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Kneihsl M, Hinteregger N, Nistl O, Deutschmann H, Horner S, Poltrum B, Fandler-Höfler S, Hatab I, Haidegger M, Pinter D, Pichler A, Willeit K, Knoflach M, Enzinger C, Gattringer T. Post-reperfusion hyperperfusion after endovascular stroke treatment: a prospective comparative study of TCD versus MRI. J Neurointerv Surg 2023; 15:983-988. [PMID: 36137745 DOI: 10.1136/jnis-2022-019213] [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: 05/31/2022] [Accepted: 08/26/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Increased middle cerebral artery (MCA) blood flow velocities on transcranial duplex sonography (TCD) were recently reported in individual patients after successful mechanical thrombectomy (MT) and were related to intracranial hemorrhage and poor outcome. However, the retrospective study design of prior studies precluded elucidation of the underlying pathomechanisms, and the relationship between TCD and brain parenchymal perfusion still remains to be determined. METHODS We prospectively investigated consecutive patients with stroke successfully recanalized by MT with TCD and MRI including contrast-enhanced perfusion sequences within 48 hours post-intervention. Increased MCA flow on TCD was defined as >30% mean blood flow velocity in the treated MCA compared with the contralateral MCA. MRI blood flow maps served to assess hyperperfusion rated by neuroradiologists blinded to TCD. RESULTS A total of 226 patients recanalized by MT underwent post-interventional TCD and 92 patients additionally had perfusion MRI. 85 patients (38%) had increased post-interventional MCA flow on TCD. Of these, 10 patients (12%) had an underlying focal stenosis. Increased TCD blood flow in the recanalized MCA was associated with larger infarct size, vasogenic edema, intracranial hemorrhage and poor 90-day outcome (all p≤0.005). In the subgroup for which both TCD and perfusion MRI were available, 29 patients (31%) had increased ipsilateral MCA flow velocities on TCD. Of these, 25 patients also showed parenchymal hyperperfusion on MRI (sensitivity 85%; specificity 62%). Hyperperfusion severity on MRI correlated with MCA flow velocities on TCD (rs=0.379, p<0.001). CONCLUSIONS TCD is a reliable bedside tool to identify post-reperfusion hyperperfusion, correlates well with perfusion MRI, and indicates risk of reperfusion injury after MT.
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Affiliation(s)
- Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Nicole Hinteregger
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Oliver Nistl
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Hannes Deutschmann
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Susanna Horner
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Birgit Poltrum
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Isra Hatab
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Daniela Pinter
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Karin Willeit
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Micheal Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
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Hawash AMA, Zaytoun TM, Helmy TA, El Reweny EM, Abdel Galeel AMA, Taleb RSZ. S100B and brain ultrasound: Novel predictors for functional outcome in acute ischemic stroke patients. Clin Neurol Neurosurg 2023; 233:107907. [PMID: 37541157 DOI: 10.1016/j.clineuro.2023.107907] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVE Stroke is a leading cause of mortality and disability worldwide. This study aimed to assess the prognostic value of serum S100B protein, transcranial color-coded duplex sonography (TCCD), and optic nerve sheath diameter (ONSD) in predicting functional outcomes in critically ill patients with acute ischemic stroke (AIS). METHODS In this prospective observational study, 80 adult AIS patients were evaluated. Serum S100B protein levels, ONSD, and middle cerebral artery pulsatility index (MCA PI) were measured on days 1 and 3. Functional outcomes at 90 days were assessed using the modified Rankin Scale (mRS) and categorized into favourable (mRS 0-2) or unfavourable (mRS 3-6) groups. The association of demographic, clinical, laboratory, and imaging parameters with mRS outcomes was analyzed. RESULTS Poor mRS outcomes occurred in 82.5 % of patients. Factors significantly associated with poor outcomes were female sex, higher National Institutes of Health Stroke Scale (NIHSS) scores on days 1, 3, and 7, and larger stroke size. Receiver Operating Characteristic (ROC) curve analysis revealed that ONSD at days 1 and 3, serum S100B levels at day 1, and right MCA PI at day 1 had significant predictive value for poor mRS outcome. Multivariate analysis identified female sex, S100B on day 1, and NIHSS on days 1, 3, and 7 as independent predictors of poor mRS outcomes. CONCLUSIONS The combination of S100B, ONSD, and MCA PI improved the prediction of functional outcomes in critically ill AIS patients. Early S100B measurement and brain ultrasound evaluation may serve as valuable prognostic tools for guiding therapeutic decision-making. This study provides novel insights into the role of S100B and brain ultrasound in stroke outcome prediction, particularly in critically ill AIS patients.
