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Rajajee V. Transcranial Ultrasound in the Neurocritical Care Unit. Neuroimaging Clin N Am 2024; 34:191-202. [PMID: 38604704 DOI: 10.1016/j.nic.2023.11.001] [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] [Indexed: 04/13/2024]
Abstract
Ultrasound evaluation of the brain is performed through acoustic windows. Transcranial Doppler has long been used to monitor patients with subarachnoid hemorrhage for cerebral vasospasm. Transcranial color-coded sonography permits parenchymal B-mode imaging and duplex evaluation. Transcranial ultrasound may also be used to assess the risk of delayed cerebral ischemia, screen patients for the presence of elevated intracranial pressure, confirm the diagnosis of brain death, measure midline shift, and detect ventriculomegaly. Transcranial ultrasound should be integrated with other point-of-care ultrasound techniques as an essential skill for the neurointensivist.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurosurgery & Neurology, University of Michigan, 3552 Taubman Health Care Center, SPC 5338 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Rajajee V, Soroushmehr R, Williamson CA, Najarian K, Ward K, Tiba H. Transcranial Color-Coded Sonography With Angle Correction As a Screening Tool for Raised Intracranial Pressure. Crit Care Explor 2023; 5:e0953. [PMID: 37644975 PMCID: PMC10461938 DOI: 10.1097/cce.0000000000000953] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES Transcranial Doppler (TCD) has been evaluated as a noninvasive intracranial pressure (ICP) assessment tool. Correction for insonation angle, a potential source of error, with transcranial color-coded sonography (TCCS) has not previously been reported while evaluating ICP with TCD. Our objective was to study the accuracy of TCCS for detection of ICP elevation, with and without the use of angle correction. DESIGN Prospective study of diagnostic accuracy. SETTING Academic neurocritical care unit. PATIENTS Consecutive adults with invasive ICP monitors. INTERVENTIONS Ultrasound assessment with TCCS. MEASUREMENTS AND MAIN RESULTS End-diastolic velocity (EDV), time-averaged peak velocity (TAPV), and pulsatility index (PI) were measured in the bilateral middle cerebral arteries with and without angle correction. Concomitant mean arterial pressure (MAP) and ICP were recorded. Estimated cerebral perfusion pressure (CPP) was calculated as estimated CPP (CPPe) = MAP × (EDV/TAPV) + 14, and estimated ICP (ICPe) = MAP-CPPe. Sixty patients were enrolled and 55 underwent TCCS. Receiver operating characteristic curve analysis of ICPe for detection of invasive ICP greater than 22 mm Hg revealed area under the curve (AUC) 0.51 (0.37-0.64) without angle correction and 0.73 (0.58-0.84) with angle correction. The optimal threshold without angle correction was ICPe greater than 18 mm Hg with sensitivity 71% (29-96%) and specificity 28% (16-43%). With angle correction, the optimal threshold was ICPe greater than 21 mm Hg with sensitivity 100% (54-100%) and specificity 30% (17-46%). The AUC for PI was 0.61 (0.47-0.74) without angle correction and 0.70 (0.55-0.92) with angle correction. CONCLUSIONS Angle correction improved the accuracy of TCCS for detection of elevated ICP. Sensitivity was high, as appropriate for a screening tool, but specificity remained low.
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Affiliation(s)
- Venkatakrishna Rajajee
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
- Department of Neurology, University of Michigan, Ann Arbor, MI
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
| | - Reza Soroushmehr
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
- Department of Computational Medicine & Bioinformatics, University of Michigan, Ann Arbor, MI
| | - Craig A Williamson
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
- Department of Neurology, University of Michigan, Ann Arbor, MI
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
| | - Kayvan Najarian
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
- Department of Computational Medicine & Bioinformatics, University of Michigan, Ann Arbor, MI
- Department of Electrical Engineering, University of Michigan, Ann Arbor, MI
| | - Kevin Ward
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Hakam Tiba
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
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Wan Y, Teng X, Li S, Yang Y. Application of transcranial Doppler in cerebrovascular diseases. Front Aging Neurosci 2022; 14:1035086. [PMID: 36425321 PMCID: PMC9679782 DOI: 10.3389/fnagi.2022.1035086] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/24/2022] [Indexed: 01/03/2024] Open
Abstract
Transcranial Doppler (TCD) is a rapid and non-invasive diagnostic technique that can provide real-time measurements of the relative changes in cerebral blood velocity (CBV). Therefore, TCD is a useful tool in the diagnosis and treatment of clinical cerebrovascular diseases (CVDs). In this review, the basic principles of TCD and its application in CVD were outlined. Specifically, TCD could be applied to evaluate occlusive CVD, assess collateral circulation in patients with ischemic stroke, and monitor cerebral vascular occlusion before and after thrombolysis as well as cerebral vasospasm (VSP) and microembolization signals after aneurysmal subarachnoid hemorrhage (SAH). Moreover, TCD could predict short-term stroke and transient cerebral ischemia in patients with anterior circulation occlusion treated with endovascular therapy and in patients with anterior circulation vascular occlusion. Additionally, TCD not only could monitor blood velocity signals during carotid endarterectomy (CEA) or carotid artery stenting (CAS) but also allowed earlier intervention through early recognition of sickle cell disease (SCD). Presently, TCD is a useful prognostic tool to guide the treatment of CVD. On the one hand, TCD is more commonly applied in clinical research, and on the other hand, TCD has an increasing role in the management of patients. Collectively, we review the principles and clinical application of TCD and propose some new research applications for TCD.
