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Cheng Y, Han X, Xie W, Xu G, Bai X, Qi L, Zhang L, Liu R, Dong W, Feng W, Pang C, Zhang W, Liu F, Cao X, Xu Y, Luo G. Safety and efficacy of magnesium-rich artificial cerebrospinal fluid for subarachnoid hemorrhage. Front Neurol 2024; 15:1376216. [PMID: 38606277 PMCID: PMC11007082 DOI: 10.3389/fneur.2024.1376216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/19/2024] [Indexed: 04/13/2024] Open
Abstract
Objectives This study aimed to investigate the efficacy of using a newly formulated magnesium-rich artificial cerebrospinal fluid (MACSF) as an alternative to normal saline (NS) for intraoperative irrigation during aneurysm clipping in improving the prognosis of patients with Aneurysmal subarachnoid hemorrhage (aSAH). Methods Patients with aSAH who underwent intraoperative irrigation with MACSF or NS during the clipping in the First Affiliated Hospital of Xi 'an Jiaotong University from March 2019 to March 2022 were selected as MACSF group and NS group, respectively. The primary prognostic indicators were the incidence of favorable outcomes (mRS 0-2). The secondary outcome measures included cerebral vasospasm (CVS), mortality, total hospital stay, and intensive care unit (ICU) stay. Safety was evaluated based on the occurrence rates of hypermagnesemia, meningitis, and hydrocephalus. Results Overall, 34 and 37 patients were enrolled in the MACSF and NS groups, respectively. At 90 days after aSAH onset, the proportion of favorable prognosis in the MACSF group was significantly higher than that in the NS group (p = 0.035). The incidence of CVS within 14 days after surgery was significantly lower in the MACSF group than that in the NS group (p = 0.026). The mortality rate in the MACSF group was significantly lower than in the NS group (p = 0.048). The median lengths of hospital stay (p = 0.008) and ICU stay (p = 0.018) were significantly shorter in the MACSF group than in the NS group. No significant differences were observed in safety measures. Conclusion Using MACSF as an irrigation fluid for aneurysm clipping can significantly improve the 90-day prognosis of patients with aSAH, which may be related to the reduced incidence of CVS. Clinical trial registration https://www.clinicaltrials.gov, identifier NCT04358445.
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Affiliation(s)
- Yawen Cheng
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiangning Han
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wanfu Xie
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Gaofeng Xu
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaobin Bai
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Lei Qi
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Linjuan Zhang
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Rui Liu
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Weihua Dong
- Department of Pharmacy Intravenous Admixture Services, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Weiyi Feng
- Department of Pharmacy Intravenous Admixture Services, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Chengsen Pang
- Department of Pharmacy Intravenous Admixture Services, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wei Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Fude Liu
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiangqi Cao
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yue Xu
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Guogang Luo
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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2
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Li W, Zhang Z, Li Z, Gui Z, Shang Y. Correlation and asynchronization of electroencephalogram and cerebral blood flow in active and passive stimulations. J Neural Eng 2023; 20:066007. [PMID: 37931297 DOI: 10.1088/1741-2552/ad0a02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 11/06/2023] [Indexed: 11/08/2023]
Abstract
Objective.Real-time brain monitoring is of importance for intraoperative surgeries and intensive care unit, in order to take timely clinical interventions. Electroencephalogram (EEG) is a conventional technique for recording neural excitations (e.g. brain waves) in the cerebral cortex, and near infrared diffuse correlation spectroscopy (DCS) is an emerging technique that can directly measure the cerebral blood flow (CBF) in microvasculature system. Currently, the relationship between the neural activities and cerebral hemodynamics that reflects the vasoconstriction features of cerebral vessels, especially under both active and passive situation, has not been elucidated thus far, which triggers the motivation of this study.Approach.We used the verbal fluency test as an active cognitive stimulus to the brain, and we manipulated blood pressure changes as a passive challenge to the brain. Under both protocols, the CBF and EEG responses were longitudinally monitored throughout the cerebral stimulus. Power spectrum approaches were applied the EEG signals and compared with CBF responses.Main results.The results show that the EEG response was significantly faster and larger in amplitude during the active cognitive task, when compared to the CBF, but with larger individual variability. By contrast, CBF is more sensitive when response to the passive task, and with better signal stability. We also found that there was a correlation (p< 0.01,r= 0.866,R2= 0.751) between CBF and EEG in initial response during the active task, but no significant correlation (p> 0.05) was found during the passive task. The similar relations were also found between regional brain waves and blood flow.Significance.The asynchronization and correlation between the two measurements indicates the necessity of monitoring both variables for comprehensive understanding of cerebral physiology. Deep exploration of their relationships provides promising implications for DCS/EEG integration in the diagnosis of various neurovascular and psychiatric diseases.
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Affiliation(s)
- Weilong Li
- State Key Laboratory of Dynamic Measurement Technology, North University of China, Taiyuan, People's Republic of China
| | - Zihao Zhang
- School of Electronics and Information Engineering, Harbin Institute of Technology, Harbin, People's Republic of China
| | - Zhiyi Li
- Electronic Information College, Northwestern Polytechnical University, Xian, People's Republic of China
| | - Zhiguo Gui
- State Key Laboratory of Dynamic Measurement Technology, North University of China, Taiyuan, People's Republic of China
| | - Yu Shang
- State Key Laboratory of Dynamic Measurement Technology, North University of China, Taiyuan, People's Republic of China
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Favilla CG, Carter S, Hartl B, Gitlevich R, Mullen MT, Yodh AG, Baker WB, Konecky S. Validation of the Openwater wearable optical system: cerebral hemodynamic monitoring during a breath hold maneuver. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.11.23296612. [PMID: 37873126 PMCID: PMC10592983 DOI: 10.1101/2023.10.11.23296612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Bedside cerebral blood flow (CBF) monitoring has the potential to inform and improve care for acute neurologic diseases, but technical challenges limit the use of existing techniques in clinical practice. Here we validate the Openwater optical system, a novel wearable headset that uses laser speckle contrast to monitor microvascular hemodynamics. We monitored 25 healthy adults with the Openwater system and concurrent transcranial Doppler (TCD) while performing a breath-hold maneuver to increase CBF. Relative blood flow (rBF) was derived from the changes in speckle contrast, and relative blood volume (rBV) was derived from the changes in speckle average intensity. A strong correlation was observed between beat-to-beat optical rBF and TCD-measured cerebral blood flow velocity (CBFv), R=0.79; the slope of the linear fit indicates good agreement, 0.87 (95% CI:0.83-0.92). Beat-to-beat rBV and CBFv were strongly correlated, R=0.72, but as expected the two variables were not proportional; changes in rBV were smaller than CBFv changes, with linear fit slope of 0.18 (95% CI:0.17-0.19). Further, strong agreement was found between rBF and CBFv waveform morphology and related metrics. This first in vivo validation of the Openwater optical system highlights its potential as a cerebral hemodynamic monitor, but additional validation is needed in disease states.
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4
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AIUM Practice Parameter for the Performance of Transcranial Doppler Ultrasound. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:E36-E44. [PMID: 37132485 DOI: 10.1002/jum.16234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 05/04/2023]
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Non-association of stroke risk with intracranial hemodynamic steal in patients with symptomatic internal carotid artery occlusions. J Stroke Cerebrovasc Dis 2023; 32:106797. [PMID: 36527943 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/18/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Paradoxical intracranial hemodynamic steal (IHS) is known in patients having persistent proximal arterial occlusions and is linked with early neurological worsening. However, stroke risk specific to symptomatic internal carotid artery occlusions (SICAO) having paradoxical IHS is unknown. Therefore, we aimed to investigate the association of paradoxical IHS in SICAO patients with stroke recurrence during a one-year follow-up. MATERIALS AND METHODS We prospectively enrolled adult patients having SICAO with a recent history of ischemic events. Steal magnitude (SM) to classify patients in IHS and non-IHS categories was evaluated by a breath-holding test using bilateral transcranial doppler (TCD). Patients were prescribed optimal medical therapy and followed up for one year for any ischemic stroke/TIA/cardiovascular death. RESULTS 36 SICAO patients, mean age of 56 years, were assessed using TCD at median 22.5 days (Interquartile range, IQR= 9-42), and 11 (30.6%) had paradoxical IHS with median SM 12% (IQR= 6%-18%). On follow-up, 7 (19.4%) patients had event recurrence and its association with IHS was non-significant (IHS vs non-IHS, 18.2% vs 20%; Log-rank statistics=0.006; P=0.940). On Cox regression analysis, event recurrence was independently associated with the presence of significant contralateral stenosis only (regression coefficient= 2.237; P= 0.012; 95% CI= 1.63-53.89). CONCLUSIONS IHS prevalence among SICAO is high. However, paradoxical IHS was not associated with an increased risk of stroke in SICAO. Therefore, the presence of paradoxical IHS in SICAO may be considered a transit state and does not necessarily imply an increased risk of stroke.
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6
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Gan L, Yin X, Huang J, Jia B. Transcranial Doppler analysis based on computer and artificial intelligence for acute cerebrovascular disease. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2023; 20:1695-1715. [PMID: 36899504 DOI: 10.3934/mbe.2023077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Cerebrovascular disease refers to damage to brain tissue caused by impaired intracranial blood circulation. It usually presents clinically as an acute nonfatal event and is characterized by high morbidity, disability, and mortality. Transcranial Doppler (TCD) ultrasonography is a non-invasive method for the diagnosis of cerebrovascular disease that uses the Doppler effect to detect the hemodynamic and physiological parameters of the major intracranial basilar arteries. It can provide important hemodynamic information that cannot be measured by other diagnostic imaging techniques for cerebrovascular disease. And the result parameters of TCD ultrasonography such as blood flow velocity and beat index can reflect the type of cerebrovascular disease and serve as a basis to assist physicians in the treatment of cerebrovascular diseases. Artificial intelligence (AI) is a branch of computer science which is used in a wide range of applications in agriculture, communications, medicine, finance, and other fields. In recent years, there are much research devoted to the application of AI to TCD. The review and summary of related technologies is an important work to promote the development of this field, which can provide an intuitive technical summary for future researchers. In this paper, we first review the development, principles, and applications of TCD ultrasonography and other related knowledge, and briefly introduce the development of AI in the field of medicine and emergency medicine. Finally, we summarize in detail the applications and advantages of AI technology in TCD ultrasonography including the establishment of an examination system combining brain computer interface (BCI) and TCD ultrasonography, the classification and noise cancellation of TCD ultrasonography signals using AI algorithms, and the use of intelligent robots to assist physicians in TCD ultrasonography and discuss the prospects for the development of AI in TCD ultrasonography.
