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Xu X, Raynald, Li X, Li R, Yang H, Zhao X, Miao Z, Mo D. New evidence for fractional pressure ratio prediction by pulsatility index from transcranial Doppler in patients with symptomatic cerebrovascular stenosis disease. Quant Imaging Med Surg 2024; 14:264-272. [PMID: 38223066 PMCID: PMC10784021 DOI: 10.21037/qims-23-701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/07/2023] [Indexed: 01/16/2024]
Abstract
Background The pulsatility index (PI) derived from transcranial Doppler (TCD) assessment may represent the cerebral resistance and altered cerebral blood flow. The purpose of this study was to assess the performance of the TCD PI in correlation with wire-based fractional pressure ratio (FPR). Methods This study included 33 patients with symptomatic atherosclerotic lesions of the extracranial and intracranial large arteries, specifically the internal carotid artery, middle cerebral artery (MCA), vertebral artery (VA) V4 segment, and basilar artery (BA), all of which exhibited luminal stenosis ranging from 50% to 70%. TCD was performed prior to angiography in order to determine the flow distal to the lesion. We performed cerebrovascular angiography with a pressure wire to measure the FPR of vessels with stenotic lesions. Bland-Altman analysis and ordinal least square (OLS) linear regression were used to quantify the correlation between PI and FPR. Results A total of 42 TCD data points were analyzed. At the TCD locations distal to the lesions, the correlation coefficients were no less than 0.90%, with almost all P values <0.001, which indicated very strong positive correlations; the exception to this was the distal TCD for MCA segment lesions (r=0.897; P=0.015) and VA V4 segment (r=0.964; P=0.036). The Bland-Altman plot demonstrated a small difference (0.003) between the distal TCD PI and the FPR, with an acceptable 95% confidence interval [95% confidence interval (CI): 0.06-0.12]. Conclusions The PI obtained through TCD assessment distal to the stenotic lesion exhibited a correlation with the FPR computed using pressure wire measurements.
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Affiliation(s)
- Xiaotong Xu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xian Li
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Ruichen Li
- School of Electronic Engineering and Computer Science, Peking University, Beijing, China
| | - Hongchao Yang
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Beijing, China
| | - Xi Zhao
- Central Research Institute, United Imaging Healthcare, Shanghai, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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2
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Shen Y, van der Harst JJ, Wei Y, Bokkers RPH, van Dijk JMC, Uyttenboogaart M. Validation of a cerebral hemodynamic model with personalized calibration in patients with aneurysmal subarachnoid hemorrhage. Front Bioeng Biotechnol 2022; 10:1031600. [PMID: 36507259 PMCID: PMC9732662 DOI: 10.3389/fbioe.2022.1031600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/08/2022] [Indexed: 11/27/2022] Open
Abstract
This study aims to validate a numerical model developed for assessing personalized circle of Willis (CoW) hemodynamics under pathological conditions. Based on 66 computed tomography angiography images, investigations were obtained from 43 acute aneurysmal subarachnoid hemorrhage (aSAH) patients from a local neurovascular center. The mean flow velocity of each artery in the CoW measured using transcranial Doppler (TCD) and simulated by the numerical model was obtained for comparison. The intraclass correlation coefficient (ICC) over all cerebral arteries for TCD and the numerical model was 0.88 (N = 561; 95% CI 0.84-0.90). In a subgroup of patients who had developed delayed cerebral ischemia (DCI), the ICC had decreased to 0.72 but remained constant with respect to changes in blood pressure, Fisher grade, and location of ruptured aneurysm. Our numerical model showed good agreement with TCD in assessing the flow velocity in the CoW of patients with aSAH. In conclusion, the proposed model can satisfactorily reproduce the cerebral hemodynamics under aSAH conditions by personalizing the numerical model with TCD measurements. Clinical trial registration: [http://www.trialregister.nl/], identifier [NL8114].
