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Busl KM, Smith CR, Troxel AB, Fava M, Illenberger N, Pop R, Yang W, Frota LM, Gao H, Shan G, Hoh BL, Maciel CB. Rationale and Design for the BLOCK-SAH Study (Pterygopalatine Fossa Block as an Opioid-Sparing Treatment for Acute Headache in Aneurysmal Subarachnoid Hemorrhage): A Phase II, Multicenter, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial with a Sequential Parallel Comparison Design. Neurocrit Care 2024:10.1007/s12028-024-02078-z. [PMID: 39138719 DOI: 10.1007/s12028-024-02078-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 07/09/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Acute post-subarachnoid hemorrhage (SAH) headaches are common and severe. Management strategies for post-SAH headaches are limited, with heavy reliance on opioids, and pain control is overall poor. Pterygopalatine fossa (PPF) nerve blocks have shown promising results in treatment of acute headache, including our preliminary and published experience with PPF-blocks for refractory post-SAH headache during hospitalization. The BLOCK-SAH trial was designed to assess the efficacy and safety of bilateral PPF-blocks in awake patients with severe headaches from aneurysmal SAH who require opioids for pain control and are able to verbalize pain scores. METHODS BLOCK-SAH is a phase II, multicenter, randomized, double-blinded, placebo-controlled clinical trial using the sequential parallel comparison design (SPCD), followed by an open-label phase. RESULTS Across 12 sites in the United States, 195 eligible study participants will be randomized into three groups to receive bilateral active or placebo PPF-injections for 2 consecutive days with periprocedural monitoring of intracranial arterial mean flow velocities with transcranial Doppler, according to SPCD (group 1: active block followed by placebo; group 2: placebo followed by active block; group 3: placebo followed by placebo). PPF-injections will be delivered under ultrasound guidance and will comprise 5-mL injectates of 20 mg of ropivacaine plus 4 mg of dexamethasone (active PPF-block) or saline solution (placebo PPF-injection). CONCLUSIONS The trial has a primary efficacy end point (oral morphine equivalent/day use within 24 h after each PPF-injection), a primary safety end point (incidence of radiographic vasospasm at 48 h from first PPF-injection), and a primary tolerability end point (rate of acceptance of second PPF-injection following the first PPF-injection). BLOCK-SAH will inform the design of a phase III trial to establish the efficacy of PPF-block, accounting for different headache phenotypes.
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Affiliation(s)
- Katharina M Busl
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA.
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA.
| | - Cameron R Smith
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Andrea B Troxel
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Maurizio Fava
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Nicholas Illenberger
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Ralisa Pop
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA
| | - Wenqing Yang
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Luciola Martins Frota
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA
| | - Hanzhi Gao
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Guogen Shan
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Brian L Hoh
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Carolina B Maciel
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
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AIUM Practice Parameter for the Performance of Transcranial Doppler Ultrasound. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:E36-E44. [PMID: 37132485 DOI: 10.1002/jum.16234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 05/04/2023]
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Moll F, Sleiman M, Sturm D, Kerry R, von Piekartz H. Pre-manipulative cervical spine testing and sustained rotation do not influence intracranial hemodynamics: an observational study with transcranial Doppler ultrasound. J Man Manip Ther 2023; 31:13-23. [PMID: 35499452 PMCID: PMC9848377 DOI: 10.1080/10669817.2022.2068824] [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: 01/21/2023] Open
Abstract
INTRODUCTION Manual joint mobilization and manipulation are recommended therapeutic interventions for people with neck pain. High-velocity thrust and sustained techniques have an uncertain association with serious arterial trauma. The validity of pre-manipulative tests of the cervical spine is often questioned, and the understanding of the effect of head/neck position on blood flow is still incomplete. Most of the evidence concerning hemodynamics in this area relates to extracranial flow (vertebral and carotid artery). Less is understood about the effects on intracranial flow while performing pre-manipulative tests and sustained positions like end of range cervical rotation mobilization. The aim of the study was to assess the influence of commonly used evaluation and treatment positions on intracranial hemodynamic parameters. METHOD A randomized, cross-over observational study using ultrasonography on healthy subjects (n = 19) was conducted to measure hemodynamic parameters (peak systolic velocity and end diastolic maximum) of intracranial arterial systems. Two test positions (sustained pre-manipulative thrust C0-1 and sustained cervical end of range rotation) were compared with a sham position for each test position. RESULTS :Neither the sequence of tests performed nor an independent variable (the two positions) had a significant effect (p < 0.05) on peak systolic velocity (PSV) or end diastolic maximum (EDM). DISCUSSION No effects from commonly used assessment and treatment of neck positions on hemodynamic parameters were found. This is consistent with previous studies. Further study is indicated on people with symptoms and known pathologies.
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Affiliation(s)
- Fabian Moll
- Department of Movement and Rehabilitation Science, University of Applied Sciences Osnabrück, Wupppertal, Germany
- Department of Physiotherapy, Klinik Für Manuelle Therapie, Hamm, Germany
- Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Mona Sleiman
- Department of Neurology, Agaplesion - Bethesda Hospital, Wuppertal, Germany
| | - Dietrich Sturm
- Department of Neurology, Agaplesion - Bethesda Hospital, Wuppertal, Germany
| | - Roger Kerry
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Harry von Piekartz
- Department of Movement and Rehabilitation Science, University of Applied Sciences Osnabrück, Wupppertal, Germany
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Hakimi R. Imaging of Central Nervous System Hemorrhage. Continuum (Minneap Minn) 2023; 29:73-103. [PMID: 36795874 DOI: 10.1212/con.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE This article aims to familiarize the reader with the various types of nontraumatic central nervous system (CNS) hemorrhage and the various neuroimaging modalities used to help diagnose and manage them. LATEST DEVELOPMENTS According to the 2019 Global Burden of Diseases, Injuries, and Risk Factors Study, intraparenchymal hemorrhage accounts for 28% of the global stroke burden. In the United States, hemorrhagic stroke makes up 13% of all strokes. The incidence of intraparenchymal hemorrhage increases substantially with age; thus, despite improvements in blood pressure control through various public health measures, the incidence is not decreasing as the population ages. In fact, in the most recent longitudinal study of aging, autopsy findings showed intraparenchymal hemorrhage and cerebral amyloid angiopathy in 30% to 35% of patients. ESSENTIAL POINTS Rapid identification of CNS hemorrhage, which includes intraparenchymal hemorrhage, intraventricular hemorrhage, and subarachnoid hemorrhage, requires either head CT or brain MRI. Once hemorrhage is identified on the screening neuroimaging study, the pattern of blood in conjunction with the history and physical examination can guide subsequent neuroimaging, laboratory, and ancillary tests as part of the etiologic assessment. After determination of the cause, the chief aims of the treatment regimen are reducing hemorrhage expansion and preventing subsequent complications such as cytotoxic cerebral edema, brain compression, and obstructive hydrocephalus. In addition, nontraumatic spinal cord hemorrhage will also be briefly discussed.
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Tsivgoulis G, Safouris A, Alexandrov AV. Ultrasonography. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00046-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Wang A, Tian X, Zuo Y, Chen S, Zhang X, Guo J, Wu S, Zhao X. Association of triglyceride-glucose index with intra- and extra-cranial arterial stenosis: a combined cross-sectional and longitudinal analysis. Endocrine 2021; 74:308-317. [PMID: 34347253 DOI: 10.1007/s12020-021-02794-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/07/2021] [Indexed: 01/28/2023]
Abstract
PURPOSE This study aimed to assess the cross-sectional and longitudinal associations of the triglyceride glucose (TyG) index, a simple surrogate marker of insulin resistance, with intra-cranial and extra-cranial artery stenosis (ICAS and ECAS) in Chinese adults. METHODS Participants were recruited from the Asymptomatic Polyvascular Abnormalities Community study, 5381 participants were enrolled in the cross-sectional analysis, then 3447 and 1853 participants in the longitudinal analysis for incident ICAS and ECAS, respectively. The TyG index was calculated as ln [fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2]. Multivariable logistic analysis was used to calculate odds ratio (OR) and 95% confidence interval (CI). RESULTS The results of the cross-sectional and longitudinal analysis were basically the same, as the fully adjusted OR comparing participants in the highest tertile versus lowest tertile of the TyG index was 1.34 (95% CI, 1.13-1.59) for the prevalence of ECAS and 1.85 (95% CI, 1.26-2.71) for incident ECAS, respectively. The addition of TyG index to a conventional model had an incremental effect on the predictive value for ECAS. However, we did not observe any significant association between the TyG index and ICAS. CONCLUSIONS Elevated TyG index was significantly associated with a higher risk of ECAS, but not with ICAS in Chinese adults. This conclusion lends support to the clinical significance of the TyG index for the assessment of artery stenosis, especially for ECAS.
