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Bankole NDA, Dujardin PA, Bala F, Ehrmann S, Desplobain K, Patat F, Boulouis G. Transcranial doppler ultrasound for the diagnosis of large vessel occlusion in patients with acute ischemic stroke: A systematic review. Clin Neurol Neurosurg 2024; 245:108506. [PMID: 39167933 DOI: 10.1016/j.clineuro.2024.108506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 08/08/2024] [Accepted: 08/10/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Transcranial Doppler (TCD) ultrasound may enhance the swift diagnosis of large vessel occlusion (LVO) in patients with a clinical suspicion of acute ischemic stroke (AIS). This is a comprehensive review of the literature on the use and performance of TCD ultrasound in diagnosing AIS caused by LVO. PATIENTS AND METHODS We conducted a systematic search in PubMed and Google scholar to identify studies reporting data on TCD biomarkers for LVO diagnosis and management of AIS. The main outcomes of interest were the identified TCD-derived biomarkers performances (specificity, sensitivity, predictive values) for LVO diagnosis. RESULTS A total of 170 studies were screened, of which 7 (4.1 %) studies with a total of 2260 patients (mean age: 65.3 +/- 4.5 years, 1114 (49.3 %) females) were included in this review. Most of the studies were prospective (n=5, 71.4 %), all of the studies had an overall low risk of bias. In 6 studies (85.7 %), TCD was used at the time of hospital admission, on triage field in one study in the context of a confirmed AIS. A total of six TCD based biomarkers were described in the included articles, with high accuracies for LVO diagnosis (ranging from 85.9 % to 99.2 %). Pulsatility Index had the highest reported performances in terms of Accuracy for LVO diagnosis (ranging from 96 % to 99.2 %). Authors reported suboptimal temporal windows for data acquisition in 13-19.7 % of patients. CONCLUSION TCD is as a promising non-invasive and cost-effective tool for LVO diagnosis, presenting opportunities to enhance stroke management.
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Affiliation(s)
- Nourou Dine Adeniran Bankole
- Clinical Investigation Center (CIC), 1415, INSERM, Department of Interventional Neuroradiology, Tours University Hospital, Tours, France.
| | - Paul-Armand Dujardin
- Clinical Investigation Center (CIC), 1415, INSERM, Tours University Hospital, Tours, France.
| | - Fouzi Bala
- Department of Interventional Neuroradiology, Tours University Hospital, Tours, France.
| | - Stephan Ehrmann
- Clinical Investigation Center (CIC), 1415, INSERM, Médecine Intensive Réanimation, Tours University Hospital, and Centre d'étude des pathologies respiratoires, INSERM U1100, Tours University, Tours, France.
| | - Katia Desplobain
- Clinical Investigation Center (CIC), 1415, INSERM, Tours University Hospital, Tours, France.
| | - Frederic Patat
- Clinical Investigation Center (CIC), 1415, INSERM, Department of Ultrasound, Tours University Hospital, Tours, France.
| | - Gregoire Boulouis
- Clinical Investigation Center (CIC), 1415, INSERM, Department of Interventional Neuroradiology, Tours University Hospital, Tours, France.
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Gunda ST, Yip JHY, Ng VTK, Chen Z, Han X, Chen X, Pang MYC, Ying MTC. The Diagnostic Accuracy of Transcranial Color-Coded Doppler Ultrasound Technique in Stratifying Intracranial Cerebral Artery Stenoses in Cerebrovascular Disease Patients: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:1507. [PMID: 38592335 PMCID: PMC10934108 DOI: 10.3390/jcm13051507] [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: 12/27/2023] [Revised: 02/17/2024] [Accepted: 03/01/2024] [Indexed: 04/10/2024] Open
Abstract
The early and accurate stratification of intracranial cerebral artery stenosis (ICAS) is critical to inform treatment management and enhance the prognostic outcomes in patients with cerebrovascular disease (CVD). Digital subtraction angiography (DSA) is an invasive and expensive procedure but is the gold standard for the diagnosis of ICAS. Over recent years, transcranial color-coded Doppler ultrasound (TCCD) has been suggested to be a useful imaging method for accurately diagnosing ICAS. However, the diagnostic accuracy of TCCD in stratifying ICASs among patients with CVD remains unclear. Therefore, this systematic review and meta-analysis aimed at evaluating the diagnostic accuracy of TCCD in the stratification of intracranial steno-occlusions among CVD patients. A total of six databases-Embase, CINAHL, Medline, PubMed, Google Scholar, and Web of Science (core collection)-were searched for studies that assessed the diagnostic accuracy of TCCD in stratifying ICASs. The meta-analysis was performed using Meta-DiSc 1.4. The Quality Assessment of Diagnostic Accuracy Studies tool version 2 (QUADAS-2) assessed the risk of bias. Eighteen studies met all of the eligibility criteria. TCCD exhibited a high pooled diagnostic accuracy in stratifying intracranial steno-occlusions in patients presenting with CVD when compared to DSA as a reference standard (sensitivity = 90%; specificity = 87%; AUC = 97%). Additionally, the ultrasound parameters peak systolic velocity (PSV) and mean flow velocity (MFV) yielded a comparable diagnostic accuracy of "AUC = 0.96". In conclusion, TCCD could be a noble, safe, and accurate alternative imaging technique to DSA that can provide useful diagnostic information in stratifying intracranial steno-occlusions in patients presenting with CVD. TCCD should be considered in clinical cases where access to DSA is limited.