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Affiliation(s)
- Yuanyuan Shen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - J. Joep van der Harst
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Yanji Wei
- Eastern Institute for Advanced Study, Yongriver Institute of Technology, Ningbo, China
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - J. Marc C. van Dijk
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands,Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, Netherlands,*Correspondence: Maarten Uyttenboogaart,
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3
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Purroy F, Sánchez E, Lecube A, Arqué G, Vicente-Pascual M, Mauri-Capdevila G, Torreguitart N, Hernández M, Barbé F, Fernández E, Pamplona R, Farràs C, Mauricio D, Bermúdez-López M. Prevalence and Predictors of Cerebral Microangiopathy Determined by Pulsatility Index in an Asymptomatic Population From the ILERVAS Project. Front Neurol 2022; 12:785640. [PMID: 34970215 PMCID: PMC8712482 DOI: 10.3389/fneur.2021.785640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Little is known about the prevalence of cerebral microangiopathy (CM), which is related to cognitive impairment, in an asymptomatic population. Pulsatility index (PI) is an easily measurable parameter of cerebral vascular resistance in transcranial duplex of the middle cerebral artery (MCA) study. We aimed to determine the prevalence of CM measured by PI of MCA in low to moderate vascular risk subjects. Methods: We included 3,721 subjects between 45 and 70 years without previous history of vascular disease or diabetes mellitus and with at least one other vascular risk factor from the cross-sectional study ILERVAS (Lleida, Spain). Patients underwent transcranial duplex to determine MCA-PI. Possible CM was defined by MCA-PI >1.1. Carotid and femoral arteries ultrasound registration was done to determine the presence, the number, and the area of atheromatous plaques. Body mass index (BMI), pulse pressure (PP) and laboratory data were also recorded. Results: 439 (11.8%) subjects were excluded due to the low quality of transcranial duplex images. Median age was 57 [IQR 52, 62] years. Possible CM was found in 424 (12.9%) subjects. CM patients had higher prevalence of plaques than non-CM (77.4 vs. 66.4%, p < 0.001). PI showed a positive linear correlation with the number of territories with plaques (r = 0.130, p < 0.001), and the total plaque area (r = 0.082, p < 0.001). The predictors of possible CM were the age, male gender, and PP. Conclusions: In low-to-moderate vascular risk asymptomatic population, the proportion of abnormal brain microvascular bed determined by MCA-PI is not negligible. The planned 10-year follow-up will describe the clinical relevance of these findings.
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Affiliation(s)
- Francisco Purroy
- Stroke Unit, University Hospital Arnau de Vilanova, Lleida, Spain.,Clinical Neurosciences Group, IRBLleida, University of Lleida, Lleida, Spain
| | - Enric Sánchez
- Endocrinology and Nutrition Department, University Hospital Arnau de Vilanova, Lleida, Spain.,Obesity, Diabetes and Metabolism (ODIM) Research Group, IRBLleida, Lleida, Spain.,University of Lleida, Lleida, Spain
| | - Albert Lecube
- Endocrinology and Nutrition Department, University Hospital Arnau de Vilanova, Lleida, Spain.,Obesity, Diabetes and Metabolism (ODIM) Research Group, IRBLleida, Lleida, Spain.,University of Lleida, Lleida, Spain.,CIBER de Diabetes y Enfermedades Metabólicas Asociadas, CIBERDEM, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Gloria Arqué
- Clinical Neurosciences Group, IRBLleida, University of Lleida, Lleida, Spain
| | | | - Gerard Mauri-Capdevila
- Stroke Unit, University Hospital Arnau de Vilanova, Lleida, Spain.,Clinical Neurosciences Group, IRBLleida, University of Lleida, Lleida, Spain
| | - Núria Torreguitart
- Clinical Neurosciences Group, IRBLleida, University of Lleida, Lleida, Spain.,Vascular Surgery Service, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Marta Hernández
- Endocrinology and Nutrition Department, University Hospital Arnau de Vilanova, Lleida, Spain.,Obesity, Diabetes and Metabolism (ODIM) Research Group, IRBLleida, Lleida, Spain.,University of Lleida, Lleida, Spain
| | - Ferrán Barbé
- Pneumology Service, Translational Research in Respiratory Medicine Research Group, IRBLleida, University Hospital Arnau de Vilanova, University of Lleida, Lleida, Spain.,CIBER de Enfermedades Respiratorias, CIBERES, Instituto de Salud Carlos III (ISCIII), Lleida, Spain
| | - Elvira Fernández
