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Malferrari G, Merli N, Inchingolo V, Siniscalchi A, Laterza D, Monaco D, Arnone G, Zini A, Prada F, Azzini C, Pugliatti M. Role of Advanced Hemodynamic Ultrasound Evaluation in the Differential Diagnosis of Middle Cerebral Artery Stenosis: Introducing Morphological Criteria. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:2428-2435. [PMID: 37550172 DOI: 10.1016/j.ultrasmedbio.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 06/28/2023] [Accepted: 07/09/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE The aim of the work described here was to determine the possible impact of the new technique advanced hemodynamic ultrasound evaluation (AHUSE) in identification of severe intracranial stenosis. Transcranial Doppler (TCD) and transcranial color-coded Doppler (TCCD) provide reliable velocimetric data, the indirect analysis of which allows us to obtain information on the patency of vessels and assumed stenosis range. However, very tight stenoses (>95%) cannot be detected with velocimetric criteria because of spectrum drops and the absence of high velocities, so that the right curve of the Spencer equation cannot be solved. Likewise, high velocities are not detected when analyzing morphologically long stenosis. Furthermore, the current classifications based on velocimetric criteria do not provide any categorization on stenoses with multiple acceleration points (MAPs). METHODS With this Technical Note we aim to introduce, in addition to velocimetric criteria, more morphological criteria based on TCCD with the algorithm of AHUSE to optimize the characterization of intracranial stenosis (IS). TCCD-AHUSE relies on intensity-based next-generation techniques and can be used to identify IS with MAPs and simultaneously perform a morphological assessment of the stenosis length. RESULTS We introduce a new technical ultrasound (U) approach that we tested in a sample of four different types of stenoses combining velocimetric data and AHUSE using Esaote Microvascularization (MicroV) technique to the M1 tract of the middle cerebral artery (MCA). CONCLUSION The authors believe that a multiparametric evaluation is more sensitive and supports the clinician by introducing the morphological concept, not just the velocimetric concept, to differentiate the IS pattern of MCA. The potential for developing a diagnostic/prognostic algorithm is discussed.
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Affiliation(s)
- Giovanni Malferrari
- Stroke Unit and Neurology Unit, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy.
| | - Nicola Merli
- Department of Neuroscience and Rehabilitation, University of Ferrara, Italy
| | - Vincenzo Inchingolo
- Neurology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Antonio Siniscalchi
- Department of Neurology and Stroke Unit, Annunziata Hospital, Cosenza, Italy
| | - Domenico Laterza
- Neurology and Stroke Unit, Nuovo Ospedale degli Infermi, Biella (BI), Italy
| | - Daniela Monaco
- Department of Emergency Neurology and Stroke Unit, "S. Spirito" Hospital, Pescara, Italy
| | - Giorgia Arnone
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Francesco Prada
- Acoustic Neuroimaging and Therapy Lab, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy; Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA; Focused Ultrasound Foundation, Charlottesville, VA, USA
| | - Cristiano Azzini
- Stroke Unit and Neurology Unit, S. Anna University Hospital, Ferrara Italy
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Italy; S. Anna University Hospital, Ferrara Italy
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Mattioni A, Cenciarelli S, Eusebi P, Brazzelli M, Mazzoli T, Del Sette M, Gandolfo C, Marinoni M, Finocchi C, Saia V, Ricci S. Transcranial Doppler sonography for detecting stenosis or occlusion of intracranial arteries in people with acute ischaemic stroke. Cochrane Database Syst Rev 2020; 2:CD010722. [PMID: 32072609 PMCID: PMC7029193 DOI: 10.1002/14651858.cd010722.