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Affiliation(s)
| | - Tayseer Mohamed Zaytoun
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Tamer AbdAllah Helmy
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ehab Mahmoud El Reweny
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Raghda Saad Zaghloul Taleb
- Clinical and Chemical Pathology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Hu Y, Zhang S, Zhang J, Wang X, Zhang F, Cui H, Yuan H, Zheng W. Early haemodynamic predictors of poor functional outcomes in patients with acute ischaemic stroke receiving endovascular therapy: a single-centre retrospective study in China. PeerJ 2023; 11:e15872. [PMID: 37637153 PMCID: PMC10448886 DOI: 10.7717/peerj.15872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/18/2023] [Indexed: 08/29/2023] Open
Abstract
Background Changes in cerebral haemodynamics following endovascular therapy (EVT) for large-vessel occlusion stroke may affect the outcomes of patients with acute ischaemic stroke (AIS); however, evidence supporting this belief is limited. This study aims to identify the early haemodynamic predictors of poor outcomes in patients with AIS caused by anterior circulation large-artery occlusion after undergoing EVT and to evaluate the usefulness of these indicators in predicting functional outcomes at 90 days. Methods This retrospective study was conducted at a single academic hospital, using prospectively collected data. We enrolled adult patients with acute anterior circulation stroke who underwent EVT. Transcranial colour-coded sonography (TCCS) examinations of the recanalised and contralateral middle cerebral artery (MCA) were performed within 12 h after undergoing EVT. Haemodynamic indicators were analysed to determine their association with poor functional outcomes (modified Rankin Scale: 3-6) 90 days after stroke. Receiver operating characteristic (ROC) curves were used to evaluate the usefulness of haemodynamic indicators in predicting functional outcomes. Results In total, 108 patients (median age: 66 years; 69.4% males) were enrolled in this study. Complete recanalization was achieved in 93 patients (86.1%); however, 60 patients (55.6%) had a poor 90-day outcome. The peak systolic velocity (PSV) ratio, adjusted PSV ratio, mean flow velocity (MFV) ratio, and adjusted MFV ratio of the MCA were significantly higher in patients with poor prognosis than in patients with good prognosis (p < 0.02). A multivariate logistic regression analysis showed that higher PSV ratio, adjusted PSV ratio, MFV ratio, and adjusted MFV ratio were independently associated with a poor 90-day outcomes (adjusted odds ratio: 1.11-1.48 for every 0.1 increase; p < 0.03). Furthermore, adding the adjusted MFV ratio significantly improved the prediction ability of the basic model for the 90-day poor functional outcome using the ROC analysis, the areas under ROC curves increased from 0.75 to 0.85 (p = 0.013). Conclusions Early TCCS examination may help in predicting poor functional outcomes at 90 days in patients with AIS who underwent EVT. Moreover, combining novel TCCS indicators (adjusted MFV ratio) with conventional parameters improved the prediction ability of the base model.