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Affiliation(s)
- Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xue Tian
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Yingting Zuo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Shuohua Chen
- Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
| | - Xiaoli Zhang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiahuan Guo
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shouling Wu
- Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China.
| | - Xingquan Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Mozaffarzadeh M, Minonzio C, de Jong N, Verweij MD, Hemm S, Daeichin V. Lamb Waves and Adaptive Beamforming for Aberration Correction in Medical Ultrasound Imaging. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2021; 68:84-91. [PMID: 32746204 DOI: 10.1109/tuffc.2020.3007345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Phase aberration in transcranial ultrasound imaging (TUI) caused by the human skull leads to an inaccurate image reconstruction. In this article, we present a novel method for estimating the speed of sound and an adaptive beamforming technique for phase aberration correction in a flat polyvinylchloride (PVC) slab as a model for the human skull. First, the speed of sound of the PVC slab is found by extracting the overlapping quasi-longitudinal wave velocities of symmetrical Lamb waves in the frequency-wavenumber domain. Then, the thickness of the plate is determined by the echoes from its front and back side. Next, an adaptive beamforming method is developed, utilizing the measured sound speed map of the imaging medium. Finally, to minimize reverberation artifacts caused by strong scatterers (i.e., needles), a dual probe setup is proposed. In this setup, we image the medium from two opposite directions, and the final image can be the minimum intensity projection of the inherently co-registered images of the opposed probes. Our results confirm that the Lamb wave method estimates the longitudinal speed of the slab with an error of 3.5% and is independent of its shear wave speed. Benefiting from the acquired sound speed map, our adaptive beamformer reduces (in real time) a mislocation error of 3.1, caused by an 8 mm slab, to 0.1 mm. Finally, the dual probe configuration shows 7 dB improvement in removing reverberation artifacts of the needle, at the cost of only 2.4-dB contrast loss. The proposed image formation method can be used, e.g., to monitor deep brain stimulation procedures and localization of the electrode(s) deep inside the brain from two temporal bones on the sides of the human skull.
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Samagh N, Bhagat H, Jangra K. Monitoring cerebral vasospasm: How much can we rely on transcranial Doppler. J Anaesthesiol Clin Pharmacol 2019; 35:12-18. [PMID: 31057233 PMCID: PMC6495622 DOI: 10.4103/joacp.joacp_192_17] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Cerebral vasospasm leading to delayed cerebral ischaemia is one of the major concerns following subarachnoid haemorrhage (SAH). Various modalities are present for evaluation and detection of cerebral vasospasm that occurs following SAH. They include transcranial Doppler (TCD), computed tomographic angiography (CTA), computed tomographic (CT) perfusion and digital subtraction angiography (DSA). The recent guidelines have advocated the use of TCD and have described it as a reasonable technique for monitoring the development of vasospasm. This review describes the functioning of TCD, the cerebral haemodynamic changes during vasospasm and TCD-based detection of vasospasm. The review shall highlight as to how the TCD derived values are relevant in the settings of neurocritical care. The data in the review have been consolidated based on our search of literature from year 1981 till 2016 using various data base.
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Affiliation(s)
- Navneh Samagh
- Department of Anesthesia and Intensive Care, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India
| | - Hemant Bhagat
- Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India
- Address for correspondence: Dr. Hemant Bhagat, Department of Anesthesia and Intensive Care, 4th Floor, PGIMER, Sector 12, Chandigarh - 160 012, India. E-mail:
| | - Kiran Jangra
- Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India
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Kaczynski J, Home R, Shields K, Walters M, Whiteley W, Wardlaw J, Newby DE. Reproducibility of Transcranial Doppler ultrasound in the middle cerebral artery. Cardiovasc Ultrasound 2018; 16:15. [PMID: 30200977 PMCID: PMC6131943 DOI: 10.1186/s12947-018-0133-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/19/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Transcranial Doppler ultrasound remains the only imaging modality that is capable of real-time measurements of blood flow velocity and microembolic signals in the cerebral circulation. We here assessed the repeatability and reproducibility of transcranial Doppler ultrasound in healthy volunteers and patients with symptomatic carotid artery stenosis. METHODS Between March and August 2017, we recruited 20 healthy volunteers and 20 patients with symptomatic carotid artery stenosis. In a quiet temperature-controlled room, two 1-h transcranial Doppler measurements of blood flow velocities and microembolic signals were performed sequentially on the same day (within-day repeatability) and a third 7-14 days later (between-day reproducibility). Levels of agreement were assessed by interclass correlation co-efficient. RESULTS In healthy volunteers (31±9 years, 11 male), within-day repeatability of Doppler measurements were 0.880 (95% CI 0.726-0.950) for peak velocity, 0.867 (95% CI 0.700-0.945) for mean velocity, and 0.887 (95% CI 0.741-0.953) for end-diastolic velocity. Between-day reproducibility was similar but lower: 0.777 (95% CI 0.526-0.905), 0.795 (95% CI 0.558-0.913), and 0.674 (95% CI 0.349-0.856) respectively. In patients (72±11 years, 11 male), within-day repeatability of Doppler measurements were higher: 0.926 (95% CI 0.826-0.970) for peak velocity, 0.922 (95% CI 0.817-0.968) for mean velocity, and 0.868 (95% CI 0.701-0.945) for end-diastolic velocity. Similarly, between-day reproducibility revealed lower values: 0.800 (95% CI 0.567-0.915), 0.786 (95% CI 0.542-0.909), and 0.778 (95% CI 0.527-0.905) respectively. In both cohorts, the intra-observer Bland Altman analysis demonstrated acceptable mean measurement differences and limits of agreement between series of middle cerebral artery velocity measurements with very few outliers. In patients, the carotid stenoses were 30-40% (n = 9), 40-50% (n = 6), 50-70% (n = 3) and > 70% (n = 2). No spontaneous embolisation was detected in either of the groups. CONCLUSIONS Transcranial Doppler generates reproducible data regarding the middle cerebral artery velocities. However, larger studies are needed to validate its clinical applicability. TRIAL REGISTRATION ClinicalTrial.gov (ID NCT 03050567), retrospectively registered on 15/05/2017.
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Affiliation(s)
- Jakub Kaczynski
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SA UK
| | - Rachel Home
- College of Medicine and Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ UK
| | - Karen Shields
- Stroke Unit, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF UK
| | - Matthew Walters
- College of Medical, Veterinary and Life Sciences, Wolfson Medical School Building, University of Glasgow, University Avenue, Glasgow, G12 8QQ UK
| | - William Whiteley
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA UK
| | - Joanna Wardlaw
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA UK
| | - David E. Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SA UK
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Qiu J, Zhou Z, Wang J, Wang Y, Liu C, Liu X, Xu Y, Yu L, Zhou H, Lin J, Guo Z, Dong C. Associations between fatty liver index and asymptomatic intracranial vertebrobasilar stenosis in Chinese population. PLoS One 2017; 12:e0187502. [PMID: 29121660 PMCID: PMC5679613 DOI: 10.1371/journal.pone.0187502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 10/21/2017] [Indexed: 01/21/2023] Open
Abstract
Metabolic diseases such as type 2 diabetes mellitus (T2DM) and metabolic syndromes (MetS) have been recognized as the important risk factors for asymptomatic intracranial vertebrobasilar stenosis (IVBS). Although fatty liver index (FLI) is significantly related with these diseases, the association between FLI and IVBS remains unclear. In the present study, 2368 participants (30–75 years) were recruited from a Chinese prospective cohort study of PMMJS. Amongst them, 2281 individuals who did not have IVBS at baseline were enrolled in the 6-year following-up study. In cross-sectional analysis based on the baseline characteristics, the results showed that FLI was positively related with IVBS prevalence. Compared to the participants with FLI < 30, the adjusted OR (95% CI) of IVBS was 2.07 (1.18, 3.62) and 2.85 (1.39, 5.18) in the groups of 30 ≤ FLI < 60 and FLI ≥ 60, respectively. In longitudinal analysis, the results showed that the participants with FLI ≥ 60 had an increased risk of asymptomatic IVBS compared to those with FLI < 30 [adjusted HR (95%CI): 1.65 (1.05, 2.60)]. Moreover, exclusion of persons with hypertension, T2DM and MetS did not alter the associations between FLI and asymptomatic IVBS. Therefore, our results suggest that elevated FLI is an independent risk factor for asymptomatic IVBS in Chinese adults.