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND An occlusion or stenosis of intracranial large arteries can be detected in the acute phase of ischaemic stroke in about 42% of patients. The approved therapies for acute ischaemic stroke are thrombolysis with intravenous recombinant tissue plasminogen activator (rt-PA), and mechanical thrombectomy; both aim to recanalise an occluded intracranial artery. The reference standard for the diagnosis of intracranial stenosis and occlusion is intra-arterial angiography (IA) and, recently, computed tomography angiography (CTA) and magnetic resonance angiography (MRA), or contrast-enhanced MRA. Transcranial Doppler (TCD) and transcranial colour Doppler (TCCD) are useful, rapid, noninvasive tools for the assessment of intracranial large arteries pathology. Due to the current lack of consensus regarding the use of TCD and TCCD in clinical practice, we systematically reviewed the literature for studies assessing the diagnostic accuracy of these techniques compared with intra-arterial IA, CTA, and MRA for the detection of intracranial stenosis and occlusion in people presenting with symptoms of ischaemic stroke. OBJECTIVES To assess the diagnostic accuracy of TCD and TCCD for detecting stenosis and occlusion of intracranial large arteries in people with acute ischaemic stroke. SEARCH METHODS We limited our searches from January 1982 onwards as the transcranial Doppler technique was only introduced into clinical practice in the 1980s. We searched MEDLINE (Ovid) (from 1982 to 2018); Embase (Ovid) (from 1982 to 2018); Database of Abstracts of Reviews of Effects (DARE); and Health Technology Assessment Database (HTA) (from 1982 to 2018). Moreover, we perused the reference lists of all retrieved articles and of previously published relevant review articles, handsearched relevant conference proceedings, searched relevant websites, and contacted experts in the field. SELECTION CRITERIA We included all studies comparing TCD or TCCD (index tests) with IA, CTA, MRA, or contrast-enhanced MRA (reference standards) in people with acute ischaemic stroke, where all participants underwent both the index test and the reference standard within 24 hours of symptom onset. We included prospective cohort studies and randomised studies of test comparisons. We also considered retrospective studies eligible for inclusion where the original population sample was recruited prospectively but the results were analysed retrospectively. DATA COLLECTION AND ANALYSIS At least two review authors independently screened the titles and abstracts identified by the search strategies, applied the inclusion criteria, extracted data, assessed methodological quality (using QUADAS-2), and investigated heterogeneity. We contacted study authors for missing data. MAIN RESULTS A comprehensive search of major relevant electronic databases (MEDLINE and Embase) from 1982 to 13 March 2018 yielded 13,534 articles, of which nine were deemed eligible for inclusion. The studies included a total of 493 participants. The mean age of included participants was 64.2 years (range 55.8 to 69.9 years). The proportion of men and women was similar across studies. Six studies recruited participants in Europe, one in south America, one in China, and one in Egypt. Risk of bias was high for participant selection but low for flow, timing, index and reference standard. The summary sensitivity and specificity estimates for TCD and TCCD were 95% (95% CI = 0.83 to 0.99) and 95% (95% CI = 0.90 to 0.98), respectively. Considering a prevalence of stenosis or occlusion of 42% (as reported in the literature), for every 1000 people who receive a TCD or TCCD test, stenosis or occlusion will be missed in 21 people (95% CI = 4 to 71) and 29 (95% CI = 12 to 58) will be wrongly diagnosed as harbouring an intracranial occlusion. However, there was substantial heterogeneity between studies, which was no longer evident when only occlusion of the MCA was considered, or when the analysis was limited to participants investigated within six hours. The performance of either TCD or TCCD in ruling in and ruling out a MCA occlusion was good. Limitations of this review were the small number of identified studies and the lack of data on the use of ultrasound contrast medium. AUTHORS' CONCLUSIONS This review provides evidence that TCD or TCCD, administered by professionals with adequate experience and skills, can provide useful diagnostic information for detecting stenosis or occlusion of intracranial vessels in people with acute ischaemic stroke, or guide the request for more invasive vascular neuroimaging, especially where CT or MR-based vascular imaging are not immediately available. More studies are needed to confirm or refute the results of this review in a larger sample of stroke patients, to verify the role of contrast medium and to evaluate the clinical advantage of the use of ultrasound.
