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Montorsi P, Mancini E, Galli S, Teruzzi G, Caputi L, Ferrari C, Troiano S, Olivares P, Ravagnani PM, Trabattoni D. Intolerance to occlusion during carotid artery stenting with proximal protection: causes, mechanisms, treatment and prevention. Minerva Cardiol Angiol 2022; 70:751-764. [PMID: 36700670 DOI: 10.23736/s2724-5683.22.06246-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Periprocedural cerebral microembolization is the most important complication of carotid artery stenting. Among several variables that play a role to reduce this risk, brain protection (proximal vs. distal) plays a pivot role. Data are accumulating in favor of a better performance of proximal vs. distal especially in symptomatic patients and high-risk carotid plaques. A prerequisite for the technique to be safe and effective is the presence of a valid intracranial collateral circulation to compensate for the target vessel hemisphere avoiding patient intolerance. This complication may occur either soon after the common carotid balloon occlusion or slowly developing during the procedure peaking at the stent post-dilation step. While Willis' circle anatomic variants are the most frequent cause of acute intolerance, a mix of anatomic, hemodynamic and patient cerebral condition play a role for the late developing form. Prevention is the best treatment of intolerance through a pre- and procedural imaging with different techniques (CT angiography, NMR angiography, transcranial Doppler assessment, digital subtraction angiography and back pressure monitoring).
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Affiliation(s)
- Piero Montorsi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy - .,Centro Cardiologico Monzino IRCCS, Milan, Italy -
| | | | | | | | - Luigi Caputi
- Division of Neurology, ASST Crema, Crema, Cremona, Italy
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Hoiland RL, Fisher JA, Ainslie PN. Regulation of the Cerebral Circulation by Arterial Carbon Dioxide. Compr Physiol 2019; 9:1101-1154. [DOI: 10.1002/cphy.c180021] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Fisher JA, Venkatraghavan L, Mikulis DJ. Magnetic Resonance Imaging–Based Cerebrovascular Reactivity and Hemodynamic Reserve. Stroke 2018; 49:2011-2018. [DOI: 10.1161/strokeaha.118.021012] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Joseph A. Fisher
- From the Department of Anesthesia and Pain Management and the Toronto General Hospital Research Institute (J.A.F., L.V.)
- Department of Anesthesiology (J.A.F., L.V.)
- Institute of Medical Sciences (J.A.F., D.J.M.)
- Department of Physiology (J.A.F.), University of Toronto, Canada
| | - Lashmi Venkatraghavan
- From the Department of Anesthesia and Pain Management and the Toronto General Hospital Research Institute (J.A.F., L.V.)
- Department of Anesthesiology (J.A.F., L.V.)
| | - David J. Mikulis
- Joint Department of Medical Imaging and the Functional Neuroimaging Laboratory (D.J.M.), University Health Network, Toronto, Canada
- Institute of Medical Sciences (J.A.F., D.J.M.)
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Egido JA, Garcia AM, Del Prado-Gonzalez N, Fuentes-Ferrer M, Lopez-Herranz M, Simal-Hernández P, Fernández-Pérez C. Impact of clinical training on supra-aortic duplex and transcranial doppler examination concordance. JOURNAL OF CLINICAL ULTRASOUND : JCU 2016; 44:571-579. [PMID: 27487744 DOI: 10.1002/jcu.22379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 06/17/2016] [Indexed: 06/06/2023]
Abstract
Sonographic tests are observer-dependent. With 1,527 consecutive patients, 22 trainees were assessed at baseline and after a hands-on 1:1 program, with a pre-examination median of 76 studies/trainee. We evaluated the required number of supervised examinations to reach a 0.80 kappa index (ki). Statistics included linear and exponential generalized estimating equation models. In the exponential model, 76 studies for carotid-duplex and >102 for vertebral-duplex and transcranial Doppler were needed for a 0.80 ki. "Relevant-categories" after-training ki was 0.80 in carotid-duplex and transcranial Doppler but 0.60 in vertebral-duplex. A fixed training does not guarantee a high ki. Measuring the acquired skills of every trainee would improve quality. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:571-579, 2016.