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Affiliation(s)
- Simon Takadiyi Gunda
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Jerica Hiu-Yui Yip
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Veronica Tsam-Kit Ng
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Ziman Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Xinyang Han
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Xiangyan Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Marco Yiu-Chung Pang
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China;
| | - Michael Tin-Cheung Ying
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
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3
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Liu WJ. The diagnosis of intracranial artery stenosis in patients with stroke by transcranial Doppler ultrasound: A meta-analysis. Technol Health Care 2024; 32:639-649. [PMID: 37661896 DOI: 10.3233/thc-220844] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
BACKGROUND Strokes are the most common cause of death and the leading cause of acquired disability in adults worldwide. OBJECTIVE The present study aimed to investigate the value of transcranial Doppler ultrasound (TCD) in the diagnosis of intracranial vascular stenosis in patients with a history of stroke. METHODS This is a meta-analysis study of diagnostic tests. PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang, and VIP databases were systematically searched. Diagnostic tests using TCD or transcranial colour Doppler ultrasound (TCCD) for detecting intracranial arterial stenosis in patients with a history of stroke were included, with reference standards of intracranial angiography, computed tomography angiography (CTA), or magnetic resonance angiography. The risk bias map was drawn by Revman v5.3, the sensitivity and specificity forest plot was drawn by Stata v16.0, the receiver operating characteristic curve was drawn, and the area under the curve (AUC) was calculated. RESULTS A total of 812 patients with stroke in 12 studies were included in the meta-analysis. The estimated sensitivity of TCD or TCCD for the detection of intracranial vascular stenosis was 0.77-1.00, and the combined sensitivity was 0.96 (95% confidence interval [CI]: 0.88-0.99); the estimated specificity was 0.32-1.00, and the combined specificity was 0.94 (95% CI: 0.82-0.98); the positive likelihood ratio was 15.8 (95% CI: 5.1-48.6); and the negative likelihood ratio was 0.04 (95% CI: 0.01-0.14). The AUC was 0.99 (95% CI: 0.97-0.99). CONCLUSION Doppler ultrasound has good consistency with conventional methods for the diagnosis of intracranial artery stenosis in patients with a history of stroke. Different reference standards may affect sensitivity and specificity; when CTA was used as the reference standard, the consistency of the TCD in the diagnosis of intracranial artery stenosis in stroke patients was relatively good.
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Wu T, Shi Z, Chen B, Geng Y, Pan J. TCD hemodynamics findings in the subacute phase of anterior circulation stroke patients treated with mechanical thrombectomy. Open Med (Wars) 2022; 17:606-613. [PMID: 35434377 PMCID: PMC8961283 DOI: 10.1515/med-2022-0464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/03/2022] Open
Abstract
Despite mechanical thrombectomy, the prognosis for many patients with anterior circulation ischemic stroke (ACIS) remains poor. This retrospective study reports consecutive mechanical thrombectomy procedures for ACIS at our hospital over 4 years. Hemodynamics were explored using transcranial Doppler ultrasound. The functional outcome was assessed using the modified Rankin scale. A total of 121 eligible cases were included: 61 (50.4%) exhibited good outcomes (modified Rankin scale score ≤2) by day 90. The logistic regression analysis showed that ipsilateral middle cerebral artery (iMCA) systolic blood flow (SBF) (OR = 0.983, 95% CI: 0.969–0.997, P = 0.014), preoperative National Institutes of Health Stroke Scale (NIHSS)score (OR = 1.160, 95% CI: 1.067–1.261, P < 0.001), intracranial hemorrhage after therapy (OR = 19.514, 95% CI: 4.364–87.265, P < 0.001), and Alberta Stroke Program Early Computed Tomography Score (OR = 0.639, 95% CI: 0.416–0.981, P = 0.040) were independently associated with prognosis. The iMCA SBF and preoperative NIHSS score were significantly predictive of a good outcome in the receiver operating characteristic analysis. In conclusion, elevated iMCA SBF might be a prognostic indicator of a good 90-day outcome following endovascular treatment in ACIS patients treated with mechanical thrombectomy, but large prospective studies are mandatory to validate the findings of our study.