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Affiliation(s)
- Lingli Gan
- Department of Neurology, Chongqing General Hospital, Chongqing 401147, China
| | - Xiaoling Yin
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
| | - Jiating Huang
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, China
| | - Bin Jia
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
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7
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Kargiotis O, Psychogios K, Safouris A, Spiliopoulos S, Karapanayiotides T, Bakola E, Mantatzis M, Dardiotis E, Ellul J, Giannopoulos S, Magoufis G, Tsivgoulis G. Diagnosis and treatment of acute isolated proximal internal carotid artery occlusions: a narrative review. Ther Adv Neurol Disord 2022; 15:17562864221136335. [PMID: 36437850 PMCID: PMC9685148 DOI: 10.1177/17562864221136335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/16/2022] [Indexed: 07/27/2023] Open
Abstract
The clinical manifestations of proximal (extracranial) internal carotid artery occlusions (pICAOs) may range from asymptomatic to acute, large, and devastating ischemic strokes. The etiology and pathophysiology of the occlusion, intracranial collateral status and patient's premorbid status are among the factors determining the clinical presentation and outcome of pICAOs. Rapid and accurate diagnosis is crucial and may be assisted by the combination of carotid and transcranial duplex sonography, or a computed tomography/magnetic resonance angiography (CTA/MRA). It should be noted that with either imaging modalities, the discrimination of a pseudo-occlusion of the extracranial internal carotid artery (ICA) from a true pICAO may not be straightforward. In the absence of randomized data, the management of acute, symptomatic pICAOs remains individualized and relies largely on expert opinion. Administration of intravenous thrombolysis is reasonable and probably beneficial in the settings of acute ischemic stroke with early presentation. Unfortunately, rates of recanalization are rather low and acute interventional reperfusion therapies emerge as a potentially powerful therapeutic option for patients with persistent and severe symptoms. However, none of the pivotal clinical trials on mechanical thrombectomy for acute ischemic stroke randomized patients with isolated extracranial large vessel occlusions. On the contrary, several lines of evidence from non-randomized studies have shown that acute carotid endarterectomy, or endovascular thrombectomy/stenting of the ICA are feasible and safe, and pοtentially beneficial. The heterogeneity in the pathophysiology and clinical presentation of acute pICAOs renders patient selection for an acute interventional treatment a complicated decision-making process. The present narrative review will outline the pathophysiology, clinical presentation, diagnostic challenges, and possible treatment options for pICAOs.
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Affiliation(s)
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
- Aktios Rehabilitation Center, Koropi,
Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional
Radiology Unit, ‘Attikon’ University General Hospital, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of
Medicine, Faculty of Health Sciences, AHEPA University General Hospital,
Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bakola
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
| | - Michail Mantatzis
- Department of Radiology, Interventional
Neuroradiology Unit, AHEPA University General Hospital, Aristotle University
of Thessaloniki, Thessaloniki, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital
of Larissa, School of Medicine, University of Thessaly, Larissa,
Greece
| | - John Ellul
- Department of Neurology, University General
Hospital of Patras, Patras, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
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8
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D'Andrea A, Fabiani D, Cante L, Caputo A, Sabatella F, Riegler L, Alfano G, Russo V. Transcranial Doppler ultrasound: Clinical applications from neurological to cardiological setting. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1212-1223. [PMID: 36218211 DOI: 10.1002/jcu.23344] [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: 07/31/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 06/16/2023]
Abstract
Transcranial Doppler (TCD) ultrasonography is a rapid, noninvasive, real-time, and low-cost imaging technique. It is performed with a low-frequency (2 MHz) probe in order to evaluate the cerebral blood flow (CBF) and its pathological alterations, through specific acoustic windows. In the recent years, TCD use has been expanded across many clinical settings. Actually, the most widespread indication for TCD exam is represented by the diagnosis of paradoxical embolism, due to patent foramen ovale, in young patients with cryptogenic stroke. In addition, TCD has also found useful applications in neurological care setting, including the following: cerebral vasospasm following acute subarachnoid hemorrhage, brain trauma, cerebrovascular atherosclerosis, and evaluation of CBF and cerebral autoregulation after an ischemic stroke event. The present review aimed to describe the most recent evidences of TCD utilization from neurological to cardiological setting.
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Affiliation(s)
- Antonello D'Andrea
- Cardiology Unit, Umberto I Hospital, University of Campania "Luigi Vanvitelli", Nocera Inferiore, Italy
| | - Dario Fabiani
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Luigi Cante
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Adriano Caputo
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Francesco Sabatella
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Lucia Riegler
- Cardiology Unit, Umberto I Hospital, University of Campania "Luigi Vanvitelli", Nocera Inferiore, Italy
| | - Gabriele Alfano
- Cardiology Unit, Umberto I Hospital, University of Campania "Luigi Vanvitelli", Nocera Inferiore, Italy
| | - Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
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9
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Dzierzęcki S, Ząbek M, Zaczyński A, Tomasiuk R. Prognostic properties of the association between the S‑100B protein levels and the mean cerebral blood flow velocity in patients diagnosed with severe traumatic brain injury. Biomed Rep 2022; 17:58. [PMID: 35719835 PMCID: PMC9201289 DOI: 10.3892/br.2022.1541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/21/2021] [Indexed: 11/06/2022] Open
Abstract
Craniocerebral injury (CBI) is tissue damage caused by a sudden mechanical force. CBI can result in neurological, neuropsychological and psychiatric dysfunctions. Currently, the severity of CBI is assessed using the Glasgow Coma Scale, brain perfusion pressure measurements, transcranial Doppler tests and biochemical markers. This study aimed to determine the applicability of the S-100B protein levels and the time-averaged mean maximum cerebral blood flow velocity (Vmean) as a means of predicting the treatment outcomes of CBI in the first 4 days of hospitalization. The results validated the standard reference ranges previously proposed for the concentration of S-100B (0.05-0.23 µg/l) and the mean of cerebral blood flow velocity (30.9 to 74.1 cm/sec). The following stratification scheme was used to predict the success of treatment: Patients with a Glasgow Outcome Scale (GOS) score ≥4 or GOS <4 were stratified into ‘favorable’ and ‘unfavorable’ groups, respectively. The favorable group showed relatively constant levels of the S-100B protein close to the normal range and exhibited an increase in Vmean, but this was still within the normal range. The unfavorable group exhibited a high level of S-100B protein and increased Vmean outside of the normal ranges. The changes in the levels of S-100B in the unfavorable and favorable groups were -0.03 and -0.006 mg/l/h, respectively. Furthermore, the rate of decrease in the Vmean value in the unfavorable and favorable groups were -0.26 and -0.18 cm/sec/h, respectively. This study showed that constant levels of S-100B protein, even slightly above the normal range, associated with an increase in Vmean was indicative of a positive therapeutic outcome. However, additional research is required to obtain the appropriate statistical strength required for clinical practice.
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Affiliation(s)
| | - Mirosław Ząbek
- Department of Neurosurgery, Postgraduate Medical Centre, 03‑242 Warsaw, Poland
| | - Artur Zaczyński
- Clinical Department of Neurosurgery, Central Clinical Hospital of the Ministry of the Interior and Administration, 02‑507 Warsaw, Poland
| | - Ryszard Tomasiuk
- Faculty of Medical Sciences and Health Sciences, Kazimierz Pulaski University of Technology and Humanities Radom, 26‑600 Radom, Poland
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10
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Baang HY, Chen HY, Herman AL, Gilmore EJ, Hirsch LJ, Sheth KN, Petersen NH, Zafar SF, Rosenthal ES, Westover MB, Kim JA. The Utility of Quantitative EEG in Detecting Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. J Clin Neurophysiol 2022; 39:207-215. [PMID: 34510093 PMCID: PMC8901442 DOI: 10.1097/wnp.0000000000000754] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY In this review, we discuss the utility of quantitative EEG parameters for the detection of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage in the context of the complex pathophysiology of DCI and the limitations of current diagnostic methods. Because of the multifactorial pathophysiology of DCI, methodologies solely assessing blood vessel narrowing (vasospasm) are insufficient to detect all DCI. Quantitative EEG has facilitated the exploration of EEG as a diagnostic modality of DCI. Multiple quantitative EEG parameters such as alpha power, relative alpha variability, and alpha/delta ratio show reliable detection of DCI in multiple studies. Recent studies on epileptiform abnormalities suggest that their potential for the detection of DCI. Quantitative EEG is a promising, continuous, noninvasive, monitoring modality of DCI implementable in daily practice. Future work should validate these parameters in larger populations, facilitated by the development of automated detection algorithms and multimodal data integration.
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Affiliation(s)
| | - Hsin Yi Chen
- Dept of Neurology, Yale University, New Haven, CT USA 06520
| | | | | | | | - Kevin N Sheth
- Dept of Neurology, Yale University, New Haven, CT USA 06520
| | | | - Sahar F Zafar
- Dept of Neurology, Massachussetts General Hospital, Boston, MA USA 02114
| | - Eric S Rosenthal
- Dept of Neurology, Massachussetts General Hospital, Boston, MA USA 02114
| | - M Brandon Westover
- Dept of Neurology, Massachussetts General Hospital, Boston, MA USA 02114
| | - Jennifer A Kim
- Dept of Neurology, Yale University, New Haven, CT USA 06520
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11
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Gao X, Zou X, Li R, Shu H, Yu Y, Yang X, Shang Y. Application of POCUS in patients with COVID-19 for acute respiratory distress syndrome management: a narrative review. BMC Pulm Med 2022; 22:52. [PMID: 35123448 PMCID: PMC8817642 DOI: 10.1186/s12890-022-01841-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 01/24/2022] [Indexed: 01/08/2023] Open
Abstract
COVID-19 has inflicted the world for over two years. The recent mutant virus strains pose greater challenges to disease prevention and treatment. COVID-19 can cause acute respiratory distress syndrome (ARDS) and extrapulmonary injury. Dynamic monitoring of each patient's condition is necessary to timely tailor treatments, improve prognosis and reduce mortality. Point-of-care ultrasound (POCUS) is broadly used in patients with ARDS. POCUS is recommended to be performed regularly in COVID-19 patients for respiratory failure management. In this review, we summarized the ultrasound characteristics of COVID-19 patients, mainly focusing on lung ultrasound and echocardiography. Furthermore, we also provided the experience of using POCUS to manage COVID-19-related ARDS.
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12
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Tsivgoulis G, Safouris A, Alexandrov AV. Ultrasonography. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00046-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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13
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Michimoto I, Miyashita K, Suzuyama H, Yano K, Kobayashi Y, Saito K, Matsukawa M. Simulation study on the effects of cancellous bone structure in the skull on ultrasonic wave propagation. Sci Rep 2021; 11:17592. [PMID: 34475422 PMCID: PMC8413454 DOI: 10.1038/s41598-021-96502-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 08/11/2021] [Indexed: 12/15/2022] Open
Abstract
The transcranial Doppler method (TCD) enables the measurement of cerebral blood flow velocity and detection of emboli by applying an ultrasound probe to the temporal bone window, or the orbital or greater occipital foramina. TCD is widely used for evaluation of cerebral vasospasm after subarachnoid hemorrhage, early detection of patients with arterial stenosis, and the assessment of brain death. However, measurements often become difficult in older women. Among various factors contributing to this problem, we focused on the effect of the diploe in the skull bone on the penetration of ultrasound into the brain. In particular, the effect of the cancellous bone structure in the diploe was investigated. Using a 2D digital bone model, wave propagation through the skull bone was investigated using the finite-difference time-domain (FDTD) method. We fabricated digital bone models with similar structure but different BV/TV (bone volume/total volume) values in the diploe. At a BV/TV of approximately 50–60% (similar to that of older women), the minimum ultrasound amplitude was observed as a result of scattering and multiple reflections in the cancellous diploe. These results suggest that structural changes such as osteoporosis may be one factor hampering TCD measurements.