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Affiliation(s)
- Alessia Mattioni
- USL Umbria 1UO NeurologiaVia Luigi Angelini 10Città di CastelloPerugiaItaly06012
| | - Silvia Cenciarelli
- USL Umbria 1UO NeurologiaVia Luigi Angelini 10Città di CastelloPerugiaItaly06012
| | - Paolo Eusebi
- Regional Health Authority of UmbriaEpidemiology DepartmentVia Mario Angeloni 61PerugiaUmbriaItaly06124
| | - Miriam Brazzelli
- University of AberdeenHealth Services Research UnitHealth Sciences BuildingForesterhillAberdeenUKAB25 2ZD
| | - Tatiana Mazzoli
- USL Umbria 1UO NeurologiaVia Luigi Angelini 10Città di CastelloPerugiaItaly06012
| | | | - Carlo Gandolfo
- Università di Genova e Ospedale Policlinico San MartiniDipartimento di Neuroscienze, Oftalmologia, Genetica e Scienze Materno‐InfantiliGenovaItaly16132
| | | | - Cinzia Finocchi
- Università di Genova e Ospedale Policlinico San MartiniDipartimento di Neuroscienze, Oftalmologia, Genetica e Scienze Materno‐InfantiliGenovaItaly16132
| | - Valentina Saia
- Ospedale di Pietra LigureUO NeurologiaPietra LigureItaly
| | - Stefano Ricci
- USL Umbria 1UO NeurologiaVia Luigi Angelini 10Città di CastelloPerugiaItaly06012
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Liu Z, Zhou Y, Yi R, He J, Yang Y, Luo L, Dai Y, Luo X. Quantitative research into the deconditioning of hemodynamic to disorder of consciousness carried out using transcranial Doppler ultrasonography and photoplethysmography obtained via finger-transmissive absorption. Neurol Sci 2016; 37:547-55. [PMID: 26758709 PMCID: PMC4819775 DOI: 10.1007/s10072-015-2429-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 11/23/2015] [Indexed: 11/06/2022]
Abstract
In this study, transcranial Doppler ultrasonography (TCD) and photoplethysmography (PPG) have been utilized, through the observation of peripheral and cerebrovascular hemodynamic changes of the disorder of consciousness (DOC) patients, measured on clinical behavior scale of Coma Recovery Score-Revised (CRS-R) to obesrve their diagnostic value in evaluation of DOC patients. TCD ultrasound was used to evaluate the flow velocity and waveform patterns of middle cerebral artery (MCA), while PPG infrared signals were utilized to assess the peripheral circulation as a mean of measuring cardiovascular activities. The research was carried out on a sample of 36 individuals, of which 16 met the DOC criteria and 20 were healthy individuals. Each person in the patients groups was assessed by the CRS-R. The velocity of middle cerebral artery in tested patients in a whole cardiac cycle, detected by TCD, decreased comparing with normal values. The values of pulsatility index (PI) of the MCA increased in patients groups comparing with normal. Through binary variables correlation analysis, we found that the PI of the left MCA of TCD of the patients significantly inversely correlated with their motor subscore, included in their CRS-R in the level of α = 0.05 (Pearson’s product-moment correlation coefficient = −0.556, p = 0.025). The values of photoplethysmographic augmentation index (PAI) that were detected by PPG increased comparing with normal. Finally, using binary variables correlation analysis we found the significant inverse correlation between the PAI of PPG and the mean velocity of the left MCA of the TCD in the level of α = 0.05 (Pearson’s product-moment correlation coefficient = −0.377, p = 0.022) in all the groups. The results of this study revealed a specific relationship between PI and PAI in the DOC patients. That relationship can potentially be exploited to enhance the capabilities in early assessment of the deconditioning of the DOC patients’ cardiovascular system and its influence on their cerebral vascular system. Ultimately, the dependency discovered can assist in predicting the tendency of the prognosis of the DOC patients in clinic.
