area of research for targeted resuscitation investigations using a hemorrhagic shock model in NHPs.
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Clinical Experience with Intraoperative Ultrasonographic Image in Microsurgical Resection of Cerebral Arteriovenous Malformations. World Neurosurg 2017; 97:93-97. [DOI: 10.1016/j.wneu.2016.09.089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/19/2016] [Accepted: 09/23/2016] [Indexed: 11/23/2022]
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Freyschlag CF, Kerschbaumer J, Eisner W, Pinggera D, Brawanski KR, Petr O, Bauer M, Grams AE, Bodner T, Seiz M, Thomé C. Optical Neuronavigation without Rigid Head Fixation During Awake Surgery. World Neurosurg 2016; 97:669-673. [PMID: 27989983 DOI: 10.1016/j.wneu.2016.10.091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/18/2016] [Accepted: 10/20/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Optical neuronavigation without rigid pin fixation of the head may lead to inaccurate results because of the patient's movements during awake surgery. In this study, we report our results using a skull-mounted reference array for optical tracking in patients undergoing awake craniotomy for eloquent gliomas. METHODS Between March 2013 and December 2014, 18 consecutive patients (10 men, 8 women) with frontotemporal (n = 16) or frontoparietal (perirolandic; n = 2) lesions underwent awake craniotomy without rigid pin fixation. All patients had a skull-mounted reference array for optical tracking placed on the forehead. Accuracy of navigation was determined with pointer tip deviation measurements on superficial and bony anatomic structures. Good accuracy was defined as a tip deviation <2 mm. RESULTS Gross total resection (>98%) was achieved in 7 patients (38%); >90% of tumor was resected in 8 patients (44%). In 3 patients, only subtotal resection or biopsy was performed secondary to stimulation results. In all patients, good accuracy of the optical neuronavigation system could be demonstrated without intraoperative peculiarities or complications. The reference array had to be repositioned because of loosening in 1 patient. Neuronavigation could be reliably applied to support stimulation-based resection. CONCLUSIONS A skull-mounted reference array is a simple and safe method for optical neuronavigation tracking without rigid pin fixation of the patient's head.
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Affiliation(s)
| | | | - Wilhelm Eisner
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniel Pinggera
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Ondra Petr
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Marlies Bauer
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Astrid E Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Bodner
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marcel Seiz
- Department of Neurosurgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
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Neulen A, Prokesch E, Stein M, König J, Giese A. Image-guided transcranial Doppler sonography for monitoring of vasospasm after subarachnoid hemorrhage. Clin Neurol Neurosurg 2016; 145:14-8. [PMID: 27062685 DOI: 10.1016/j.clineuro.2016.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/13/2016] [Accepted: 03/16/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Transcranial Doppler ultrasound (TCD) is a standard method for bedside vasospasm monitoring after subarachnoid hemorrhage (SAH). Image guidance has previously been shown to reduce intra- and interobserver variability of this method. The aim of the present study was to compare image-guided and conventional TCD in vasospasm monitoring after SAH. PATIENTS AND METHODS 418 TCD exams of 24 consecutive SAH patients registered in a database were evaluated. Of these, 130 image-guided exams were identified which had been performed on the same day as conventional Doppler exams. These matched pairs were taken for statistical analysis. Data were tested statistically using the sign test applied at patient level to aggregated data. RESULTS The rate of complete exams (both M1, A1, P1 segments) was significantly higher in image-guided exams (92% vs. 74%, p<0.001), and the superiority of image-guided exams was significantly related to smaller sizes of the temporal bone window. There were more exams with Doppler sonographic vasospasm (mean flow velocity>120cm/s) in image-guided exams (38% vs. 33%) which, however, did not reach statistical significance. CONCLUSION Image-guidance leads to a standardization of serial TCD exams, which resulted in significantly more complete exams, most prominent in patients with poor temporal bone windows, and a higher detection rate of Doppler sonographic vasospasms. Image-guided TCD therefore has the capability to improve bedside vasospasm monitoring after SAH.
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Affiliation(s)
- A Neulen
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
| | - E Prokesch
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - M Stein
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - J König
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center, Johannes-Gutenberg-University of Mainz, Obere Zahlbacher Straße 69, 55131 Mainz, Germany
| | - A Giese
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
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