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14
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Evaluation of neurosonology versus digital subtraction angiography in acute stroke patients. J Clin Neurosci 2021; 91:378-382. [PMID: 34373055 DOI: 10.1016/j.jocn.2021.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 11/22/2022]
Abstract
Stroke is one of the most common neurological disorders with a high incidence in Middle-eastern regions. We aimed to assess the diagnostic accuracy of neurovascular ultrasound to detect of cerebral artery stenosis compared to digital subtraction angiography (DSA) as a gold standard method. Eighty patients presenting with symptoms of cerebral ischemia were enrolled in the study. They were examined by cervical color Doppler ultrasound and TCCS to determine stenosis of extracranial and intracranial arteries, respectively. DSA was performed 24-48 h after the initial examination. The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of neurovascular ultrasound in comparison to DSA were calculated. The agreement between the two methods was determined by kappa statistics. Eighty patients (60% male, 40% female) with a mean age of 61.32 ± 12.6 years were included. In 65% of patients, stenosis in carotid artery caused ischemic symptoms. We did not observe any stenosis in anterior cerebral artery, posterior cerebral artery and basilar artery in patients. The agreement between the neurovascular ultrasound and DSA in various arterial vessels was 0.9 for common carotid artery, 0.86 for internal carotid artery, 0.78 for middle cerebral artery, and 0.86 for vertebral artery. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and kappa value of the neurovascular ultrasound for detecting stenosis regarding the arterial segments were 84.8%, 81%, 92.6%, 65.4%, 83.8, and 0.71, respectively. In conclusion, the neurovascular ultrasound is a valuable, non-invasive, and repeatable method to investigate cerebral artery stenosis with high diagnostic accuracy.
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15
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Mazumder D, Wu MM, Ozana N, Tamborini D, Franceschini MA, Carp SA. Optimization of time domain diffuse correlation spectroscopy parameters for measuring brain blood flow. NEUROPHOTONICS 2021; 8:035005. [PMID: 34395719 PMCID: PMC8358828 DOI: 10.1117/1.nph.8.3.035005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/15/2021] [Indexed: 05/05/2023]
Abstract
Significance: Time domain diffuse correlation spectroscopy (TD-DCS) can offer increased sensitivity to cerebral hemodynamics and reduced contamination from extracerebral layers by differentiating photons based on their travel time in tissue. We have developed rigorous simulation and evaluation procedures to determine the optimal time gate parameters for monitoring cerebral perfusion considering instrumentation characteristics and realistic measurement noise. Aim: We simulate TD-DCS cerebral perfusion monitoring performance for different instrument response functions (IRFs) in the presence of realistic experimental noise and evaluate metrics of sensitivity to brain blood flow, signal-to-noise ratio (SNR), and ability to reject the influence of extracerebral blood flow across a variety of time gates to determine optimal operating parameters. Approach: Light propagation was modeled on an MRI-derived human head geometry using Monte Carlo simulations for 765- and 1064-nm excitation wavelengths. We use a virtual probe with a source-detector separation of 1 cm placed in the pre-frontal region. Performance metrics described above were evaluated to determine optimal time gate(s) for different IRFs. Validation of simulation noise estimates was done with experiments conducted on an intralipid-based liquid phantom. Results: We find that TD-DCS performance strongly depends on the system IRF. Among Gaussian pulse shapes, ∼ 300 ps pulse length appears to offer the best performance, at wide gates (500 ps and larger) with start times 400 and 600 ps after the peak of the TPSF at 765 and 1064 nm, respectively, for a 1-s integration time at photon detection rates seen experimentally (600 kcps at 765 nm and 4 Mcps at 1064 nm). Conclusions: Our work shows that optimal time gates satisfy competing requirements for sufficient sensitivity and sufficient SNR. The achievable performance is further impacted by system IRF with ∼ 300 ps quasi-Gaussian pulse obtained using electro-optic laser shaping providing the best results.
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Affiliation(s)
- Dibbyan Mazumder
- Harvard Medical School, Massachusetts General Hospital, Optics at Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Charlestown, Massachusetts, United States
- Address all correspondence to Dibbyan Mazumder,
| | - Melissa M. Wu
- Harvard Medical School, Massachusetts General Hospital, Optics at Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Charlestown, Massachusetts, United States
| | - Nisan Ozana
- Harvard Medical School, Massachusetts General Hospital, Optics at Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Charlestown, Massachusetts, United States
| | - Davide Tamborini
- Harvard Medical School, Massachusetts General Hospital, Optics at Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Charlestown, Massachusetts, United States
| | - Maria Angela Franceschini
- Harvard Medical School, Massachusetts General Hospital, Optics at Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Charlestown, Massachusetts, United States
| | - Stefan A. Carp
- Harvard Medical School, Massachusetts General Hospital, Optics at Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Charlestown, Massachusetts, United States
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16
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O'Brien NF, Reuter-Rice K, Wainwright MS, Kaplan SL, Appavu B, Erklauer JC, Ghosh S, Kirschen M, Kozak B, Lidsky K, Lovett ME, Mehollin-Ray AR, Miles DK, Press CA, Simon DW, Tasker RC, LaRovere KL. Practice Recommendations for Transcranial Doppler Ultrasonography in Critically Ill Children in the Pediatric Intensive Care Unit: A Multidisciplinary Expert Consensus Statement. J Pediatr Intensive Care 2021; 10:133-142. [PMID: 33884214 PMCID: PMC8052112 DOI: 10.1055/s-0040-1715128] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/12/2020] [Indexed: 12/16/2022] Open
Abstract
Transcranial Doppler ultrasonography (TCD) is being used in many pediatric intensive care units (PICUs) to aid in the diagnosis and monitoring of children with known or suspected pathophysiological changes to cerebral hemodynamics. Standardized approaches to scanning protocols, interpretation, and documentation of TCD examinations in this setting are lacking. A panel of multidisciplinary clinicians with expertise in the use of TCD in the PICU undertook a three-round modified Delphi process to reach unanimous agreement on 34 statements and then create practice recommendations for TCD use in the PICU. Use of these recommendations will help to ensure that high quality TCD images are captured, interpreted, and reported using standard nomenclature. Furthermore, use will aid in ensuring reproducible and meaningful study results between TCD practitioners and across PICUs.
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Affiliation(s)
- Nicole Fortier O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Ohio, United States
| | - Karin Reuter-Rice
- Department of Pediatrics, Division of Pediatric Critical Care, School of Medicine, School of Nursing, Duke University, Duke Institute for Brain Sciences, North Carolina, United States
| | - Mark S. Wainwright
- Department of Neurology, University of Washington, Seattle Children's Hospital, Washington, United States
| | - Summer L. Kaplan
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Brian Appavu
- Department of Pediatrics, Division of Critical Care Medicine, Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine—Phoenix, Arizona, United States
| | - Jennifer C. Erklauer
- Department of Pediatrics, Division of Critical Care Medicine and Neurology, Baylor College of Medicine, Texas Children's Hospital, Texas, United States
| | - Suman Ghosh
- Department of Pediatrics, Division of Pediatric Neurology, University of Florida, College of Medicine, Florida, United States
| | - Matthew Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Brandi Kozak
- Department of Radiology, Ultrasound Division, Center for Pediatric Contrast Ultrasound, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Karen Lidsky
- Department of Pediatrics, Division of Pediatric Critical Care, Wolfson Children's Hospital, University of Florida, Florida, United States
| | - Marlina Elizabeth Lovett
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Ohio, United States
| | - Amy R. Mehollin-Ray
- Department of Radiology, Baylor College of Medicine, E.B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Texas, United States
| | - Darryl K. Miles
- Department of Pediatrics/Division of Critical Care, UT Southwestern Medical Center, Texas, United States
| | - Craig A. Press
- Department of Pediatrics, Section of Child Neurology, University of Colorado, Children's Hospital Colorado, Colorado, United States
| | - Dennis W. Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pennsylvania, United States
| | - Robert C. Tasker
- Departments of Neurology & Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Massachusetts, United States
| | - Kerri Lynn LaRovere
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Massachusetts, United States
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17
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Sallam A, Abdelaal Ahmed Mahmoud M Alkhatip A, Kamel MG, Hamza MK, Yassin HM, Hosny H, Younis MI, Ramadan E, Algameel HZ, Abdelhaq M, Abdelkader M, Mills KE, Mohamed H. The Diagnostic Accuracy of Noninvasive Methods to Measure the Intracranial Pressure: A Systematic Review and Meta-analysis. Anesth Analg 2021; 132:686-695. [PMID: 32991330 DOI: 10.1213/ane.0000000000005189] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although invasive monitoring is the standard method for intracranial pressure (ICP) measurement, it is not without potential for serious complications. Noninvasive methods have been proposed as alternatives to invasive ICP monitoring. The study aimed to investigate the diagnostic accuracy of the currently available noninvasive methods for intracranial hypertension (ICH) monitoring. METHODS We searched 5 databases for articles evaluating the diagnostic accuracy of noninvasive methods in diagnosing ICH in PubMed, Institute of Science Index, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase. The quantitative analysis was conducted if there were at least 2 studies evaluating a specific method. The accuracy measures included the sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. RESULTS We included 134 articles. Ultrasonographic optic nerve sheath diameter (US ONSD) had high diagnostic accuracy (estimated sensitivity of 90%; 95% confidence interval [CI], 87-92, estimated specificity of 88%; 95% CI, 84-91) while the magnetic resonance imaging (MRI) ONSD had estimated sensitivity of 77%; 95% CI, 64-87 and estimated specificity of 89%; 95% CI, 84-93, and computed tomography (CT) ONSD had estimated sensitivity of 93%; 95% CI, 90-96 and estimated specificity of 79%; 95% CI, 56-92. All MRI signs had a very high estimated specificity ranging from 90% to 99% but a low estimated sensitivity except for sinus stenosis which had high estimated sensitivity as well as specificity (90%; 95% CI, 75-96 and 96%; 95% CI, 91-99, respectively). Among the physical examination signs, pupillary dilation had a high estimated specificity (86%; 95% CI, 76-93). Other diagnostic tests to be considered included pulsatility index, papilledema, transcranial Doppler, compression or absence of basal cisterns, and ≥10 mm midline shift. Setting the cutoff value of ICH to ≥20 mm Hg instead of values <20 mm Hg was associated with higher sensitivity. Moreover, if the delay between invasive and noninvasive methods was within 1 hour, the MRI ONSD and papilledema had a significantly higher diagnostic accuracy compared to the >1 hour subgroup. CONCLUSIONS Our study showed several promising tools for diagnosing ICH. Moreover, we demonstrated that using multiple, readily available, noninvasive methods is better than depending on a single sign such as physical examination or CT alone.