- Vascular and Renal Translational Research Group, IRBLleida, ReinRen-ISCIII, University of Lleida, Lleida, Spain
| | - Reinald Pamplona
- Department of Experimental Medicine, Metabolic Pathophysiology Research Group, IRBLleida, University of Lleida, Lleida, Spain
| | - Cristina Farràs
- DAP Lleida, Unitat de Suport a la Recerca - IDIAP Jordi Gol, Lleida, Spain
| | - Dídac Mauricio
- Department of Endocrinology and Nutrition, CIBER of Diabetes and Associated Metabolic Diseases, Hospital de la Sant Creu i Sant Pau, Barcelona, Spain
| | - Marcelino Bermúdez-López
- Vascular and Renal Translational Research Group, IRBLleida, ReinRen-ISCIII, University of Lleida, Lleida, Spain
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4
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Estepp JH, Cong Z, Agodoa I, Kang G, Ding J, McCarville MB, Hankins JS, Wang WC. What drives transcranial Doppler velocity improvement in paediatric sickle cell anaemia: analysis from the Sickle Cell Clinical Research and Intervention Program (SCCRIP) longitudinal cohort study. Br J Haematol 2021; 194:463-468. [PMID: 34131902 DOI: 10.1111/bjh.17620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 05/14/2021] [Accepted: 05/14/2021] [Indexed: 11/27/2022]
Abstract
Children with sickle cell anaemia (SCA) and conditional transcranial Doppler (TCD) flow velocities (conditional: 170-199 cm/s; normal: <170 cm/s) have an increased risk of stroke. The Sickle Cell Clinical Research and Intervention Program (SCCRIP), a lifetime observational study, assessed the influence of haematological markers on TCD velocities. In children (≤16 years) with SCA (HbSS/HbSβ0 -thalassaemia) and conditional TCD velocities (n = 32), increases in haemoglobin and in fetal haemoglobin after hydroxyurea initiation were significantly associated with decreases in TCD velocities. The benefit of pharmacological intervention to increase haemoglobin and fetal haemoglobin and normalise TCD velocities was demonstrated in this real-world dataset.
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Affiliation(s)
- Jeremie H Estepp
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ze Cong
- Global Blood Therapeutics, South San Francisco, CA, USA
| | - Irene Agodoa
- Global Blood Therapeutics, South San Francisco, CA, USA
| | - Guolian Kang
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Juan Ding
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - M Beth McCarville
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Jane S Hankins
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Winfred C Wang
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN, USA
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5
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Rubin MN, Alexandrov AV, Douville C, Rinsky B, Tsivgoulis G. Novel robotic TCD ultrasound with bubbles versus standard care to detect right to left shunt: Study methods. J Neuroimaging 2021; 31:858-863. [PMID: 34081363 PMCID: PMC8518840 DOI: 10.1111/jon.12890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE Right to left shunt (RLS), from patent foramen ovale (PFO) or elsewhere, is a recognized risk factor for stroke. Current standard of care for RLS diagnosis includes transthoracic echocardiography (TTE) which is insensitive, transesophageal echocardiography (TEE) which is invasive, and transcranial Doppler (TCD) which has excellent sensitivity and specificity for RLS but is heavily operator dependent and expertise is scarce. The purpose of this study was to evaluate the RLS detection rate of a novel robotic-assisted TCD (ra-TCD) to standard of care diagnostic techniques, including TTE, TEE, and TCD. METHODS This is a multicenter, prospective, single-arm, nonsignificant risk device study of ra-TCD versus TTE for RLS diagnosis in adult patients who present with neurological signs and symptoms that include embolic stroke or transient ischemic attack on the differential diagnosis. Up to 150 subjects will be enrolled at up to seven centers considering the prevalence of PFO, suboptimal transtemporal windows, and potential dropouts. Enrolled patients will undergo ra-TCD supine and at 45° in a manner otherwise in line with standard of care TCD bubble technique. The enrolled patients will have undergone TTE, and optionally standard TCD and TEE, per usual care. RESULTS The primary efficacy endpoint is percent detection of RLS by ra-TCD compared against TTE. The primary safety endpoint is the incidence of device-related serious adverse events. CONCLUSIONS This is the first multicenter, prospective study evaluating the accuracy, feasibility, and safety of novel ra-TCD for the diagnosis of RLS as compared to standard of care diagnostics.