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Affiliation(s)
- Zhen Liu
- Department of Neurosurgery, No. 263 Clinical Department of Beijing Army General Hospital, Beijing, 101149, China.
| | - Yan Zhou
- Department of Internal Medicine, TongZhou Maternal and Child Health Hospital of Beijing, Beijing, 100000, China
| | - Rui Yi
- Department of Neurosurgery, Beijing Army General Hospital, Beijing, 100700, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Army General Hospital, Beijing, 100700, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Army General Hospital, Beijing, 100700, China
| | - Li Luo
- Department of Neurosurgery, Beijing Army General Hospital, Beijing, 100700, China
| | - Yiwu Dai
- Department of Neurosurgery, Beijing Army General Hospital, Beijing, 100700, China
| | - Xiaomin Luo
- Healthcare Department, Beijing Genomics Institute, Shenzhen, 518083, China
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Kim JS, Lee SW, Eun MY, Seo WK. Power motion-mode Doppler signature: a useful tool for assessing middle cerebral artery stenosis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2014; 42:348-354. [PMID: 24449334 DOI: 10.1002/jcu.22134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 09/27/2013] [Accepted: 12/16/2013] [Indexed: 06/03/2023]
Abstract
PURPOSE To identify power motion-mode Doppler (PMD) patterns and assess their diagnostic value for the diagnosis of middle cerebral artery (MCA) stenosis. METHODS Retrospective analyses of PMD data were performed for the identification of specific patterns related to MCA stenosis. The interrater reliability and the validity of these patterns were studied, using magnetic resonance angiography and conventional transcranial Doppler sonography as gold standards. RESULTS Three PMD patterns were identified: the so-called black-hole, the white-hole, and the diastolic-band patterns in 58 among 178 MCAs. The mean flow velocity was significantly higher in arterial segments with the black-hole patterns and lower in segments with the diastolic-band pattern compared with the segments with normal patterns. The interrater reliability was good for each pattern. The black-hole pattern or its combination with the white-hole pattern showed the highest validity. CONCLUSION Despite some limitations, the black-hole PMD pattern or its combination with the white-hole pattern appeared as a reliable and valid marker for the diagnosis of MCA stenosis.
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Affiliation(s)
- Ji-Sun Kim
- Department of Neurology, College of Medicine, Korea University, Seoul, Korea
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Fu X, Yin J, Wong KS, Gao C. Reevaluating the transcranial Doppler criteria for estimation of anterior circulation artery stenosis: transcranial Doppler sonography versus digital subtraction angiography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:1187-1191. [PMID: 22837282 DOI: 10.7863/jum.2012.31.8.1187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES The criteria for evaluating cerebral artery stenosis by transcranial Doppler sonography are inconsistent. We aimed to identify the accuracy of transcranial Doppler criteria compared with digital subtraction angiography for diagnosis of anterior circulation artery stenosis. METHODS A total of 170 patients who underwent transcranial Doppler sonography and digital subtraction angiography were recruited. The anterior circulation arteries were evaluated by transcranial Doppler sonography and digital subtraction angiography. We defined the best cutoff value for substantial anterior circulation artery stenosis by receiver operating characteristic curve analyses and calculated the sensitivity, specificity, and positive and negative predictive values. RESULTS An anterior circulation artery peak systolic velocity (PSV) of 120 cm/s had the largest area under the receiver operating characteristic curve compared with PSVs of 110, 130, and 140 cm/s and mean flow velocities of 60, 70, and 80 cm/s. The sensitivity, specificity, false-positive rate, false-negative rate, accuracy, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, and Youden index for transcranial Doppler sonography were 90.6%, 85.0%, 15.0%, 9.4%, 87.9%, 87.2%, 88.9%, 6.04, 0.11, and 0.756, respectively. The reliability index included the agreement rate and κ value, which were 87.9% and 0.757. CONCLUSIONS A PSV of 120 cm/s combined with additional parameters was an accurate criterion for diagnosing anterior circulation artery stenosis. Transcranial Doppler sonography could be considered a valuable method for screening diagnosis of cerebral artery stenosis.