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Affiliation(s)
- Amr Sallam
- From the Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland.,Department of Anaesthesia, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Ahmed Abdelaal Ahmed Mahmoud M Alkhatip
- Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, United Kingdom.,Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | | | | | - Hany Mahmoud Yassin
- Department of Anesthesia, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Hisham Hosny
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt.,Department of Anaesthesia, Essex Cardiothoracic Center, Basildon and Thurrock University Hospital, Basildon, United Kingdom
| | - Mohamed I Younis
- Department of Anaesthesia, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Eslam Ramadan
- From the Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland.,Department of Anaesthesia, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Haytham Zien Algameel
- Department of Anaesthesia, Aberdeen Royal Infirmary Hospital, Aberdeen, United Kingdom
| | - Mohamed Abdelhaq
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Abdelkader
- Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Kerry E Mills
- Department of Science and Technology, University of Canberra, Canberra, ACT, Australia
| | - Hassan Mohamed
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt.,Department of Anaesthesia and Intensive Care, Cork University Hospital, Cork, Ireland
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18
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Atwi S, Sweeny M, Cohen E, Robertson AD, Marzolini S, Swardfager W, Swartz RH, Oh PI, MacIntosh BJ. Cerebrovascular assessments to help understand brain-related changes associated with aerobic exercise after stroke. Appl Physiol Nutr Metab 2021; 46:412-415. [PMID: 33400620 DOI: 10.1139/apnm-2020-0228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Evidence suggests exercise is "good medicine" after stroke, yet consensus is lacking on the time to initiate, type, exertion level, and duration per session. It remains a challenge to identify outcome measures for stroke-exercise trials that are sufficiently sensitive to intervention parameters. Cerebrovascular assessments, namely cerebral blood flow and intracranial pulsatility, are herein discussed as examples of quantitative brain-specific measures that may be useful to monitor exercise-related brain changes and help to guide stroke rehabilitation interventions. Novelty: Cerebral blood flow and arterial stiffness are potential vascular targets for stroke exercise trials.
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Affiliation(s)
- Sarah Atwi
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Michelle Sweeny
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Ellen Cohen
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Andrew D Robertson
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Susan Marzolini
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, ON M4G 2V6, Canada
| | - Walter Swardfager
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Richard H Swartz
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada.,Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Paul I Oh
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, ON M4G 2V6, Canada
| | - Bradley J MacIntosh
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Research Institute, University of Toronto, Toronto, ON M4N 3M5, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
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19
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Viticchi G, Falsetti L, Buratti L, Acciarri MC, Emiliani A, Bartolini M, Silvestrini M. Carotid occlusion: Impact of cerebral hemodynamic impairment on cognitive performances. Int J Geriatr Psychiatry 2021; 36:197-206. [PMID: 32857468 DOI: 10.1002/gps.5414] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 06/11/2020] [Accepted: 08/14/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The aim of this study was to investigate whether the presence of carotid artery occlusion (CO) may be associated with different cognitive performances in relation to the side of the occlusion and its hemodynamic consequences. METHODS During a 12-month period, 61 asymptomatic patients, 32 with right and 29 with left CO, were enrolled. Each patient underwent an assessment of cerebrovascular reactivity (CVR) to hypercapnia with transcranial Doppler (TCD) ultrasonography using the breath-holding index (BHI). Neuropsychological assessment evaluating performances of the hemisphere ipsilateral to CO were administered at entry (T0 ) and then repeated after 2 years (T1 ). RESULTS Scores obtained at colored progressive matrices (CPM) and Rey Complex Figure Copy Test were significantly lower at T0 in patients with reduced BHI values ipsilateral to CO. Multivariate models showed that reduced BHI values were also associated to a significant decrease from T0 to T1 in scores obtained for CPM and Categorical Verbal Fluency tests, respectively, in patients with right (P = 0.002) or left CO (P = 0.004). CONCLUSIONS These findings suggest that hemodynamic alterations could be involved in the reduction in cognitive function regulated by the hemisphere ipsilateral to CO. The assessment of CVR with TCD ultrasonography may be a reliable approach for the individuation of asymptomatic patients with CO at increased risk of cognitive deterioration.
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Affiliation(s)
| | - Lorenzo Falsetti
- Internal and Subintensive Medicine, Ospedali Riuniti, Ancona, Italy
| | - Laura Buratti
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Maria C Acciarri
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Andrea Emiliani
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Marco Bartolini
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
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20
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Transcranial Doppler Ultrasound Evidence of Active Cerebral Embolization in COVID-19. J Stroke Cerebrovasc Dis 2020; 30:105542. [PMID: 33341023 PMCID: PMC7837312 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105542] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/05/2020] [Indexed: 12/22/2022] Open
Abstract
Objective To report six consecutive patients with confirmed coronavirus disease-2019 (COVID-19) who underwent Transcranial Doppler (TCD) ultrasonography evaluation for cerebral microemboli in the setting of suspected or confirmed acute ischemic stroke. Methods Patient data were obtained from medical records from Northwestern Memorial Hospital, Chicago, IL between May and June 2020. All patients with confirmed COVID-19 who underwent clinical TCD ultrasonography for microemboli detection were included. Results A total of eight TCD studies were performed in six patients with COVID-19 (4 men and 2 women, median age 65±5), four with confirmed ischemic stroke and two with refractory encephalopathy. Microemboli were detected in three male patients, two patients had suffered a confirmed ischemic stroke and one who developed prolonged encephalopathy. Microemboli of varying intensity were identified in multiple vascular territories in two patients, and microemboli persisted despite therapeutic anticoagulation in a third patient. Of the three patients without evidence of microemboli on TCD ultrasonography, two patients had suffered a confirmed ischemic stroke, while one remained with refractory encephalopathy. Conclusions TCD ultrasonography for microemboli detection identified three patients with confirmed COVID-19 with evidence of cerebral arterial microemboli, including one who was therapeutically anticoagulated. TCD ultrasonography provides a non-invasive method for evaluating cerebral microemboli in patients with COVID-19 and may be useful in assessing response to treatment in cases with suspected or confirmed disorders of hypercoagulability. Further studies investigating the prevalence of cerebral microemboli and associated risk factors are needed to characterize their pathogenic mechanism and guide therapeutic interventions in hospitalized COVID-19 patients.
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21
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Mowla A, Shakibajahromi B, Kabir R, Garami Z, Volpi JJ. Transcranial Doppler and magnetic resonance angiography assessment of intracranial stenosis: An analysis of screening modalities. Brain Circ 2020; 6:181-184. [PMID: 33210042 PMCID: PMC7646396 DOI: 10.4103/bc.bc_21_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/15/2020] [Accepted: 08/05/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND: Time-of-flight (TOF) magnetic resonance angiography (MRA) of the head and transcranial Doppler (TCD) are used to diagnose intracranial stenosis, an important cause of ischemic stroke. We aimed to compare TCD findings with TOF-MRA results in a population of patients with symptoms of cerebrovascular disease in whom both tests were done within a short intervening period of each other. METHODS: This is a retrospective, single-center study. Among adult patients referred for symptoms of cerebrovascular disease in both outpatient and inpatient settings, those who received a TCD with adequate insonation of all intracranial arteries and underwent MRA within 3 months intervals of TCD were included in this study. We evaluated the agreement between the results of these two modalities, and also assessed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TCD through receiver-operating characteristic (ROC) curve analysis, while MRA considered as a comparator. RESULTS: Among eighty included patients, 720 arteries were examined. An overall significant agreement of 96.5% was observed between TCD and MRA (Kappa = 0.377, P < 0.001). Compared to MRA, TCD had sensitivity of 42.1%, specificity of 99.6%, PPV of 72.7%, and NPV of 98.4% (ROC area: 0.708 [0.594–0.822]). TCD is specifically accurate in evaluating middle cerebral artery (MCA) (ROC area = 0.83). CONCLUSIONS: The high NPV of TCD in our study indicates the utility of TCD as a diagnostic test to exclude the presence of intracranial stenosis. This study supports TCD as a convenient, safe, and reproducible imaging modality applicable in the screening of intracranial stenosis, especially to evaluate MCA.
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Affiliation(s)
- Ashkan Mowla
- Department of Neurological Surgery, Division of Endovascular Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Rasadul Kabir
- Department of Neurology, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Zsolt Garami
- Institute for Academic Medicine, Research Institute, Weill Cornell Medical College, Houston, TX, USA.,Vascular Ultrasound Laboratory, Houston Methodist Hospital, Weill Cornell Medical College, Houston, TX, USA
| | - John J Volpi
- Department of Neurology, Houston Methodist Neurological Institute, Houston, TX, USA
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22
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Long J, Sun D, Zhou X, Huang X, Hu J, Xia J, Yang G. A mathematical model for predicting intracranial pressure based on noninvasively acquired PC-MRI parameters in communicating hydrocephalus. J Clin Monit Comput 2020; 35:1325-1332. [PMID: 33001400 PMCID: PMC7528454 DOI: 10.1007/s10877-020-00598-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/22/2020] [Indexed: 11/23/2022]
Abstract
To develop and validate a mathematical model for predicting intracranial pressure (ICP) noninvasively using phase-contrast cine MRI (PC-MRI). We performed a retrospective analysis of PC-MRI from patients with communicating hydrocephalus (n = 138). The patients were recruited from Shenzhen Second People’s Hospital between November 2017 and April 2020, and randomly allocated into training (n = 97) and independent validation (n = 41) groups. All participants underwent lumbar puncture and PC-MRI in order to evaluate ICP and cerebrospinal fluid (CSF) parameters (i.e., aqueduct diameter and flow velocity), respectively. A novel ICP-predicting model was then developed based on the nonlinear relationships between the CSF parameters, using the Levenberg–Marquardt and general global optimisation methods. There was no significant difference in baseline demographic characteristics between the training and independent validation groups. The accuracy of the model for predicting ICP was 0.899 in the training cohort (n = 97) and 0.861 in the independent validation cohort (n = 41). We obtained an ICP-predicting model that showed excellent performance in the noninvasive diagnosis of clinically significant communicating hydrocephalus.
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Affiliation(s)
- Jia Long
- Department of Radiology, Pinghu Hospital Shenzhen University, Shenzhen, China.,Department of Radiology, Shenzhen Second People's Hospital, Health Science Center, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Deshun Sun
- Shenzhen Key Laboratory of Tissue Engineering, Shenzhen Laboratory of Digital Orthopedic Engineering, Guangdong Provincial Research Center for Artificial Intelligence and Digital Orthopedic Technology, Shenzhen Second People's Hospital, Health Science Center, The First Hospital Affiliated To Shenzhen University, Shenzhen, 518035, China
| | - Xi Zhou
- Department of Radiology, Shenzhen Second People's Hospital, Health Science Center, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Xianjian Huang
- Department of Neurosurgery, Shenzhen Second People's Hospital, Health Science Center, The First Affiliated Hospital of Shenzhen University, Shenzhen, 518035, China
| | - Jiani Hu
- Department of Radiology, School of Medicine, Wayne State University, Detroit, MI, 48201, USA
| | - Jun Xia
- Department of Radiology, Shenzhen Second People's Hospital, Health Science Center, The First Affiliated Hospital of Shenzhen University, Shenzhen, China.
| | - Guang Yang
- Cardiovascular Research Centre, Royal Brompton Hospital, London, SW3 6NP, UK.,National Heart and Lung Institute, Imperial College London, London, SW7 2AZ, UK
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23
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Kienzler JC, Zakelis R, Bäbler S, Remonda E, Ragauskas A, Fandino J. Validation of Noninvasive Absolute Intracranial Pressure Measurements in Traumatic Brain Injury and Intracranial Hemorrhage. Oper Neurosurg (Hagerstown) 2020; 16:186-196. [PMID: 29726988 DOI: 10.1093/ons/opy088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 03/22/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Increased intracranial pressure (ICP) causes secondary damage in traumatic brain injury (TBI), and intracranial hemorrhage (ICH). Current methods of ICP monitoring require surgery and carry risks of complications. OBJECTIVE To validate a new instrument for noninvasive ICP measurement by comparing values obtained from noninvasive measurements to those from commercial implantable devices through this pilot study. METHODS The ophthalmic artery (OA) served as a natural ICP sensor. ICP measurements obtained using noninvasive, self-calibrating device utilizing Doppler ultrasound to evaluate OA flow were compared to standard implantable ICP measurement probes. RESULTS A total of 78 simultaneous, paired, invasive, and noninvasive ICP measurements were obtained in 11 ICU patients over a 17-mo period with the diagnosis of TBI, SAH, or ICH. A total of 24 paired data points were initially excluded because of questions about data independence. Analysis of variance was performed first on the 54 remaining data points and then on the entire set of 78 data points. There was no difference between the 2 groups nor was there any correlation between type of sensor and the patient (F[10, 43] = 1.516, P = .167), or the accuracy and precision of noninvasive ICP measurements (F[1, 43] = 0.511, P = .479). Accuracy was [-1.130; 0.539] mm Hg (CL = 95%). Patient-specific calibration was not needed. Standard deviation (precision) was [1.632; 2.396] mm Hg (CL = 95%). No adverse events were encountered. CONCLUSION This pilot study revealed no significant differences between invasive and noninvasive ICP measurements (P < .05), suggesting that noninvasive ICP measurements obtained by this method are comparable and reliable.