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Affiliation(s)
- Mark N Rubin
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | | | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Second Department of Neurology, University of Athens, Athens, Greece
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6
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Li J, Wan C. Non-invasive detection of intracranial pressure related to the optic nerve. Quant Imaging Med Surg 2021; 11:2823-2836. [PMID: 34079745 DOI: 10.21037/qims-20-1188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial pressure (ICP) is associated with a variety of diseases. Early diagnosis and the timely intervention of elevated ICP are effective means to clinically reduce the morbidity and mortality of some diseases. The detection and judgment of reduced ICP are beneficial to glaucoma doctor and neuro ophthalmologist to diagnose optic nerve disease earlier. It is important to evaluate and monitor ICP clinically. Although invasive ICP detection is the gold standard, it can have complications. Most non-invasive ICP tests are related to the optic nerve and surrounding tissues due to their anatomical characteristics. Ultrasound, magnetic resonance imaging, transcranial Doppler, papilledema on optical coherence tomography, visual evoked potential, ophthalmodynamometry, the assessment of spontaneous retinal venous pulsations, and eye-tracking have potential for application. Although none of these methods can completely replace invasive technology; however, its repeatable, low risk, high accuracy, gradually attracted people's attention. This review summarizes the non-invasive ICP detection methods related to the optic nerve and the role of the diagnosis and prognosis of neurological disorders and glaucoma. We discuss the advantages and challenges and predict possible areas of development in the future.
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Affiliation(s)
- Jian Li
- Department of Radiology, the First Hospital of China Medical University, Shenyang, China
| | - Chao Wan
- Department of Ophthalmology, the First Hospital of China Medical University, Shenyang, China
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7
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Jin T, Lian W, Xu K, Liu Y, Xu Z, Lu R, Liu M. Effect of combination invasive intracranial pressure (ICP) monitoring and transcranial Doppler in the treatment of severe craniocerebral injury patients with decompressive craniectomy. Ann Palliat Med 2021; 10:4472-4478. [PMID: 33894726 DOI: 10.21037/apm-21-504] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/01/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim of the present study was to explore the clinical effect and to predict the prognosis of severe craniocerebral injury patients with decompressive craniectomy by combining transcranial Doppler (TCD) and invasive intracranial pressure (ICP). METHODS A total of 60 severe craniocerebral injury patients with decompressive craniectomy, who were admitted to Shantou Central Hospital from June 2017 to March 2019, were enrolled in this retrospective study. Of these, 25 patients who had a Glasgow Coma Scale (GCS) score no greater 8 and no less than 6 underwent transcranial Doppler (TCD) before decompressive craniectomy, as well as ICP, after removing the skull and suturing the dura mater. The 60 patients were divided into 2 groups according to the following standards: (I) GCS score ≥8 on the 7th day postoperatively; (II) ICP continuously lower than 25 mmHg for the entire 7-day duration postoperatively; and (III) brain tissue consistently offset from the skull surface by 5 mm. The clinical outcome was determined based on the Glasgow Outcome Scale (GOS) 1, 3, and 6 months postoperatively. The TCD value, ICP, and prognosis were compared between the 2 groups. RESULTS The average postoperative ICP <19 mmHg in the first 24 h, mean blood flow velocity >56.33 cm/s, end-diastolic blood flow velocity >40.28 cm/s, and resistance index <0.57 were statistically significant indicators to predict good prognosis . CONCLUSIONS The use of TCD can predict the prognosis of severe craniocerebral injury patients.