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Affiliation(s)
- Jing Qiu
- Department of Epidemiology and Statistics, School of Public Health, Jiangsu Key Laboratory and Translational Medicine for Geriatric Disease, Medical College of Soochow University, Suzhou, China
| | - Zhiwei Zhou
- Department of Epidemiology and Statistics, School of Public Health, Jiangsu Key Laboratory and Translational Medicine for Geriatric Disease, Medical College of Soochow University, Suzhou, China
| | - Jie Wang
- Department of Epidemiology and Statistics, School of Public Health, Jiangsu Key Laboratory and Translational Medicine for Geriatric Disease, Medical College of Soochow University, Suzhou, China
| | - Yiying Wang
- Department of Epidemiology and Statistics, School of Public Health, Jiangsu Key Laboratory and Translational Medicine for Geriatric Disease, Medical College of Soochow University, Suzhou, China
| | - Chunxing Liu
- Department of Epidemiology and Statistics, School of Public Health, Jiangsu Key Laboratory and Translational Medicine for Geriatric Disease, Medical College of Soochow University, Suzhou, China
- Department of Laboratory Medicine, East China Sanatorium, Wuxi, China
| | - Xingxiang Liu
- Department of Laboratory Medicine, Huai’an Forth Hospital, Huai’an, China
| | - Yunfang Xu
- Department of Laboratory Medicine, Huai’an Forth Hospital, Huai’an, China
| | - Lugang Yu
- Suzhou Industrial Park Centers for Disease Control and Prevention, Suzhou, China
| | - Hui Zhou
- Suzhou Industrial Park Centers for Disease Control and Prevention, Suzhou, China
| | - Jie Lin
- Suzhou Vocational Health College, Suzhou, China
| | - Zhirong Guo
- Department of Epidemiology and Statistics, School of Public Health, Jiangsu Key Laboratory and Translational Medicine for Geriatric Disease, Medical College of Soochow University, Suzhou, China
| | - Chen Dong
- Department of Epidemiology and Statistics, School of Public Health, Jiangsu Key Laboratory and Translational Medicine for Geriatric Disease, Medical College of Soochow University, Suzhou, China
- * E-mail:
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Li Z, Li J, Wang A, Pan H, Wu S, Zhao X. Decreased Estimated Glomerular Filtration Rate (eGFR), Not Proteinuria, Is Associated with Asymptomatic Intracranial Arterial Stenosis in Chinese General Population. Sci Rep 2017; 7:4619. [PMID: 28676650 PMCID: PMC5496910 DOI: 10.1038/s41598-017-04549-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 05/17/2017] [Indexed: 11/24/2022] Open
Abstract
The relationship between chronic kidney disease (CKD), which is defined by declined estimated glomerular filtration rate (eGFR) and/or proteinuria, and asymptomatic intracranial arterial stenosis (ICAS) is largely unknown. We conducted a population-based, cross-sectional study by recruiting 5209 participants free of previous stroke, transient ischemic attack and coronary heart disease. eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula and proteinuria was estimated with urine dipstick. The presence of ICAS was assessed by transcranial color-coded Doppler (TCD). Out of the whole population, 684 (13.1%) participants suffered ICAS. After adjusting for the confounding factors, eGFR < 45 ml/min/m2 was an independent risk factor of asymptomatic ICAS (odds ratio [OR], 3.29, 95% confidence interval [CI], 1.67–6.51), but the trend was different between the two groups stratified by the age of 60 (P = 0.01). However, the association between proteinuria and asymptomatic ICAS was not statistically significant. In conclusion, declined eGFR, not proteinuria, is associated with asymptomatic ICAS in Chinese general population, especially in people over 60 years old.
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Affiliation(s)
- Zhaoxia Li
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jinxin Li
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Hua Pan
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China. .,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
| | - Shouling Wu
- Department of Cardiology, Kailuan Hospital, Hebei United University, Tangshan, China.
| | - Xingquan Zhao
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China. .,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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Association between High-density-lipoprotein-cholesterol Levels and the Prevalence of Asymptomatic Intracranial Arterial Stenosis. Sci Rep 2017; 7:573. [PMID: 28373708 PMCID: PMC5428728 DOI: 10.1038/s41598-017-00596-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/07/2017] [Indexed: 01/09/2023] Open
Abstract
Intracranial atherosclerotic stenosis (ICAS) is a common cause of ischemic stroke, and a low level of high-density lipoprotein cholesterol (HDL-C) is also considered to be a predictor for stroke. However, the association between the HDL-C level and asymptomatic ICAS is uncertain. From 2010 to 2011, a random sample of 5,351 participants were enrolled in the Asymptomatic Polyvascular Abnormalities Community (APAC) study. The recruited participants were then separated into 5 roughly uniform-sized factions with varying HDL-C levels. Multivariate logistic regression was implemented to assess the connection of the HDL-C levels and the prevalence of asymptomatic ICAS. The prevalence of asymptomatic ICAS showed no gradual decrease with the increase of HDL-C levels. After adjustment for conventional risk factors, HDL-C levels still showed no significant association with asymptomatic ICAS. The odds ratios (OR) of the prevalence of asymptomatic ICAS between the first group and the other 4 groups were 0.98, 1.00, 0.92, and 0.87 with 95% confidence intervals (CI) being 0.76–1.27, 0.78–1.29, 0.71–1.19, and 0.66–1.13, respectively. The study showed little correlation between HDL-C levels and asymptomatic ICAS. Normal levels of HDL-C are not an independent risk factor for asymptomatic ICAS.
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Yeo LLL, Tan BYQ, Andersson T. Review of Post Ischemic Stroke Imaging and Its Clinical Relevance. Eur J Radiol 2017; 96:145-152. [PMID: 28237773 DOI: 10.1016/j.ejrad.2017.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/09/2017] [Accepted: 02/11/2017] [Indexed: 10/20/2022]
Abstract
In this day and age, multiple imaging modalities are available to the stroke physician in the post-treatment phase.The practical challenge for physicians who treat stroke is to evaluate the pros and cons of each technique and select the best choice for the situation. The choice of imaging modality remains contentious at best and varies among different institutions and centres. This is no simple task an there are many factors to consider, including the differential diagnosis which need to be evaluated, the availability and reliability of the imaging technique and time and expertise required to perform and interpret the scanning. Other ancillary competing interest also come into play such as the financial cost of the modality, the requirement for patient monitoring during the imaging procedure and patient comfort. In an effort to clear some of the ambiguity surrounding this topic we present some of the current techniques in use and others, which are still in the realm of research and have not yet transitioned into clinical practice.
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Affiliation(s)
- Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Benjamin Y Q Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
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Wang HB, Laskowitz DT, Dodds JA, Xie GQ, Zhang PH, Huang YN, Wang B, Wu YF. Peak Systolic Velocity Measurements with Transcranial Doppler Ultrasound Is a Predictor of Incident Stroke among the General Population in China. PLoS One 2016; 11:e0160967. [PMID: 27513983 PMCID: PMC4981305 DOI: 10.1371/journal.pone.0160967] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 07/27/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVE It is necessary to develop an effective and low-cost screening tool for identifying Chinese people at high risk of stroke. Transcranial Doppler ultrasound (TCD) is a powerful predictor of stroke in the pediatric sickle cell disease population, as demonstrated in the STOP trial. Our study was conducted to determine the prediction value of peak systolic velocities as measured by TCD on subsequent stroke risk in a prospective cohort of the general population from Beijing, China. METHODS In 2002, a prospective cohort study was conducted among 1392 residents from 11 villages of the Shijingshan district of Beijing, China. The cohort was scheduled for follow up with regard to incident stroke in 2005, 2007, and 2012 by a study team comprised of epidemiologists, nurses, and physicians. Univariate and multivariate Cox proportional hazard regression models were used to determine the factors associated with incident stroke. RESULTS Participants identified by TCD criteria as having intracranial stenosis had a 3.6-fold greater risk of incident stroke (hazard ratio (HR) 3.57, 95% confidence interval (CI) 1.86-6.83, P<0.01) than those without TCD evidence of intracranial stenosis. The association remained significant in multivariate analysis (HR 2.53, 95% CI 1.31-4.87) after adjusting for other risk factors or confounders. Older age, cigarette smoking, hypertension, and diabetes mellitus remained statistically significant as risk factors after controlling for other factors. CONCLUSIONS The study confirmed the screening value of TCD among the general population in urban China. Increasing the availability of TCD screening may help identify subjects as higher risk for stroke.