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Affiliation(s)
- Jenny C Kienzler
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Rolandas Zakelis
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.,Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Sabrina Bäbler
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Elke Remonda
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Arminas Ragauskas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
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Kargiotis O, Psychogios K, Safouris A, Magoufis G, Palaiodimou L, Theodorou A, Bakola E, Stamboulis E, Krogias C, Tsivgoulis G. Transcranial Doppler Monitoring of Acute Reperfusion Therapies in Acute Ischemic Stroke Patients with Underlying Large Vessel Occlusions. ACTA ACUST UNITED AC 2020. [DOI: 10.31728/jnn.2020.00084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Canac N, Jalaleddini K, Thorpe SG, Thibeault CM, Hamilton RB. Review: pathophysiology of intracranial hypertension and noninvasive intracranial pressure monitoring. Fluids Barriers CNS 2020; 17:40. [PMID: 32576216 PMCID: PMC7310456 DOI: 10.1186/s12987-020-00201-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/11/2020] [Indexed: 12/30/2022] Open
Abstract
Measurement of intracranial pressure (ICP) is crucial in the management of many neurological conditions. However, due to the invasiveness, high cost, and required expertise of available ICP monitoring techniques, many patients who could benefit from ICP monitoring do not receive it. As a result, there has been a substantial effort to explore and develop novel noninvasive ICP monitoring techniques to improve the overall clinical care of patients who may be suffering from ICP disorders. This review attempts to summarize the general pathophysiology of ICP, discuss the importance and current state of ICP monitoring, and describe the many methods that have been proposed for noninvasive ICP monitoring. These noninvasive methods can be broken down into four major categories: fluid dynamic, otic, ophthalmic, and electrophysiologic. Each category is discussed in detail along with its associated techniques and their advantages, disadvantages, and reported accuracy. A particular emphasis in this review will be dedicated to methods based on the use of transcranial Doppler ultrasound. At present, it appears that the available noninvasive methods are either not sufficiently accurate, reliable, or robust enough for widespread clinical adoption or require additional independent validation. However, several methods appear promising and through additional study and clinical validation, could eventually make their way into clinical practice.
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Safouris A, Kargiotis O, Psychogios K, Kalyvas P, Ikonomidis I, Drakopoulou M, Toutouzas K, Tsivgoulis G. A Narrative and Critical Review of Randomized-Controlled Clinical Trials on Patent Foramen Ovale Closure for Reducing the Risk of Stroke Recurrence. Front Neurol 2020; 11:434. [PMID: 32655469 PMCID: PMC7326015 DOI: 10.3389/fneur.2020.00434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/23/2020] [Indexed: 01/03/2023] Open
Abstract
Patent foramen ovale (PFO) is a common cardiac anatomic variant that has been increasingly found in young (<60 years) cryptogenic stroke patients. Despite initial neutral randomized-controlled clinical trials (RCTs), there have been four recent RCTs providing consistent data in favor of the efficacy and safety of PFO closure compared to medical therapy for secondary stroke prevention. However, taking into consideration the high prevalence of PFO, the low risk of stroke recurrence under medical treatment and the uncommon yet severe adverse events of the intervention, patient selection is crucial for attaining meaningful clinical benefits. Thorough workup to exclude alternative causes of stroke and identification of high-risk PFOs through clinical, neuroimaging and echocardiographic criteria are essential. Cost effectiveness of the procedure cannot be proven for the time being, since there are no robust data on clinical outcome after PFO-associated stroke but only limited anecdotal data suggesting low risk for long-term disability.
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Affiliation(s)
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Pireus, Greece.,Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Ignatios Ikonomidis
- Department of Echocardiography and Laboratory of Preventive Cardiology, Second Cardiology Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Drakopoulou
- First Department of Cardiology, Athens School of Medicine, Hippokration Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical School of Athens University, Hippokration Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, United States
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Huang G, Johnson LL, Peacock JE, Tegeler C, Davis K, Sarwal A. Transcranial Doppler Emboli Monitoring for Infective Endocarditis. J Neuroimaging 2020; 30:486-492. [PMID: 32488942 DOI: 10.1111/jon.12721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE Ischemic stroke can occur in 20-55% of patients with infective endocarditis (IE) with 75% occurring during the first 2 weeks of treatment. CT or MRI brain can diagnose the sequelae of stroke but transcranial Doppler (TCD) can document active embolization. We undertook a retrospective review of our patient cohort and a systematic review of literature to assess the role of TCD in early diagnosis and management of ischemic stroke in IE. METHODS Retrospective chart review and literature review. RESULTS We found 89 patients with stroke caused by IE at our institution from December 2011 to April 2018. TCDs were obtained on 26 patients; 16 were abnormal for cerebrovascular abnormalities. Only 4 patients had 30-minute emboli monitoring performed, of which one revealed emboli. We found 3 studies investigating the role of TCDs in IE that showed promise in its use as a predictive tool in stroke risk stratification. CONCLUSIONS Presence of embolization in the form of high-intensity transient signals (HITS) detected on TCDs can be used for early diagnosis of IE, assessing efficacy of antibiotic therapy, and stratification of stroke risk in IE. This can aid further research into testing preventative interventions for reducing stroke burden in IE such as earlier valvular surgery or vacuum-assisted vegetation extraction.
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Affiliation(s)
- Glen Huang
- Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA
| | - Leilani L Johnson
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - James E Peacock
- Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Charles Tegeler
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Kyle Davis
- Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Aarti Sarwal
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC
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Ghoshal S, Gomez J, Sarwal A. Noninvasive ICP Monitoring by Serial Transcranial Doppler in Coagulopathic Patient. Neurocrit Care 2020; 31:216-221. [PMID: 31065876 DOI: 10.1007/s12028-019-00716-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - Jonathan Gomez
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Aarti Sarwal
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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Barrientos-Guerra JD, Flores-Silva F, Cantú-Brito C, Chiquete E. Evaluation of Cerebral Hemodynamics with Color-Coded Duplex Sonography: Normative Values with Correction of Insonation Angles. J Stroke Cerebrovasc Dis 2020; 29:104595. [PMID: 31917090 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Transcranial color-coded sonography (TCCS) allows direct observation of arteries and the possibility of correcting the insonation angle for reliable evaluation of hemodynamics. We obtained TCCS reference values of the cerebral hemodynamics after correction of insonation angles. METHODS We studied 195 healthy adults equally allocated into 3 age groups: 18-40, 41-60, and greater than or equal to 61 years. The middle (MCA), anterior (ACA), and posterior cerebral arteries (PCA) were evaluated through the temporal acoustic window using conventional pulsed transcranial Doppler and TCCS. Peak systolic, end diastolic, and mean blood flow velocities were registered, as well as pulsatility and resistance indices at 0° and with correction by alignment of insonation angle parallel to the blood flow vector. We derived normative values assuming both the parametric and nonparametric distributions. RESULTS We excluded 33 participants due to inadequate acoustic window (10.3%), carotid disease (2.1%), and embryonic variants (4.6%), leaving out 162 for final analysis (50% female, median age 48 years). The 2.5th-97.5th percentiles of the corrected angle for MCA was 0°-60°, ACA 0°-44°, and PCA 30°-60°. After angle correction, 2.5th-97.5th percentiles for flow velocity of MCA, ACA, and PCA were 37.7-112.5 cm/s, 25.6-71.2 cm/s, and 29.2-80.8 cm/s, respectively. There were wide discrepancies between hemodynamics values obtained with insonation angles at 0° and after angle correction. No differences were found between ultrasound methods at exactly 0° or between hemispheres, however, there were differences according to age and sex. CONCLUSIONS Specific normative tables should be used in TCCS when the corrected angle is greater than 0° since the hemodynamics values greatly differ after correction of the insonation angle. Further studies are necessary to determine critical cutoffs indicating disease.
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Affiliation(s)
- José Domingo Barrientos-Guerra
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Fernando Flores-Silva
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos Cantú-Brito
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Erwin Chiquete
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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Potential Utility of Neurosonology in Paroxysmal Atrial Fibrillation Detection in Patients with Cryptogenic Stroke. J Clin Med 2019; 8:jcm8112002. [PMID: 31744102 PMCID: PMC6912531 DOI: 10.3390/jcm8112002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Occult paroxysmal atrial fibrillation (PAF) is a common and potential treatable cause of cryptogenic stroke (CS). We sought to prospectively identify independent predictors of atrial fibrillation (AF) detection in patients with CS and sinus rhythm on baseline electrocardiogram (ECG), without prior AF history. We had hypothesized that cardiac arrhythmia detection during neurosonology examinations (Carotid Duplex (CDU) and Transcranial Doppler (TCD)) may be associated with higher likelihood of AF detection. Methods: Consecutive CS patients were prospectively evaluated over a six-year period. Demographics, clinical and imaging characteristics of cerebral ischemia were documented. The presence of arrhythmia during spectral waveform analysis of CDU/TCD was recorded. Left atrial enlargement was documented during echocardiography using standard definitions. The outcome event of interest included PAF detection on outpatient 24-h Holter ECG recordings. Statistical analyses were performed using univariate and multivariate logistic regression models. Results: A total of 373 patients with CS were evaluated (mean age 60 ± 11 years, 67% men, median NIHSS-score 4 points). The rate of PAF detection of any duration on Holter ECG recordings was 11% (95% CI 8%–14%). The following three variables were independently associated with the likelihood of AF detection on 24-h Holter-ECG recordings in both multivariate analyses adjusting for potential confounders: age (OR per 10-year increase: 1.68; 95% CI: 1.19–2.37; p = 0.003), moderate or severe left atrial enlargement (OR: 4.81; 95% CI: 1.77–13.03; p = 0.002) and arrhythmia detection during neurosonology evaluations (OR: 3.09; 95% CI: 1.47–6.48; p = 0.003). Conclusion: Our findings underline the potential utility of neurosonology in improving the detection rate of PAF in patients with CS.