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Affiliation(s)
- Tao Jin
- Department of Neurosurgery, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, China
| | - Weijie Lian
- Department of Neurosurgery, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, China
| | - Ke Xu
- Department of Neurosurgery, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, China
| | - Yan Liu
- Department of Neurosurgery, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, China
| | - Zhennan Xu
- Department of Neurosurgery, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, China
| | - Rongzhang Lu
- Department of Neurosurgery, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, China
| | - Mingfa Liu
- Department of Neurosurgery, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, China
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Abstract
Transcranial Doppler (TCD) screening is an established tool to identify children with sickle cell disease at high risk of stroke. Our objective was to study TCD velocities among sickle cell disease patients while in a steady state. This cross-sectional study included 78 steady state sickle cell disease patients [31 Hb SS (βS/βS) (sickle cell anemia), 47 Hb S/β-thalassemia (HBB: c.20A>T/β-thal)], attending the Pediatric Hematology Clinic at Cairo University Children's Hospital, Cairo, Egypt. All patients underwent TCD velocity assessment as per the Stroke Prevention Trial in Sickle Cell Anemia (STOP) protocol. In our cohort, TCD velocities were comparable among Hb S/β-thal vs. SS patients. Hemolysis indicators correlated significantly to TCD velocities in Hb S/β-thal patients; positive correlation was found between total bilirubin level and right middle cerebral artery (MCA) and right distal internal carotid artery (dICA) TCD velocities (r = 0.428, p = 0.00, r = 0.360, p = 0.01), respectively as well as between reticulocyte count and right MCA, right dICA and right anterior cerebral artery (ACA) TCD velocities (r = 0.424, p = 0.01), (r = 0.40, p = 0.00), (r = 0.303, p = 0.04), respectively. On the other hand, statistically significant negative correlations were found between hemoglobin (Hb) level and right ACA, right dICA TCD velocities (r = -0.290, p = 0.05), (r = -0.324, p = 0.03). Although Hb F is considered an ameliorating factor for disease severity; hemolysis stands as an indicator of risk for TCD velocity elevation, and in turn, risk for stroke among sickle cell disease patients.
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Affiliation(s)
- Khaled Salama
- Department of Pediatrics, Pediatric Hematology & Bone Marrow Transplantation (BMT) Unit, Cairo University, Cairo, Egypt
| | - Rasha Rady
- Department of Pediatrics, Pediatric Hematology & Bone Marrow Transplantation (BMT) Unit, Cairo University, Cairo, Egypt
| | - Rania H Hashem
- Department of Diagnostic and Interventional Radiology, Cairo University, Cairo, Egypt
| | - Mona El-Ghamrawy
- Department of Pediatrics, Pediatric Hematology & Bone Marrow Transplantation (BMT) Unit, Cairo University, Cairo, Egypt
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Abstract
Ultrasound methods are useful in stroke prevention in several ways. Measurement of carotid plaque burden, as either total plaque area (TPA) or total plaque volume (TPV) are strong predictors of cardiovascular risk: much stronger than intima-media thickness, which does not represent true atherosclerosis, but a biologically and genetically distinct phenotype. Measurement of plaque burden is also useful for the study of genetics, and of new risk factors such as toxic products of the intestinal microbiome. Carotid plaque burden is highly correlated with and as predictive of risk as coronary calcium scores, but is less costly and does not require radiation. Furthermore, because carotid plaques change in time over a period of months, they can be used for a new approach to vascular prevention: "Treating arteries instead of treating risk factors". In high-risk patients with asymptomatic carotid stenosis (ACS), this approach, implemented in 2003 in our clinics, was associated with a >80% reduction of stroke and myocardial infarction over 2 years. "Treating arteries without measuring plaque would be like treating hypertension without measuring blood pressure". Ultrasound methods can also be used to assess plaque vulnerability, by detecting echolucency, ulceration and plaque inhomogeneity on assessment of plaque texture. Transcranial Doppler (TCD) embolus detection is useful for risk stratification in patients with ACS; patients with two or more microemboli in an hour of monitoring have a 1-year risk of 15.6%, vs. 1% without microemboli, so this very clearly distinguishes which patients with ACS could benefit from intervention. TCD saline studies are more sensitive than trans-esophageal echocardiography for detection of patent foramen ovale, and more predictive of recurrent stroke. These methods should be more widely used, to reduce the increasing burden of stroke in our aging populations.