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Affiliation(s)
- Tingting Wu
- Department of Neurology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College) , Hangzhou , 310014 , Zhejiang China
| | - Zongjie Shi
- Department of Neurology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College) , Hangzhou , 310014 , Zhejiang China
| | - Bo Chen
- Department of Neurology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College) , Hangzhou , 310014 , Zhejiang China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College) , Hangzhou , 310014 , Zhejiang China
| | - Jie Pan
- Department of Neurology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College) , No. 158 Shangtang Road , Hangzhou , 310014 , Zhejiang China
- Medical College of Soochow University , Suzhou , 215123 , China
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5
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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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6
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Shahripour RB, Azarpazhooh MR, Akhuanzada H, Labin E, Borhani-Haghighi A, Agrawal K, Meyer D, Meyer B, Hemmen T. Transcranial Doppler to evaluate postreperfusion therapy following acute ischemic stroke: A literature review. J Neuroimaging 2021; 31:849-857. [PMID: 34128299 DOI: 10.1111/jon.12887] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/22/2021] [Accepted: 05/11/2021] [Indexed: 12/15/2022] Open
Abstract
Cerebral vessel recanalization therapy, either intravenous thrombolysis or mechanical thrombectomy, is the main treatment that can significantly improve clinical outcomes after acute ischemic stroke. The degree of recanalization and cerebral reperfusion of the ischemic penumbra are dependent on cerebral hemodynamics. Currently, the main imaging modalities to assess reperfusion are MRI and CT perfusion. However, these imaging techniques cannot predict reperfusion-associated complications and are not readily available in many centers. It is also not feasible to repeat them frequently for sequential assessments, which is important because of the changing nature of cerebral hemodynamics following stroke. Transcranial Doppler sonography (TCD) is a valid, safe, and inexpensive technique that can assess recanalized vessels and reperfused tissue in real-time at the bedside. Post thrombectomy reocclusion, hyperperfusion syndrome, distal embolization, and remote infarction result in poor outcomes after mechanical or intravenous reperfusion therapy. Managing blood pressure following these endovascular treatments can also be a dilemma. TCD has an important role, with major clinical implications, in evaluating cerebral hemodynamics and collateral vessel status, guiding clinicians in making individualized decisions based on cerebral blood flow during acute stroke care. This review summarizes the most relevant literature on the role of TCD in evaluating patients after reperfusion therapy. We also discuss the importance of performing TCD in the first few hours following thrombolytic therapy in identifying hyperperfusion syndrome and embolic signals, predicting recurrent stroke, and detecting reocclusions, all of which may help improve patient prognosis. We recommend TCD during the hyperacute phase of stroke in comprehensive stroke centers.
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Affiliation(s)
- Reza Bavarsad Shahripour
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California San Diego, San Diego, California, USA
| | - M Reza Azarpazhooh
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada.,Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - Humayon Akhuanzada
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Edward Labin
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California San Diego, San Diego, California, USA
| | | | - Kunal Agrawal
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California San Diego, San Diego, California, USA
| | - Dawn Meyer
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California San Diego, San Diego, California, USA
| | - Brett Meyer
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California San Diego, San Diego, California, USA
| | - Thomas Hemmen
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California San Diego, San Diego, California, USA
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7
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van Meenen LCC, van Stigt MN, Siegers A, Smeekes MD, van Grondelle JAF, Geuzebroek G, Marquering HA, Majoie CBLM, Roos YBWEM, Koelman JHTM, Potters WV, Coutinho JM. Detection of Large Vessel Occlusion Stroke in the Prehospital Setting: Electroencephalography as a Potential Triage Instrument. Stroke 2021; 52:e347-e355. [PMID: 33940955 DOI: 10.1161/strokeaha.120.033053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A reliable and fast instrument for prehospital detection of large vessel occlusion (LVO) stroke would be a game-changer in stroke care, because it would enable direct transportation of LVO stroke patients to the nearest comprehensive stroke center for endovascular treatment. This strategy would substantially improve treatment times and thus clinical outcomes of patients. Here, we outline our view on the requirements of an effective prehospital LVO detection method, namely: high diagnostic accuracy; fast application and interpretation; user-friendliness; compactness; and low costs. We argue that existing methods for prehospital LVO detection, including clinical scales, mobile stroke units and transcranial Doppler, do not fulfill all criteria, hindering broad implementation of these methods. Instead, electroencephalography may be suitable for prehospital LVO detection since in-hospital studies have shown that quantification of hypoxia-induced changes in the electroencephalography signal have good diagnostic accuracy for LVO stroke. Although performing electroencephalography measurements in the prehospital setting comes with challenges, solutions for fast and simple application of this method are available. Currently, the feasibility and diagnostic accuracy of electroencephalography in the prehospital setting are being investigated in clinical trials.