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Affiliation(s)
- Xian Fu
- Institute of Neuroscience, Second Affiliated Hospital, Guangzhou Medical University, 510000 Guangzhou, China
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Hao Q, Gao S, Leung TWH, Guo MH, You Y, Wong KS. Pilot Study of New Diagnostic Criteria for Middle Cerebral Artery Stenosis by Transcranial Doppler. J Neuroimaging 2010; 20:122-9. [DOI: 10.1111/j.1552-6569.2008.00337.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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You Y, Hao Q, Leung T, Mok V, Chen X, Lau A, Leung H, Wong KS. Detection of the Siphon Internal Carotid Artery Stenosis: Transcranial Doppler versus Digital Subtraction Angiography. J Neuroimaging 2009; 20:234-9. [DOI: 10.1111/j.1552-6569.2009.00434.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Wu B, Wang X, Guo J, Xie S, Wong EC, Zhang J, Jiang X, Fang J. Collateral circulation imaging: MR perfusion territory arterial spin-labeling at 3T. AJNR Am J Neuroradiol 2008; 29:1855-60. [PMID: 18784211 DOI: 10.3174/ajnr.a1259] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Current knowledge of the collateral circulation remains sparse, and a noninvasive method to better characterize the role of collaterals is desirable. The aim of our study was to investigate the presence and distal flow of collaterals by using a new MR perfusion territory imaging, vessel-encoded arterial spin-labeling (VE-ASL). MATERIALS AND METHODS Fifty-six patients with internal carotid artery (ICA) or middle cerebral artery (MCA) stenosis were identified by sonography. VE-ASL was performed to assess the presence and function of collateral flow. The perfusion information was combined with VE maps into high signal-intensity-to-noise-ratio 3-colored maps of the left carotid, right carotid, and posterior circulation territories. The presence of the anterior and posterior collateral flow was demonstrated by the color of the standard anterior cerebral artery/MCA flow territory. The distal function of collateral flow was categorized as adequate (cerebral blood flow [CBF] >/=10 mL/min/100 g) or deficient (CBF <10 mL/min/100 g). The results were compared with those of MR angiography (MRA) and intra-arterial digital subtraction angiography (DSA) in cross table, and kappa coefficients were calculated to determine the agreement among different methods. RESULTS The kappa coefficients of the presence of anterior and posterior collaterals by using VE-ASL and MRA were 0.785 and 0.700, respectively. The kappa coefficient of the function of collaterals by using VE-ASL and DSA was 0.726. Apart from collaterals through the circle of Willis, VE-ASL showed collateral flow via leptomeningeal anastomoses. CONCLUSIONS In patients with ICA or MCA stenosis, VE-ASL could show the presence, the origin, and distal function of collateral flow noninvasively.
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Affiliation(s)
- B Wu
- Department of Radiology, Peking University First Hospital, Beijing, China
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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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Lee SM, Chou YH, Li MH, Wan FJ, Yen MH. Effects of haloperidol and risperidone on cerebrohemodynamics in drug-naive schizophrenic patients. J Psychiatr Res 2008; 42:328-35. [PMID: 17412363 DOI: 10.1016/j.jpsychires.2007.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Revised: 01/11/2007] [Accepted: 02/06/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Use of antipsychotics may be associated with cerebrovascular adverse events in psychotic patients. In this study, the effects of haloperidol and risperidone on the cerebral hemodynamics and the possible relationships between antipsychotics and cerebrovascular risks tendency were evaluated by Transcranial Doppler ultrasonography (TCD). METHODS Twenty drug-nai ve schizophrenic patients and 20 normal control subjects were included. The patients were divided into haloperidol- and risperidone-treated groups and received treatment for 8 weeks double-blindly. The subjects' cerebral blood flow mean velocities (MV) and pulsatility index (PI) were measured weekly by TCD. The Positive and Negative Syndrome Scale for schizophrenia (PANSS) was used to assess the patients' psychopathological symptoms. RESULTS Increased MV and decreased PI were found significantly in drug-nai ve schizophrenic patients than normal subjects before treatment (p<0.01). The decreased PI could be normalized after 8 weeks of antipsychotic treatment, while the increased MV could not. Treatment with haloperidol could significantly increase the PI than the treatment with risperidone (p<0.01) throughout the treatment course. The PANSS scores of both groups were significantly improved (p<0.05) at the endpoints of treatment. CONCLUSIONS Our findings indicate that haloperidol may affect the cerebral hemodynamics in drug-naive schizophrenics more prominently than that of risperidone via TCD monitoring.