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Affiliation(s)
- Hai-Bo Wang
- Peking University Clinical Research Institute, Xueyuan Rd 38#, Haidian Dist, Beijing, 100191, China
| | - Daniel T. Laskowitz
- Department of Neurology, Duke University Medicine Center, Durham, North Carolina, 27710, United States of America
| | - Jodi A. Dodds
- Department of Neurology, Duke University Medicine Center, Durham, North Carolina, 27710, United States of America
| | - Gao-Qiang Xie
- Peking University Clinical Research Institute, Xueyuan Rd 38#, Haidian Dist, Beijing, 100191, China
| | - Pu-Hong Zhang
- The George Institute for Global Health at Peking University Health Science Center, Beijing, 100191, China
| | - Yi-Ning Huang
- Department of Neurology, Peking University First Hospital, Beijing, 100034, China
| | - Bo Wang
- Department of Neurology, Peking Union Medical Hospital, Beijing, 100730, China
| | - Yang-Feng Wu
- Peking University Clinical Research Institute, Xueyuan Rd 38#, Haidian Dist, Beijing, 100191, China
- The George Institute for Global Health at Peking University Health Science Center, Beijing, 100191, China
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, 100191, China
- * E-mail:
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Latin American consensus on the use of transcranial Doppler in the diagnosis of brain death. Rev Bras Ter Intensiva 2016; 26:240-52. [PMID: 25295818 PMCID: PMC4188460 DOI: 10.5935/0103-507x.20140035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 03/17/2014] [Indexed: 12/13/2022] Open
Abstract
Transcranial Doppler evaluates cerebral hemodynamics in patients with brain injury and is a useful technical tool in diagnosing cerebral circulatory arrest, usually present in the brain-dead patient. This Latin American Consensus was formed by a group of 26 physicians experienced in the use of transcranial Doppler in the context of brain death. The purpose of this agreement was to make recommendations regarding the indications, technique, and interpretation of the study of transcranial ultrasonography in patients with a clinical diagnosis of brain death or in the patient whose clinical diagnosis presents difficulties; a working group was formed to enable further knowledge and to strengthen ties between Latin American physicians working on the same topic. A review of the literature, concepts,and experiences were exchanged in two meetings and via the Internet. Questions about pathophysiology, equipment, techniques, findings, common problems, and the interpretation of transcranial Doppler in the context of brain death were answered. The basic consensus statements are the following: cerebral circulatory arrest is the final stage in the evolution of progressive intracranial hypertension, which is visualized with transcranial Doppler as a "pattern of cerebral circulatory arrest". The following are accepted as the standard of cerebral circulatory arrest: reverberant pattern, systolic spikes, and absence of previously demonstrated flow. Ultrasonography should be used - in acceptable hemodynamic conditions - in the anterior circulation bilaterally (middle cerebral artery) and in the posterior (basilar artery) territory. If no ultrasonographic images are found in any or all of these vessels, their proximal arteries are acceptable to be studied to look for a a pattern of cerebral circulatory arrest.
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Haršány M, Tsivgoulis G, Alexandrov AV. Ultrasonography. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00046-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Wang J, Wu J, Zhang S, Zhang L, Wang C, Gao X, Zhou Y, Wang A, Wu S, Zhao X. Elevated fasting glucose as a potential predictor for asymptomatic cerebral artery stenosis: A cross-sectional study in Chinese adults. Atherosclerosis 2014; 237:661-5. [DOI: 10.1016/j.atherosclerosis.2014.10.083] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 09/27/2014] [Accepted: 10/22/2014] [Indexed: 11/16/2022]
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Elevated plasma total cholesterol level is associated with the risk of asymptomatic intracranial arterial stenosis. PLoS One 2014; 9:e101232. [PMID: 24992466 PMCID: PMC4081648 DOI: 10.1371/journal.pone.0101232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 06/04/2014] [Indexed: 11/30/2022] Open
Abstract
Background Intracranial arterial stenosis (ICAS) is one of the most common causes of stroke, and dyslipidemia was one of the most common risk factors related to ICAS. However, the correlation between the plasma total cholesterol level (PTC) and ICAS, especially asymptomatic ICAS (AICAS) is not clear. Materials and Methods 5,300 participants were enrolled in this study. The diagnosis of AICAS was made by transcranial Doppler ultrasonography. The participants were then divided into 5 essentially equal-sized groups based on their PTC levels. The multivariate logistic regression was used to analyze the correlation between the PTC level and the prevalence of AICAS. Results 13.0% of the participants were diagnosed with AICAS. The prevalence of AICAS gradually increased with the increasing PTC level. After adjusted by the possible confounding factors, the Odds Ratios (OR) of the AICAS prevalence between the 1st quintile group and the other 4 groups were 1.13, 1.23, 1.63 and 1.75 with 95% confident intervals (CI) of 0.84–1.52, 0.91–1.66, 1.20–2.22 and 1.23–2.47, respectively. The further subgroup analysis revealed that the PTC level was stronger for males (OR 1.42 95%CI 1.23–1.64), regarding the prevalence of AICAS. Conclusions In this large community-based study, the prevalence of AICAS is 13.0%, subjects with higher PTC levels showed a mild increase in the prevalence of AICAS. The PTC level is an independent risk factor of AICAS. Males seem to be significantly more vulnerable to the risk of AICAS.
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Wang J, Liu Y, Zhang L, Li N, Wang C, Gao X, Zhou Y, Wang A, Wu S, Zhao X. Associations of high sensitivity C-reactive protein levels with the prevalence of asymptomatic intracranial arterial stenosis. Eur J Neurol 2014; 21:512-8. [PMID: 24447587 DOI: 10.1111/ene.12342] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 12/11/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE High sensitivity C-reactive protein (hs-CRP), an inflammatory biomarker, has been demonstrated to contribute to the process of atherosclerosis and artery stenosis. The aim of this study was to evaluate whether hs-CRP level is associated with asymptomatic intracranial artery stenosis (ICAS). METHODS A random sample of 5440 participants aged 40 years or older (40.1% women) were enrolled in the Asymptomatic Polyvascular Abnormalities Community study in 2010-2011. Information on the potential risk factors for ICAS was collected and the presence of ICAS was assessed by transcranial Doppler in 5309 participants. Participants were stratified into three groups according to hs-CRP levels. A multivariate logistic regression was used to examine the association between hs-CRP levels and asymptomatic ICAS. RESULTS The prevalence of asymptomatic ICAS was 13.2% in this cohort. The median of hs-CRP levels was positively associated with the increasing numbers of ICASs. After adjusting for possible risk factors, hs-CRP ≥ 3 mg/l remained significantly associated with asymptomatic ICAS (odds ratio 1.28, 95% confidence interval 1.02-1.61). CONCLUSIONS In this large community-based study, subjects with higher hs-CRP levels showed a mild increase in the prevalence of asymptomatic ICAS, independent of traditional vascular risk factors. hs-CRP is an independent predictor of asymptomatic ICAS and intracranial atherosclerotic burden.
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Affiliation(s)
- J Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Novak L, Emri M, Molnar P, Balkay L, Szabo S, Rozsa L, Lengyel Z, Tron L. Regional cerebral18FDG uptake during subarachnoid hemorrhage induced vasospasm. Neurol Res 2013; 28:864-70. [PMID: 17288747 DOI: 10.1179/016164105x49328] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The aim was to elucidate whether aneurysmal subarachnoid hemorrhage (SAH)-induced vasospasm induces changes of regional glucose uptake in surgically treated, asymptomatic cases. METHODS (18)FDG uptake (standardized uptake value, SUV) was analysed with PET in eight surgically treated aneurismal patients with a mean middle cerebral artery flow velocity >120 cm/seconds measured with transcranial Doppler ultrasound. Data were compared with a healthy control group using Statistical Parametric Mapping (SPM99b). RESULTS Six of the eight patients had no focal neurological signs. The inhomogeneous bilateral increase in SUV (p<0.0001) was asymmetrical, with an almost 70% larger volume on the operated side. Reduced glucose uptake was found in the frontal and temporobasal regions of the two patients with neurological deficits (p<0.0001); the affected volume was 40% larger on the operated side. DISCUSSION SAH-induced vasospasm results in widespread increase of glucose uptake-probably reflecting increased glycolysis. This was earlier than neurological focal signs appear. Decreased glucose uptake can be detected in severe cases of vasospasm reflected by neurological deficit. Although the changes are more prominent where surgery had taken place our results suggest that not only the surgery, but also subarachnoid blood might have resulted in our findings.
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Affiliation(s)
- Laszlo Novak
- Department of Neurosurgery, University of Debrecen, Health and Life Sciences Centre, Nagyerdei krt. 98., 4012 Debrecen, Hungary.
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Color Doppler of the extracranial and intracranial arteries in the acute phase of cerebral ischemia. J Ultrasound 2013; 16:187-93. [PMID: 24432173 DOI: 10.1007/s40477-013-0036-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 08/19/2013] [Indexed: 10/26/2022] Open
Abstract
Vascular imaging greatly improves the possibility of locating the site of vascular occlusion in patients with acute cerebrovascular disease. Different occlusive patterns may underlie the same clinical presentation, with different prognosis and different treatment: for this reason, a diagnostic tool able to identify quickly the status of the extra- and intracranial vessels is needed. Color Doppler ultrasound of the extracranial arteries is a reliable and accurate method able to localize and quantify the carotid artery stenosis. The ultrasound quantification of the degree of stenosis is based on both morphological and velocimetric criteria: B-mode, color or power Doppler and spectral analysis are used for this purpose. Also the analysis of the plaque is an integral part of the ultrasound examination: the B mode plaque characterization (structure and surface) plays an important role in the evaluation of risk of stroke. So color Doppler ultrasound is able to select patients who may require medical therapy, carotid endarterectomy or angioplasty and stenting. Transcranial color Doppler is an inexpensive, reliable, fast, non-invasive, bedside tool: in the acute phase of stroke, it is able to evaluate quickly the intracranial arteries and monitor the possible recanalization of occluded vessel ensuring the follow-up of dynamic lesions, such as the intracranial stenosis and occlusions.