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Affiliation(s)
- Laura C C van Meenen
- Department of Neurology (L.C.C.v.M., Y.B.W.E.M.R., W.V.P., J.M.C.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Maritta N van Stigt
- Department of Clinical Neurophysiology (M.N.v.S., J.H.T.M.K., W.V.P.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Arjen Siegers
- Ambulance Amsterdam, Amsterdam, the Netherlands (A.S., J.A.F.v.G., G.G.)
| | - Martin D Smeekes
- Emergency Medical Services North-Holland North, Alkmaar, the Netherlands (M.D.S.)
| | | | - Geertje Geuzebroek
- Ambulance Amsterdam, Amsterdam, the Netherlands (A.S., J.A.F.v.G., G.G.)
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (H.A.M., C.B.L.M.M.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine (H.A.M., C.B.L.M.M.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Yvo B W E M Roos
- Department of Neurology (L.C.C.v.M., Y.B.W.E.M.R., W.V.P., J.M.C.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Johannes H T M Koelman
- Department of Clinical Neurophysiology (M.N.v.S., J.H.T.M.K., W.V.P.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Wouter V Potters
- Department of Neurology (L.C.C.v.M., Y.B.W.E.M.R., W.V.P., J.M.C.), Amsterdam UMC, University of Amsterdam, the Netherlands.,Department of Clinical Neurophysiology (M.N.v.S., J.H.T.M.K., W.V.P.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology (L.C.C.v.M., Y.B.W.E.M.R., W.V.P., J.M.C.), Amsterdam UMC, University of Amsterdam, the Netherlands
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8
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Brunser AM, Lavados PM, Cavada G, Muñoz-Venturelli P, Olavarría VV, Navia V, Mansilla E, Díaz V. Transcranial Doppler as a Predictor of Ischemic Events in Vertebral Artery Dissection. J Neuroimaging 2020; 30:890-895. [PMID: 32857896 DOI: 10.1111/jon.12773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Transcranial Doppler (TCD) helps identify patients with carotid dissections at risk of ischemic events (IEs). There is paucity of data identifying independent predictors of IE in vertebral arterial dissection (VAD). We sought to investigate the clinical and ultrasound predictors of IE. METHODS Patients with VAD admitted between June 2017 and February 2020 were evaluated clinically and with TCD; sonographic curves, microembolic signals (MES), and the breath-holding index (BHI) test were applied. Covariates found on univariate screen (P < .25) were included in a multivariable linear regression to identify independent predictors of IEs. RESULTS Of 88 patients with 100 VAD, 75 (85.2%) were females with a mean age 37.9 ± 7.5 years. All patients received antiplatelet treatment. TCD monitoring lasted an average of 21 ± 2.1 minutes. TCD was abnormal in 23 cases (26.1%); 21 patients had abnormal sonographic curves in the vertebral/basilar arteries, while in 4 cases, MES were present and in 5 (4.5%), BHI was abnormal. None of the patients with a normal TCD had an IE. Six strokes occurred during follow up. On univariate analysis, male sex, diabetes, dyslipidemia, a previous myocardial infarct, migraine, time of consultation to the ER, bilateral VAD, MES, BHI abnormalities, post stenotic flow in the basilar artery (PFB), and basilar/vertebral velocities were significantly associated with the risk of IEs. In the multivariate analysis, only the presence of PFB was a significant predictor of IE (OR: 68.6, 95% CI 5-937, <.001). CONCLUSIONS TCD in VAD predicts patients at high risk of IE.