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Safouris A, Katsanos AH, Kerasnoudis A, Krogias C, Kinsella JA, Sztajzel R, Lambadiari V, Deftereos S, Kargiotis O, Sharma VK, Demchuk AM, Saqqur M, McCabe DJH, Tsivgoulis G. Statin Pretreatment and Microembolic Signals in Large Artery Atherosclerosis. Stroke 2019; 49:1992-1995. [PMID: 29991656 DOI: 10.1161/strokeaha.118.021542] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Scarce data indicate that statin pretreatment (SP) in patients with acute cerebral ischemia because of large artery atherosclerosis may be related to lower risk of recurrent stroke because of a decreased incidence of microembolic signals (MES) during transcranial Doppler monitoring. Methods- We performed a systematic review and meta-analysis of available observational studies reporting MES presence/absence or MES burden, categorized according to SP status, in patients with acute cerebral ischemia because of symptomatic (≥50%) large artery atherosclerosis. In studies with partially-published data, authors were contacted for previously unpublished information. We also performed a sensitivity analysis of studies with data on MES burden categorized according to SP status, and an additional subgroup analysis in patients receiving higher-dose SP (atorvastatin 80 mg or rosuvastatin 40 mg daily). Results- Seven eligible study protocols were identified (610 patients, 54% with SP). SP was associated with a reduced risk of MES detection during transcranial Doppler monitoring (risk ratio=0.67; 95% CI, 0.45-0.98), with substantial heterogeneity between studies ( I2=52%). In studies reporting MES burden (n=4), a significantly lower number of MES were identified in patients with compared with those without SP (mean difference=-0.92; 95% CI, -1.64 to -0.19), with no evidence of heterogeneity between studies ( I2=49%). Subgroup analysis revealed that higher-dose SP reduced the risk of detecting MES (risk ratio=0.23; 95% CI, 0.06-0.88), with no evidence of heterogeneity between studies ( I2=0%). Conclusions- SP seems to be associated with a lower incidence and burden of MES in patients with acute cerebral ischemia because of large artery atherosclerosis.
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Affiliation(s)
- Apostolos Safouris
- From the Second Department of Neurology (A.S., A.H.K., G.T.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (A.S., O.K.)
| | - Aristeidis H Katsanos
- From the Second Department of Neurology (A.S., A.H.K., G.T.).,Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.)
| | - Antonios Kerasnoudis
- Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (A.K., C.K.)
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (A.K., C.K.)
| | - Justin A Kinsella
- Department of Neurology, St Vincent's University Hospital, University College Dublin, Ireland (J.A.K.)
| | - Roman Sztajzel
- Department of Neurology, University Hospital Geneva and Medical School, Switzerland (R.S.)
| | | | - Spyridon Deftereos
- Second Department of Cardiology (S.D.), Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | | | - Vijay K Sharma
- Division of Neurology, Yong Loo Lin School of Medicine, National University of Singapore, National University Hospital (V.K.S.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (A.M.D.)
| | - Maher Saqqur
- Department of Neurology, University of Alberta, Edmonton, Canada (M.S.)
| | - Dominick J H McCabe
- Vascular Neurology Research Foundation, Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Ireland (D.J.H.M.).,Irish Centre for Vascular Biology, Ireland (D.J.H.M.).,Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom (D.J.H.M.).,Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland (D.J.H.M.)
| | - Georgios Tsivgoulis
- From the Second Department of Neurology (A.S., A.H.K., G.T.).,Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
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Montrief T, Alerhand S, Jewell C, Scott J. Incorporation of Transcranial Doppler into the ED for the neurocritical care patient. Am J Emerg Med 2019; 37:1144-1152. [PMID: 30894296 DOI: 10.1016/j.ajem.2019.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/05/2019] [Accepted: 03/04/2019] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION In the catastrophic neurologic emergency, a complete neurological exam is not always possible or feasible given the time-sensitive nature of the underlying disease process, or if emergent airway management is indicated. As the neurologic exam may be limited in some patients, the emergency physician is reliant on the assessment of brainstem structures to determine neurological function. Physicians thus routinely depend on advanced imaging modalities to further investigate for potential catastrophic diagnoses. Acquiring these tests introduces the risks of transport as well as delays in managing time-sensitive neurologic processes. A more immediate, non-invasive bedside approach complementing these modalities has evolved: Transcranial Doppler (TCD). OBJECTIVE This narrative review will provide a description of scenarios in which TCD may be applicable. It will summarize the sonographic findings and associated underlying pathophysiology in such neurocritical care patients. An illustrated tutorial, along with pearls and pitfalls, is provided. DISCUSSION Although there are numerous formalized TCD protocols utilizing four views (transtemporal, submandibular, suboccipital, and transorbital), point-of-care TCD is best accomplished through the transtemporal window. The core applications include the evaluation of midline shift, vasospasm after subarachnoid hemorrhage, acute ischemic stroke, and elevated intracranial pressure. An illustrative tutorial is provided. CONCLUSIONS With the wide dissemination of bedside ultrasound within the emergency department, there is a unique opportunity for the emergency physician to utilize TCD for a variety of conditions. While barriers to training exist, emergency physician performance of limited point-of-care TCD is feasible and may provide rapid and reliable clinical information with high temporal resolution.
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Affiliation(s)
- Tim Montrief
- Department of Emergency Medicine, Jackson Memorial Health System, Miami, FL 33136, USA.
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Corlin Jewell
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
| | - Jeffery Scott
- Department of Emergency Medicine, Jackson Memorial Health System, Miami, FL 33136, USA
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Kargiotis O, Psychogios K, Safouris A, Magoufis G, Zervas PD, Stamboulis E, Tsivgoulis G. The Role of Transcranial Doppler Monitoring in Patients with Multi‐Territory Acute Embolic Strokes: A Review. J Neuroimaging 2019; 29:309-322. [DOI: 10.1111/jon.12602] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/21/2019] [Accepted: 01/21/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
| | | | - Apostolos Safouris
- Stroke UnitMetropolitan Hospital Piraeus Greece
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
| | | | - Paschalis D. Zervas
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
| | | | - Georgios Tsivgoulis
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
- Department of NeurologyThe University of Tennessee Health Science Center Memphis TN
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Abstract
Neuromonitoring is important for patients with acute brain injury. The bedside neurologic examination is standard for neurologic monitoring; however, a clinical examination may not reliably detect subtle changes in intracranial physiology. Changes found during neurologic examinations are often late signs. The assessment of multiple physiological variables in real time can provide new clinical insights into treatment decisions. No single monitoring modality is ideal for all patients. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism, such as in multimodal monitoring, allows an innovative approach to individualized patient care.
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Affiliation(s)
- Sarah H Peacock
- Sarah H. Peacock is Acute Care Nurse Practitioner, Department of Critical Care Medicine, Instructor of Medicine, College of Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 . Amanda D. Tomlinson is Acute Nurse Practitioner, Department of Critical Care Medicine, Instructor of Neurology, College of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Amanda D Tomlinson
- Sarah H. Peacock is Acute Care Nurse Practitioner, Department of Critical Care Medicine, Instructor of Medicine, College of Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 . Amanda D. Tomlinson is Acute Nurse Practitioner, Department of Critical Care Medicine, Instructor of Neurology, College of Medicine, Mayo Clinic, Jacksonville, Florida
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Cerebral Blood Flow in Polytrauma: Transcranial Doppler Analysis in a Nonhuman Primate Shock Model. J Surg Res 2018; 232:146-153. [PMID: 30463710 DOI: 10.1016/j.jss.2018.05.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/05/2018] [Accepted: 05/24/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND In combat-related trauma, resuscitation goals are to attenuate tissue hypoxia and maintain circulation. During hemorrhagic shock, compensatory and autoregulatory mechanisms are activated to preserve cerebral blood flow. Transcranial Doppler (TCD) ultrasonography may be an ideal noninvasive modality to monitor cerebral hemodynamics. Using a nonhuman primate (NHP) model, we attempted to characterize cerebral hemodynamics during polytraumatic hemorrhagic shock using TCD ultrasonography. MATERIALS AND METHODS The ophthalmic artery was insonated at multiple time points during varying stages of shock. Hemorrhage was controlled and pressure targeted to 20 mmHg to initiate and maintain the shock period. Mean flow velocity (MFV), peak systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) were recorded. Results represent mean ± standard deviation; statistical significance is P < 0.05; n = 12. RESULTS Compared to baseline, MFV, PSV, EDV, and RI show significant changes after 60 min of hemorrhagic shock, (9.81 ± 3.60 cm/s; P < 0.01), (21.15 ± 8.59 cm/s; P < 0.01), (5.15 ± 0.21 cm/s; P < 0.01), (0.70 ± 0.11; P < 0.05), respectively. PI did not change during hemorrhagic shock. At end of prehospital care (T30), cerebral flow recovers for MFV, PSV, and RI while EDV remained decreased at T30 (6.15 ± 1.13 cm/s; P < 0.01) and 1 h of simulated transport (T90) (5.87 ± 0.62 cm/s; P < 0.01). Changes in PI at T30 and T90 were not significant. MFV diminished (16.45 ± 3.85 cm/s; P < 0.05) at T90. CONCLUSIONS This study establishes baseline and hemorrhagic shock values for NHP cerebral blood flow velocities and cerebrovascular indices. TCD ultrasonography may represent an important area of research for targeted resuscitation investigations using a hemorrhagic shock model in NHPs.
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Saranteas T, Igoumenou VG, Megaloikonomos PD, Mavrogenis AF. Ultrasonography in Trauma: Physics, Practice, and Training. JBJS Rev 2018; 6:e12. [PMID: 29688910 DOI: 10.2106/jbjs.rvw.17.00132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Theodosios Saranteas
- Second Department of Anesthesiology (T.S.) and First Department of Orthopaedics (V.G.I., P.D.M., and A.F.M.), National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
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Lau VI, Arntfield RT. Point-of-care transcranial Doppler by intensivists. Crit Ultrasound J 2017; 9:21. [PMID: 29030715 PMCID: PMC5640565 DOI: 10.1186/s13089-017-0077-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/06/2017] [Indexed: 11/10/2022] Open
Abstract
In the unconscious patient, there is a diagnostic void between the neurologic physical exam, and more invasive, costly and potentially harmful investigations. Transcranial color-coded sonography and two-dimensional transcranial Doppler imaging of the brain have the potential to be a middle ground to bridge this gap for certain diagnoses. With the increasing availability of point-of-care ultrasound devices, coupled with the need for rapid diagnosis of deteriorating neurologic patients, intensivists may be trained to perform point-of-care transcranial Doppler at the bedside. The feasibility and value of this technique in the intensive care unit to help rule-in specific intra-cranial pathologies will form the focus of this article. The proposed scope for point-of-care transcranial Doppler for the intensivist will be put forth and illustrated using four representative cases: presence of midline shift, vasospasm, raised intra-cranial pressure, and progression of cerebral circulatory arrest. We will review the technical details, including methods of image acquisition and interpretation. Common pitfalls and limitations of point-of-care transcranial Doppler will also be reviewed, as they must be understood for accurate diagnoses during interpretation, as well as the drawbacks and inadequacies of the modality in general.