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Affiliation(s)
- Jose A Egido
- Stroke Unit and Neurosonology Laboratory, Hospital Clinico San Carlos, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos (IdSSC), Madrid, Spain.
| | - Ana M Garcia
- Acute Stroke Unit, Worcestershire Royal Hospital, Worcester, United Kingdom
| | | | - Manuel Fuentes-Ferrer
- Unidad de Apoyo a la Investigación, Servicio de Medicina Preventiva, IdSSC, UAX, Madrid, Spain
| | | | - Patricia Simal-Hernández
- Stroke Unit and Neurosonology Laboratory, Hospital Clinico San Carlos, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos (IdSSC), Madrid, Spain
| | - Cristina Fernández-Pérez
- Unidad de Apoyo a la Investigación. Servicio de Medicina Preventiva, IdSSC, UCM, UAX, Madrid, Spain
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Jung KH, Lee YS. Clinical-Sonographic Index (CSI): A Novel Transcranial Doppler Diagnostic Model for Middle Cerebral Artery Stenosis. J Neuroimaging 2008; 18:256-61. [DOI: 10.1111/j.1552-6569.2007.00181.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Bang OY, Cho JH, Han BI, Joo IS, Kim DI, Huh K. Transcranial Doppler findings in middle cerebral arterial occlusive disease in relation to degree of stenosis and presence of concomitant stenoses. JOURNAL OF CLINICAL ULTRASOUND : JCU 2003; 31:142-151. [PMID: 12594799 DOI: 10.1002/jcu.10150] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
PURPOSE We evaluated the accuracy of transcranial Doppler (TCD) criteria in detecting middle cerebral artery (MCA) stenoses other than solitary severe stenoses. METHODS Three TCD criteria were evaluated in patients with acute MCA territory infarction who also underwent angiography: abnormalities in mean velocity (MV), focal areas of spectral waveform abnormalities, and compensatory increase in MV in collateral vessels. RESULTS Among 102 patients studied, angiography revealed MCA lesions in 48: 16 had uncomplicated lesions (single stenosis of moderate to severe degree), 19 had mildly complicated lesions (single MCA stenosis of other than moderate to severe degree, or moderate to severe MCA stenosis with a concomitant lesion outside the MCA), and 13 had severely complicated lesions (MCA stenosis of other than moderate to severe degree with a concomitant lesion outside the MCA). The sensitivity of abnormalities in MV in uncomplicated MCA lesions was 81%, whereas it was 53% in mildly complicated MCA lesions and 38% in severely complicated MCA lesions. However, a compensatory increase in MV in collaterals was more frequently found in complicated MCA lesions, and focal areas of spectral waveform abnormalities were observed fairly consistently in all groups. CONCLUSIONS TCD findings of focal areas of spectral waveform abnormalities and compensatory collateral flow were common in complicated MCA lesions and may improve the specificity of TCD in the diagnosis of MCA stenosis.
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Affiliation(s)
- Oh Young Bang
- Department of Neurology, School of Medicine, Ajou University, Woncheon-dong San 5, Paldal-ku, Suwon, Kyungki-do 442-749, South Korea
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Wain RA, Veith FJ, Berkowitz BA, Legatt AD, Schwartz M, Lipsitz EC, Haut SR, Bello JA. Angiographic criteria reliably predict when carotid endarterectomy can be safely performed without a shunt. J Am Coll Surg 1999; 189:93-100; discussion 100-1. [PMID: 10401745 DOI: 10.1016/s1072-7515(99)00070-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Selective shunting during carotid endarterectomy is widely performed, but the optimal approach for predicting when a shunt is unnecessary remains uncertain. We evaluated the ability of preoperative cerebral angiography to predict when carotid endarterectomy could be safely performed without a shunt. STUDY DESIGN Eighty-seven patients undergoing carotid endarterectomy between August 1991 and December 1997 had preoperative cerebral angiograms. The angiograms were evaluated for the presence of collateral flow from the contralateral carotid through the anterior communicating artery and from the posterior circulation through the posterior communicating artery. Patients then underwent endarterectomy and were selectively shunted based on somatosensory evoked potential changes. Internal carotid artery stump pressure was routinely measured in all patients. RESULTS Nine patients (10%) had a shunt placed based on somatosensory evoked potential changes and none of the 87 patients had a perioperative (30 days) stroke. Angiography revealed that 36 patients (41%) had no cross-filling from the contralateral carotid through the anterior communicating artery. Nine of these patients (25%) required a shunt; none of the 51 patients with adequate cross-filling (p < 0.001) did. Furthermore, 94% of the patients without cross-filling but with a patent ipsilateral posterior communicating artery did not require a shunt using somatosensory evoked potential changes as the standard for shunt insertion. Stump pressure measurements (> or = 25 mmHg) or (> or = 50 mmHg) did not reliably exclude the need for a shunt. Only 2 of 15 patients with contralateral carotid occlusion and 1 of 16 patients with a prior ipsilateral stroke required shunts. CONCLUSIONS In the presence of cross-filling from the contralateral carotid artery, shunt insertion was uniformly unnecessary. In addition, routine shunting of patients with previous ipsilateral strokes or contralateral carotid occlusion was not always necessary. Stump pressures were less sensitive than angiographic criteria in determining when a shunt was unnecessary. Evaluation of cross-filling from the contralateral carotid artery on preoperative angiography can predict with certainty which patients will not require a shunt.