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Affiliation(s)
- Shin-Min Lee
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
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Navarro JC, Lao AY, Sharma VK, Tsivgoulis G, Alexandrov AV. The accuracy of transcranial Doppler in the diagnosis of middle cerebral artery stenosis. Cerebrovasc Dis 2007; 23:325-30. [PMID: 17268162 DOI: 10.1159/000099130] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Accepted: 11/12/2006] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND PURPOSE It was the aim of this study to systematically review available literature on the accuracy of transcranial Doppler (TCD) compared with angiography for the diagnosis of > or =50% middle cerebral artery stenosis in patients with transient ischemic attack or ischemic stroke. METHODS We performed a systematic review that included original articles published on TCD accuracy from 1982 until the end of December 2005 using angiography as the gold standard. The following measures of diagnostic accuracy were obtained from each primary study: sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Weighted mean averages were then calculated from individual results for different velocity cutoffs. RESULTS Six papers met our selection criteria. Using laboratory-specific variable mean flow velocity cutoffs, self-reported best accuracy results yield a mean weighted average sensitivity of 92%, specificity of 92%, PPV of 88% and NPV of 98% for 80 cm/s cutoff. For 100 cm/s cutoff, the sensitivities were 100%, specificity 97%, PPV 88% and NPV 100%. CONCLUSIONS Although limited to few reports, this analysis demonstrates fair TCD performance against angiography. Since increasing velocity cutoffs do not yield decreasing sensitivity and increasing specificity, further studies are required to determine optimal velocity values and possibly other criteria such as velocity ratios to develop a screening test with balanced performance parameters.
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MESH Headings
- Angiography, Digital Subtraction
- Blood Flow Velocity
- Cerebral Angiography/methods
- Cerebrovascular Circulation
- Constriction, Pathologic/diagnosis
- Constriction, Pathologic/pathology
- Constriction, Pathologic/physiopathology
- Humans
- Infarction, Middle Cerebral Artery/diagnosis
- Infarction, Middle Cerebral Artery/etiology
- Infarction, Middle Cerebral Artery/pathology
- Infarction, Middle Cerebral Artery/physiopathology
- Ischemic Attack, Transient/complications
- Ischemic Attack, Transient/pathology
- Ischemic Attack, Transient/physiopathology
- Magnetic Resonance Angiography
- Middle Cerebral Artery/pathology
- Middle Cerebral Artery/physiopathology
- Predictive Value of Tests
- Reproducibility of Results
- Sensitivity and Specificity
- Stroke/complications
- Stroke/pathology
- Stroke/physiopathology
- Tomography, X-Ray Computed
- Ultrasonography, Doppler, Transcranial
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Affiliation(s)
- Jose C Navarro
- Department of Neurology and Psychiatry, University of Santo Tomas Hospital, Manila, Philippines
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Yoon W, Seo JJ, Cho KH, Kim MK, Kim BC, Park MS, Kim TS, Kim JK, Kang HK. Symptomatic middle cerebral artery stenosis treated with intracranial angioplasty: experience in 32 patients. Radiology 2005; 237:620-6. [PMID: 16192322 DOI: 10.1148/radiol.2372041620] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively review the outcome after angioplasty in patients with symptomatic, high-grade middle cerebral artery (MCA) stenosis refractory to medical therapy. MATERIALS AND METHODS Institutional review board approval to perform angioplasty procedures for MCA stenosis was obtained, and written informed consent was obtained from each patient or the patient's family. Institutional review board approval was also obtained for the retrospective review of patients' data. The institutional review board waived the need for informed consent for