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Affiliation(s)
- Vincent Issac Lau
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
- London Health Sciences Centre, Victoria Hospital Rm, D2-528, 800 Commissioners Road East, London, ON N6A 5W9 Canada
| | - Robert Thomas Arntfield
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
- London Health Sciences Centre, Victoria Hospital Rm, D2-528, 800 Commissioners Road East, London, ON N6A 5W9 Canada
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Zhang X, Medow JE, Iskandar BJ, Wang F, Shokoueinejad M, Koueik J, Webster JG. Invasive and noninvasive means of measuring intracranial pressure: a review. Physiol Meas 2017; 38:R143-R182. [PMID: 28489610 DOI: 10.1088/1361-6579/aa7256] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Measurement of intracranial pressure (ICP) can be invaluable in the management of critically ill patients. Cerebrospinal fluid is produced by the choroid plexus in the brain ventricles (a set of communicating chambers), after which it circulates through the different ventricles and exits into the subarachnoid space around the brain, where it is reabsorbed into the venous system. If the fluid does not drain out of the brain or get reabsorbed, the ICP increases, which may lead to brain damage or death. ICP elevation accompanied by dilatation of the cerebral ventricles is termed hydrocephalus, whereas ICP elevation accompanied by normal or small ventricles is termed idiopathic intracranial hypertension. OBJECTIVE We performed a comprehensive literature review on how to measure ICP invasively and noninvasively. APPROACH This review discusses the advantages and disadvantages of current invasive and noninvasive approaches. MAIN RESULTS Invasive methods remain the most accurate at measuring ICP, but they are prone to a variety of complications including infection, hemorrhage and neurological deficits. Ventricular catheters remain the gold standard but also carry the highest risk of complications, including difficult or incorrect placement. Direct telemetric intraparenchymal ICP monitoring devices are a good alternative. Noninvasive methods for measuring and evaluating ICP have been developed and classified in five broad categories, but have not been reliable enough to use on a routine basis. These methods include the fluid dynamic, ophthalmic, otic, and electrophysiologic methods, as well as magnetic resonance imaging, transcranial Doppler ultrasonography (TCD), cerebral blood flow velocity, near-infrared spectroscopy, transcranial time-of-flight, spontaneous venous pulsations, venous ophthalmodynamometry, optical coherence tomography of retina, optic nerve sheath diameter (ONSD) assessment, pupillometry constriction, sensing tympanic membrane displacement, analyzing otoacoustic emissions/acoustic measure, transcranial acoustic signals, visual-evoked potentials, electroencephalography, skull vibrations, brain tissue resonance and the jugular vein. SIGNIFICANCE This review provides a current perspective of invasive and noninvasive ICP measurements, along with a sense of their relative strengths, drawbacks and areas for further improvement. At present, none of the noninvasive methods demonstrates sufficient accuracy and ease of use while allowing continuous monitoring in routine clinical use. However, they provide a realizable ICP measurement in specific patients especially when invasive monitoring is contraindicated or unavailable. Among all noninvasive ICP measurement methods, ONSD and TCD are attractive and may be useful in selected settings though they cannot be used as invasive ICP measurement substitutes. For a sufficiently accurate and universal continuous ICP monitoring method/device, future research and developments are needed to integrate further refinements of the existing methods, combine telemetric sensors and/or technologies, and validate large numbers of clinical studies on relevant patient populations.
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Affiliation(s)
- Xuan Zhang
- Department of Electrical and Computer Engineering, University of Wisconsin, Madison, WI 53706, United States of America
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Safouris A, Krogias C, Sharma VK, Katsanos AH, Faissner S, Roussopoulou A, Zompola C, Kneiphof J, Kargiotis O, Deftereos S, Giannopoulos G, Triantafyllou N, Voumvourakis K, Vadikolias K, Tsivgoulis G. Statin Pretreatment and Microembolic Signals in Large Artery Atherosclerosis. Arterioscler Thromb Vasc Biol 2017; 37:1415-1422. [PMID: 28450295 DOI: 10.1161/atvbaha.117.309292] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/17/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Although statin pretreatment (SP) is associated with better outcomes in patients with acute cerebral ischemia after an ischemic stroke/transient ischemic attack, data on the underlying mechanism of this beneficial effect are limited. APPROACH AND RESULTS We sought to evaluate the potential association between SP and microembolic signal (MES) burden in acute cerebral ischemia because of large artery atherosclerosis (LAA). We prospectively evaluated consecutive patients with first-ever acute cerebral ischemia because of LAA in 3 tertiary stroke centers over a 2-year period. All patients underwent continuous 1-hour transcranial Doppler monitoring of the relevant vessel at baseline (≤24 hours). SP was recorded and dichotomized as high dose or low-to-moderate dose. SP was documented in 43 (41%) of 106 LAA patients (mean age, 65.4±10.3 years; 72% men; low-to-moderate dose, 32%; high dose, 8%). There was a significant (P=0.022) dose-dependent effect between SP and MES prevalence: no SP (37%), SP with low-to-moderate dose (18%), and SP with high dose (0%). Similarly, a significant (P=0.045) dose-dependent effect was documented between SP and MES burden: no SP (1.1±1.8), SP with low-to-moderate dose (0.7±1.6), and SP with high dose (0±0). In multivariable logistic regression analysis adjusting for demographics, vascular risk factors, location of LAA, stroke severity, and other prevention therapies, SP was associated with lower likelihood of MES presence (odds ratio, 0.29; 95% confidence interval, 0.09-0.92; P=0.036). In addition, SP was found also to be independently related to higher odds of functional improvement (common odds ratio, 3.33; 95% confidence interval, 1.07-10.0; P=0.037). CONCLUSIONS We found that SP in patients with acute LAA is related with reduced MES presence and lower MES burden with an apparently dose-dependent association.
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Affiliation(s)
- Apostolos Safouris
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Christos Krogias
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Vijay K Sharma
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Aristeidis H Katsanos
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Simon Faissner
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Andromachi Roussopoulou
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Christina Zompola
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Janina Kneiphof
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Odysseas Kargiotis
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Spyridon Deftereos
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Georgios Giannopoulos
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Nikos Triantafyllou
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Konstantinos Voumvourakis
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Konstantinos Vadikolias
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.)
| | - Georgios Tsivgoulis
- From the Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.S., A.H.K., A.R., C.Z., K.V., G.T.); Acute Stroke Unit, Metropolitan Hospital, Pireus, Greece (A.S., O.K.); Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany (C.K., S.F., J.K.); Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.); Division of Neurology, National University Hospital, Singapore (V.K.S.); Department of Neurology, University Hospital of Ioannina, School of Medicine, University of Ioannina, Greece (A.H.K.); Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Greece (S.D., G.G.); First Department of Neurology, University of Athens, School of Medicine, Eginition University Hospital, Greece (N.T.); and Department of Neurology, Alexandroupolis University Hospital, School of Medicine, Democritus University of Thrace, Greece (K.V.).
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Baracchini C, Viaro F, Favaretto S, Palmieri A, Kulyk C, Causin F, Farina F, Ballotta E. Safety and Tolerability of SonoVue® in Patients with Large Artery Anterior Circulation Acute Stroke. J Neuroimaging 2016; 27:409-413. [DOI: 10.1111/jon.12416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 11/10/2016] [Indexed: 01/30/2023] Open
Affiliation(s)
- Claudio Baracchini
- Department of Neuroscience; University of Padua School of Medicine; Padua-Italy
| | - Federica Viaro
- Department of Neuroscience; University of Padua School of Medicine; Padua-Italy
| | - Silvia Favaretto
- Department of Neuroscience; University of Padua School of Medicine; Padua-Italy
| | - Anna Palmieri
- Department of Neuroscience; University of Padua School of Medicine; Padua-Italy
| | - Caterina Kulyk
- Department of Neuroscience; University of Padua School of Medicine; Padua-Italy
| | - Francesco Causin
- Institute of Neuroradiology; University of Padua School of Medicine; Padua-Italy
| | - Filippo Farina
- Department of Neuroscience; University of Padua School of Medicine; Padua-Italy
| | - Enzo Ballotta
- Vascular Study Group of the Department of Surgical, Oncological and Gastroenterological Sciences; University of Padua School of Medicine; Padua-Italy
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Abstract
Holistic ultrasound is a total body examination using an ultrasound device aiming to achieve immediate patient care and decision making. In the setting of trauma, it is one of the most fundamental components of care of the injured patients. Ground-breaking imaging software allows physicians to examine various organs thoroughly, recognize imaging signs early, and potentially foresee the onset or the possible outcome of certain types of injuries. Holistic ultrasound can be performed on a routine basis at the bedside of the patients, at admission and during the perioperative period. Trauma care physicians should be aware of the diagnostic and guidance benefits of ultrasound and should receive appropriate training for the optimal management of their patients. In this paper, the findings of holistic ultrasound in trauma patients are presented, with emphasis on the lungs, heart, cerebral circulation, abdomen, and airway. Additionally, the benefits of ultrasound imaging in interventional anaesthesia techniques such as ultrasound-guided peripheral nerve blocks and central vein catheterization are described.
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Affiliation(s)
- Theodosios Saranteas
- Department of Anaesthesiology, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece.
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D’Andrea A, Conte M, Cavallaro M, Scarafile R, Riegler L, Cocchia R, Pezzullo E, Carbone A, Natale F, Santoro G, Caso P, Russo MG, Bossone E, Calabrò R. Transcranial Doppler ultrasonography: From methodology to major clinical applications. World J Cardiol 2016; 8:383-400. [PMID: 27468332 PMCID: PMC4958690 DOI: 10.4330/wjc.v8.i7.383] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/22/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023] Open
Abstract
Non-invasive Doppler ultrasonographic study of cerebral arteries [transcranial Doppler (TCD)] has been extensively applied on both outpatient and inpatient settings. It is performed placing a low-frequency (≤ 2 MHz) transducer on the scalp of the patient over specific acoustic windows, in order to visualize the intracranial arterial vessels and to evaluate the cerebral blood flow velocity and its alteration in many different conditions. Nowadays the most widespread indication for TCD in outpatient setting is the research of right to left shunting, responsable of so called “paradoxical embolism”, most often due to patency of foramen ovale which is responsable of the majority of cryptogenic strokes occuring in patients younger than 55 years old. TCD also allows to classify the grade of severity of such shunts using the so called “microembolic signal grading score”. In addition TCD has found many useful applications in neurocritical care practice. It is useful on both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoidal haemorrhage (caused by aneurysm rupture or traumatic injury), traumatic brain injury, brain stem death. It is used also to evaluate cerebral hemodynamic changes after stroke. It also allows to investigate cerebral pressure autoregulation and for the clinical evaluation of cerebral autoregulatory reserve.
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Noninvasive Brain Physiology Monitoring for Extreme Environments: A Critical Review. J Neurosurg Anesthesiol 2016; 27:318-28. [PMID: 25811362 DOI: 10.1097/ana.0000000000000175] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Our ability to monitor the brain physiology is advancing; however, most of the technology is bulky, expensive, and designed for traditional clinical settings. With long-duration space exploration, there is a need for developing medical technologies that are reliable, low energy, portable, and semiautonomous. Our aim was to review the state of the art for noninvasive technologies capable of monitoring brain physiology in diverse settings. A literature review of PubMed and the Texas Medical Center library sites was performed using prespecified search criteria to identify portable technologies for monitoring physiological aspects of the brain physiology. Most brain-monitoring technologies require a moderate to high degree of operator skill. Some are low energy, but many require a constant external power supply. Most of the technologies lack the accuracy seen in gold standard measures, due to the need for calibration, but may be useful for screening or monitoring relative changes in a parameter. Most of the technologies use ultrasound or electromagnetic radiation as energy sources. There is an important need for further development of portable technologies that can be operated in a variety of extreme environments to monitor brain health.