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Affiliation(s)
| | | | | | - Yanchao Yang
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
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Liang Y, Duan Y, Xing C, Jin J, Yan L, Liu X, Wang J. Clinical Value of TCCD for Evaluating the Prognosis of Patients with Severe Traumatic Brain Injury After Large Decompressive Craniectomy: A Retrospective Study. Adv Ther 2022; 39:4556-4567. [PMID: 35934765 DOI: 10.1007/s12325-022-02251-w] [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: 04/23/2022] [Accepted: 06/29/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION It is challenging to assess the prognosis of patients with severe traumatic brain injury (sTBI) after large decompressive craniectomy (DC). The aim of this study was to evaluate the clinical value of transcranial color-coded duplex sonography (TCCD) for assessing the prognosis of sTBI patients 6 months after large DC. METHODS This was a retrospective observational study that consecutively enrolled 84 patients with sTBI who were followed up for prognosis until 6 months after large DC. The primary endpoint was the Glasgow Outcome Score (GOS). According to the GOS, patients were divided into an unfavorable prognosis group (GOS 1-3, n = 47) and a favorable prognosis group (GOS 4-5, n = 37). RESULTS Significant between-group differences were found in age and hemodynamic parameters (systolic peak blood flow velocity, end-diastolic blood flow velocity, mean blood flow velocity, pulsatility index and resistance index) of the middle cerebral artery detected by TCCD (P < 0.05 for all). Subsequently, ridge regression was used to build a prognostic model for patients with large DC. Based on the cerebral hemodynamic parameters measured by TCCD and age, the mean (± standard deviation) area under the curve of the prognostic model in patients with sTBI after large DC was 0.76 ± 0.22. The sensitivity and specificity were 82.08% and 74.17%, respectively. CONCLUSIONS The cerebral hemodynamic parameters detected by TCCD, combined with age, may be used to predict the outcomes of patients with sTBI at 6 months after large DC. As a noninvasive method, TCCD has the potential to assess the prognosis of these patients. TRIAL REGISTRATION ChiCTR: ChiCTR1800019758. Registered 27 November 2018-retrospectively registered ( http://www.chictr.org.cn/index.aspx ).
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Affiliation(s)
- Yuan Liang
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Yunyou Duan
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Changyang Xing
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jinglan Jin
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Lingjuan Yan
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Xi Liu
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jia Wang
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China.
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Gao Y, Li Q, Wu C, Liu S, Zhang M. Use of a Doppler-Based Pulsatility Index to Evaluate Cerebral Hemodynamics in Neurocritical Patients After Hemicraniectomy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2469-2475. [PMID: 30697782 PMCID: PMC6850122 DOI: 10.1002/jum.14945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 12/07/2018] [Accepted: 01/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES As a noninvasive method for evaluation of cerebral hemodynamics, the correct interpretation of transcranial Doppler or transcranial imaging (TCI) data remains a major challenge. We explored how to interpret the pulsatility index (PI) derived via TCI during evaluations of cerebral hemodynamics in posthemicraniectomy patients. METHODS We included patients who underwent invasive arterial pressure and intracranial pressure (ICP) monitoring and simultaneous TCI examinations after hemicraniectomy. We classified the PI of the middle cerebral artery (MCA) into ipsilateral (craniectomy side) and contralateral (opposite side) and analyzed both data sets. The statistical analysis was performed by the Bland-Altman approach, by calculating intraclass correlation coefficients and Spearman correlations, and by drawing receiver operating characteristic curves. Pulsatility index probability charts were created for ICPs exceeding 20, 25, and 30 mm Hg and cerebral perfusion pressures (CPPs) lower than 70, 60, and 50 mm Hg; we thus explored defined ICP and CPP values. RESULTS The ipsilateral and contralateral MCA PI data differed. Only the ipsilateral MCA PI showed a weak correlation with ICP (r = 0.378; P < .001). The receiver operating characteristic curve analysis revealed limited diagnostic utility of bilateral MCA PIs for ICP and CPP assessments. An extremely elevated MCA PI indicated that patients were at high risk of a dangerous ICP elevation or CPP reduction. However, MCA PI values within the normal range did not effectively rule out an ICP of 20 mm Hg or higher but effectively eliminated a CPP lower than 50 mm Hg. CONCLUSIONS In posthemicraniectomy patients, the Doppler-based MCA PI value was ineffectively for quantitative ICP and CPP evaluations but a useful index for assessment of cerebral hemodynamics in terms of the probability of an ICP elevation or a CPP reduction.
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Affiliation(s)
- Yu‐zhi Gao
- Department of Emergency MedicineSecond Affiliated Hospital, Zhejiang University School of MedicineHangzhouChina
| | - Qiang Li
- Department of Emergency MedicineSecond Affiliated Hospital, Zhejiang University School of MedicineHangzhouChina
| | - Chun‐shuang Wu
- Department of Emergency MedicineSecond Affiliated Hospital, Zhejiang University School of MedicineHangzhouChina
| | - Shao‐yun Liu
- Department of Emergency MedicineSecond Affiliated Hospital, Zhejiang University School of MedicineHangzhouChina
| | - Mao Zhang
- Department of Emergency MedicineSecond Affiliated Hospital, Zhejiang University School of MedicineHangzhouChina
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Robba C, Goffi A, Geeraerts T, Cardim D, Via G, Czosnyka M, Park S, Sarwal A, Padayachy L, Rasulo F, Citerio G. Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review. Intensive Care Med 2019; 45:913-927. [PMID: 31025061 DOI: 10.1007/s00134-019-05610-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/26/2019] [Indexed: 12/20/2022]
Abstract
Brain ultrasonography can be used to evaluate cerebral anatomy and pathology, as well as cerebral circulation through analysis of blood flow velocities. Transcranial colour-coded duplex sonography is a generally safe, repeatable, non-invasive, bedside technique that has a strong potential in neurocritical care patients in many clinical scenarios, including traumatic brain injury, aneurysmal subarachnoid haemorrhage, hydrocephalus, and the diagnosis of cerebral circulatory arrest. Furthermore, the clinical applications of this technique may extend to different settings, including the general intensive care unit and the emergency department. Its increasing use reflects a growing interest in non-invasive cerebral and systemic assessment. The aim of this manuscript is to provide an overview of the basic and advanced principles underlying brain ultrasonography, and to review the different techniques and different clinical applications of this approach in the monitoring and treatment of critically ill patients.
