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von Bary C, Deneke T, Arentz T, Schade A, Lehrmann H, Schwab-Malek S, Fredersdorf S, Baldaranov D, Maier L, Schlachetzki F. Clinical Impact of the Microembolic Signal Burden During Catheter Ablation for Atrial Fibrillation: Just a Lot of Noise? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1091-1101. [PMID: 29034496 DOI: 10.1002/jum.14447] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Microembolic signal detection by transcranial Doppler ultrasonography may be considered a surrogate for cerebral events during invasive cardiac procedures. However, the impact of the microembolic signal count during pulmonary vein isolation on the clinical outcome is not well evaluated. We investigated the effect of the microembolic signal count on the occurrence of new silent cerebral embolism measured by diffusion-weighted imaging (DWI)-magnetic resonance imaging (MRI), changes in neuropsychological testing, and the occurrence of clinical events during long-term follow-up after pulmonary vein isolation. METHODS Pulmonary vein isolation was performed in 41 patients. The total microembolic signal burden (classified into "solid," "gaseous," and "equivocal") and sustained thromboembolic showers of greater than 30 seconds were recorded. Diffusion-weighted imaging-MRI and neuropsychological testing were performed before and after pulmonary vein isolation to assess for silent cerebral embolism and neuropsychological sequelae. Long-term follow-up was performed by telephone to assess for stroke/transient ischemic attack. RESULTS A total of 68,729 microembolic signals (14,893 solid, 11,909 gaseous, and 41,927 equivocal) with an average of 1676 signals per patient and 42 thromboembolic showers were recorded. No correlation between the microembolic signal/thromboembolic shower count and the occurrence of new DWI lesions or neuropsychological capability was found. After a mean follow-up ± SD of 49 ± 4 months, 1 patient had an overt transient ischemic event, which was not associated with a high microembolic signal count. CONCLUSIONS In this multicenter study, we found no impact of the intraprocedural microembolic symbol/thromboembolic shower count on the occurrence of new DWI lesions, neuropsychological capability, or overt neurologic deficits after pulmonary vein isolation. Thus, not only the microembolic signal count but also procedural/individual factors may contribute to commensurable clinical damage, which may challenge this method as a valid biomarker during pulmonary vein isolation.
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Affiliation(s)
- Christian von Bary
- Department of Cardiology, Rotkreuzklinikum München, Munich, Germany
- Department of Internal Medicine II, University of Regensburg, Regensburg, Germany
| | - Thomas Deneke
- Department of Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt, Germany
| | - Thomas Arentz
- Department of Cardiology and Angiology, Heart Center Bad Krozingen, Bad Krozingen, Germany
| | - Anja Schade
- Department of Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt, Germany
| | - Heiko Lehrmann
- Department of Cardiology and Angiology, Heart Center Bad Krozingen, Bad Krozingen, Germany
| | - Susanne Schwab-Malek
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Regensburg, Germany
| | - Sabine Fredersdorf
- Department of Internal Medicine II, University of Regensburg, Regensburg, Germany
| | - Dobri Baldaranov
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Regensburg, Germany
| | - Lars Maier
- Department of Internal Medicine II, University of Regensburg, Regensburg, Germany
| | - Felix Schlachetzki
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Regensburg, Germany
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von Bary C, Deneke T, Arentz T, Schade A, Lehrmann H, Fredersdorf S, Baldaranov D, Maier L, Schlachetzki F. Online Measurement of Microembolic Signal Burden by Transcranial Doppler during Catheter Ablation for Atrial Fibrillation-Results of a Multicenter Trial. Front Neurol 2017; 8:131. [PMID: 28424659 PMCID: PMC5380664 DOI: 10.3389/fneur.2017.00131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 03/21/2017] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Left atrial pulmonary vein isolation (PVI) is an accepted treatment option for patients with symptomatic atrial fibrillation (AF). This procedure can be complicated by stroke or silent cerebral embolism. Online measurement of microembolic signals (MESs) by transcranial Doppler (TCD) may be useful for characterizing