Transcranial Color-Coded Sonography Criteria for Moderate and Severe Middle Cerebral Artery Stenosis

The Diagnostic Accuracy of Transcranial Color-Coded Doppler Ultrasound Technique in Stratifying Intracranial Cerebral Artery Stenoses in Cerebrovascular Disease Patients: A Systematic Review and Meta-Analysis

The early and accurate stratification of intracranial cerebral artery stenosis (ICAS) is critical to inform treatment management and enhance the prognostic outcomes in patients with cerebrovascular disease (CVD). Digital subtraction angiography (DSA) is an invasive and expensive procedure but is the gold standard for the diagnosis of ICAS. Over recent years, transcranial color-coded Doppler ultrasound (TCCD) has been suggested to be a useful imaging method for accurately diagnosing ICAS. However, the diagnostic accuracy of TCCD in stratifying ICASs among patients with CVD remains unclear. Therefore, this systematic review and meta-analysis aimed at evaluating the diagnostic accuracy of TCCD in the stratification of intracranial steno-occlusions among CVD patients. A total of six databases-Embase, CINAHL, Medline, PubMed, Google Scholar, and Web of Science (core collection)-were searched for studies that assessed the diagnostic accuracy of TCCD in stratifying ICASs. The meta-analysis was performed using Meta-DiSc 1.4. The Quality Assessment of Diagnostic Accuracy Studies tool version 2 (QUADAS-2) assessed the risk of bias. Eighteen studies met all of the eligibility criteria. TCCD exhibited a high pooled diagnostic accuracy in stratifying intracranial steno-occlusions in patients presenting with CVD when compared to DSA as a reference standard (sensitivity = 90%; specificity = 87%; AUC = 97%). Additionally, the ultrasound parameters peak systolic velocity (PSV) and mean flow velocity (MFV) yielded a comparable diagnostic accuracy of "AUC = 0.96". In conclusion, TCCD could be a noble, safe, and accurate alternative imaging technique to DSA that can provide useful diagnostic information in stratifying intracranial steno-occlusions in patients presenting with CVD. TCCD should be considered in clinical cases where access to DSA is limited.

Diagnostic feasibility of middle cerebral artery stenosis or occlusion evaluated by TCCS and CEUS: Repeatability, reproducibility, and diagnostic agreement with DSA

AIM

This study aimed to evaluate the feasibility of transcranial color-coded sonography (TCCS) and contrast-enhanced ultrasound (CEUS) in assessing middle cerebral artery (MCA) stem stenosis or occlusion compared to digital subtraction angiography (DSA).

METHODS

A total of 48 cases including 96 MCAs suspected stem stenosis or obstruction in the MCA were assessed by TCCS, CE-TCCS, and DSA. The diameters of the most severe stenosis (Ds), proximal normal artery (Dn), and diameter stenosis rate of MCA were measured using both the color doppler flow imaging (CDFI) modality of TCCS or CEUS and the CEUS imaging modality. The intraclass correlation coefficients (ICCs) and 95 % confidence intervals (CI) were evaluated, and a weighted Kappa value was used to evaluate the intra-observer agreement, inter-observer agreement, agreement between CDFI modality and DSA stenosis or occlusion, and agreement between CEUS imaging modality and DSA stenosis or occlusion.

RESULTS

The ICC results indicated excellent repeatability and reproducibility (all ICCs > 0.75; weighted Kappa values >0.81). Compared with DSA, the weighted Kappa values and 95 % CIs of stenosis (the first measurement was taken by two observers) of CDFI modality and CEUS imaging modality were 0.175 (0.041, 0.308) and 0.779 (0.570, 0.988) for observers A and 0.181 (0.046, 0.316) and 0.779 (0.570, 0.988) for observers B respectively.

CONCLUSION

This study indicates that inter- and intra-observer agreements were good for the direct method of measuring percentages of MCA stenosis by TCCS and CEUS. CEUS imaging modality is a new and reliable imaging modality approach to evaluate the MCAs stenosis and occlusion.

Role of Advanced Hemodynamic Ultrasound Evaluation in the Differential Diagnosis of Middle Cerebral Artery Stenosis: Introducing Morphological Criteria

OBJECTIVE

The aim of the work described here was to determine the possible impact of the new technique advanced hemodynamic ultrasound evaluation (AHUSE) in identification of severe intracranial stenosis. Transcranial Doppler (TCD) and transcranial color-coded Doppler (TCCD) provide reliable velocimetric data, the indirect analysis of which allows us to obtain information on the patency of vessels and assumed stenosis range. However, very tight stenoses (>95%) cannot be detected with velocimetric criteria because of spectrum drops and the absence of high velocities, so that the right curve of the Spencer equation cannot be solved. Likewise, high velocities are not detected when analyzing morphologically long stenosis. Furthermore, the current classifications based on velocimetric criteria do not provide any categorization on stenoses with multiple acceleration points (MAPs).

METHODS

With this Technical Note we aim to introduce, in addition to velocimetric criteria, more morphological criteria based on TCCD with the algorithm of AHUSE to optimize the characterization of intracranial stenosis (IS). TCCD-AHUSE relies on intensity-based next-generation techniques and can be used to identify IS with MAPs and simultaneously perform a morphological assessment of the stenosis length.