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Affiliation(s)
- Chiara Robba
- Department of Anaesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Geeraerts
- Department of Anaesthesia and Intensive Care, University Hospital of Toulouse, Toulouse NeuroImaging Center (ToNIC), Inserm-UPS, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Soojin Park
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University, New York, USA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Llewellyn Padayachy
- Department of Neurosurgery, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Frank Rasulo
- Department of Anaesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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Connolly F, Schreiber SJ, Leithner C, Bohner G, Vajkoczy P, Valdueza JM. Assessment of intracranial venous blood flow after subarachnoid hemorrhage: a new approach to diagnose vasospasm with transcranial color-coded duplex sonography. J Neurosurg 2018; 129:1136-1142. [PMID: 29243981 DOI: 10.3171/2017.5.jns17232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 05/30/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVETranscranial color-coded duplex sonography (TCCS) is a reliable tool that is used to assess vasospasm in the M1 segment of the middle cerebral artery (MCA) after subarachnoid hemorrhage (SAH). A distinct increase in blood flow velocity (BFV) is the principal criterion for vasospasm. The MCA/internal carotid artery (ICA) index (Lindegaard Index) is also widely used to distinguish between vasospasm and cerebral hyperperfusion. However, extracranial ultrasonography assessment of the neck vessels might be difficult in an intensive care unit. Therefore, the authors evaluated whether the relationship of intracranial arterial to venous BFV might indicate vasospasm with similar or even better accuracy.METHODSPatients who presented between 2008 and 2015 with aneurysmal SAH were prospectively enrolled in the study. Digital subtraction angiography (DSA) and TCCS were performed within 24 hours of each other to assess vasospasm 8-10 days after SAH. The following different TCCS parameters were analyzed to assess vasospasm in the MCA and were compared with the gold-standard DSA parameters: 1) mean time-averaged maximum BFV (Vmean) of the MCA, 2) peak systolic velocity (PSV) of the MCA, 3) the Lindegaard Index using Vmean as well as PSV, and 4) a new arteriovenous index (AVI) between the MCA and the basal vein of Rosenthal using Vmean and PSV. The best cutoff values for these parameters to distinguish vasospasm from normal perfusion or hyperperfusion were calculated using receiver operating characteristic curve analysis. Sensitivity, specificity, positive predictive value, and negative predictive value as well as the overall accuracy for each cutoff value were analyzed.RESULTSA total of 102 patients (mean age 52 ± 12 years) were evaluated. Bilateral MCA assessment by TCCS was successful in all patients. In 6 cases (3%), the BFV of the basal vein of Rosenthal could not be analyzed. The AVI could not be calculated in 50 of 204 cases (25%) because the insonation quality was very low in one of the ICAs. An AVI > 10 for Vmean and an AVI > 12 for systolic velocity provided the highest accuracies of 87% and 86%, respectively. Regarding the Lindegaard Index, the accuracy was highest using a threshold of > 3 for the mean BFV (84%) as well as systolic BFV (80%). BFVs in the MCA of ≥ 120 cm/sec (Vmean) and ≥ 200 cm/sec (PSV) predicted vasospasm with accuracies of 84% and 83%, respectively. A combined analysis of the MCA BFV and the AVI led to a slight increase in specificity (Vmean, 94%; PSV, 93%) and positive predictive value (Vmean, 88%; PSV 86%) without further improvement in accuracy (Vmean, 88%; PSV, 84%).CONCLUSIONSThe intracranial AVI is a reliable parameter that can be used to assess vasospasm after SAH. Its reliability for differentiating vasospasm and hyperperfusion is slightly higher than that for the established Lindegaard Index, and this method has the additional advantage of a remarkably lower failure rate.
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Affiliation(s)
| | | | | | | | | | - José M Valdueza
- 4Neurological Center, Segeberger Kliniken, Bad Segeberg, Germany
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Noninvasive Neuromonitoring: Current Utility in Subarachnoid Hemorrhage, Traumatic Brain Injury, and Stroke. Neurocrit Care 2018; 27:122-140. [PMID: 28004334 DOI: 10.1007/s12028-016-0361-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Noninvasive neuromonitoring is increasingly being used to monitor the course of primary brain injury and limit secondary brain damage of patients in the neurocritical care unit. Proposed advantages over invasive neuromonitoring methods include a lower risk of infection and bleeding, no need for surgical installation, mobility and portability of some devices, and safety. The question, however, is whether noninvasive neuromonitoring is practical and trustworthy enough already. We searched the recent literature and reviewed English-language studies on noninvasive neuromonitoring in subarachnoid hemorrhage, traumatic brain injury, and ischemic and hemorrhagic stroke between the years 2010 and 2015. We found 88 studies that were eligible for review including the methods transcranial ultrasound, electroencephalography, evoked potentials, near-infrared spectroscopy, bispectral index, and pupillometry. Noninvasive neuromonitoring cannot yet completely replace invasive methods in most situations, but has great potential being complementarily integrated into multimodality monitoring, for guiding management, and for limiting the use of invasive devices and in-hospital transports for imaging.