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Feasibility of transcranial Doppler and single photon emission computed tomography in compound neuroactivation task. Acta Neurol Belg 2013; 113:303-11. [PMID: 23111780 DOI: 10.1007/s13760-012-0152-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 10/15/2012] [Indexed: 10/27/2022]
Abstract
The aim of this study was to test feasibility of transcranial Doppler (TCD) and single photon emission computed tomography (SPECT) during compound neuroactivation task. The study was performed in 60 healthy right-handed volunteers. Cerebral blood flow velocity was measured by TCD in both middle cerebral arteries (MCA) at baseline and during computer game. The same stimulus and response pattern was used in 15 subjects that additionally underwent brain SPECT. Percentage differences between measurements were determined through quantitative result assessment. Both methods detected a statistically significant cerebral blood flow increase during neuroactivation. Correlation of TCD and SPECT showed statistically significant correlation only for the increase of cerebral blood flow velocity in the right MCA and for the right-sided cerebral blood flow increase, demonstrating that both methods partially measure similar cerebral blood flow changes that occur during neuroactivation. Comparison of TCD and SPECT showed TCD to be inadequately sensitive method for evaluation of cerebral blood flow during complex activation paradigm.
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Abstract
Transcranial Doppler (TCD) is a portable device that uses a handheld 2-MHz transducer. It is most commonly used in subarachnoid hemorrhage where cerebral blood flow velocities in major intracranial blood vessels are measured to detect vasospasm in the first 2 to 3 weeks. TCD is used to detect vasospasm in traumatic brain injury and post-tumor resection, measurement of cerebral autoregulation and cerebrovascular reactivity, diagnosis of acute arterial occlusions in stroke, screening for patent foramen ovale and monitoring of emboli. It can be used to detect abnormally high intracranial pressure and for confirmation of total cerebral circulatory arrest in brain death.
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Zhang Q, Zhang S, Wang C, Gao X, Zhou Y, Zhou H, Wang A, Wu J, Bian L, Wu S, Zhao X. Ideal cardiovascular health metrics on the prevalence of asymptomatic intracranial artery stenosis: a cross-sectional study. PLoS One 2013; 8:e58923. [PMID: 23554958 PMCID: PMC3595221 DOI: 10.1371/journal.pone.0058923] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 02/08/2013] [Indexed: 12/04/2022] Open
Abstract
Background and Purpose Intracranial Artery Stenosis (ICAS) is one of the most common causes of ischemic stroke in Asia. Previous studies have shown the number of ideal cardiovascular health (CVH) metrics was associated with lower risk of stroke. This study aimed to investigate the relationship between ideal CVH metrics and prevalence of ICAS. Methods A random sample of 5,412 participants (selected from Kailuan Study as a reference population) aged 40 years or older (40.10% women), free of stroke, transient ischemic attack, and coronary disease, were enrolled in the Asymptomatic Polyvascular Abnormalities Community study from 2010 to 2011. We collected information on the seven CVH metrics (including smoking, body mass index, dietary intake, physical activity, blood pressure, total cholesterol and fasting blood glucose); and assessed ICAS by transcranial Doppler. The relationship between the ideal CVH metrics and prevalence of ICAS was analyzed using the multivariate logistic regression. Results After adjusting for age, sex, and other potential confounders, the adjusted odds ratios(95% confidence interval) for ICAS were 0.76(0.58–0.99), 0.55(0.43–0.72), 0.49(0.37–0.65), 0.43(0.31–0.61), and 0.36(0.22–0.62), respectively, for those having 2, 3, 4, 5, and 6–7 ideal CVH metrics compared with those having 0–1 ideal metric(p-trend<0.0001). Similar inverse associations were observed in different age and gender groups (all p-trends<0.05). Conclusion We found a clear gradient relationship between the number of ideal CVH metrics and lower prevalence of ICAS in a Chinese population, which supports the importance of ideal health behaviors and factors in the prevention of ICAS.
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Affiliation(s)
- Qian Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Cell Transplantation, the General Hospital of Chinese People’s Armed Police Forces, Beijing, China
| | - Shufeng Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, the General Hospital of Chinese People’s Armed Police Forces, Beijing, China
| | - Chunxue Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiang Gao
- Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard University School of Public Health, Boston, Massachusetts, United States of America
| | - Yong Zhou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heng Zhou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianwei Wu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liheng Bian
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shouling Wu
- Department of Cardiology, Kailuan Hospital, Tangshan, China
- * E-mail: (XQZ); (SLW)
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- * E-mail: (XQZ); (SLW)
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Mace E, Montaldo G, Osmanski BF, Cohen I, Fink M, Tanter M. Functional ultrasound imaging of the brain: theory and basic principles. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2013; 60:492-506. [PMID: 23475916 DOI: 10.1109/tuffc.2013.2592] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Hemodynamic changes in the brain are often used as surrogates of neuronal activity to infer the loci of brain activity. A major limitation of conventional Doppler ultrasound for the imaging of these changes is that it is not sensitive enough to detect the blood flow in small vessels where the major part of the hemodynamic response occurs. Here, we present a μDoppler ultrasound method able to detect and map the cerebral blood volume (CBV) over the entire brain with an important increase in sensitivity. This method is based on imaging the brain at an ultrafast frame rate (1 kHz) using compounded plane wave emissions. A theoretical model demonstrates that the gain in sensitivity of the μDoppler method is due to the combination of 1) the high signal-to-noise ratio of the gray scale images, resulting from the synthetic compounding of backscattered echoes; and 2) the extensive signal averaging enabled by the high temporal sampling of ultrafast frame rates. This μDoppler imaging is performed in vivo on trepanned rats without the use of contrast agents. The resulting images reveal detailed maps of the rat brain vascularization with an acquisition time as short as 320 ms per slice. This new method is the basis for a real-time functional ultrasound (fUS) imaging of the brain.
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Affiliation(s)
- Emilie Mace
- Institut Langevin, CNRS UMR7587, Inserm U979, Université Paris VII, Ecole Superieure de Physique et de Chimie Industrielles de Paris, Paris, France.
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Abstract
Transcranial Doppler (TCD) ultrasound provides rapid, noninvasive, real-time measures of cerebrovascular function. TCD can be used to measure flow velocity in the basal arteries of the brain to assess relative changes in flow, diagnose focal vascular stenosis, or to detect embolic signals within these arteries. TCD can also be used to assess the physiologic health of a particular vascular territory by measuring blood flow responses to changes in blood pressure (cerebral autoregulation), changes in end-tidal CO2 (cerebral vasoreactivity), or cognitive and motor activation (neurovascular coupling or functional hyperemia). TCD has established utility in the clinical diagnosis of a number of cerebrovascular disorders such as acute ischemic stroke, vasospasm, subarachnoid hemorrhage, sickle cell disease, as well as other conditions such as brain death. Clinical indication and research applications for this mode of imaging continue to expand. In this review, the authors summarize the basic principles and clinical utility of TCD and provide an overview of a few TCD research applications.
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Abstract
Changes on Transcranial Doppler (TCD) ultrasonography have been proposed as significant predictors of cerebrovascular complications in sickle cell disease (SCD). However, consensus with regards to the TCD criteria to recognize abnormalities in cerebral vasculature is lacking. We studied the TCD characteristics of cerebral arteries among Omani patients with SCD and correlated them with cerebrovascular events. TCD was performed through the temporal and suboccipital windows using a 2 MHz probe (DWL). Thirty-three of 59 patients (56%) with SCD had neurological symptoms including stroke--12 (20%) and epilepsy--7. Fifteen patients (25%) had significant TCD abnormalities including: markedly increased velocities--11 (3 with stroke); turbulent flow--2; and reversal of flow--2. No patient had a time averaged maximum mean velocity of >200 cm/s in anterior circulation. On applying a modified definition of "abnormal TCD" to anterior and posterior circulation studies, increased TCD velocities in posterior circulation correlated with history of stroke (P < 0.05). TCD velocities in the 18 adult patients ( older than 15 y) were significantly lower than in children. Logistic regression analysis revealed abnormal TCD in the left posterior cerebral artery to be an independent predictor of stroke in this cohort (P = 0.035).
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Simm RF, de Aguiar PHP, de Oliveira Lima M, Paiva BL. Transcranial Doppler as a routine in the treatment of vasospasm following subarachanoid hemorrhage (SAH). ACTA NEUROCHIRURGICA. SUPPLEMENT 2012; 115:75-6. [PMID: 22890648 DOI: 10.1007/978-3-7091-1192-5_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Vasospasm is an important complication observed after subarachnoid hemorrhage (SAH) and is a frequent cause of mortality and morbidity. We present our routine management of vasospasm after SAH and emphasize the importance of transcranial Doppler (TCD) ultrasonography in this management. METHOD Historical records and images were sampled from June 2005 to September 2011 for 110 patients with SAH due to ruptured aneurysm in the anterior circulation. All surviving patients were followed after discharge. Vasospasm was defined as mild (Lindegaard index 3-4), moderate (Lindegaard index 4-5), and severe (Lindegaard index greater than 5). We excluded patients treated after 72 h of symptom onset. TCD was performed twice per day. FINDINGS Ninety-nine patients had surgical clipping of the aneurysm, and 11 had endovascular treatment. Seventy patients treated by clipping and six treated by endovascular procedure had vasospasm. Of the 70 clipped patients with vasospasm, 40 had mild vasospasm, 13 had moderate vasospasm, and 17 had severe vasospasm. All six patients treated by coils had moderate vasospasm. The average duration of vasospasm was 9 days (from 7 to 32 days). CONCLUSIONS TCD was crucial for monitoring patients with SAH, and to identify which patients will have a higher risk of developing vasospasm.