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Affiliation(s)
- Yanyan Hu
- Department of Neurology, The Second Affiliation Hospital of Shandong First Medical University, Taian, Shandong, China
| | - Shizhong Zhang
- Department of Neurosurgery, The Affiliated Taian City Central Hospital of Qingdao University, Taian, Shandong, China
| | - Jiajun Zhang
- Department of Ultrasound, The Second Affiliation Hospital of Shandong First Medical University, Taian, Shandong, China
| | - Xin Wang
- Department of Ultrasound, The Affiliated Taian City Central Hospital of Qingdao University, Taian, Shandong, China
| | - Feng Zhang
- Department of Ultrasound, The Affiliated Taian City Central Hospital of Qingdao University, Taian, Shandong, China
| | - Hong Cui
- Department of Ultrasound, The Affiliated Taian City Central Hospital of Qingdao University, Taian, Shandong, China
| | - Hui Yuan
- Department of Neurology, The Second Affiliation Hospital of Shandong First Medical University, Taian, Shandong, China
| | - Wei Zheng
- Department of Neurosurgery, The Second Affiliation Hospital of Shandong First Medical University, Taian, Shandong, China
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Schlachetzki F, Nedelmann M, Eyding J, Ritter M, Schminke U, Schulte-Altedorneburg G, Köhrmann M, Harrer JU. Sonografisches Neuromonitoring auf der Stroke Unit und in der
neurologischen Intensivmedizin. KLIN NEUROPHYSIOL 2022. [DOI: 10.1055/a-1810-0728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Zusammenfassung
Hintergrund Der Artikel gibt einen Überblick über die
aktuellen diagnostischen Einsatzmöglichkeiten sonographischer Anwendung
in der neurologischen Intensivmedizin.
Methoden Selektive Literaturrecherche mit kritischer Beurteilung ab dem
Jahr 1984 sowie nationaler und internationaler Leitlinien sowie
Expertenmeinung.
Ergebnisse Neben der raschen validen Abklärung akuter
Schlaganfälle bieten verschiedene neurosonografische
Monitoring-verfahren gerade in der Intensivmedizin spezifische Vorteile wie die
beliebig häufige Wiederholbarkeit am Patientenbett selbst und die
Darstellung in Echtzeit. Innovative Entwicklungen machen die Neurosonografie
auch wissenschaftlich zu einem interessanten Gebiet.
Schlussfolgerung Die neurosonografische Diagnostik nimmt seit Jahren einen
wichtigen Stellenwert in der neurologischen Intensivmedizin ein. Weitere
Anstrengungen sind notwendig, um die Verbreitung der Methode zu fördern
und durch wissenschaftliche Evidenz zu stärken.
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Affiliation(s)
- Felix Schlachetzki
- Klinik und Poliklinik für Neurologie der Universität
Regensburg, Zentrum für Vaskuläre Neurologie und
Intensivmedizin, medbo Bezirksklinikum Regensburg, Regensburg
- Klinik und Poliklinik für Neurologie,
Universitätsklinikum Regensburg, Regensburg
| | - Max Nedelmann
- Klinik für Neurologie, Regio Kliniken Pinneberg,
Pinneberg
| | - Jens Eyding
- Abteilung für Neurologie, Gemeinschaftskrankenhaus Herdecke und
Medizinische Fakultät der Ruhr-Universität Bochum,
Bochum
| | | | - Ulf Schminke
- Klinik für Neurologie, Universitätsmedizin Greifswald,
Greifswald
| | | | | | - Judith U. Harrer
- Neurologische Praxis in der Villa Pfahler, St. Ingbert
- Klinik für Neurologie, Universitätsklinikum der RWTH
Aachen, Aachen
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Gómez-Escalonilla C, Simal P, García-Moreno H, Sánchez TL, Canalejo DM, Jiménez MR, Hernández LS, Alfocea DT, Moreu M, Pérez-García C, Rosati S, Egido JA. Transcranial Doppler 6 h after Successful Reperfusion as a Predictor of Infarct Volume. J Stroke Cerebrovasc Dis 2021; 31:106149. [PMID: 34688211 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The aim of the study is to analyze the hemodynamic changes in the middle cerebral artery (MCA) after endovascular revascularization in acute ischemic stroke (AIS) due to large vessel occlusion and its association with the infarct volume size in the control head CT. MATERIALS AND METHODS Prospective study of patients with AIS due to internal carotid artery terminus or M1 segment of the MCA occlusion, who underwent endovascular treatment with a final TICI 2b-3 score, without concomitant stenosis ≥50% in both cervical carotid arteries. Transcranial Doppler ultrasound (TCD) of both MCAs was carried out at 6 h after the endovascular procedure. Mean flow velocities (MFV) after arterial reperfusion and its association