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ACR Appropriateness Criteria ® Cerebrovascular Disease. J Am Coll Radiol 2018; 14:S34-S61. [PMID: 28473091 DOI: 10.1016/j.jacr.2017.01.051] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 01/27/2017] [Accepted: 01/31/2017] [Indexed: 11/23/2022]
Abstract
Diseases of the cerebral vasculature represent a heterogeneous group of ischemic and hemorrhagic etiologies, which often manifest clinically as an acute neurologic deficit also known as stroke or less commonly with symptoms such as headache or seizures. Stroke is the fourth leading cause of death and is a leading cause of serious long-term disability in the United States. Eighty-seven percent of strokes are ischemic, 10% are due to intracerebral hemorrhage, and 3% are secondary to subarachnoid hemorrhage. The past two decades have seen significant developments in the screening, diagnosis, and treatment of ischemic and hemorrhagic causes of stroke with advancements in CT and MRI technology and novel treatment devices and techniques. Multiple different imaging modalities can be used in the evaluation of cerebrovascular disease. The different imaging modalities all have their own niches and their own advantages and disadvantages in the evaluation of cerebrovascular disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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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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Miller C, Armonda R. Monitoring of cerebral blood flow and ischemia in the critically ill. Neurocrit Care 2015; 21 Suppl 2:S121-8. [PMID: 25208667 DOI: 10.1007/s12028-014-0021-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Secondary ischemic injury is common after acute brain injury and can be evaluated with the use of neuromonitoring devices. This manuscript provides guidelines for the use of devices to monitor cerebral blood flow (CBF) in critically ill patients. A Medline search was conducted to address essential pre-specified questions related to the utility of CBF monitoring. Peer-reviewed recommendations were constructed according to the GRADE criteria based upon the available supporting literature. Transcranial Doppler ultrasonography (TCD) and transcranial color-coded duplex sonography (TCCS) are predictive of angiographic vasospasm and delayed ischemic neurological deficits after aneurysmal subarachnoid hemorrhage. TCD and TCCS may be beneficial in identifying vasospasm after traumatic brain injury. TCD and TCCS have shortcomings in identifying some secondary ischemic risks. Implantable thermal diffusion flowmetry (TDF) probes may provide real-time continuous quantitative assessment of ischemic risks. Data are lacking regarding ischemic thresholds for TDF or their correlation with ischemic injury and clinical outcomes.TCD and TCCS can be used to monitor CBF in the neurocritical care unit. Better and more developed methods of continuous CBF monitoring are needed to limit secondary ischemic injury in the neurocritical care unit.
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Affiliation(s)
- Chad Miller
- Department of Neurology and Neurosurgery, Wexner Medical Center at the Ohio State University, 395 W 12th Avenue, Room 782, Columbus, OH, 43210, USA,
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Sadahiro H, Inamura A, Sugimoto K, Yamane A, Ishihara H, Shirao S, Yoneda H, Suzuki M. Cranioplasty and Duraplasty with Transcranial Color-Coded Duplex Sonography after Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2015; 24:2640-5. [PMID: 26350695 DOI: 10.1016/j.jstrokecerebrovasdis.2015.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 06/30/2015] [Accepted: 07/20/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Transcranial color-coded duplex sonography (TCCS) is a noninvasive technique for monitoring of cerebral vasospasm after neurosurgery for aneurismal subarachnoid hemorrhage. In this surgery, surgical materials are used. The goal of the study was to identify materials that can be used with ultrasound and to propose methods for cranioplasty and duraplasty using materials that permit TCCS. METHODS The chosen neurosurgical materials were titanium mesh plate (TMP), Gore-tex, SEAMDURA, gelatinous sponge, and oxidized cellulose. B-mode imaging was recorded with the materials placed between urethane resin 10 mm in diameter and the urethane phantom model. TCCS was performed to detect middle cerebral artery flow through TMP and Gore-tex. RESULTS TMP and SEAMDURA permitted penetration of ultrasound in B-mode and Doppler imaging, but the other materials did not do so. CONCLUSIONS A postcraniotomy window (PCW) on a line extending from the horizontal portion of M1 using only TMP permitted flow imaging with TCCS. In external decompression, TCCS was effective only without use of Gore-tex around the postcraniotomy window. This method allows the middle cerebral artery flow to be detected easily.
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Affiliation(s)
- Hirokazu Sadahiro
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan.
| | - Akinori Inamura
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Kazutaka Sugimoto
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Akiko Yamane
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Hideyuki Ishihara
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Satoshi Shirao
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Hiroshi Yoneda
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Michiyasu Suzuki
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
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Abstract
PURPOSE OF REVIEW To present the practical aspects of transcranial Doppler (TCD) and provide evidence supporting its use for the management of traumatic brain injury (TBI) patients. RECENT FINDINGS TCD measures systolic, mean, and diastolic cerebral blood flow (CBF) velocities and calculates the pulsatility index from basal intracranial arteries. These variables reflect the brain circulation, provided there is control of potential confounding factors. TCD can be useful in patients with severe TBI to detect low CBF, for example, during intracranial hypertension, and to assess cerebral autoregulation. In the emergency room, TCD might complement brain computed tomography (CT) scan and clinical examination to screen patients at risk for further neurological deterioration after mild-to-moderate TBI. SUMMARY The diagnostic value of TCD should be incorporated into other findings from multimodal brain monitoring and CT scan to optimize the bedside management of patients with TBI and help guide the choice of appropriate therapies.
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Bilotta F, Dei Giudici L, Lam A, Rosa G. Ultrasound-based imaging in neurocritical care patients: a review of clinical applications. Neurol Res 2013; 35:149-58. [PMID: 23452577 DOI: 10.1179/1743132812y.0000000155] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To analyze the diagnostic, monitoring, and procedural applications of ultrasound (US) imaging in neurocritical care (NCC) patients. METHOD US imaging has been extensively validated in various subset of critically ill patients, but not specifically in the NCC population. We reviewed the clinical applications of US imaging for heart, vascular, brain, and lung evaluation and for possible procedural uses in NCC patients. Major neurosurgical books, journals, testimonials, authors' personal experience, and scientific databases were analyzed. RESULTS Cardiac US imaging provides accurate information at NCC arrival to stratify risk factors, including presence of atrial septal defect/patent formen ovale, abnormal ventricular function, or pericardial effusion, and to monitor cardiac anatomy and function during the NCC stay for guiding goal-directed therapy. Vascular US in NCC patients has three especially relevant indications: to screen anatomy and flow in extracranial supra-aortic arteries, to diagnose deep vein thrombosis, and to optimize the safety of central venous catheterization. Brain US has important clinical applications in the NCC, including transcranial Doppler and emerging techniques for cerebral blood flow evaluation with contrast-enhanced US imaging. Lung US, as demonstrated in other intensive care unit patients, provides accurate diagnosis of anatomical and functional abnormalities and enables diagnosis of pleural effusion, pneumothorax, lung consolidation, pulmonary abscess and interstitial-alveolar syndrome, and lung recruitment/derecruitment. US imaging can effectively guide percutaneous tracheostomy. CONCLUSION In conclusion, US imaging is an important diagnostic tool that provides real-time information at the bedside to stratify risk, monitor for complications, and guide invasive procedures in NCC patients.