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Affiliation(s)
- Renata F Simm
- Department of Neurology, Santa Paula Hospital, Sao Paulo, Brazil.
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Abstract
Abstract
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Gujjar AR, William R, Jacob PC, Jain R, Al-Asmi AR. Transcranial Doppler ultrasonography in acute ischemic stroke predicts stroke subtype and clinical outcome: a study in Omani population. J Clin Monit Comput 2011; 25:121-8. [PMID: 21713538 DOI: 10.1007/s10877-011-9288-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 06/11/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Transcranial Doppler ultrasonography (TCD) is being increasingly used for its ability to provide cerebral hemodynamic information in stroke. Few studies have explored its association with cerebral arteriographic changes and stroke subtype. This study explored the relation of TCD changes in acute stroke with stroke subtypes, MR cerebral arteriography and clinical outcome in Omani population. METHODS Adult patients presenting with acute ischemic stroke within 4 days of stroke onset were subjected to TCD through the temporal and suboccipital windows using a 2 MHz probe; flow velocities, pulsatility and direction of flow were recorded from arteries at the skull base. MR arteriographic (MRA) changes on corresponding arteries were graded on a scale of 1-4. ANOVA, student's t test and ROC analysis were used to evaluate TCD in relation to stroke type, outcome and stenosis on MRA. RESULTS Of 60 patients recruited, 52 (M:F::36:16; mean age: 60 + 13 years) had adequate bone window for TCD study. Large artery stroke occurred in 30 (58%) patients; lacunar stroke-11 (21%); cardioembolic and mixed groups 9 (17%), other specificed causes-2 (4%). 86.5% had evidence of intracranial disease. 10/52 patients (19%) died while 33 (63%) had good outcome (modified Rankin Score 0-3). Of the 186 arteries studied by the two methods, 52 had TCD evidence of stenosis while 42 were abnormal on MRA, giving a sensitivity of 60%, specificity: 81.25%; positive likelihood ratio: 3.18 and negative likelihood ratio: 0.5. 29/52 (56%) of patients had TCD changes in the arteries corresponding to stroke location. Abnormal TCD was associated with large artery strokes (p = 0.007), poor outcome (p = 0.038) and mortality (p = 0.01). CONCLUSION This study of TCD in acute stroke in Omani population demonstrates a relatively higher burden of intracranial arterial disease. TCD changes are associated with type of stroke and outcome in this population. TCD is a simple and fairly useful method of evaluation in patients with acute stroke. Adopting TCD in evaluation of stroke patients may provide useful information regarding the pathophysiology which could enhance patient management.
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Affiliation(s)
- Arunodaya R Gujjar
- Department of Medicine (Neurology), College of Medicine and Health Sciences, Sultan Qaboos University, PO Box 35, PC 123 Muscat, Oman.
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Alexandrov AV, Sloan MA, Tegeler CH, Newell DN, Lumsden A, Garami Z, Levy CR, Wong LK, Douville C, Kaps M, Tsivgoulis G. Practice Standards for Transcranial Doppler (TCD) Ultrasound. Part II. Clinical Indications and Expected Outcomes. J Neuroimaging 2010; 22:215-24. [DOI: 10.1111/j.1552-6569.2010.00523.x] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Ahn SW, Park SS, Lee YS. Novel parameter for the diagnosis of distal middle cerebral artery stenosis with transcranial Doppler sonography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2010; 38:420-425. [PMID: 20533446 DOI: 10.1002/jcu.20711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
PURPOSE Transcranial Doppler sonography (TCD) is commonly used for the diagnosis of middle cerebral artery (MCA) stenosis. However, TCD indices to predict distal MCA (M2) stenosis have not yet been established. We compared TCD and magnetic resonance angiography (MRA) to validate a new index for the diagnosis of M2 stenosis. METHODS Consecutive patients who underwent TCD and MRA were included. Based on MRA, M2 stenosis was defined as >50% narrowing beyond the bifurcation area. TCD index of the M2/M1 ratio was defined as the ratio between the mean flow velocity (MFV) obtained at a depth of 30-44 mm (M2) and a depth of 45-65 mm (M1). Sensitivity and specificity of the M2/M1 ratio were calculated from the receiver operating characteristic curve. The diagnostic yield of elevated MFV (>80 cm/s) and asymmetry index of >30% for M2 stenosis were also investigated. RESULTS Among the consecutive patients, 105 with M2 stenosis were compared with 123 without MCA stenosis. The M2/M1 ratio was significantly higher in the M2 stenosis group (1.10 versus 0.86, p < 0.001). Sensitivity and specificity for M2 stenosis were most satisfying when the M2/M1 ratio of 0.97 was adopted as the cutoff value. Diagnostic yield of the M2/M1 ratio was better than MFV or asymmetry index. CONCLUSIONS The M2/M1 ratio may be a highly specific parameter for assessing M2 stenosis with TCD.
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Affiliation(s)
- Suk-Won Ahn
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
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Marinoni M, Alari F, Mastronardi V, Peris A, Innocenti P. The relevance of early TCD monitoring in the intensive care units for the confirming of brain death diagnosis. Neurol Sci 2010; 32:73-7. [PMID: 20872036 DOI: 10.1007/s10072-010-0407-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Accepted: 09/01/2010] [Indexed: 01/20/2023]
Abstract
Brain death (BD) diagnosis is the clinical assessment of the irreversible loss of function of the entire brain, including the brainstem. Transcranial Doppler (TCD) examination is used in several countries as a confirmatory test to assess cerebral circulatory arrest (CCA). A total of 1,400 TCD examinations were performed in 623 patients (pts) admitted to intensive care units (ICUs) of our hospital during the last 6 years. Oscillating flow, systolic spikes and the absence of any TCD signal were considered as diagnostic patterns of irreversible CCA. TCD patterns of CCA were detected in 56 pts. In 25 pts, deeply sedated with barbiturate therapy, TCD was employed as confirmatory test for BD diagnosis and 14 of them could become organ and/or tissue donors. TCD is a safe and inexpensive tool that can be performed at the bedside, and it allows to shorten the diagnostic process of BD, which is the prerequisite for organ donation.
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Affiliation(s)
- Marinella Marinoni
- Department of Neurological and Psychiatrics Sciences, University of Florence, Viale Morgagni, 85, 50134, Florence, Italy.
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Carp SA, Dai GP, Boas DA, Franceschini MA, Kim YR. Validation of diffuse correlation spectroscopy measurements of rodent cerebral blood flow with simultaneous arterial spin labeling MRI; towards MRI-optical continuous cerebral metabolic monitoring. BIOMEDICAL OPTICS EXPRESS 2010; 1:553-565. [PMID: 21258489 PMCID: PMC3017992 DOI: 10.1364/boe.1.000553] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 07/13/2010] [Accepted: 07/13/2010] [Indexed: 05/18/2023]
Abstract
Cerebral blood flow (CBF) during stepped hypercapnia was measured simultaneously in the rat brain using near-infrared diffuse correlation spectroscopy (DCS) and arterial spin labeling MRI (ASL). DCS and ASL CBF values agree very well, with high correlation (R=0.86, p< 10(-9)), even when physiological instability perturbed the vascular response. A partial volume effect was evident in the smaller magnitude of the optical CBF response compared to the MRI values (averaged over the cortical area), primarily due to the inclusion of white matter in the optically sampled volume. The 8.2 and 11.7 mm mid-separation channels of the multi-distance optical probe had the lowest partial volume impact, reflecting ~75 % of the MR signal change. Using a multiplicative correction factor, the ASL CBF could be predicted with no more than 10% relative error, affording an opportunity for real-time relative cerebral metabolism monitoring in conjunction with MR measurement of cerebral blood volume using super paramagnetic contrast agents.
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Affiliation(s)
- S. A. Carp
- Athinoula A. Martinos Center for Biomedical Imaging,
Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129,
USA
| | - G. P. Dai
- Athinoula A. Martinos Center for Biomedical Imaging,
Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129,
USA
| | - D. A. Boas
- Athinoula A. Martinos Center for Biomedical Imaging,
Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129,
USA
| | - M. A. Franceschini
- Athinoula A. Martinos Center for Biomedical Imaging,
Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129,
USA
| | - Y. R. Kim
- Athinoula A. Martinos Center for Biomedical Imaging,
Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129,
USA
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Lepur D, Peterković V, Višković K, Kalabrić Lepur N. Leukoencephalopathy in pneumococcal meningitis: a diagnostic pitfall and treatment challenge. Neurol Sci 2010; 32:139-42. [PMID: 20526642 DOI: 10.1007/s10072-010-0336-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 05/11/2010] [Indexed: 10/19/2022]
Abstract
We present a case of pneumococcal meningitis complicated by leukoencephalopathy. Possible pathogenic mechanisms, a diagnostic pitfall, and optimal treatment options are discussed.