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Affiliation(s)
- Alejandro M Brunser
- Department of General Emergency, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana - Universidad del Desarrollo, Santiago, Chile.,Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica, Alemana de Santiago, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Pablo M Lavados
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica, Alemana de Santiago, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Gabriel Cavada
- Unidad de Investigación y Ensayos Clínicos, Departamento de Desarrollo Académico e Investigación, Clínica Alemana de Santiago, Santiago, Chile
| | - Paula Muñoz-Venturelli
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica, Alemana de Santiago, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,Centro de Estudio Clínico (CEC), Instituto de Ciencias e Innovación en Medicina (ICIM), Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Verónica V Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica, Alemana de Santiago, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Victor Navia
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica, Alemana de Santiago, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Eloy Mansilla
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica, Alemana de Santiago, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Violeta Díaz
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica, Alemana de Santiago, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
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9
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Mattioni A, Cenciarelli S, Eusebi P, Brazzelli M, Mazzoli T, Del Sette M, Gandolfo C, Marinoni M, Finocchi C, Saia V, Ricci S. Transcranial Doppler sonography for detecting stenosis or occlusion of intracranial arteries in people with acute ischaemic stroke. Cochrane Database Syst Rev 2020; 2:CD010722. [PMID: 32072609 PMCID: PMC7029193 DOI: 10.1002/14651858.cd010722.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND An occlusion or stenosis of intracranial large arteries can be detected in the acute phase of ischaemic stroke in about 42% of patients. The approved therapies for acute ischaemic stroke are thrombolysis with intravenous recombinant tissue plasminogen activator (rt-PA), and mechanical thrombectomy; both aim to recanalise an occluded intracranial artery. The reference standard for the diagnosis of intracranial stenosis and occlusion is intra-arterial angiography (IA) and, recently, computed tomography angiography (CTA) and magnetic resonance angiography (MRA), or contrast-enhanced MRA. Transcranial Doppler (TCD) and transcranial colour Doppler (TCCD) are useful, rapid, noninvasive tools for the assessment of intracranial large arteries pathology. Due to the current lack of consensus regarding the use of TCD and TCCD in clinical practice, we systematically reviewed the literature for studies assessing the diagnostic accuracy of these techniques compared with intra-arterial IA, CTA, and MRA for the detection of intracranial stenosis and occlusion in people presenting with symptoms of ischaemic stroke. OBJECTIVES To assess the diagnostic accuracy of TCD and TCCD for detecting stenosis and occlusion of intracranial large arteries in people with acute ischaemic stroke. SEARCH METHODS We limited our searches from January 1982 onwards as the transcranial Doppler technique was only introduced into clinical practice in the 1980s. We searched MEDLINE (Ovid) (from 1982 to 2018); Embase (Ovid) (from 1982 to 2018); Database of Abstracts of Reviews of Effects (DARE); and Health Technology Assessment Database (HTA) (from 1982 to 2018). Moreover, we perused the reference lists of all retrieved articles and of previously published relevant review articles, handsearched relevant conference proceedings, searched relevant websites, and contacted experts in the field. SELECTION CRITERIA We included all studies comparing TCD or TCCD (index tests) with IA, CTA, MRA, or contrast-enhanced MRA (reference standards) in people with acute ischaemic stroke, where all participants underwent both the index test and the reference standard within 24 hours of symptom onset. We included prospective cohort studies and randomised studies of test comparisons. We also considered retrospective studies eligible for inclusion where the original population sample was recruited prospectively but the results were analysed retrospectively. DATA COLLECTION AND ANALYSIS At least two review authors independently screened the titles and abstracts identified by the search strategies, applied the inclusion criteria, extracted data, assessed methodological quality (using QUADAS-2), and investigated heterogeneity. We contacted study authors for missing data. MAIN RESULTS A comprehensive search of major relevant electronic databases (MEDLINE and Embase) from 1982 to 13 March 2018 yielded 13,534 articles, of which nine were deemed eligible for inclusion. The studies included a total of 493 participants. The mean age of included participants was 64.2 years (range 55.8 to 69.9 years). The proportion of men and women was similar across studies. Six studies recruited participants in Europe, one in south America, one in China, and one in Egypt. Risk of bias was high for participant selection but low for flow, timing, index and reference standard. The summary sensitivity and specificity estimates for TCD and TCCD were 95% (95% CI = 0.83 to 0.99) and 95% (95% CI = 0.90 to 0.98), respectively. Considering a prevalence of stenosis or occlusion of 42% (as reported in the literature), for every 1000 people who receive a TCD or TCCD test, stenosis or occlusion will be missed in 21 people (95% CI = 4 to 71) and 29 (95% CI = 12 to 58) will be wrongly diagnosed as harbouring an intracranial occlusion. However, there was substantial heterogeneity between studies, which was no longer evident when only occlusion of the MCA was considered, or when the analysis was limited to participants investigated within six hours. The performance of either TCD or TCCD in ruling in and ruling out a MCA occlusion was good. Limitations of this review were the small number of identified studies and the lack of data on the use of ultrasound contrast medium. AUTHORS' CONCLUSIONS This review provides evidence that TCD or TCCD, administered by professionals with adequate experience and skills, can provide useful diagnostic information for detecting stenosis or occlusion of intracranial vessels in people with acute ischaemic stroke, or guide the request for more invasive vascular neuroimaging, especially where CT or MR-based vascular imaging are not immediately available. More studies are needed to confirm or refute the results of this review in a larger sample of stroke patients, to verify the role of contrast medium and to evaluate the clinical advantage of the use of ultrasound.