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Affiliation(s)
- Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Section of Neuroanesthesia and Neurocritical Care, Sapienza University of Rome, Rome, Italy.
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Kirsch JD, Mathur M, Johnson MH, Gowthaman G, Scoutt LM. Advances in transcranial Doppler US: imaging ahead. Radiographics 2013; 33:E1-E14. [PMID: 23322845 DOI: 10.1148/rg.331125071] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Transcranial Doppler ultrasonography (US) is a noninvasive, portable technique for evaluating the intracranial vasculature. It has found its most useful clinical application in the detection of vasospasm involving the cerebral vessels after subarachnoid hemorrhage due to aneurysm rupture. The technique has become an integral part of monitoring and managing patients with subarachnoid hemorrhage in the neurologic intensive care unit. In addition, it has proved useful for evaluating the intracranial vasculature in patients with sickle cell disease, stroke, or brain death. Transcranial US originated as a "blind" nonimaging study in which pulsed Doppler technology was used. Identification of the major intracranial vessels and evaluation of those vessels for vasospasm relied on spectral waveforms obtained in each vessel and was based on the depth of the vessel from the skull, the direction of blood flow, and the orientation of the transducer. Recent advances in US technology allow the use of gray-scale, spectral Doppler, and color Doppler flow imaging to directly visualize intracranial vessels, thereby simplifying flow velocity measurements and enhancing their accuracy for vasospasm detection. In particular, measurements of peak systolic velocity and mean flow velocity and calculation of the Lindegaard ratio facilitate the identification of vessels that may be in vasospasm and help differentiate vasospasm from physiologic conditions such as hyperemia and autoregulation. Thus, gray-scale and color Doppler flow imaging offer many advantages over the original pulsed Doppler technique for evaluating the intracranial vasculature.
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Affiliation(s)
- Jonathan D Kirsch
- Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar St, PO Box 208042, New Haven, CT 06520, USA.
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Arkuszewski M, Swiat M, Hurst R, Weigele J, Al-Okaili R, Kasner S, Melhem E, Krejza J. Vertebral and Basilar Arteries: Transcranial Color-Coded Duplex Ultrasonography versus Conventional TCD in Detection of Narrowings. Neuroradiol J 2012; 25:509-14. [DOI: 10.1177/197140091202500502] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 08/31/2012] [Indexed: 11/16/2022] Open
Abstract
We prospectively compared the accuracies of conventional transcranial Doppler ultrasound (TCD) and transcranial color-coded duplex sonography (TCCS) in the diagnosis of narrowing of the basilar (BA) and vertebral arteries (VA). Fifty-six consecutive patients (mean age 55.8 years; 34 women) after subarachnoid hemorrhage (n=46), stroke or transient ischemic attack (n=5), and for other reasons (n=5) underwent on the same day TCD, TCCS and the intra-arterial digital subtraction angiography (DSA) – the reference standard. The accuracy of peak-systolic (VPS), mean (VM), and end-diastolic velocities (VED) in detection of any arterial narrowing was estimated using the receiver operator characteristic (ROC) curve methodology and the total area (Az) under the curve. Accuracy of TCCS in detection of VA narrowing based on VPS and VM measurements was significantly higher than accuracy of TCD (Az =0.65 for VPS and Az =0.62 for VM versus Az =0.51 and Az =0.50, respectively, p<0.05 for both). Accuracy of TCCS in detection of BA narrowing was also higher than accuracy of TCD based on VPS measurements (Az =0.69 versus Az =0.50, respectively), with a trend toward significant difference, p=0.085. The accuracy of TCCS is superior to accuracy of TCD in detection of narrowings of vertebral and basilar arteries, thus TCCS should be preferred in routine clinical practice.
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Affiliation(s)
- M. Arkuszewski
- Department of Radiology, Division of Neuroradiology, University of Pennsylvania; Philadelphia, PA, USA
- Department of Neurology, Medical University of Silesia; Katowice, Poland
| | - M. Swiat
- Department of Radiology, Division of Neuroradiology, University of Pennsylvania; Philadelphia, PA, USA
- Department of Neurology, Medical University of Silesia; Katowice, Poland
| | - R.W. Hurst
- Department of Radiology, Division of Neuroradiology, University of Pennsylvania; Philadelphia, PA, USA
| | - J.B. Weigele
- Department of Radiology, Division of Neuroradiology, University of Pennsylvania; Philadelphia, PA, USA
| | - R.N. Al-Okaili
- Department of Radiology, Division of Neuroradiology, University of Pennsylvania; Philadelphia, PA, USA
| | - S.E. Kasner
- Department of Neurology, Hospital of the University of Pennsylvania; Philadelphia, PA, USA
| | - E.R. Melhem
- Department of Radiology, Division of Neuroradiology, University of Pennsylvania; Philadelphia, PA, USA
| | - J. Krejza
- Department of Radiology, Division of Neuroradiology, University of Pennsylvania; Philadelphia, PA, USA
- Department of Nuclear Medicine, Medical University of Gdansk; Gdansk, Poland
- Al-Imam Muhammad Ibn Saud Islamic University; Riyadh, Saudi Arabia
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Accuracy of transcranial colour-coded sonography in the diagnosis of anterior cerebral artery vasospasm. Neurol Neurochir Pol 2012; 46:233-8. [PMID: 22773509 DOI: 10.5114/ninp.2012.29131] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Transcranial colour-coded sonography (TCCS) has been proven to be a method of high performance in the diagnosis of spasm of the middle cerebral artery (MCA). Relevant data concerning the anterior cerebral artery (ACA) varies amongst studies. The aim of this study was to assess the performance of TCCS in the diagnosis of spasm affecting the ACA. MATERIAL AND METHODS Ninety-two patients (39 women and 53 men, age 51 ± 12.1 years) were examined using TCCS before cerebral angiography. Of 184 examined ACAs, only 133 arteries could be visualized due to insufficiency of the temporal acoustic window. Therefore, only 15 out of 25 arteries in which vasospasm was diagnosed with angiography (by two neuroradiologists not informed about the sonographic findings) could be included in the analysis. Receiver operating characteristic (ROC) curves were constructed for specific blood flow velocities: peak systolic (PSV), mean (M) and end-diastolic (EDV). The area under the ROC curve was used to measure the overall diagnostic performance of TCCS. RESULTS The area under the ROC curve for PSV was 0.83, which indicates good performance. The PSV threshold of 98 cm/s corresponded to maximum accuracy and was associated with 71% sensitivity vs. 88% specificity. Average systolic blood flow velocity in the vessels with vasospasm was 129 cm/s, whereas in unaffected vessels it was 76 cm/s. CONCLUSIONS The accuracy of TCCS in the diagnosis of ACA spasm is relatively high - the value of the area under the ROC amounts to 0.83. PSV performs best and the threshold of 98 cm/s is associated with an optimal trade-off between sensitivity and specificity.