with the infarct volume size in 24-36 h control head CT were determined. RESULTS 91 patients (51 women) were included with a median age of 78 years and National institute of Health Stroke Scale of 18. The MCA was occluded in 76.92%, and intravenous thrombolysis was administered in 40.7%. The incidence of symptomatic intracranial hemorrhage was 5.5%. At three months, mortality was 19.8% and a 52.7% of patients achieved functional independence (modified Rankin Scale 0-2). After a multivariable logistic regression analysis, an increase in the MFV greater than 50% at 6 h in the treated MCA compared to contralateral MCA, was an independent predictor of large infarct volume in the control head CT with an OR 9.615 (95%CI: 1.908-47.620), p=0.006 CONCLUSIONS: Increased MFV assessed by TCD examination following endovascular recanalization is independently associated with larger infarct volume.
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Affiliation(s)
- Carlos Gómez-Escalonilla
- Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, Madrid, 28040, Spain.
| | - Patricia Simal
- Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, Madrid, 28040, Spain
| | - Hector García-Moreno
- Department of Clinical and Movement Neurosciences, University College London, UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, United Kingdom.
| | - Talía Liaño Sánchez
- Neurology, Complejo Hospitalario Ruber Juan Bravo, Calle Juan Bravo 39, Madrid, 28006, Spain
| | - Diego Mayo Canalejo
- Neurology, Hospital Universitario de Móstoles, Rio Jucar S/N, Móstoles, 28935, Spain
| | - María Romeral Jiménez
- Neurology, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, Madrid, 28040, Spain
| | - Lorenzo Silva Hernández
- Neurology, Hospital Universitario Puerta de Hierro, C/Manuel de Falla 2, Majadahonda, 28222, Spain.
| | - Daniel Toledo Alfocea
- Neurology, Hospital Universitario 12 de Octubre, Av de Córdoba, s/n, Madrid, 28041, Spain
| | - Manuel Moreu
- Interventional Neuroradiology, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, Madrid, 28040, Spain
| | - Carlos Pérez-García
- Interventional Neuroradiology, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, Madrid, 28040, Spain
| | - Santiago Rosati
- Interventional Neuroradiology, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, Madrid, 28040, Spain
| | - Jose Antonio Egido
- Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, Madrid, 28040, Spain
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Skinner BD, Davies RJ, Weaver SR, Cable NT, Lucas SJE, Lucas RAI. A Systematic Review and Meta-Analysis Examining Whether Changing Ovarian Sex Steroid Hormone Levels Influence Cerebrovascular Function. Front Physiol 2021; 12:687591. [PMID: 34220552 PMCID: PMC8248489 DOI: 10.3389/fphys.2021.687591] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/21/2021] [Indexed: 01/14/2023] Open
Abstract
Sex differences in cerebrovascular disease rates indicate a possible role for ovarian sex steroid hormones in cerebrovascular function. To synthesise and identify knowledge gaps, a systematic review and meta-analysis was conducted to assess how ovarian sex steroid hormone changes across the lifespan affect cerebrovascular function in women. Three databases (EMBASE, MEDLINE and Web of Science) were systematically searched for studies on adult cerebrovascular function and ovarian sex steroid hormones. Forty-five studies met pre-defined inclusion criteria. Studied hormone groups included hormone replacement therapy (HRT; n = 17), pregnancy (n = 12), menstrual cycle (n = 7), menopause (n = 5), oral contraception (n = 2), and ovarian hyperstimulation (n = 2). Outcome measures included pulsatility index (PI), cerebral blood flow/velocity (CBF), resistance index (RI), cerebral autoregulation, and cerebrovascular reactivity. Meta-analysis was carried out on HRT studies. PI significantly decreased [−0.05, 95% CI: (−0.10, −0.01); p = 0.01] in post-menopausal women undergoing HRT compared to post-menopausal women who were not, though there was considerable heterogeneity (I2 = 96.8%). No effects of HRT were seen in CBF (p = 0.24) or RI (p = 0.77). This review indicates that HRT improves PI in post-menopausal women. However, there remains insufficient evidence to determine how changing ovarian sex steroid hormone levels affects cerebrovascular function in women during other hormonal phases (e.g., pregnancy, oral contraception).