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Affiliation(s)
- Alessia Mattioni
- USL Umbria 1UO NeurologiaVia Luigi Angelini 10Città di CastelloPerugiaItaly06012
| | - Silvia Cenciarelli
- USL Umbria 1UO NeurologiaVia Luigi Angelini 10Città di CastelloPerugiaItaly06012
| | - Paolo Eusebi
- Regional Health Authority of UmbriaEpidemiology DepartmentVia Mario Angeloni 61PerugiaUmbriaItaly06124
| | - Miriam Brazzelli
- University of AberdeenHealth Services Research UnitHealth Sciences BuildingForesterhillAberdeenUKAB25 2ZD
| | - Tatiana Mazzoli
- USL Umbria 1UO NeurologiaVia Luigi Angelini 10Città di CastelloPerugiaItaly06012
| | | | - Carlo Gandolfo
- Università di Genova e Ospedale Policlinico San MartiniDipartimento di Neuroscienze, Oftalmologia, Genetica e Scienze Materno‐InfantiliGenovaItaly16132
| | | | - Cinzia Finocchi
- Università di Genova e Ospedale Policlinico San MartiniDipartimento di Neuroscienze, Oftalmologia, Genetica e Scienze Materno‐InfantiliGenovaItaly16132
| | - Valentina Saia
- Ospedale di Pietra LigureUO NeurologiaPietra LigureItaly
| | - Stefano Ricci
- USL Umbria 1UO NeurologiaVia Luigi Angelini 10Città di CastelloPerugiaItaly06012
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10
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Thorpe SG, Thibeault CM, Canac N, Jalaleddini K, Dorn A, Wilk SJ, Devlin T, Scalzo F, Hamilton RB. Toward automated classification of pathological transcranial Doppler waveform morphology via spectral clustering. PLoS One 2020; 15:e0228642. [PMID: 32027714 PMCID: PMC7004309 DOI: 10.1371/journal.pone.0228642] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/20/2020] [Indexed: 11/21/2022] Open
Abstract
Cerebral Blood Flow Velocity waveforms acquired via Transcranial Doppler (TCD) can provide evidence for cerebrovascular occlusion and stenosis. Thrombolysis in Brain Ischemia (TIBI) flow grades are widely used for this purpose, but require subjective assessment by expert evaluators to be reliable. In this work we seek to determine whether TCD morphology can be objectively assessed using an unsupervised machine learning approach to waveform categorization. TCD beat waveforms were recorded at multiple depths from the Middle Cerebral Arteries of 106 subjects; 33 with Large Vessel Occlusion (LVO). From each waveform, three morphological features were extracted, quantifying onset of maximal velocity, systolic canopy length, and the number/prominence of peaks/troughs. Spectral clustering identified groups implicit in the resultant three-dimensional feature space, with gap statistic criteria establishing the optimal cluster number. We found that gap statistic disparity was maximized at four clusters, referred to as flow types I, II, III, and IV. Types I and II were primarily composed of control subject waveforms, whereas types III and IV derived mainly from LVO patients. Cluster morphologies for types I and IV aligned clearly with Normal and Blunted TIBI flows, respectively. Types II and III represented commonly observed flow-types not delineated by TIBI, which nonetheless deviate from normal and blunted flows. We conclude that important morphological variability exists beyond that currently quantified by TIBI in populations experiencing or at-risk for acute ischemic stroke, and posit that the observed flow-types provide the foundation for objective methods of real-time automated flow type classification.
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Affiliation(s)
- Samuel G. Thorpe
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
- * E-mail:
| | - Corey M. Thibeault
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
| | - Nicolas Canac
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
| | - Kian Jalaleddini
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
| | - Amber Dorn
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
| | - Seth J. Wilk
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
| | - Thomas Devlin
- Department of Neurology, Erlanger Medical Center, Chattanooga, Tennessee, United States of America
| | - Fabien Scalzo
- Department of Neurology, University of California Los Angeles, Los Angeles, California, United States of America
| | - Robert B. Hamilton
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
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11
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Antipova D, Eadie L, Macaden AS, Wilson P. Diagnostic value of transcranial ultrasonography for selecting subjects with large vessel occlusion: a systematic review. Ultrasound J 2019; 11:29. [PMID: 31641895 PMCID: PMC6805840 DOI: 10.1186/s13089-019-0143-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/04/2019] [Indexed: 11/10/2022] Open
Abstract
Introduction A number of pre-hospital clinical assessment tools have been developed to triage subjects with acute stroke due to large vessel occlusion (LVO) to a specialised endovascular centre, but their false negative rates remain high leading to inappropriate and costly emergency transfers. Transcranial ultrasonography may represent a valuable pre-hospital tool for selecting patients with LVO who could benefit from rapid transfer to a dedicated centre. Methods Diagnostic accuracy of transcranial ultrasonography in acute stroke was subjected to systematic review. Medline, Embase, PubMed, Scopus, and The Cochrane Library were searched. Published articles reporting diagnostic accuracy of transcranial ultrasonography in comparison to a reference imaging method were selected. Studies reporting estimates of diagnostic accuracy were included in the meta-analysis. Results Twenty-seven published articles were selected for the systematic review. Transcranial Doppler findings, such as absent or diminished blood flow signal in a major cerebral artery and asymmetry index ≥ 21% were shown to be suggestive of LVO. It demonstrated sensitivity ranging from 68 to 100% and specificity of 78–99% for detecting acute steno-occlusive lesions. Area under the receiver operating characteristics curve was 0.91. Transcranial ultrasonography can also detect haemorrhagic foci, however, its application is largely restricted by lesion location. Conclusions Transcranial ultrasonography might potentially be used for the selection of subjects with acute LVO, to help streamline patient care and allow direct transfer to specialised endovascular centres. It can also assist in detecting haemorrhagic lesions in some cases, however, its applicability here is largely restricted. Additional research should optimize the scanning technique. Further work is required to demonstrate whether this diagnostic approach, possibly combined with clinical assessment, could be used at the pre-hospital stage to justify direct transfer to a regional thrombectomy centre in suitable cases.