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Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada
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10
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Escamilla-Ocañas CE, Venkatasubba Rao CP, Bershad E, Damani R. Temporal Relationship between Hyponatremia and Development of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage Patients: A Retrospective Observational Study. J Stroke Cerebrovasc Dis 2020; 29:104789. [PMID: 32205028 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/19/2020] [Accepted: 02/24/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Hyponatremia is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). Previous studies have reported an association between hyponatremia and vasospasm, however whether hyponatremia directly contributes to the pathogenesis of cerebral vasospasm (CVS), or is a by-product is still unclear. The aim of this study was to explore an association between hyponatremia and CVS after aSAH, and evaluating the temporality of these 2 events. METHODS A retrospective study of consecutive patients with aSAH admitted to the Baylor St. Luke's Medical center between January 2008 and December 2012 was conducted. Demographics, baseline characteristics, serum sodium levels, and evidence of vasospasm detected by transcranial Doppler, CT Angiogram, MR angiogram, and digital subtracted angiography were collected. Patients were dichotomized into a hyponatremic and a normonatremic group. CVS incidence and clinical outcome was compared between groups. Timing of CVS after initial hyponatremia episodes was recorded Results: One hundred and sixty 4 patients with aSAH were included. Hyponatremia was identified in 66 patients (40.2%) and CVS occurred in 71 subjects (43.2%). The incidence of CVS was higher in the hyponatremic group compared to the normonatremic group, 65.1 % versus 28.5%, respectively (P < .001). Hyponatremia preceded CVS by median 1.5 days suggesting a temporal trend. CONCLUSIONS Our study shows a significant association between hyponatremia and CVS, with hyponatremia preceding CVS events. This retrospective finding denotes the need for larger prospective studies, aiming to clarify the temporal relationship of serum sodium levels and CVS.
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Inusa BPD, Sainati L, MacMahon C, Colombatti R, Casale M, Perrotta S, Rampazzo P, Hemmaway C, Padayachee ST. An Educational Study Promoting the Delivery of Transcranial Doppler Ultrasound Screening in Paediatric Sickle Cell Disease: A European Multi-Centre Perspective. J Clin Med 2019; 9:jcm9010044. [PMID: 31878188 PMCID: PMC7019609 DOI: 10.3390/jcm9010044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Effective stroke prevention in sickle cell disease (SCD) is recommended for children with sickle cell anaemia. Effective implementation relies on the correct stratification of stroke risk using Transcranial Doppler Ultrasound (TCD), prior to committing children to long-term treatment with transfusion. Nevertheless, less than 50% of children with SCD in Europe receive annual TCD—one of the reasons being a lack of trained personnel. The present European multi-centre study was designed to promote the standardisation and delivery of effective screening. Methods: Fifty-five practitioners from differing professional backgrounds were recruited to the TCD training program. The impact of the training programme was evaluated in three European haematology clinics by comparing stroke risk classification and middle cerebral artery time-averaged maximum velocity (TAMMV) obtained from a cohort of 555 patients, before and after training. Results: 42% (23/55) of trainees successfully completed the program. The TAMMV, used to predict stroke risk at each Centre, demonstrated the highest values in Centre 3 (p < 0.0001) before training. The imaging-TCD TAMMV was also higher in Centre 3 (p < 0.001). Following training, the TAMMV showed closer agreement between centres for both imaging-TCD and non-imaging TCD. The stroke risk distribution of children at each centre varied significantly before training (p < 0.001), but improved after training (Fisher’s Exact: no treatment = 5.6, p = 0.41, treatment = 13.8, p < 0.01). The same consistency in stroke risk distribution following training was demonstrated with both non-imaging and imaging-TCD data. Conclusion: The attainment of competency in stroke screening using transcranial Doppler scanning (TCD) in sickle cell disease is more feasible for professionals with an ultrasound imaging background. A quality assurance (QA) system is required to ensure that standards are maintained. Further work is in progress to develop an achievable and reproducible QA program.
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Affiliation(s)
- Baba P. D. Inusa
- Paediatric Haematology Department, Evelina London Children’s Hospital, Guy’s & St Thomas’ NHS Foundation Trust, St Thomas Street, London SE1 7EH, UK
- Correspondence: ; Tel.: +44-0207-1884676
| | - Laura Sainati
- Clinic of Pediatric Hematology-Oncology, Department of Child and Maternal Health, Azienda Ospedaliera-Università di Padova, Via 8 Febbraio 1848, 2, 35122 Padova, Italy; (L.S.); (R.C.)
| | - Corrina MacMahon
- Paediatric Haematology, Our Lady’s Children’s Hospital, Cooley Rd, Crumlin, D12 N512 Dublin, Ireland;
| | - Raffaella Colombatti
- Clinic of Pediatric Hematology-Oncology, Department of Child and Maternal Health, Azienda Ospedaliera-Università di Padova, Via 8 Febbraio 1848, 2, 35122 Padova, Italy; (L.S.); (R.C.)