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Arkuszewski M, Krejza J, Chen R, Kwiatkowski JL, Ichord R, Zimmerman R, Ohene-Frempong K, Melhem ER. Sickle cell disease in children: accuracy of imaging transcranial Doppler ultrasonography in detection of intracranial arterial stenosis. Neuroradiol J 2012; 25:402-10. [PMID: 24029032 DOI: 10.1177/197140091202500402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 06/09/2012] [Indexed: 11/17/2022] Open
Abstract
This study aimed to determine the accuracy of imaging transcranial Doppler sonography in detection of intracranial arterial stenosis in children with sickle cell disease using three-dimensional MR angiography as a reference standard. Sixty-one children (mean age 102±39 months, 30 males), who had no history of overt stroke, and were classified as at lowest risk of stroke by mean flow velocity criterion <170 cm/s, underwent conventional and imaging transcranial Doppler ultrasonographic examinations. We employed the area under the receiver operating characteristic curve (AUC) to determine the accuracy of flow velocity measurements obtained with imaging ultrasonography with and without correction for the angle of insonation as well as with conventional ultrasonography. We also established the most efficacious velocity thresholds for detection of the stenosis. We found ten intracranial stenoses in six patients on MR angiography, but we calculated AUC only for detection of stenosis (n=6) of the left intracranial internal carotid artery. The accuracy of flow velocity with angle correction was lower than the accuracy of velocity without angle correction (AUC=0.73, 95% CI, 0.53-0.93 versus AUC=0.87, 95% CI, 0.74-1.00; p=0.017). The accuracy of flow velocity obtained with conventional ultrasonography (AUC=0.82, 95% CI, 0.67-0.97) was not different from the accuracy of flow velocities obtained with imaging ultrasonography. We found that the threshold of 165 cm/s of mean velocity without angle correction is associated with highest efficiency for imaging (92%) and conventional ultrasonography (90%). Velocity measurements without angle-correction provide good accuracy in detection of stenosis of the terminal internal carotid artery, whereas angle-corrected velocities have lower accuracy.
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Affiliation(s)
- M Arkuszewski
- Department of Radiology, Division of Neuroradiology, University of Pennsylvania; Philadelphia, PA, USA - Department of Neurology, Medical University of Silesia; Katowice, Poland -
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20
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Noninvasive detection of elevated intracranial pressure using a portable ultrasound system. Am J Emerg Med 2012; 30:936-41. [DOI: 10.1016/j.ajem.2011.05.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 04/11/2011] [Accepted: 05/05/2011] [Indexed: 11/23/2022] Open
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Schöning M, Scheel P, Wittibschläger J, Kehrer M, Will BE. The effect of vasospasm on cerebral perfusion: a colour duplex study of the extra- and intracranial cerebral arteries. ULTRASOUND IN MEDICINE & BIOLOGY 2012; 38:360-367. [PMID: 22266230 DOI: 10.1016/j.ultrasmedbio.2011.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 12/05/2011] [Accepted: 12/12/2011] [Indexed: 05/31/2023]
Abstract
To assess whether middle cerebral artery (MCA) vasospasm reduces the flow volume in the corresponding extracranial internal carotid artery (ICA) or global cerebral blood flow volume (CBFV) in subarachnoid haemorrhage (SAH) patients, a colour duplex ultrasound study of the intra- and extracranial cerebral arteries was performed. MCA vasospasm was defined as a time-averaged maximum flow velocity (TAMX) exceeding 120 cm/s. ICA flow volumes and CBFV, were compared in each patient at maximum TAMX recorded in one MCA ("maximum-vasospasm") and when TAMX in the same vessel was closest to mean reference values ("no-vasospasm"). Additionally, the CBFV course during the first 3 weeks after SAH was evaluated longitudinally. Data from age- and gender-matched healthy test persons served as control. In 28 patients with MCA vasospasm, 337 measurements were completed. Global CBFV was significantly reduced starting from day 3 after SAH. ICA flow volumes and CBFV were not different when comparing at "maximum-vasospasm" and "no-vasospasm". Compared with the control group, both were lower at either condition. Thus, in SAH patients, vasospasm even severe, in general does not further diminish ICA flow volumes and global CBFV, which are reduced already before the onset of vasospasm.
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Affiliation(s)
- Martin Schöning
- Department of Child Neurology, Children's Hospital of the University of Tübingen, Tübingen, Germany.