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Noninvasive Vascular Methods for Detection of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. J Clin Neurophysiol 2016; 33:260-7. [DOI: 10.1097/wnp.0000000000000271] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kargiotis O, Safouris A, Magoufis G, Stamboulis E, Tsivgoulis G. Transcranial Color-Coded Duplex in Acute Encephalitis: Current Status and Future Prospects. J Neuroimaging 2016; 26:377-82. [PMID: 27171686 DOI: 10.1111/jon.12353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/28/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUP AND PURPOSE There are limited data regarding the diagnostic yield of transcranial color-coded Doppler (TCCD) in acute encephalitis. We present our preliminary observations of consecutive ultrasound evaluations in 2 patients with acute encephalitis and we review the possible diagnostic role of TCCD in such cases. METHODS We describe two cases of acute encephalitis that presented with aphasia and confusion and underwent repeat TCCD evaluation at baseline and after 48 hours in both patients. We also critically review the current literature regarding potential TCCD applications in acute central nervous system infections. RESULTS Serial TCCD evaluations revealed the following triad of abnormal findings in both patients: (i) elevated pulsatility index (PI) in the left middle cerebral artery (M1 MCA) at baseline (>1.2), (ii) increased PI in left M1 MCA by >25% in comparison to right M1 MCA, and (iii) decrease in PI in left M1 MCA by >25% at the follow-up evaluation at 48 hours. The decrease in PI in left M1 MCA coincided with symptom improvement in both patients. DISCUSSION The focal transient increase in left M1 MCA PI may be attributed to focally increased intracranial pressure or peripheral vasospasm of distal left MCA branches. Since there are limited reports in the literature concerning TCCD evaluation of patients with central nervous system infections, our preliminary findings require independent confirmation in a larger series of patients.
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Affiliation(s)
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece.,Stroke Unit, Department of Neurology, Brugmann University Hospital, Place Van Gehuchten 4, 1020, Bruxelles, Belgium
| | | | | | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Athens, Greece.,Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN.,International Clinical Research Center, Department of Neurology, St. Anne's University Hospital in Brno, Brno, Czech Republic
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Katsanos AH, Psaltopoulou T, Sergentanis TN, Frogoudaki A, Vrettou AR, Ikonomidis I, Paraskevaidis I, Parissis J, Bogiatzi C, Zompola C, Ellul J, Triantafyllou N, Voumvourakis K, Kyritsis AP, Giannopoulos S, Alexandrov AW, Alexandrov AV, Tsivgoulis G. Transcranial Doppler versus transthoracic echocardiography for the detection of patent foramen ovale in patients with cryptogenic cerebral ischemia: A systematic review and diagnostic test accuracy meta-analysis. Ann Neurol 2016; 79:625-35. [PMID: 26833864 DOI: 10.1002/ana.24609] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Patent foramen ovale (PFO) can be detected in up to 43% of patients with cryptogenic cerebral ischemia undergoing investigation with transesophageal echocardiography (TEE). The diagnostic value of transthoracic echocardiography (TTE) in the detection of PFO in patients with cryptogenic ischemic stroke or transient ischemic attack has not been compared with that of transcranial Doppler (TCD) using a comprehensive meta-analytical approach. METHODS We performed a systematic literature review to identify all prospective observational studies of patients with cryptogenic cerebral ischemia that provided both sensitivity and specificity measures of TTE, TCD, or both compared to the gold standard of TEE. RESULTS Our literature search identified 35 eligible studies including 3,067 patients. The pooled sensitivity and specificity for TCD was 96.1% (95% confidence interval [CI] = 93.0-97.8%) and 92.4% (95% CI = 85.5-96.1%), whereas the respective measures for TTE were 45.1% (95% CI = 30.8-60.3%) and 99.6% (95% CI = 96.5-99.9%). TTE was superior in terms of higher positive likelihood ratio values (LR+ = 106.61, 95% CI = 15.09-753.30 for TTE vs LR+ = 12.62, 95% CI = 6.52-24.43 for TCD; p = 0.043), whereas TCD demonstrated lower negative likelihood values (LR- = 0.04, 95% CI = 0.02-0.08) compared to TTE (LR- = 0.55, 95% CI = 0.42-0.72; p < 0.001). Finally, the area under the summary receiver operating curve (AUC) was significantly greater (p < 0.001) in TCD (AUC = 0.98, 95% CI = 0.97-0.99) compared to TTE studies (AUC = 0.86, 95% CI = 0.82-0.89). INTERPRETATION TCD is more sensitive but less specific compared to TTE for the detection of PFO in patients with cryptogenic cerebral ischemia. The overall diagnostic yield of TCD appears to outweigh that of TTE.
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Affiliation(s)
- Aristeidis H Katsanos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece.,Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology, and Medical Statistics, School of Medicine, University of Athens, Athens, Greece
| | - Theodoros N Sergentanis
- Department of Hygiene, Epidemiology, and Medical Statistics, School of Medicine, University of Athens, Athens, Greece
| | - Alexandra Frogoudaki
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Agathi-Rosa Vrettou
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Ignatios Ikonomidis
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Ioannis Paraskevaidis
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - John Parissis
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Chrysa Bogiatzi
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Christina Zompola
- Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - John Ellul
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | - Nikolaos Triantafyllou
- First Department of Neurology, Eginition Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | | | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN.,School of Nursing, Australian Catholic University, Sydney, Australia
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN.,International Clinical Research Center, Department of Neurology, St Anne's University Hospital Brno, Brno, Czech Republic
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Marzban C, Gu W, Mourad PD. Mixture Models for Estimating Maximum Blood Flow Velocity. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:93-101. [PMID: 26643758 DOI: 10.7863/ultra.14.05069] [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: 05/28/2014] [Accepted: 04/30/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES A gaussian mixture model (GMM) was recently developed for estimating the probability density function of blood flow velocity measured with transcranial Doppler ultrasound data. In turn, the quantiles of the probability density function allow one to construct estimators of the "maximum" blood flow velocity. However, GMMs assume gaussianity, a feature that is not omnipresent in observed data. The objective of this work was to develop mixture models that do not invoke the gaussian assumption. METHODS Here, GMMs were extended to a skewed GMM and a nongaussian kernel mixture model. All models were developed on data from 59 patients with closed head injuries from multiple hospitals in the United States, with ages ranging from 13 to 81 years and Glasgow Coma Scale scores ranging from 3 to 11. The models were assessed in terms of the log likelihood (a goodness-of-fit measure) and via visual comparison with the underlying spectrograms. RESULTS Among the models examined, the skewed GMM showed a significantly (P< .05) higher log likelihood for 56 of the 59 patients and produced maximum flow velocity estimates consistent with the observed spectrograms for all patients. Kernel mixture models are generally less "robust" in that their quality is inconsistent across patients. CONCLUSIONS Among the models examined, it was found that the skewed GMM provided a better model of the data both in terms of the quality of the fit and in terms of visual comparison of the underlying spectrogram and the estimated maximum blood flow velocity. Nongaussian mixture models have potential for even higher-quality assessment of blood flow, but further development is called for.
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Affiliation(s)
- Caren Marzban
- From the Applied Physics Laboratory (C.M., P.D.M.) and Departments of Statistics (C.M., W.G.), Neurological Surgery (P.D.M.), and Bioengineering (P.D.M.), University of Washington, Seattle, Washington USA.
| | - Wenxiao Gu
- From the Applied Physics Laboratory (C.M., P.D.M.) and Departments of Statistics (C.M., W.G.), Neurological Surgery (P.D.M.), and Bioengineering (P.D.M.), University of Washington, Seattle, Washington USA
| | - Pierre D Mourad
- From the Applied Physics Laboratory (C.M., P.D.M.) and Departments of Statistics (C.M., W.G.), Neurological Surgery (P.D.M.), and Bioengineering (P.D.M.), University of Washington, Seattle, Washington USA
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D'Andrea A, Conte M, Scarafile R, Riegler L, Cocchia R, Pezzullo E, Cavallaro M, Carbone A, Natale F, Russo MG, Gregorio G, Calabrò R. Transcranial Doppler Ultrasound: Physical Principles and Principal Applications in Neurocritical Care Unit. J Cardiovasc Echogr 2016; 26:28-41. [PMID: 28465958 PMCID: PMC5224659 DOI: 10.4103/2211-4122.183746] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Transcranial Doppler (TCD) ultrasonography is a noninvasive ultrasound study, which has been extensively applied on both outpatient and inpatient settings. It involves the use of a low-frequency (≤2 MHz) transducer, placed on the scalp, to insonate the basal cerebral arteries through relatively thin bone windows and to measure the cerebral blood flow velocity and its alteration in many different conditions. In neurointensive care setting, TCD is useful for both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, and brain stem death. It also allows to investigate the cerebrovascular autoregulation in setting of carotid disease and syncope. In this review, we will describe physical principles underlying TCD, flow indices most frequently used in clinical practice and critical care applications in Neurocritical Unit care.
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Affiliation(s)
- Antonello D'Andrea
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Marianna Conte
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Raffaella Scarafile
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Lucia Riegler
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Rosangela Cocchia
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Enrica Pezzullo
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Massimo Cavallaro
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Andreina Carbone
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Francesco Natale
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Maria Giovanna Russo
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Giovanni Gregorio
- Department of Cardiology, San Luca Hospital, Vallo della Lucania, Salerno, Italy
| | - Raffaele Calabrò
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
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Haršány M, Tsivgoulis G, Alexandrov AV. Ultrasonography. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00046-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Malinova V, Dolatowski K, Schramm P, Moerer O, Rohde V, Mielke D. Early whole-brain CT perfusion for detection of patients at risk for delayed cerebral ischemia after subarachnoid hemorrhage. J Neurosurg 2015; 125:128-36. [PMID: 26684786 DOI: 10.3171/2015.6.jns15720] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This prospective study investigated the role of whole-brain CT perfusion (CTP) studies in the identification of patients at risk for delayed ischemic neurological deficits (DIND) and of tissue at risk for delayed cerebral infarction (DCI). METHODS Forty-three patients with aneurysmal subarachnoid hemorrhage (aSAH) were included in this study. A CTP study was routinely performed in the early phase (Day 3). The CTP study was repeated in cases of transcranial Doppler sonography (TCD)-measured blood flow velocity (BFV) increase of > 50 cm/sec within 24 hours and/or on Day 7 in patients who were intubated/sedated. RESULTS Early CTP studies revealed perfusion deficits in 14 patients, of whom 10 patients (72%) developed DIND, and 6 of these 10 patients (60%) had DCI. Three of the 14 patients (21%) with early perfusion deficits developed DCI without having had DIND, and the remaining patient (7%) had neither DIND nor DCI. There was a statistically significant correlation between early perfusion deficits and occurrence of DIND and DCI (p < 0.0001). A repeated CTP was performed in 8 patients with a TCD-measured BFV increase > 50 cm/sec within 24 hours, revealing a perfusion deficit in 3 of them (38%). Two of the 3 patients (67%) developed DCI without preceding DIND and 1 patient (33%) had DIND without DCI. In 4 of the 7 patients (57%) who were sedated and/or comatose, additional CTP studies on Day 7 showed perfusion deficits. All 4 patients developed DCI. CONCLUSIONS Whole-brain CTP on Day 3 after aSAH allows early and reliable identification of patients at risk for DIND and tissue at risk for DCI. Additional CTP investigations, guided by TCD-measured BFV increase or persisting coma, do not contribute to information gain.
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Affiliation(s)
| | | | - Peter Schramm
- Neuroradiology, and.,Department of Neuroradiology, University of Lübeck, Germany
| | - Onnen Moerer
- Anaesthesiology, Georg-August-University, Göttingen; and
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