this retrospective analysis.Thirty-two consecutive patients (18 men, 14 women; median age, 55 years) with symptomatic MCA stenosis greater than 70% underwent angioplasty between June 1994 and July 2003. The indication for angioplasty was recurrent transient ischemic attack (TIA) refractory to antithrombotic therapy in 24 patients and acute ischemic stroke in eight. Patient records were retrospectively reviewed for angiographic findings, periprocedural complications, and follow-up data. RESULTS Angioplasty reduced the degree of stenosis to less than 50% in 29 of 32 patients (91%). There were two major complications during angioplasty: acute occlusion of the treated MCA and vascular rupture that resulted in death. Thus, the risk of disabling stroke or death was 6% (two of 32 patients), and the mortality rate was 3% (one of 32 patients). The rate of periprocedural TIA was 19% (six of 32 patients). Five patients had asymptomatic intimal dissection. During the follow-up period, which ranged from 5 to 92 months (median, 20 months), TIA occurred in one patient in whom the results of angioplasty were suboptimal. The remaining 29 patients did not experience further ischemic events attributable to the treated MCA stenosis during the follow-up period. Asymptomatic restenosis occurred in one of five patients in whom data from follow-up angiography were available. CONCLUSION MCA angioplasty resulted in a low recurrence rate of ischemic symptoms during long-term follow-up.
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Affiliation(s)
- Woong Yoon
- Department of Radiology, Chonnam National University Hospital, Chonnam National University Medical School, Dong-ku, Gwangju 501-757, South Korea.
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Tang SC, Jeng JS, Yip PK, Lu CJ, Hwang BS, Lin WH, Liu HM. Transcranial color-coded sonography for the detection of middle cerebral artery stenosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2005; 24:451-460. [PMID: 15784763 DOI: 10.7863/jum.2005.24.4.451] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE The purpose of this study was to validate the accuracy and criteria of transcranial color-coded sonography (TCCS) in detecting severe middle cerebral artery (MCA) stenosis. METHODS One hundred ninety-three patients with acute ischemic cerebrovascular disease who received both TCCS and magnetic resonance angiography (MRA) examinations were evaluated. Middle cerebral artery stenosis assessed by MRA was graded as follows: grade 0, normal to mild (< 50%); grade 1, focal severe stenosis (> or = 50% and stenotic length within the M1 prebifurcation segment); and grade 2, diffuse severe stenosis (> or = 50% and stenotic length greater than the M1 prebifurcation segment). The peak systolic velocity (Vs) and mean velocity (Vm) of bilateral MCAs were obtained by TCCS. Estimates of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for TCCS relative to MRA. RESULTS After 46 patients were excluded, 309 MCAs (grade 0, 77.3%; grade 1, 15.5%; and grade 2, 7.1%) were evaluated. The optimal diagnostic accuracy of TCCS for the detection of grade 1 MCA stenosis can be reached if Vs is 140 cm/s or higher or Vm is 90 cm/s or higher (sensitivity, 83.3%; specificity, 91.2%). The optimal diagnostic accuracy of grade 2 MCA stenosis can be obtained if V(s) is lower than 50 cm/s or V(s) is 140 cm/s or higher (sensitivity, 81.8%; specificity, 92.1%). In our study, none of the grade 1 but around half of the grade 2 stenosis showed a low flow velocity pattern. CONCLUSIONS Transcranial color-coded sonography is reliable in detecting severe MCA stenosis. Except for high flow velocity, the addition of a low cutoff of normal flow velocity in our criteria not only increases the study sensitivity but also enables the identification of around half of diffuse severe MCA stenosis.
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Affiliation(s)
- Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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