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Affiliation(s)
- R A Wain
- Montefiore Medical Center and Albert Einstein College of Medicine, New York, NY, USA
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Vernieri F, Pasqualetti P, Passarelli F, Rossini PM, Silvestrini M. Outcome of carotid artery occlusion is predicted by cerebrovascular reactivity. Stroke 1999; 30:593-8. [PMID: 10066857 DOI: 10.1161/01.str.30.3.593] [Citation(s) in RCA: 181] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to investigate the possibility of obtaining prognostic indications in patients with internal carotid occlusion on the basis of intracranial hemodynamic status, presence of previous symptoms of cerebrovascular failure, and baseline characteristics. METHODS Cerebral hemodynamics were studied with transcranial Doppler ultrasonography. Cerebrovascular reactivity to apnea was calculated by means of the breath-holding index (BHI) in the middle cerebral arteries. Sixty-five patients with internal carotid artery occlusion were followed-up prospectively (median, 24 months), 23 patients were asymptomatic and 42 symptomatic (20 with transient ischemic attack and 22 with stroke). RESULTS During the follow-up period, 11 symptomatic patients and 1 asymptomatic patient had another ischemic event ipsilateral to carotid occlusion. Among factors considered, only lower BHI values in the middle cerebral arteries ipsilateral to carotid occlusion and older age were significantly associated with the risk of developing symptoms (P=0.002 and P=0.003, respectively; Cox regression multivariate analysis). Based on our data, a cut point of the BHI value for distinguishing between pathological and normal cerebrovascular reactivity was determined to be 0.69. All patients except one, who developed TIA or stroke during the follow-up period, had BHI values ipsilateral to carotid occlusion of <0.69. CONCLUSIONS These data suggest that impaired cerebrovascular reactivity is predictive for cerebral ischemic events in patients with carotid occlusion.
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Affiliation(s)
- F Vernieri
- AFaR CRCCS: Divisione di Neurologia-Ospedale Fatebenefratelli, Isola Tiberina, Roma, Italy.
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Jargiello T, Pietura R, Rakowski P, Szczerbo-Trojanowska M, Szajner M, Janczarek M. Power Doppler imaging in the evaluation of extracranial vertebral artery compression in patients with vertebrobasilar insufficiency. EUROPEAN JOURNAL OF ULTRASOUND : OFFICIAL JOURNAL OF THE EUROPEAN FEDERATION OF SOCIETIES FOR ULTRASOUND IN MEDICINE AND BIOLOGY 1998; 8:149-56. [PMID: 9971893 DOI: 10.1016/s0929-8266(98)00067-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The recent introduction of Power Doppler Imaging (PDI) made a promise for better visualization of blood vessels lying in regions anatomically difficult for ultrasound imaging, i.e. vertebral arteries. The purpose of our study was to assess usefulness of PDI technique in visualization of vertebral artery course and to assess its utility in the detecting spondylotic vertebral artery compression in patients with vertebrobasilar insufficiency (VBI). METHODS A total of 428 patients with VBI symptoms was evaluated. A total of 282 (66%) patients related their symptoms to a specific head position. Thus, all Doppler examinations were performed in four head positions: hyperextension, flexion and right/left rotation and also in a position reported by a patient to produce symptoms. PDI technique was employed as vertebral artery mapping for precise PW-Doppler range gate placing. RESULTS Vertebral artery compression was found in 73 (17%) patients: 65 unilateral and eight bilateral. The diagnosis was based on flow decrease or its absence shown on PW-Doppler scans, after a specific head turning. CONCLUSION Vertebral artery compression, related to a specific head position is relatively frequent in patients with VBI symptoms, especially in an older population commonly suffering from cervical spondylosis. PDI facilitates noninvasive Doppler US diagnosis by showing the real course of vertebral artery, particularly its intertransverse portion.