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Affiliation(s)
- Bethany D Skinner
- School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Human Brain Health, University of Birmingham, Birmingham, United Kingdom
| | - Rebecca J Davies
- School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Samuel R Weaver
- School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Human Brain Health, University of Birmingham, Birmingham, United Kingdom
| | - N Tim Cable
- School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Samuel J E Lucas
- School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Human Brain Health, University of Birmingham, Birmingham, United Kingdom
| | - Rebekah A I Lucas
- School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom
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Trans-cranial Doppler predicts early neurologic deterioration in anterior circulation ischemic stroke after successful endovascular treatment. Chin Med J (Engl) 2021; 133:1655-1661. [PMID: 32604178 PMCID: PMC7401737 DOI: 10.1097/cm9.0000000000000881] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Early neurologic deterioration (END) may occur in patients with anterior circulation ischemic stroke (ACIS) after receiving endovascular treatment (EVT). Hemodynamic insufficiency, re-occlusion, and post-re-canalization hyper-perfusion are likely to play a critical role in END. We hypothesized that hemodynamic changes can predict END in patients with ACIS post-successful EVT using trans-cranial Doppler (TCD). Methods We utilized a prospectively maintained database of ACIS patients treated with EVT between September 2016 and June 2018 in the Xuanwu Hospital, Capital Medical University. TCD parameters including peak systolic velocity (PSV), bilateral mean flow velocity (MFV), and pulse index (PI) were determined via the middle cerebral arteries within 72 h post-EVT. A logistic regression model was applied to detect independent predictors for END. Results Totally, 112 EVT patients were included in this study and 80/112 patients experienced successful re-canalization with <50% residual stenosis, while 17/80 (21.3%) patients suffered END, for which vasogenic cerebral edema (11/17) was considered as a leading role and followed by symptomatic intra-cranial hemorrhage (4/17) and ischemia progression (2/17). For the 80 patients, the PSV (median: 127 cm/s vs. 116 cm/s, P = 0.039), the ratio of ipsilateral-MFV/contra-lateral-MFV (iMFV/cMFV) (median: 1.29 vs. 1.02, P = 0.036) and iMFV/mean blood pressure (MBP) (median: 0.97 vs. 0.79, P = 0.008) in END patients were higher than those of non-END. Using the receiver-operating characteristic curve to obtain cut-off values for PSV, PI, iMFV/cMFV, and iMFV/MBP for END, we found that PI ≥0.85 (odds ratio: 11.03, 95% confidence interval: 1.92–63.46, P = 0.007) and iMFV/MBP ≥0.84 (odds ratio: 9.20, 95% confidence interval: 2.07–40.84, P = 0.004) were independent predictors of END in a multivariate logistic regression model, with a sensitivity of 82.4% and 76.5% and a specificity of 42.9% and 66.7%, respectively, and had the positive predictive values of 29.0% and 38.2%, and negative predictive values of 90.0% and 91.3%, with an area under the receiver-operating characteristic curve of 0.57 and 0.71, respectively. Conclusion TCD examination of EVT patients may be used as a real-time tool to detect END predictors, such as the higher PI and iMFV/MBP, allowing for better post-thrombectomy management in ACIS patients.