thromboembolic burden during PVI. In this prospective multicenter trial, we investigated the burden, characteristics, and composition of MES during left atrial catheter ablation using a variety of catheter technologies. MATERIALS AND METHODS PVI was performed in a total of 42 patients using the circular-shaped multielectrode pulmonary vein ablation catheter (PVAC) technology in 23, an irrigated radiofrequency (IRF) in 14, and the cryoballoon (CB) technology in 5 patients. TCD was used to detect the total MES burden and sustained thromboembolic showers (TESs) of >30 s. During TES, the site of ablation within the left atrium was registered. MES composition was classified manually into "solid," "gaseous," or "equivocal" by off-line expert assessment. RESULTS The total MES burden was higher when using IRF compared to CB (2,336 ± 1,654 vs. 593 ± 231; p = 0.007) and showed a tendency toward a higher burden when using IRF compared to PVAC (2,336 ± 1,654 vs. 1,685 ± 2,255; p = 0.08). TES occurred more often when using PVAC compared to IRF (1.5 ± 2 vs. 0.4 ± 1.3; p = 0.04) and most frequently when ablation was performed close to the left superior pulmonary vein (LSPV). Of the MES, 17.004 (23%) were characterized as definitely solid, 13.204 (18%) as clearly gaseous, and 44.366 (59%) as equivocal. DISCUSSION We investigated the burden and characteristics of MES during left atrial catheter ablation for AF. All ablation techniques applied in this study generated a relevant number of MES. There was a significant difference in total MES burden using IRF compared to CB and a tendency toward a higher burden using IRF compared to PVAC. The highest TES burden was found in the PVAC group, particularly during ablation close to the LSPV. The composition of thromboembolic particles was balanced. The impact of MES, TES, and composition of thromboembolic particles on neurological outcome needs to be evaluated further. (Clinical Trial Registration: Deutsches Register Klinischer Studien, https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00003465. DRKS00003465.).
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Affiliation(s)
- Christian von Bary
- Department of Cardiology, Rotkreuzklinikum München, Munich, Germany.,Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Deneke
- Department of Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt, Germany
| | - Thomas Arentz
- Department of Cardiology and Angiology, Heart Center Bad Krozingen, Bad Krozingen, Germany
| | - Anja Schade
- Department of Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt, Germany
| | - Heiko Lehrmann
- Department of Cardiology and Angiology, Heart Center Bad Krozingen, Bad Krozingen, Germany
| | - Sabine Fredersdorf
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dobri Baldaranov
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Lars Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Felix Schlachetzki
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
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Mukerji N, Cook DJ, Steinberg GK. An Alternative Display Could Lead to Earlier Diagnosis of Intracerebral Pathology with a Hemedex Flow Probe In Situ. World Neurosurg 2015; 84:2079.e1-5. [PMID: 26341435 DOI: 10.1016/j.wneu.2015.08.032] [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: 04/29/2015] [Revised: 08/13/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To report 2 cases of patients who had an ischemic stroke and an intracerebral hematoma after a superficial temporal artery-middle cerebral artery bypass with a thermal diffusion blood flow probe in situ and emphasize how a change in the way the data are presented could have led to an earlier diagnosis. METHODS Both patients had flow probes within 2 cm of the graft site and were thus close enough to be representative of local or regional rather than global perfusion. Data smoothening was applied to the raw data that were available and displayed on the monitor. Both the smoothed plots and the raw plots were analyzed. RESULTS Good clinical correlation was observed between the flow probe data and the clinical condition of both patients. This was more apparent when viewing the smoothed plots. CONCLUSIONS Although there was good clinical correlation, data displayed on the perfusion monitor can be incorrectly interpreted because the signal-to-noise ratio is small. We therefore suggest an alternative presentation of perfusion data for clinicians to recognize hypoperfusion and to take informed action before a stroke or hematoma is clinically manifest.