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Affiliation(s)
- Dragan Lepur
- Department of Neuroinfections and Intensive Care Medicine, University Hospital for Infectious Diseases Dr. Fran Mihaljević, Mirogojska 8, 10000, Zagreb, Croatia.
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Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT, Hobson R, Kidwell CS, Koroshetz WJ, Mathews V, Villablanca P, Warach S, Walters B. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. Stroke 2009; 40:3646-78. [PMID: 19797189 DOI: 10.1161/strokeaha.108.192616] [Citation(s) in RCA: 291] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Sharma VK, Teoh HL, Chan BPL, Ong BKC. Reversed flow in the basilar artery in acute vertebrobasilar ischemia. J Clin Neurosci 2009; 16:1493-5. [PMID: 19656684 DOI: 10.1016/j.jocn.2009.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Revised: 01/14/2009] [Accepted: 01/24/2009] [Indexed: 11/28/2022]
Abstract
Acute vertebrobasilar ischemia is a potentially sinister pathology with high mortality and poor functional outcome in survivors. We report the findings of multi-modal assessment (MRI and cerebrovascular ultrasonography) of cerebral hemodynamics in a patient who suffered from acute brainstem infarction with National Institute of Health Stroke Scale (NIHSS) score of 16 points. Our patient demonstrated reversal of blood flow in the basilar artery on the second day of his stroke and this was associated with significant and rapid clinical recovery over the following 2 days (NIHSS score dropped to 4 points). He had recovered completely when seen in the outpatient clinic 3 months later.
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Affiliation(s)
- Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Hospital, 119074 Singapore.
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Treger I, Luzki L, Gil M, Ring H. Transcranial doppler monitoring during language tasks in stroke patients with aphasia. Disabil Rehabil 2009; 29:1177-83. [PMID: 17653991 DOI: 10.1080/09638280600999493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To investigate the pattern of hemispheric activation, according to cerebral blood flow changes, as measured by Transcranial Doppler Ultrasonography (TCD) during language tasks in stroke patients with aphasia. METHOD Prospective study investigating results of TCD monitoring during language naming and recognition tasks in ischemic stroke patients (n = 32) with and without aphasia and 5 control subjects. RESULTS Delta mean flow velocity (MFV) in the left Middle Cerebral Artery (MCA) was found to be much lower in aphasia patients as compared to healthy subjects. Negative statistical correlation was found between the improvement of language ability and the blood flow velocity parameters in the left hemisphere. Aphasia patients with good language ability showed much higher MFV in the right MCA during the first test. Left hemispheric blood flow velocity shift was found to be higher during speech tasks in the patients with poor language ability. CONCLUSIONS Our study suggests that the performance of language tasks in aphasia patients during early recovery after stroke is associated with relatively high right hemisphere activation. High blood flow velocity in the right MCA of aphasia patients was found to be a good prognostic sign for better language ability. Arterial blood flow that shifted towards the left hemisphere during speech tasks was associated with poor language ability.
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Affiliation(s)
- I Treger
- Loewenstein Rehabilitation Hospital, Ra'anana, Israel
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40
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Koskinen LOD, Olivecrona M, Rodling-Wahlström M, Naredi S. Prostacyclin treatment normalises the MCA flow velocity in nimodipine-resistant cerebral vasospasm after aneurysmal subarachnoid haemorrhage: a pilot study. Acta Neurochir (Wien) 2009; 151:595-9; discussion 599. [PMID: 19350202 DOI: 10.1007/s00701-009-0295-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Accepted: 03/13/2009] [Indexed: 01/08/2023]
Abstract
BACKGROUND Cerebral vasospasm triggered by subarachnoid haemorrhage is one of the major causes of post-haemorrhage morbidity and mortality. Several treatment modalities have been proposed, and none of them are fully effective. METHODS In this study we treated five patients with prostacyclin suffering vasospasm after a ruptured aneurysm not responding to high i.v. doses of nimodipine. All patients were severely ill, unconscious and in need of intensive care. FINDINGS A low dose of prostacyclin i.v. infusion for 72 h reversed the vasospasm as measured by transcranial Doppler technique. The mean MCA blood flow velocity decreased from 199 +/- 31 cm/s to 92 +/- 6 cm/s within 72 h after the start of the prostacyclin infusion. CONCLUSIONS We suggest that low-dose prostacyclin treatment, an old treatment strategy, can be a treatment option in patients with vasospasm not responding to ordinary measures.
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Middle cerebral artery vasospasm: Transcranial color-coded duplex sonography versus conventional nonimaging transcranial Doppler sonography*. Crit Care Med 2009; 37:963-8. [DOI: 10.1097/ccm.0b013e31819b8165] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Romano JG, Rabinstein AA, Arheart KL, Nathan S, Campo-Bustillo I, Koch S, Forteza AM. Microemboli in Aneurysmal Subarachnoid Hemorrhage. J Neuroimaging 2008; 18:396-401. [DOI: 10.1111/j.1552-6569.2007.00215.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Affiliation(s)
- Lawrence K S Wong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
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Learning vector quantization neural networks improve accuracy of transcranial color-coded duplex sonography in detection of middle cerebral artery spasm--preliminary report. Neuroinformatics 2008; 6:279-90. [PMID: 18704768 DOI: 10.1007/s12021-008-9023-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2007] [Accepted: 07/08/2008] [Indexed: 10/21/2022]
Abstract
To determine the performance of an artificial neural network in transcranial color-coded duplex sonography (TCCS) diagnosis of middle cerebral artery (MCA) spasm. TCCS was prospectively acquired within 2 h prior to routine cerebral angiography in 100 consecutive patients (54M:46F, median age 50 years). Angiographic MCA vasospasm was classified as mild (<25% of vessel caliber reduction), moderate (25-50%), or severe (>50%). A Learning Vector Quantization neural network classified MCA spasm based on TCCS peak-systolic, mean, and end-diastolic velocity data. During a four-class discrimination task, accurate classification by the network ranged from 64.9% to 72.3%, depending on the number of neurons in the Kohonen layer. Accurate classification of vasospasm ranged from 79.6% to 87.6%, with an accuracy of 84.7% to 92.1% for the detection of moderate-to-severe vasospasm. An artificial neural network may increase the accuracy of TCCS in diagnosis of MCA spasm.
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Rasulo FA, De Peri E, Lavinio A. Transcranial Doppler ultrasonography in intensive care. EUROPEAN JOURNAL OF ANAESTHESIOLOGY. SUPPLEMENT 2008; 42:167-73. [PMID: 18289437 DOI: 10.1017/s0265021507003341] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Transcranial Doppler is an innovative, flexible, accessible tool for the bedside monitoring of static and dynamic cerebral flow and treatment response. Introduced by Rune Aaslid in 1982, it has become indispensable in clinical practice. The main obstacle to ultrasound penetration of the skull is bone. Low frequencies, 1-2 MHz, reduce the attenuation of the ultrasound wave caused by bone. Transcranial Doppler also provides the advantage of acoustic windows representing specific points of the skull where the bone is thin enough to allow ultrasounds to penetrate. There are four acoustic windows: transtemporal, transorbital, suboccipital and retromandibular. The identification of each intracranial vessel is based on the following elements: (a) velocity and direction; (b) depth of signal capture; (c) possibility of following the vessel its whole length; (d) spatial relationship with other vessels; and (e) response to homolateral and contralateral carotid compression. The main fields of clinical application of transcranial Doppler are assessment of vasospasm, detection of stenosis of the intracranial arteries, evaluation of cerebrovascular autoregulation, non-invasive estimation of intracranial pressure, measure of effective downstream pressure and assessment of brain death. Mean flow velocity is directly proportional to flow and inversely proportional to the section of the vessel. Any circumstance that leads to a variation of one of these factors can thus affect mean velocity. The main pathological condition affecting flow velocity is the vasospasm. Vasospasm is a frequent complication of subarachnoid haemorrhage, it often remains clinically silent and the factors that make it symptomatic are largely unknown. Threshold velocities above which vasospasm comes into place are well defined as regards the median cerebral artery, while there is no consensus for the other vessels. Nevertheless, an increase in velocity alone is not sufficient to arrive at a diagnosis of vasospasm; a condition of hyperaemia also presents with an increase in flow velocity. The Lindegaard Index has therefore been introduced, which is defined by the ratio between the mean flow velocity in the median cerebral artery and the mean flow velocity in the internal carotid artery. Criteria for diagnosis of a stenosis >50% of an intracranial vessel with transcranial Doppler include: (a) segmentary acceleration of flow velocity; (b) drop in velocity below the stenotic segment; (c) asymmetry; and (d) circumscribed flow disturbances (turbulence and musical murmur). The transcranial Doppler enables us to assess both components of self-regulation. The static component is measured by observing changes in flow velocity caused by pharmacologically induced episodes of hypertension and hypotension. The dynamic component of autoregulation can be measured using a method devised by Aaslid known as the 'cuff test'. A very effective and safe device for measuring cerebral autoregulation is the transient hyperaemic response test. This test is based on the compensatory vasodilatation of the arterioles, which occurs after brief compression of the common carotid. Csonyka proposed the following formula based on clinical observation for the calculation of cerebral perfusion pressure: CPP = MAP x FVd/FVm + 14. Brain death is defined as the irreversible cessation of all functions of the whole brain. The clinical criteria are usually considered sufficient to establish a diagnosis of brain death; however, they might not be sufficient in patients who have been on sedatives or when there are ethical or legal controversies. Many authors have demonstrated the existence of a transcranial Doppler pattern, which is typical of brain death.