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Barrozo H, De Guzman M, Navarro J, Venketasubramanian N. Asymmetric TCD Findings in Malignant MCA Infarction, Resolution after Decompressive Hemicraniectomy: A Case Report. Case Rep Neurol 2020; 12:127-136. [DOI: 10.1159/000508589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/09/2020] [Indexed: 11/19/2022] Open
Abstract
Transcranial Doppler (TCD) is a non-invasive method for assessing cerebral hemodynamics in the acute phase of stroke. We report a case of a 33-year-old man who presented with a massive left hemispheric infarct developing into “malignant” MCA infarction. TCD was utilized to monitor intracranial hemodynamics while the clinical and neuroimaging findings were used to help us in the decision to proceed with decompressive craniectomy (DC). Pre-operatively, there was reduced mean flow velocities (MFV) of the middle cerebral artery (MCA) with increasing pulsatility index (PI) ipsilateral to the infarct. The subsequent but smaller rise in the PI in the contralateral MCA was suggestive of very high intracranial pressure (ICP) from massive brain swelling. Serial TCD examinations post-operatively showed normalization of the PI, and subsequent rise in the left MCA MFV. Clinical improvement was also noted as the TCD findings improved. The asymmetry in TCD findings can be attributed to occlusion of the MCA with subsequent spontaneous recanalisation, occlusion of the MCA with subsequent recanalisation due to the DC, or initial occlusion and subsequent pressure effects on the arterioles of the MCA due to the “malignant” edema of that hemisphere that was relieved by DC. This case illustrates the value of TCD as a useful modality in monitoring intracranial hemodynamics in acute stroke.
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9
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Baracchini C, Farina F, Palmieri A, Kulyk C, Pieroni A, Viaro F, Cester G, Causin F, Manara R. Early hemodynamic predictors of good outcome and reperfusion injury after endovascular treatment. Neurology 2019; 92:e2774-e2783. [DOI: 10.1212/wnl.0000000000007646] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 02/06/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo find early hemodynamic predictors of outcome and reperfusion injury in patients with acute ischemic stroke due to anterior circulation large artery occlusion (LAO) after endovascular treatment (EVT).MethodsSerial transcranial color-coded sonography examinations assessed the vessel status and cerebral hemodynamics of 185 (109 [58.9%] men, mean age 69.5 ± 12.3 years) consecutive patients with acute anterior circulation LAO soon after, at 48 hours after, and 1 week after EVT.ResultsSuccessful recanalization (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.11–0.61) and normal peak systolic velocity (PSV) ratio (PSV of recanalized middle cerebral artery/PSV of contralateral middle cerebral artery) at 48 hours (OR 0.22, 95% CI 0.15–0.64) and after 1 week (OR 0.11, 95% CI 0.07–0.31) from EVT were independent predictors of good outcome at 3 months. Thrombectomy failure (OR 10.22, 95% CI 1.47–45.53) and pathologic PSV ratio at 1 week from EVT (OR 15.23, 95% CI 4.54–46.72) were associated with a worse 90-day outcome. Patients who subsequently developed postinterventional intracranial hemorrhage (ICH) showed a higher mean PSV ratio (3.5 ± 0.2 vs 2.4 ± 0.1, p < 0.0001) soon after successful recanalization. In multivariate analysis, early PSV ratio was independently associated with postprocedural ICH (OR 8.474, 95% CI 3.066–45.122, p < 0.01]. At 1 week from EVT, 15 of 21 (71.4%) patients with ICH who resumed normal PSV values had a better 90-day outcome (modified Rankin Scale score 0–2: 40% vs 0%).ConclusionPost-EVT ultrasound monitoring of stroke patients might be an effective bedside method for assessing treatment efficacy, shedding light on outcome variability and identifying patients at increased risk of ICH.