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Affiliation(s)
- Nitin Mukerji
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Douglas J Cook
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
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Meairs S, Hennerici M, Mohr J. Ultrasonography. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Martina AD, Meyer-Wiethe K, Allémann E, Seidel G. Ultrasound Contrast Agents for Brain Perfusion Imaging and Ischemic Stroke Therapy. J Neuroimaging 2006. [DOI: 10.1111/j.1552-6569.2005.tb00314.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Shiogai T, Takayasu N, Mizuno T, Nakagawa M, Furuhata H. Comparison of Transcranial Brain Tissue Perfusion Images Between Ultraharmonic, Second Harmonic, and Power Harmonic Imaging. Stroke 2004; 35:687-93. [PMID: 14963286 DOI: 10.1161/01.str.0000116102.15636.65] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
To clarify optimal brain tissue perfusion images visualized by transcranial ultrasound harmonic imaging, we compared gray-scale integrated backscatter (IBS) images of new ultraharmonic imaging (UHI) and conventional second harmonic imaging (SHI) with power harmonic imaging (PHI) (harmonic B-mode with harmonic power Doppler images) in 10 patients with and 4 without a temporal skull.
Methods—
Using a SONOS 5500 (Philips), we evaluated transient response images taken after a bolus Levovist injection at a horizontal diencephalic plane via temporal windows. Based on transmitting/receiving frequencies (MHz), 4 imaging procedures using an S3 transducer (SHI2.6 [1.3/2.6], UHI [1.3/3.6], PHI2.6 [1.3/2.6], and PHI3.2 [1.6/3.2]) and 2 imaging procedures using an S4 transducer (SHI3.6 [1.8/3.6] and PHI3.6 [1.8/3.6]) were compared in terms of size and location, peak intensity (PI), contrast area demarcation, and background image quality.
Results—
In intact skull cases, gray-scale imaging tended to show larger contrast areas than PHI. A large contrast area was most frequently observed in SHI2.6 images, despite there being more high-PI cases in UHI. No contrast area with unclear background was observed in a few cases. In craniectomized cases, all contrast images tended to have large and high PI compared with the intact skull cases. PHI, particularly PHI3.6, demonstrated sharper demarcation and a clearer background than gray-scale imaging.
Conclusions—
Transcranial gray-scale SHI using a low receiving frequency of 2.6 MHz is the superior method. PHI identifies contrast area localization better than gray-scale imaging and is particularly suitable for intraoperative and postoperative cases.
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Affiliation(s)
- Toshiyuki Shiogai
- Department of Clinical Neurosciences, Kyoto Takeda Hospital, Minamikinuta-cho 11, Nishinanajo, Shimogyo-ku, Kyoto 600-8884, Japan.
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Hynynen K, McDannold N, Martin H, Jolesz FA, Vykhodtseva N. The threshold for brain damage in rabbits induced by bursts of ultrasound in the presence of an ultrasound contrast agent (Optison). ULTRASOUND IN MEDICINE & BIOLOGY 2003; 29:473-81. [PMID: 12706199 DOI: 10.1016/s0301-5629(02)00741-x] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
The purpose of this study was to test the hypothesis that burst ultrasound (US) in the presence of a US contrast agent using parameters similar to those used in brain blood flow measurements causes tissue damage. The brains of 10 rabbits were sonicated in 3-8 locations with 1.5-MHz, 10- micro s bursts repeated at a frequency of 1 kHz at temporal peak acoustic pressure amplitudes ranging from 2 to 12.7 MPa. The total sonication time for each location was 20 s. Before each sonication, a bolus of US contrast agent was injected IV. Contrast-enhanced magnetic resonance (MR) images were obtained after the sonications to detect local enhancement in the brain. Whole brain histological evaluation was performed, and the sections were stained with hematoxylin and eosin (H and E), TUNEL, and vanadium acid fuchsin (VAF) staining to evaluate tissue effects, including apoptosis and ischemia. Both the magnetic resonance imaging (MRI) contrast enhancement and histology findings indicated that brain tissue damage was induced at a pressure amplitude level of 6.3 MPa. The damage included vascular wall damage, hemorrhage and, eventually, necrosis. Mild vascular damage was observed localized in a few microscopic tissue volumes in about half of the sonicated locations at all pressure values tested (down to 2 MPa). However, these sonications did not induce any detectable tissue effects, including ischemia or apoptosis. As a conclusion, the study showed that the US exposure levels currently used for blood flow measurements in brain are below the threshold of blood-brain barrier opening or brain tissue damage. However, one should be aware that brain damage can be induced if the exposure level is increased.