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Affiliation(s)
- F A Rasulo
- Institute of Anesthesiology and Intensive Care, Spedali Civili University Hospital of Brescia, Piazzale Spedali Civili, Brescia, Italy.
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Abstract
PURPOSE OF REVIEW Pediatric arterial ischemic stroke is relatively rare but carries a considerable impact and high risk of recurrence--especially in patients with sickle cell disease and various forms of vasculopathy. We will discuss risk factors, vascular physiology, and primary/secondary/rehabilitative therapies. Goals for future investigation and treatment are suggested. RECENT FINDINGS Risk factors include chronic disease, vasculopathy, acute illness, cardiac disease, head and neck trauma, infection, and prothrombic disorders. Research has begun to implicate genetic risk factors--initially in sickle cell disease and more recently in prothrombotic disorders, moyamoya, and nitric oxide regulation. The vascular physiology of pediatric arterial ischemic stroke, especially sickle cell disease stroke, is currently undergoing study in animal models and in humans. No primary prevention therapy for pediatric arterial ischemic stroke is known. Various primary and secondary prevention therapies are used, however, in at-risk sickle cell disease patients. Aspirin, coumadin, and heparin are often initiated as secondary prevention therapies for non-sickle cell disease-associated arterial ischemic stroke, but no studies have assessed efficacy. SUMMARY Pediatric arterial ischemic stroke is under-recognized and under-studied. Investigation into the hemodynamic aspects of arterial ischemic stroke, although best studied thus far in sickle cell disease, has been neglected. It is likely that enhanced study of hemodynamics and autoregulation will elucidate both new prevention opportunities and novel treatments.
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Affiliation(s)
- Carly Seidman
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Bos MJ, Koudstaal PJ, Hofman A, Witteman JCM, Breteler MMB. Transcranial Doppler hemodynamic parameters and risk of stroke: the Rotterdam study. Stroke 2007; 38:2453-8. [PMID: 17673712 DOI: 10.1161/strokeaha.107.483073] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We explored the association between transcranial Doppler hemodynamic parameters and the risk of stroke in the general population. METHODS At baseline, we assessed mean flow velocity, peak systolic flow velocity, end diastolic flow velocity, and vasomotor reactivity with transcranial Doppler in 2022 Rotterdam Study participants aged 61 years and over in both middle cerebral arteries. All participants, who at baseline were free from previous stroke, were subsequently followed for occurrence of stroke (average follow-up time 5.1 years). We calculated hazard ratios for the association between hemodynamic parameters and risk of stroke using Cox proportional hazards models with adjustment for age, sex, systolic blood pressure, antihypertensive drug use, diabetes mellitus, ever smoking, current smoking, carotid intima media thickness, and carotid distensibility. RESULTS Risk of stroke (n=122) and ischemic stroke (n=89) increased with increasing middle cerebral artery flow velocity; when comparing the tertile with highest velocity to the tertile with lowest velocity, the hazard ratio was 1.74 (95% CI: 1.09 to 2.77) for the association between mean flow velocity and stroke, 1.63 (95% CI: 1.03 to 2.58) for end diastolic flow velocity and stroke, and 1.33 (95% CI: 0.86 to 2.08) for peak systolic flow velocity and stroke. These estimates increased 10% to 26% when only ischemic strokes were included. The side of highest flow velocity was not associated with the side of stroke. We found no associations between vasomotor reactivity and risk of stroke. CONCLUSIONS Risk of stroke increased strongly with increasing middle cerebral artery flow velocity as measured with transcranial Doppler in the general population.
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Affiliation(s)
- Michiel J Bos
- Department of Epidemiology & Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands
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Alexandrov AV, Sloan MA, Wong LKS, Douville C, Razumovsky AY, Koroshetz WJ, Kaps M, Tegeler CH. Practice Standards for Transcranial Doppler Ultrasound: Part I-Test Performance. J Neuroimaging 2007; 17:11-8. [PMID: 17238867 DOI: 10.1111/j.1552-6569.2006.00088.x] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Indications for the clinical use of transcranial Doppler (TCD) continue to expand while scanning protocols and quality of reporting vary between institutions. Based on literature analysis and extensive personal experience, an international expert panel started the development of guidelines for TCD performance, interpretation, and competence. The first part describes complete diagnostic spectral TCD examination for patients with cerebrovascular diseases. Cranial temporal bone windows are used for the detection of the middle cerebral arteries (MCA), anterior cerebral arteries (ACA), posterior cerebral arteries (PCA), C1 segment of the internal carotid arteries (ICA), and collateralization of flow via the anterior (AComA) and posterior (PComA) communicating arteries; orbital windows-for the ophthalmic artery (OA) and ICA siphon; the foraminal window-for the terminal vertebral (VA) and basilar (BA) arteries. Although there is a significant individual variability of the circle of Willis with and without disease, the complete diagnostic TCD examination should include bilateral assessment of the M2 (arbitrarily located at 30-40 mm depth), M1 (40-65 mm) MCA [with M1 MCA mid-point at 50 mm (range 45-55 mm), average length 16 mm (range 5-24 mm), A1 ACA (60-75 mm), C1 ICA (60-70 mm), P1-P2 PCA (average depth 63 mm (range 55-75 mm), AComA (70-80 mm), PComA (58-65 mm), OA (40-50 mm), ICA siphons (55-65 mm), terminal VA (40-75 mm), proximal (75-80), mid (80-90 mm), and distal (90-110 mm) BA]. The distal ICA on the neck (40-60 mm) can be located via submandibular windows to calculate the VMCA/VICA index, or the Lindegaard ratio for vasospasm grading after subarachnoid hemorrhage. Performance goals of diagnostic TCD are to detect and optimize arterial segment-specific spectral waveforms, determine flow direction, measure cerebral blood flow velocities and flow pulsatility in the above-mentioned arteries. These practice standards will assist laboratory accreditation processes by providing a standard scanning protocol with transducer positioning and orientation, depth selection and vessel identification for ultrasound devices equipped with spectral Doppler and power motion Doppler.
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Masdeu JC, Irimia P, Asenbaum S, Bogousslavsky J, Brainin M, Chabriat H, Herholz K, Markus HS, Martínez-Vila E, Niederkorn K, Schellinger PD, Seitz RJ. EFNS guideline on neuroimaging in acute stroke. Report of an EFNS task force. Eur J Neurol 2006; 13:1271-83. [PMID: 17116208 DOI: 10.1111/j.1468-1331.2006.01507.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Neuroimaging techniques are necessary for the evaluation of stroke, one of the leading causes of death and neurological impairment in developed countries. The multiplicity of techniques available has increased the complexity of decision making for physicians. We performed a comprehensive review of the literature in English for the period 1965-2005 and critically assessed the relevant publications. The members of the panel reviewed and corrected an initial draft, until a consensus was reached on recommendations stratified according to the European Federation of Neurological Societies (EFNS) criteria. Non-contrast computed tomography (CT) scan is the established imaging procedure for the initial evaluation of stroke patients. However, magnetic resonance imaging (MRI) has a higher sensitivity than CT for the demonstration of infarcted or ischemic areas and depicts well acute and chronic intracerebral hemorrhage. Perfusion and diffusion MRI together with MR angiography (MRA) are very helpful for the acute evaluation of patients with ischemic stroke. MRI and MRA are the recommended techniques for screening cerebral aneurysms and for the diagnosis of cerebral venous thrombosis and arterial dissection. For the non-invasive study of extracranial vessels, MRA is less portable and more expensive than ultrasonography but it has higher sensitivity and specificity for carotid stenosis. Transcranial Doppler is very useful for monitoring arterial reperfusion after thrombolysis, for the diagnosis of intracranial stenosis and of right-to-left shunts, and for monitoring vasospasm after subarachnoid hemorrhage. Currently, single photon emission computed tomography and positron emission tomography have a more limited role in the evaluation of the acute stroke patient.
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Affiliation(s)
- J C Masdeu
- Department of Neurology and Neurosurgery, University of Navarra, Pamplona, Spain.
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