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Krejza J, Chen R, Romanowicz G, Kwiatkowski JL, Ichord R, Arkuszewski M, Zimmerman R, Ohene-Frempong K, Desiderio L, Melhem ER. Sickle cell disease and transcranial Doppler imaging: inter-hemispheric differences in blood flow Doppler parameters. Stroke 2010; 42:81-6. [PMID: 21088242 DOI: 10.1161/strokeaha.110.591818] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE to establish reference values of interhemispheric differences and ratios of blood flow Doppler parameters in the terminal internal carotid artery, middle cerebral artery, and anterior cerebral artery in children with sickle cell anemia. METHODS fifty-seven out of 74 recruited children (mean age, 7.8 ± 3.4 years; range limits, 3-14 years), who were free of neurological deficits and intracranial narrowing detectable by MRA and had flow velocities <170 cm/s by conventional transcranial Doppler ultrasound, underwent transcranial color-coded duplex ultrasonography. Reference limits of flow parameters corrected and uncorrected for the angle of insonation were estimated using tolerance intervals, with P=0.90 for all possible data values from 95% of a population. RESULTS reference limits for left-to-right differences in cm/s in the mean angle-corrected and uncorrected flow velocities were -56 to 53 and -72 to 75 for middle cerebral artery, -49 to 57 and -81 to 91 for anterior cerebral artery, and -55 to 64 and -73 to 78 for terminal internal carotid artery, respectively. Respective reference limits for left-to-right velocity ratios were 0.31 to 1.84 and 0.38 to 1.75 for middle cerebral artery, 0.48 to 2.99 and 0.46 to 2.89 for anterior cerebral artery, and 0.61 to 2.56 and 0.56 to 2.23 for terminal internal carotid artery. CONCLUSIONS the study provides reference limits of interhemispheric differences and ratios of blood flow Doppler parameters that may be helpful in identification of intracranial arterial narrowing in children with sickle cell disease undergoing ultrasound screening for stroke prevention.
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Affiliation(s)
- Jaroslaw Krejza
- Department of Radiology, Division of Neuroradiology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Marshall SA, Nyquist P, Ziai WC. The role of transcranial Doppler ultrasonography in the diagnosis and management of vasospasm after aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am 2010; 21:291-303. [PMID: 20380971 DOI: 10.1016/j.nec.2009.10.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Transcranial Doppler ultrasonography (TCD) is a tool employed by the neurosurgeon and neurointensivist in the management of vasospasm in the intensive care unit after aneurysmal subarachnoid hemorrhage. A review of the current indications, monitoring parameters, indices, and relevance of modern TCD technology is provided, as well as algorithms for the use of TCD ultrasonography in the management of patients with subarachnoid hemorrhage. Other current uses of TCD ultrasonography are also discussed in the setting of neurocritical care.
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Affiliation(s)
- Scott A Marshall
- Division of Neurosciences Critical Care, Departments of Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Meyer 8-140, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Hattingen E, Blasel S, Dumesnil R, Vatter H, Zanella FE, Weidauer S. MR angiography in patients with subarachnoid hemorrhage: adequate to evaluate vasospasm-induced vascular narrowing? Neurosurg Rev 2010; 33:431-9. [PMID: 20532584 DOI: 10.1007/s10143-010-0267-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 03/16/2010] [Accepted: 04/25/2010] [Indexed: 10/19/2022]
Abstract
The diagnosis of cerebral vasospasm (CVS) following subarachnoid hemorrhage (SAH) is still challenging. We evaluate the accuracy of time of flight MR angiography (TOF-MRA) to assess the arterial diameters of the circle of Willis in SAH patients with suspected CVS. MR examinations (1.5 Tesla) including 3D TOF-MRA with maximum intensity projections (MIP) and digital subtraction angiography (DSA) were performed within 24 h in 21 patients with acute aneurysmal SAH and suspicion of CVS. Arterial diameters of the circle of Willis including the distal internal carotid artery (ICA) were measured as ratios to the extradural ICA in standard projections. The diagnosis of CVS was established by comparing the luminal size of baseline and follow-up DSA. The correlation between the arterial ratios measured on MIP angiograms and on follow-up DSA was assessed with Pearson's linear regression analysis. Arterial ratios on MIP angiograms were categorized as correct, overestimated, and underestimated compared to the ratios on follow-up DSA. Pearson's correlation coefficient between the ratios of MIP angiograms and DSA was r = 0.5799 and the regression coefficient was b = 0.4775. Highest correlation was found for the category of severe CVS (r = 0.8201). Of all MIP angiograms, 34.9% showed consistent results compared to the DSA, while 44.2% of MIP images overestimated the vascular narrowing. Standard MIP angiograms from TOF-MRA are not accurate to assess vascular narrowing in patients with suspected CVS after aneurysmal SAH. The multifocal arterial stenoses in CVS may induce severe changes in blood flow dynamics, which compromise the diagnostic accuracy of the TOF-MRA.
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Affiliation(s)
- Elke Hattingen
- Institute of Neuroradiology, Goethe University Frankfurt, Frankfurt/M, Germany.