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Affiliation(s)
- Kullervo Hynynen
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Eyding J, Wilkening W, Postert T. Brain perfusion and ultrasonic imaging techniques. EUROPEAN JOURNAL OF ULTRASOUND : OFFICIAL JOURNAL OF THE EUROPEAN FEDERATION OF SOCIETIES FOR ULTRASOUND IN MEDICINE AND BIOLOGY 2002; 16:91-104. [PMID: 12470854 DOI: 10.1016/s0929-8266(02)00042-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Advances in neurosonology have generated several techniques of ultrasonic perfusion imaging employing ultrasound echo contrast agents (ECAs). Doppler imaging techniques cannot measure the low flow velocities that are associated with parenchymal perfusion. Ultrasonic perfusion imaging, therefore, is a combination of a contrast agent-specific ultrasound imaging technique (CAI) mode and a data acquisition and processing (DAP) technique that is suited to observe and evaluate the perfusion kinetics. The intensity in CAI images is a measure of ECA concentration but also depends on various other parameters, e.g. depth of examination. Moreover, ECAs can be destroyed by ultrasound, which is an artifact but can also be a feature. Thus, many different DAPs have been developed for certain CAI techniques, ECAs and target organs. Although substantial progress in ECA and CAI technology can be foreseen, ultrasound contrast imaging has yet to reliably differentiate between normal and pathological perfusion conditions. Destructive imaging techniques, such as contrast burst imaging (CBI) or time variance imaging (TVI), in combination with new DAP techniques provide sufficient signal-to-noise ratio (SNR) for transcranial applications, and consider contrast agent kinetics and destruction to eliminate depth dependency and to calculate semi-quantitative parameters. Since ultrasound machines are widely accessible and cost-effective, ultrasonic perfusion imaging techniques should become supplementary standard perfusion imaging techniques in acute stroke diagnosis and monitoring. This paper gives an overview on different CAI and DAP techniques with special focus on recent innovations and their clinical potential.
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Affiliation(s)
- Jens Eyding
- Department of Neurology, Ruhr-University Bochum, D-44791, Bochum, Germany.
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Bauer A, Solbiati L, Weissman N. Ultrasound imaging with SonoVue: low mechanical index real-time imaging. Acad Radiol 2002; 9 Suppl 2:S282-4. [PMID: 12188249 DOI: 10.1016/s1076-6332(03)80204-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- A Bauer
- Bracco Research USA, Princeton, NJ 08540
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Schlachetzki F, Hoelscher T, Ullrich OW, Schalke B, Bogdahn U. Dynamic and three-dimensional transcranial ultrasonography of an arachnoid cyst in the cerebral convexity. Technical note. J Neurosurg 2001; 94:655-9. [PMID: 11302671 DOI: 10.3171/jns.2001.94.4.0655] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Structural imaging of the brain, such as cerebral computerized tomography (CT) and magnetic resonance (MR) imaging, is state-of-the-art. Dynamic transcranial (dTC) ultrasonography and three-dimensional (3D) transcranial color-coded duplex (TCC) ultrasonography are complementary, noninvasive procedures with the capacity for real-time imaging, which may aid in the temporary management of space-occupying lesions. A 16-year-old woman presented with recurrent tension-type headaches. A space-occupying arachnoid cyst in the cerebral convexity was demonstrated on MR images. The patient underwent an examination for raised intracranial pressure. which was performed using a standard color-coded duplex ultrasonography system attached to a personal computer-based system for 3D data acquisition. Transcranial ultrasonography was used to identify the outer arachnoid membrane of the cyst, which undulated freely in response to rotation of the patient's head (headshake maneuver). Three-dimensional data sets were acquired and, using a multiplanar reformatting reconstruction algorithm, the authors obtained high-resolution images that corresponded to the initial MR image and a follow-up cranial CT scan. No detectable differences were observed on dTC or 3D TC ultrasonograms obtained at follow-up examinations performed 9 and 28 months later. Three-dimensional TCC and dTC ultrasonography may complement conventional diagnostic procedures such as MR and CT imaging. This report represents evidence of the high resolution and good reproducibility of 3D TC methods. Ultrasonography is a mobile and inexpensive tool and may be used to improve management and therapeutic strategies for patients with space-occupying brain lesions in selected cases.
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Affiliation(s)
- F Schlachetzki
- Department of Neurology, University of Regensburg, Germany.
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