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Prediction of functional outcome using the novel asymmetric middle cerebral artery index in cryptogenic stroke patients. PLoS One 2019; 14:e0208918. [PMID: 30601840 PMCID: PMC6314577 DOI: 10.1371/journal.pone.0208918] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 11/26/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Etiology is unknown in approximately one-quarter of stroke patients after evaluation, which is termed cryptogenic stroke (CS). The prognosis of CS patients is largely undetermined. We created a novel index from transcranial Doppler parameters including mean flow velocity (MV) and pulsatility index (PI) and investigated whether the calculation of asymmetry in the novel parameter can predict functional outcomes in CS patients. METHODS We made the middle cerebral artery (MCA) index (%) as a novel parameter, which was calculated as 100 X (MCA MV + MCA PI X 10) / (MCA MV-MCA PI X 10). The MCA asymmetry index (%) was also calculated as 100 X (|Rt MCA index-Lt MCA index|) / (Rt MCA index + Lt MCA index) / 2. Poor functional outcomes were defined as modified Rankin Scale score (mRS) ≥3 at 3 months after stroke onset. RESULTS A total of 377 CS patients were included. Among them, 52 (13.8%) patients had a poor outcome. The overall MCA asymmetry index was two-fold higher in CS patients with a poor outcome (10.26%) compared to those with a good outcome (5.41%, p = 0.002). In multivariable analysis, the overall MCA asymmetry index (OR, 1.054, 95% CI, 1.013-1.096, p = 0.009) and the cutoff value of the overall MCA asymmetry index >9 were associated with poor outcomes at 3 months (OR, 3.737, 95% CI, 1.530-9.128, p = 0.004). CONCLUSION We demonstrated that the novel asymmetric MCA index can predict short-term functional outcomes in CS patients.
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Ikenberg B, Scharsich B, Mönch S, Wunderlich S, Bernkopf K, Boeckh-Behrens T, Friedrich B, Maegerlein C, Poppert H, Seifert CL. Neurosonography After Mechanical Thrombectomy for Acute Stroke Treatment. J Neuroimaging 2019; 29:364-370. [PMID: 30600871 DOI: 10.1111/jon.12592] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/05/2018] [Accepted: 12/21/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy has been shown to be effective for acute stroke treatment, but lesions of cerebral vessels can develop thereafter. Such lesions of recanalized vessels and altered cerebral hemodynamics after mechanical thrombectomy are poorly investigated. In particular for neurosonography, data are sparse. We aimed to describe hemodynamic changes and incidence of de-novo stenosis after mechanical thrombectomy with neurosonography. METHODS Retrospective analysis of patients after successful mechanical thrombectomy for acute stroke therapy who received one neurosonography at baseline and during follow up. Peak systolic velocity (PSV) of all intracranial recanalized and reference vessels was extracted for analysis. Patients with an isolated increase or decrease of PSV (50% or 50 cm/second for anterior and 30% or 30 cm/second for posterior circulation) were identified and characterized. RESULTS Eighty-eight patients (mean age 64.4; 34.1% female) were included in this study. In 9 (10.2%) patients, the vessel occlusion was located in the posterior, and in 79 (89.9%) patients the vessel occlusion was located in the anterior circulation. With predominance to the recanalized vessel, mean PSV decreased at both, the recanalized and the reference vessel during follow up. In 3 (3.4%) patients, an isolated increase of PSV was observed in the recanalized vessel, and in 6 (6.8%) patients an isolated decrease of PSV was observed in the recanalized vessel. CONCLUSION Sonographic incidence of de-novo stenosis following mechanical thrombectomy seems to be low, in line with prior angiographic studies. However, as measured by neurosonography, cerebral hemodynamic in the recanalized vessel is dynamic after thrombectomy. This result is of interest for further prospective analysis.