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Diagnóstico de la isquemia cerebral tardía y el vasospasmo cerebral en la hemorragia subaracnoidea. Neurologia 2010. [DOI: 10.1016/j.nrl.2009.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Brandi G, Béchir M, Sailer S, Haberthür C, Stocker R, Stover JF. Transcranial color-coded duplex sonography allows to assess cerebral perfusion pressure noninvasively following severe traumatic brain injury. Acta Neurochir (Wien) 2010; 152:965-72. [PMID: 20379747 DOI: 10.1007/s00701-010-0643-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 03/17/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Assess optimal equation to noninvasively estimate intracranial pressure (eICP) and cerebral perfusion pressure (eCPP) following severe traumatic brain injury (TBI) using transcranial color-coded duplex sonography (TCCDS). DESIGN AND SETTING This is an observational clinical study in a university hospital. PATIENTS A total of 45 continuously sedated (BIS < 50), normoventilated (paCO(2) > 35 mmHg), and non-febrile TBI patients. METHODS eICP and eCPP based on TCCDS-derived flow velocities and arterial blood pressure values using three different equations were compared to actually measured ICP and CPP in severe TBI patients subjected to standard treatment. Optimal equation was assessed by Bland-Altman analysis. RESULTS The equations: ICP = 10:927 x PI(pulsatility index) - 1:284 and CPP = 89:646 - 8:258 PI resulted in eICP and eCPP similar to actually measured ICP and CPP with eICP 10.6 +/- 4.8 vs. ICP 10.3 +/- 2.8 and eCPP 81.1 +/- 7.9 vs. CPP 80.9 +/- 2.1 mmHg, respectively. The other two equations, eCPP = (MABP x EDV)/mFV + 14 and eCPP = mFV / (mFV - EDV)] x (MABP - RRdiast), resulted in significantly decreased eCPP values: 72.9 +/- 10.1 and 67 +/- 19.5 mmHg, respectively. Superiority of the first equation was confirmed by Bland-Altman revealing a smallest standard deviations for eCPP and eICP. CONCLUSIONS TCCDS-based equation (ICP = 10.927 x PI - 1.284) allows to screen patients at risk of increased ICP and decreased CPP. However, adequate therapeutic interventions need to be based on continuously determined ICP and CPP values.
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Affiliation(s)
- Giovanna Brandi
- Surgical Intensive Care, University Hospital Zuerich, Zurich, Switzerland
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Rodríguez García P, Rodríguez Pupo L, Rodríguez García D. Diagnosis of delayed cerebral ischaemia and cerebral vasospasm in subarachnoid haemorrhage. NEUROLOGÍA (ENGLISH EDITION) 2010. [DOI: 10.1016/s2173-5808(10)70060-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
PURPOSE Stroke and subclinical "silent infarcts" are major causes of morbidity in children with Sickle Cell Disease (SCD). Ischemic strokes are more common in younger children while hemorrhagic strokes are more frequent in adults. The goal of neuroimaging in acute stroke is to document whether the stroke is ischemic or hemorrhagic, to assess the extent of parenchymal abnormalities and to determine the presence of other cerebrovascular lesions. Computed Tomography (CT) is the primary modality for the assessment of acute stroke patients because of its 24/7 availability and ability to exclude hemorrhagic causes. Magnetic resonance imaging (MRI) and MR angiography (MRA) are recommended to determine precisely extent of infarction and detect cerebrovascular abnormalities. The goal of neuroimaging in patients with hemorrhagic stroke is to identify an arteriovenous malformation or aneurysm(s) amenable to surgery or catheter intervention.The risk of first stroke is very high in asymptomatic children with intracranial arterial mean velocities over 200 cm/s on transcranial Doppler (TCD) examination. The risk can be substantially reduced if chronic blood transfusions are timely implemented. Large cerebral vessel disease detected by TCD can be confirmed or excluded by MRI/MRA. Those with evidence of parenchymal and/or cerebrovascular lesions should be followed by preventive therapy. In patients with neurologic symptoms and negative MRI/MRA findings Positron Emission Tomography or single photon emission CT is recommended. There are no specific neuroimaging findings that suggest that blood transfusions can be safely halted in children with SCD.
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Swiercz M, Swiat M, Pawlak M, Weigele J, Tarasewicz R, Sobolewski A, Hurst RW, Mariak ZD, Melhem ER, Krejza J. Narrowing of the middle cerebral artery: artificial intelligence methods and comparison of transcranial color coded duplex sonography with conventional TCD. ULTRASOUND IN MEDICINE & BIOLOGY 2010; 36:17-28. [PMID: 19854564 DOI: 10.1016/j.ultrasmedbio.2009.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Revised: 04/30/2009] [Accepted: 05/11/2009] [Indexed: 05/28/2023]
Abstract
The goal of the study was to compare performances of transcranial color-coded duplex sonography (TCCS) and transcranial Doppler sonography (TCD) in the diagnosis of the middle cerebral artery (MCA) narrowing in the same population of patients using statistical and nonstatistical intelligent models for data analysis. We prospectively collected data from 179 consecutive routine digital subtraction angiography (DSA) procedures performed in 111 patients (mean age 54.17+/-14.4 years; 59 women, 52 men) who underwent TCD and TCCS examinations simultaneously. Each patient was examined independently using both ultrasound techniques, 267 M1 segments of MCA were assessed and narrowings were classified as < or =50% and >50% lumen reduction. Diagnostic performance was estimated by two statistical and two artificial neural networks (ANN) classification methods. Separate models were constructed for the TCD and TCCS sonographic data, as well as for detection of "any narrowing" and "severe narrowing" of the MCA. Input for each classifier consisted of the peak-systolic, mean and end-diastolic velocities measured with each sonographic method; the output was MCA narrowing. Arterial narrowings less or equal 50% of lumen reduction were found in 55 and >50% narrowings in 26 out of 267 arteries, as indicated by DSA. In the category of "any narrowing" the rate of correct assignment by all models was 82% to 83% for TCCS and 79% to 81% for TCD. In the diagnosis of >50% narrowing the overall classification accuracy remained in the range of 89% to 90% for TCCS data and 90% to 91% for TCD data. For the diagnosis of any narrowing, the sensitivity of the TCCS was significantly higher than that of the TCD, while for diagnosis of >50% MCA narrowing, sensitivity of the TCCS was similar to sensitivity of the TCD. Our study showed that TCCS outperforms conventional TCD in detection of < or =50% MCA narrowing, whereas no significant difference in accuracy between both methods was found in the diagnosis of >50% MCA narrowing. (E-mail: jaroslaw.krejza@uphs.upenn.edu).
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Cerebral vasospasm in patients suffering from aneurysmal subarachnoid hemorrhage: An unresolved diagnostic and therapeutic challenge*. Crit Care Med 2009; 37:1150-1. [DOI: 10.1097/ccm.0b013e3181987ce9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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