| | - Maddalena Casale
- Università degli Studi della Campania, Luigi Vanvitelli, Via Luciano Armanni, 14-20, 80138 Napoli, Italy; (M.C.); (S.P.)
| | - Silverio Perrotta
- Università degli Studi della Campania, Luigi Vanvitelli, Via Luciano Armanni, 14-20, 80138 Napoli, Italy; (M.C.); (S.P.)
| | - Paola Rampazzo
- Department of Neurosciences, Azienda Ospedaliera-Università di Padova, Via 8 Febbraio 1848, 2, 35122 Padova, Italy;
| | - Claire Hemmaway
- Department of Haematology, Queen’s Hospital, Rom Valley Way, Romford RM7 0AG, UK;
| | - Soundrie T. Padayachee
- Ultrasonic Angiology Department, Guy’s & St Thomas’ NHS Foundation Trust, London SE1 9RT, UK;
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Abstract
Transcranial Doppler (TCD) is the only diagnostic tool that can provide continuous information about cerebral hemodynamics in real time and over extended periods. In the previous paper (Part 1), we have already presented the basic ultrasound physics pertaining to TCD, insonation methods, and various flow patterns. This article describes various advanced applications of TCD such as detection of right-to-left shunt, emboli monitoring, vasomotor reactivity (VMR), monitoring of vasospasm in subarachnoid hemorrhage (SAH), monitoring of intracranial pressure, its role in stoke prevention in sickle cell disease, and as a supplementary test for confirmation of brain death.
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Affiliation(s)
- Arvind K Sharma
- Department of Neurology, Zydus Hospital and BJ Medical College, Civil Hospital, Ahmedabad, Gujarat, India
| | - Lokesh Bathala
- Department of Neurology, BGS Global Hospital, Bangalore, Karnataka, India
| | - Amit Batra
- Department of Neurology, Max Specialty Hopsital, Delhi, India
| | | | - Vijay K Sharma
- Department of Neurology, National University Hospital and YLL School of Medicine, National University of Singapore, Singapore
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13
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Mijalski C, Dakay K, Miller-Patterson C, Saad A, Silver B, Khan M. Magnesium for Treatment of Reversible Cerebral Vasoconstriction Syndrome: Case Series. Neurohospitalist 2015; 6:111-3. [PMID: 27366294 DOI: 10.1177/1941874415613834] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We describe 2 cases of reversible cerebral vasoconstriction syndrome (RCVS) with refractory headache aborted by intravenous magnesium. Case 1 is a 53-year-old woman with subarachnoid hemorrhage due to RCVS presented with refractory headache and persistent vasospasm, despite aggressive treatment with calcium channel blockers (CCBs) and systemic corticosteroids. Subsequently, she experienced dramatic relief of symptoms with intravenous magnesium therapy. She continued oral maintenance therapy and remained symptom free. Case 2 is a 71-year-old female with bilateral temporo-occipital infarcts due to RCVS, presented with refractory headache and persistent vasospasm on transcranial Doppler (TCD), despite aggressive treatment with CCBs. She experienced dramatic relief of symptoms with intravenous magnesium and resolution of vasospasm on TCD. Magnesium may be beneficial for the treatment of refractory headaches in patients with RCVS. Future studies are needed to determine whether it should be considered as a first-line agent.