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Affiliation(s)
- Daria Antipova
- Centre for Rural Health, University of Aberdeen, Old Perth Road, Inverness, IV2 3JH, UK.
| | - Leila Eadie
- Centre for Rural Health, University of Aberdeen, Old Perth Road, Inverness, IV2 3JH, UK
| | - Ashish Stephen Macaden
- Department of Stroke and Rehabilitation Medicine, Raigmore Hospital, NHS Highland, Inverness, IV2 3UJ, UK
| | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Old Perth Road, Inverness, IV2 3JH, UK
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12
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Connolly F, Röhl JE, Guthke C, Wengert O, Valdueza JM, Schreiber SJ. Emergency Room Use of "Fast-Track" Ultrasound in Acute Stroke: An Observational Study. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:1103-1111. [PMID: 30773376 DOI: 10.1016/j.ultrasmedbio.2019.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/01/2019] [Accepted: 01/04/2019] [Indexed: 06/09/2023]
Abstract
Early information on vascular status in acute stroke is essential. We analyzed whether duplex ultrasound (DUS) using a fast-track protocol provides this information without relevant delay. One hundred forty-six patients were prospectively enrolled. DUS was performed by sonographers with two levels of experience. The carotid and vertebral arteries, as well as all basal cerebral arteries, were bilaterally analyzed. Criteria for vessel analysis were (i) normal or stenosis <50%, (ii) stenosis ≥50% and (iii) occlusion. The mean duration of the ultrasound investigation was 6:07 ± 2:06 min with a significant difference between more and less experienced investigators (p < 0.0001). Insonation times decreased during the study in both groups. The sensitivity, specificity, positive predictive value and negative predictive value of ultrasound findings in comparison with computed tomography angiography were 73%, 99%, 84% and 98%, respectively. Our data suggest that "fast track" DUS is feasible and reliable. The time required for DUS assessment depends on the sonographer´s experience.
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Affiliation(s)
- Florian Connolly
- Department of Neurology, Charité, Universitätsmedizin Berlin, Berlin, Germany.
| | - Jens-Eric Röhl
- Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Carolin Guthke
- Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Oliver Wengert
- Department of Neurology, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - José M Valdueza
- Neurological Center, Segeberger Kliniken, Bad Segeberg, Germany
| | - Stephan J Schreiber
- Department of Neurology, Asklepios Fachklinikum Brandenburg, Brandenburg an der Havel, Germany
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13
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Thorpe SG, Thibeault CM, Canac N, Wilk SJ, Devlin T, Hamilton RB. Decision Criteria for Large Vessel Occlusion Using Transcranial Doppler Waveform Morphology. Front Neurol 2018; 9:847. [PMID: 30386287 PMCID: PMC6199366 DOI: 10.3389/fneur.2018.00847] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/21/2018] [Indexed: 01/23/2023] Open
Abstract
Background: The current lack of effective tools for prehospital identification of Large Vessel Occlusion (LVO) represents a significant barrier to efficient triage of stroke patients and detriment to treatment efficacy. The validation of objective Transcranial Doppler (TCD) metrics for LVO detection could provide first responders with requisite tools for informing stroke transfer decisions, dramatically improving patient care. Objective: To compare the diagnostic efficacy of two such candidate metrics: Velocity Asymmetry Index (VAI), which quantifies disparity of blood flow velocity across the cerebral hemispheres, and Velocity Curvature Index (VCI), a recently proposed TCD morphological biomarker. Additionally, we investigate a simple decision tree combining both metrics. Methods: We retrospectively compare accuracy/sensitivity/specificity (ACC/SEN/SPE) of each method (relative to standard CT-Angiography) in detecting LVO in a population of 66 subjects presenting with stroke symptoms (33 with CTA-confirmed LVO), enrolled consecutively at Erlanger Southeast Regional Stroke Center in Chattanooga, TN. Results: Individual VCI and VAI metrics demonstrated robust performance, with area under receiver operating characteristic curve (ROC-AUC) of 94% and 88%, respectively. Additionally, leave-one-out cross-validation at optimal identified thresholds resulted in 88% ACC (88% SEN) for VCI, vs. 79% ACC (76% SEN) for VAI. When combined, the resultant decision tree achieved 91% ACC (94% SEN). Discussion: We conclude VCI to be superior to VAI for LVO detection, and provide evidence that simple decision criteria incorporating both metrics may further optimize. Performance: Our results suggest that machine-learning approaches to TCD morphological analysis may soon enable robust prehospital LVO identification. Registration: Was not required for this feasibility study.