RESULTS

We introduce a new technical ultrasound (U) approach that we tested in a sample of four different types of stenoses combining velocimetric data and AHUSE using Esaote Microvascularization (MicroV) technique to the M1 tract of the middle cerebral artery (MCA).

CONCLUSION

The authors believe that a multiparametric evaluation is more sensitive and supports the clinician by introducing the morphological concept, not just the velocimetric concept, to differentiate the IS pattern of MCA. The potential for developing a diagnostic/prognostic algorithm is discussed.

Neck-brain integrated ultrasound as a noninvasive screening tool to identify morphological features of middle cerebral artery disease

BACKGROUND AND AIMS

Endovascular treatment is suitable for middle cerebral artery (MCA) with focal lesion. Therefore, accurate evaluation of the morphological features of MCA disease is critical. Ultrasonography is commonly used to screen for MCA lesions. However, there are few studies on lesion length. Using ultrasonography, we aimed to prospectively evaluate MCA disease with focal stenosis, long stenosis, focal occlusion, and long occlusion.

METHODS

Patients with symptomatic MCA disease scheduled for digital subtraction angiography were enrolled. The ultrasonic parameters recorded included mean flow velocity at MCA (V_MCA) and extracranial internal carotid artery (V_ICA), bilateral V_MCA ratio, bilateral V_ICA ratio, and MCA flow continuity.

RESULTS

A total of 278 MCAs were included. Compared to normal vessels, the bilateral V_MCA ratio increased in the focal stenosis group and decreased in the long lesion and focal occlusion groups (all p < 0.05); the V_ICA and bilateral V_ICA ratio decreased in the long lesion group (all p < 0.01), and there was no significant difference in the focal lesion group (all p > 0.05). The optimal cut-offs were bilateral V_MCA ratio <0.80 to predict long lesions and focal occlusions (sensitivity: 0.898, specificity: 0.975), and bilateral V_ICA ratio <0.84 to predict long lesions (sensitivity: 0.704, specificity: 0.879). The sensitivity and specificity to predict long occlusions were 96.7% and 94.8%, respectively, in the absence of MCA flow continuity.

CONCLUSIONS

Neck-brain integrated ultrasound is an appropriate screening method for identifying MCA lesions with different morphologies. Endovascular treatment might not be recommended when bilateral V_ICA ratio <0.84 in patients with MCA lesions.

The Effect of CT Imaging Technology in the Diagnosis of Thoracic and Cardiac Surgery Diseases

In order to increase doctors' cognition of the three-dimensional anatomical structure of cardiothoracic and cardiothoracic surgery and increase the diagnosis rate and cure rate of cardiothoracic surgery diseases, the authors propose a method of CT imaging technology for diagnosing cardiothoracic surgery diseases. Through the joint Hookwire positioning of 3D-CTBA, application in thoracoscopic segmentectomy and CT energy spectrum curve, retrospective analysis of diagnosis of intrathoracic lymph node metastasis in non-small-cell lung cancer, 3D-CTBA and CT-guided Hookwire localization, and preoperative CT-enhanced scanning were performed using two methods. The experimental results showed that the chest tube placement time, postoperative thoracic drainage volume, and postoperative hospital stay after the first operation all showed a good trend. The diagnostic sensitivity was 87.1%. The specificity was 92.6%. The correct index was 79.7%. The accuracy was 91.3%. The positive predictive value was 79.4%. And the negative predictive value was 95.7%. These data prove that CT imaging technology has high diagnostic value for thoracic and cardiac surgery diseases and can effectively help the formulation and implementation of thoracic and cardiac surgery diseases.

Non-invasive Detection of Diffuse Intracranial Vertebrobasilar Artery Stenosis: A Prospective Comparison with Digital Subtraction Angiography

The aim of this study was to prospectively evaluate diffuse intracranial vertebrobasilar artery stenosis by ultrasonic examination with digital subtraction angiography as the reference. Five hundred forty-one vertebrobasilar arteries with a normal lumen or intracranial stenosis were enrolled. Peak systolic velocity, mean flow velocity and end-diastolic velocity (EDV) at the intracranial vertebrobasilar arteries and extracranial vertebral arteries (VAs) were measured. The resistance index (RI) at extracranial VAs and the difference between the RI of extracranial VAs and the RI of the extracranial internal carotid artery (RI_ica) were calculated. Compared with normal arteries, all stenotic arteries were divided into the high-velocity group (focal stenosis, multiple-segment stenosis and multiple-artery stenosis) and low-velocity group (critical stenosis and long stenosis). The consistency between ultrasonic examination and digital subtraction angiography for evaluation of vertebrobasilar arteries with multiple-segment stenosis and multiple-artery stenosis was not favorable when applying the widely used Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis criteria (κ = 0.442 and 0.438, respectively). The optimal low-velocity criteria for identifying intracranial vertebrobasilar arteries with critical stenosis and long stenosis were determined by receiver operating characteristic curve analysis and were as follows: EDV ≤15 cm/s and RI ≥0.68 at the extracranial VA and RIica ≥0.10.