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Affiliation(s)
- T Jargiello
- Department of Interventional Radiology and Neuroradiology, University School of Medicine, Jaczewskiego 8, 20-950 Lublin, Poland
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Doblar DD, Plyushcheva NV, Jordan W, McDowell H. Predicting the effect of carotid artery occlusion during carotid endarterectomy: comparing transcranial doppler measurements and cerebral angiography. Stroke 1998; 29:2038-42. [PMID: 9756578 DOI: 10.1161/01.str.29.10.2038] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE We correlated the mean transcranial Doppler blood flow velocity (FVm) during carotid endarterectomy with the functional collateral pathway(s) documented by angiography. METHODS Three patient groups were established: group 1 was dependent on the anterior communicating artery, group 2 on the anterior communicating artery and ipsilateral posterior communicating artery, and group 3 on the ipsilateral posterior communicating artery. Continuous middle cerebral artery FVm and electroencephalographic monitoring were performed in 45 patients during carotid endarterectomy. RESULTS Clamped FVm was lowest in group 3 at 17+/-9 cm/s versus 36+/-16 and 33+/-11 cm/s for groups 1 and 2 (P<0.01). FVm values in groups 1 and 2 were similar. There was significant cerebral arterial vasodilation in group 3 patients on the basis of a pulsatility index of 0.38+/-0.15. The maximum FVm after clamp release was similar among the 3 groups. Normalized blood flow velocity 1 minute before release of the clamp was increased from the minimum flow velocity after clamping only in group 1 and 2 patients. CONCLUSIONS The ipsilateral posterior communicating artery is a minor collateral pathway during acute carotid occlusion that contributes little to the collateral flow if there is a functional anterior communicating artery. Collateral flow through the middle cerebral artery is not recruited during occlusion in group 3 patients. The reperfusion FVm transient is independent of the primary collateral pathway. Documentation of functional collateral pathways on the basis of Doppler or angiographic examination may be advantageous in future studies since it can provide the basis for comparison among studies.
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Affiliation(s)
- D D Doblar
- Departments of Anesthesiology, Biomedical Engineering, University of Alabama at Birmingham
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Hedera P, Bujdáková J, Traubner P, Pancák J. Stroke risk factors and development of collateral flow in carotid occlusive disease. Acta Neurol Scand 1998; 98:182-6. [PMID: 9786615 DOI: 10.1111/j.1600-0404.1998.tb07291.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Blood flow through collateral vessels compensates for reduced blood flow through stenotic or occluded extracranial carotid arteries. Previous studies have shown that extent of collateral flow influences likelihood of stroke and its outcome. Here we analyzed the relationship between stroke risk factors (hypertension, coronary artery disease, diabetes mellitus, tobacco smoking and hypercholesterolemia) and number of patent intracranial collaterals detected by transcranial Doppler ultrasonography. SUBJECTS AND METHODS We studied 182 patients with various degrees of angiography proven unilateral stenosis of the internal carotid artery. Contribution of the anterior and posterior communicating arteries to the perfusion of the cerebral hemisphere on the side of the stenosis or occlusion was evaluated by a series of compression tests performed during continuous insonation of the middle cerebral artery. The number of detected collateral vessels was correlated with analyzed stroke risk factors. RESULTS Subjects with stenosis more than 75% or occlusion of the internal carotid artery had a higher frequency of two major intracranial collateral vessels (P< or =0.01 and P< or =0.001, respectively). Hypertensive patients with stenosis more than 75% or total carotid occlusion were more likely to have only a single collateral vessel than patients without hypertension (P< or =0.01 and P< or =0.05, respectively). Other risk factors did not influence the patency of preformed collateral vessels. CONCLUSIONS Hypertension hindered the development of preformed intracranial collateral vessels in our patients with carotid occlusive disease.