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Affiliation(s)
- Benno Ikenberg
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar, München, Germany
| | - Benjamin Scharsich
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar, München, Germany
| | - Sebastian Mönch
- Abteilung für Diagnostische und Interventionelle Neuroradiologie, Klinikum rechts der Isar, München, Germany
| | - Silke Wunderlich
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar, München, Germany
| | - Kathleen Bernkopf
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar, München, Germany
| | - Tobias Boeckh-Behrens
- Abteilung für Diagnostische und Interventionelle Neuroradiologie, Klinikum rechts der Isar, München, Germany
| | - Benjamin Friedrich
- Abteilung für Diagnostische und Interventionelle Neuroradiologie, Klinikum rechts der Isar, München, Germany
| | - Christian Maegerlein
- Abteilung für Diagnostische und Interventionelle Neuroradiologie, Klinikum rechts der Isar, München, Germany
| | - Holger Poppert
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar, München, Germany.,Klinik für Neurologie, Helios Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Christian L Seifert
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar, München, Germany
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Kneihsl M, Niederkorn K, Deutschmann H, Enzinger C, Poltrum B, Fischer R, Thaler D, Hermetter C, Wünsch G, Fazekas F, Gattringer T. Increased middle cerebral artery mean blood flow velocity index after stroke thrombectomy indicates increased risk for intracranial hemorrhage. J Neurointerv Surg 2017; 10:882-887. [DOI: 10.1136/neurintsurg-2017-013617] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 11/03/2022]
Abstract
Background and purposeCerebral hyperperfusion has been related to the risk of intracranial hemorrhage (ICH) in stroke patients after vessel recanalization therapy. We hypothesized that after successful mechanical thrombectomy for acute anterior circulation stroke, hemodynamics detectable by transcranial Duplex (TCD) sonography would vary, and that increased blood flow velocities would be associated with ICH.MethodsWe retrospectively identified all ischemic stroke patients with successful endovascular recanalization for anterior circulation vessel occlusion (Thrombolysis in Cerebral Infarction 2b–3) between 2010 and 2017. We reviewed their postinterventional TCD examinations for mean blood flow (MBF) velocities of the recanalized and contralateral middle cerebral artery (MCA) and searched for an association with postinterventional ICH and clinical outcome.Results123 stroke patients (mean age 63±14 years, 40% women) with successful anterior circulation thrombectomy were analyzed. Of those, 18 patients had postinterventional ICH. ICH patients had an increased MCA MBF velocity index (=MBF velocity of the recanalized divided by the contralateral MCA) compared with non-ICH patients (1.32±0.39 vs 1.02±0.32, P<0.001). In multivariate analysis, a higher MCA MBF velocity index was associated with postinterventional ICH and poor 90 day outcome.ConclusionsA high MCA MBF velocity index on TCD after successful recanalization therapy for anterior circulation stroke indicates a risk for postinterventional ICH and worse prognosis.
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Thrombolytic therapy with rt-PA and transcranial color Doppler ultrasound (TCCS) combined with microbubbles for embolic thrombus. Thromb Res 2015; 136:1027-32. [DOI: 10.1016/j.thromres.2015.08.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/29/2015] [Accepted: 08/29/2015] [Indexed: 11/22/2022]
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Ding D. Outcomes of acute ischemic stroke patients following endovascular intervention: role and clinical utility of transcranial Doppler. J Neurol Sci 2014; 338:241-2. [PMID: 24439145 DOI: 10.1016/j.jns.2013.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 12/31/2013] [Indexed: 11/19/2022]
Affiliation(s)
- Dale Ding
- University of Virginia, Department of Neurological Surgery, P.O. Box 800212, Charlottesville, VA 22908, United States.
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Aoki J, Raber LN, Katzan IL, Hussain MS, Hui FK, Uchino K. Response to a letter regarding a paper entitled, “Post-intervention TCD examination may be useful to predict outcome in acute ischemic stroke patients with successful intra-arterial intervention”. J Neurol Sci 2014; 338:243. [DOI: 10.1016/j.jns.2013.12.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 12/31/2013] [Indexed: 10/25/2022]
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