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Affiliation(s)
- Christina Mijalski
- Department of Neurology, Rhode Island Hospital/Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Katarina Dakay
- Department of Neurology, Rhode Island Hospital/Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Cameron Miller-Patterson
- Department of Neurology, Rhode Island Hospital/Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ali Saad
- Department of Neurology, Rhode Island Hospital/Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Brian Silver
- Department of Neurology, Rhode Island Hospital/Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Muhib Khan
- Department of Neurology, Rhode Island Hospital/Warren Alpert Medical School of Brown University, Providence, RI, USA
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14
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Kanavaki A, Kattamis A, Delaporta P, Papassotiriou I, Spengos K. Evaluation of Intracranial Cerebral Blood Flow Velocities in Splenectomised and Non-Splenectomised Patients with β-Thalassemia Intermedia Using Transcranial Doppler Sonography. In Vivo 2015; 29:501-504. [PMID: 26130796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND A high incidence of clinically-silent cerebral ischemic events has been reported in splenectomised patients with β-thalassemia intermedia (βTI). These could be due to cerebral large-vessel disease. Based on the example of sickle cell disease, we applied transcranial Doppler sonography (TCD) to evaluate cerebral vessels velocity as a possible indicator of cerebral vasculopathy. PATIENTS AND METHODS In our study, we included 17 splenectomised and 13 non-splenectomised (control group) patients with βTI. Non-imaging TCD was performed and the time-averaged mean velocity (TAMV) values of cerebral arteries were measured. RESULTS There was no statistically significant difference between the two groups concerning age, gender, hemoglobin and hematocrit levels, nor in the TAMV values for all examined vessels (p>0.05). A statistically significant difference was found in platelet count (PLT) (p<0.01) that was higher in splenectomised patients. CONCLUSION Our results do not support the presence of large-vessel vasculopathy in splenectomised βTI patients and agree with recent studies reporting that cerebral ischemic events in these patients might be due to microangiopathy or venous thromboembolism.
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Affiliation(s)
- Aikaterini Kanavaki
- First Department of Pediatrics, University of Athens, Medical School, Athens, Greece
| | - Antonis Kattamis
- First Department of Pediatrics, University of Athens, Medical School, Athens, Greece
| | - Polyxeni Delaporta
- First Department of Pediatrics, University of Athens, Medical School, Athens, Greece
| | - Ioannis Papassotiriou
- Department of Clinical Biochemistry, Aghia Sophia Children's Hospital, Goudi, Athens, Greece
| | - Konstantinos Spengos
- First Department of Neurology, Eginition Hospital, University of Athens, Medical School, Athens, Greece
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15
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Lin CJ, Chu YK, Chern CM. RBC volume deficiency in patients with excessive orthostatic decrease in cerebral blood flow velocity. J Chin Med Assoc 2014; 77:174-8. [PMID: 24612999 DOI: 10.1016/j.jcma.2014.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 07/30/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Orthostatic intolerance (OI) is common but heterogeneous. There is a subgroup of OI patients who have excessive decrease in cerebral blood flow velocity (CBFV) of bilateral middle cerebral arteries (MCAs) during head-up tilt without systemic blood pressure change. This study evaluated the role of blood volume reduction in such patients. METHODS Patients with idiopathic OI who had excessive orthostatic decrease (>20% of the supine level) in mean CBFV of bilateral MCAs and who also received blood volume determination were collected. The chromium (⁵¹Cr) dilution method was used for red blood cell (RBC) volume determination in these patients. The blood volume was expressed as a percentage of the expected volume. These patients were further divided into two groups, those with postural tachycardia syndrome (POTS group) and those without (non-POTS group). The data of RBC volume were compared between the two groups. Besides, we used multivariate linear regression to evaluate the factors that predict RBC volume. RESULTS Twenty-five patients (13 females, median age = 28 years) were enrolled in this study. Nine of these patients had POTS (5 females, median age = 26 years) and 16 did not (8 females, median age = 29.5 years). Compared with the expected volume, the RBC volume was significantly reduced in all patients (median = 82% of the expected volume). Moreover, the RBC volume was significantly lower in the POTS group than that in the non-POTS group (78% vs. 85% of the expected volume, p = 0.013). The orthostatic decrease of MCA flow velocity was 28.3% in the POTS group and 32.5% in the non-POTS group (p = 0.140). The orthostatic pulsatility index increment was 15.4% in the POTS group and 20.5% in the non-POTS group (p = 0.438). Moreover, basic demography and hemoglobin levels were not different between the two groups. After multivariate linear regression (dependent variables including age, sex, body surface, and groups), only the presence of POTS significantly predicted the RBC volume (p = 0.006). CONCLUSION The results of our study indicated that low RBC volume may play an important role in the pathophysiology of OI in this group of patients. Moreover, its role seems even more relevant in patients with POTS than in those without. Further studies for mechanistic evaluation are needed in the future.
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Affiliation(s)
- Chun-Jen Lin
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yum-Kung Chu
- Department of Nuclear Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chang-Ming Chern
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC.
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