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Affiliation(s)
- P Hedera
- First Neurological Clinic, University Hospital, Department of Neurology, Medical School of Comenius University, Bratislava, Slovakia
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Gossetti B, Martinelli O, Guerricchio R, Irace L, Benedetti-Valentini F. Transcranial Doppler in 178 patients before, during, and after carotid endarterectomy. J Neuroimaging 1997; 7:213-6. [PMID: 9344002 DOI: 10.1111/jon199774213] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
From July 1991 to March 1995, 178 patients who underwent 198 carotid surgical repairs were investigated preoperatively, intraoperatively, and postoperatively by transcranial Doppler sonography (TCD). Preoperative TCD evaluation showed stenosis of the middle cerebral artery (MCA) in 4 patients (2.2%), siphon stenosis in 3 (1.6%), incomplete circle of Willis in 23 (12.9%), a decrease of mean blood flow velocity more than 70% of the basal value during digital common carotid compression in 31 (17.9%), and a critical reduction of vasomotor reactivity (no significant increase of mean blood flow velocity in the MCA during breath-holding test) in 34 (19.1%). Nine patients (5%) had surgery without preoperative angiography. In those patients the indication for surgery was based on color Doppler imaging and TCD investigations. Ninety surgical procedures were carried out under general anesthesia and 188 under locoregional anesthesia. In 37 surgeries (31.7%) a shunt was inserted. The use of a shunt was based on a decrease of mean blood flow velocity in the MCA below 50% of the basal value under general anesthesia or loss of consciousness combined with a decrease of mean blood flow velocity in the MCA higher than 70% of the basal value when locoregional anesthesia was employed. Intraoperative TCD monitoring showed a decrease of mean blood flow velocity in the MCA due to shunt malfunction in (8.3%) of 36 surgeries, turbulence of blood flow during declamping in 79 procedures (39.8%), and microembolic events in 10 patients (5%) that were related to one transient and one permanent neurological deficit. Another permanent deficit occurred in a patient without TCD signs. After surgery, TCD reliably detected an early asymptomatic occlusion of the carotid artery, hyperperfusion syndrome in 12 (6.0%), and an increase of vasomotor reactivity in 10 (29.4%) of 34 surgeries.
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MESH Headings
- Anesthesia, Conduction
- Anesthesia, General
- Apnea/physiopathology
- Arterial Occlusive Diseases/diagnostic imaging
- Arterial Occlusive Diseases/surgery
- Arteriovenous Shunt, Surgical
- Blood Flow Velocity
- Carotid Artery, Common/diagnostic imaging
- Carotid Stenosis/diagnostic imaging
- Carotid Stenosis/etiology
- Cerebral Angiography
- Cerebral Arterial Diseases/diagnostic imaging
- Cerebral Arterial Diseases/surgery
- Cerebral Arteries/diagnostic imaging
- Cerebrovascular Circulation
- Circle of Willis/diagnostic imaging
- Circle of Willis/surgery
- Constriction, Pathologic/diagnostic imaging
- Constriction, Pathologic/surgery
- Endarterectomy, Carotid
- Hemorheology
- Humans
- Intracranial Embolism and Thrombosis/diagnostic imaging
- Intracranial Embolism and Thrombosis/etiology
- Ischemic Attack, Transient/diagnostic imaging
- Ischemic Attack, Transient/surgery
- Monitoring, Intraoperative
- Neurologic Examination
- Postoperative Care
- Reproducibility of Results
- Ultrasonography, Doppler, Color
- Ultrasonography, Doppler, Transcranial
- Vasomotor System/diagnostic imaging
- Vasomotor System/physiopathology
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Affiliation(s)
- B Gossetti
- 2nd Chair of Vascular Surgery, La Sapienza University of Roma, Italy
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