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Affiliation(s)
| | | | - Nicolas Canac
- Neural Analytics, Inc., Los Angeles, CA, United States
| | - Seth J Wilk
- Neural Analytics, Inc., Los Angeles, CA, United States
| | - Thomas Devlin
- Erlanger Medical Center, Chattanooga, TN, United States
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14
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Thorpe SG, Thibeault CM, Wilk SJ, O'Brien M, Canac N, Ranjbaran M, Devlin C, Devlin T, Hamilton RB. Velocity Curvature Index: a Novel Diagnostic Biomarker for Large Vessel Occlusion. Transl Stroke Res 2018; 10:475-484. [PMID: 30293170 PMCID: PMC6733810 DOI: 10.1007/s12975-018-0667-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/06/2018] [Accepted: 09/24/2018] [Indexed: 11/25/2022]
Abstract
Despite being a conveniently portable technology for stroke assessment, Transcranial Doppler ultrasound (TCD) remains widely underutilized due to complex training requirements necessary to reliably obtain and interpret cerebral blood flow velocity (CBFV) waveforms. The validation of objective TCD metrics for large vessel occlusion (LVO) represents a first critical step toward enabling use by less formally trained personnel. In this work, we assess the diagnostic utility, relative to current standard CT angiography (CTA), of a novel TCD-derived biomarker for detecting LVO. Patients admitted to the hospital with stroke symptoms underwent TCD screening and were grouped into LVO and control groups based on the presence of CTA confirmed occlusion. Velocity curvature index (VCI) was computed from CBFV waveforms recorded at multiple depths from the middle cerebral arteries (MCA) of both cerebral hemispheres. VCI was assessed for 66 patients, 33 of which had occlusions of the MCA or internal carotid artery. Our results show that VCI was more informative when measured from the cerebral hemisphere ipsilateral to the site of occlusion relative to contralateral. Moreover, given any pair of bilateral recordings, VCI separated LVO patients from controls with average area under receiver operating characteristic curve of 92%, which improved to greater than 94% when pairs were selected by maximal velocity. We conclude that VCI is an analytically valid candidate biomarker for LVO diagnosis, possessing comparable accuracy, and several important advantages, relative to current TCD diagnostic methodologies.
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Affiliation(s)
- Samuel G Thorpe
- Neural Analytics, Inc., 2440 S. Sepulveda Blvd. Suite 115, Los Angeles, CA, 90064, USA.
| | - Corey M Thibeault
- Neural Analytics, Inc., 2440 S. Sepulveda Blvd. Suite 115, Los Angeles, CA, 90064, USA
| | - Seth J Wilk
- Neural Analytics, Inc., 2440 S. Sepulveda Blvd. Suite 115, Los Angeles, CA, 90064, USA
| | - Michael O'Brien
- Neural Analytics, Inc., 2440 S. Sepulveda Blvd. Suite 115, Los Angeles, CA, 90064, USA
| | - Nicolas Canac
- Neural Analytics, Inc., 2440 S. Sepulveda Blvd. Suite 115, Los Angeles, CA, 90064, USA
| | - Mina Ranjbaran
- Neural Analytics, Inc., 2440 S. Sepulveda Blvd. Suite 115, Los Angeles, CA, 90064, USA
| | - Christian Devlin
- Cardiac Biomechanics Group, University of Virginia, Charlottesville, VA, USA
| | - Thomas Devlin
- Department of Neurology, Erlanger Medical Center, Chattanooga, TN, USA
| | - Robert B Hamilton
- Neural Analytics, Inc., 2440 S. Sepulveda Blvd. Suite 115, Los Angeles, CA, 90064, USA
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15
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Abstract
Ultrasound is an efficacious, versatile and affordable imaging technique in emergencies, but has limited utility without expert interpretation. Telesonography, in which experts may remotely support the use of ultrasound through a telecommunications link, may broaden access to ultrasound and improve patient outcomes, particularly in remote settings. This review assesses the literature regarding telesonography in emergency medicine, focussing on evidence of feasibility, diagnostic accuracy and clinical utility. A systematic search was performed for articles published from 1946 to February 2017 using the Cochrane, Medline, EMBASE, and CINAHL databases. Further searches utilising Scopus, Google Scholar, and citation lists were conducted. 4388 titles were identified and screened against inclusion criteria which resulted in the inclusion of 28 papers. These included feasibility, diagnostic accuracy and clinical pilot studies. Study design, methodology and quality were heterogeneous. There was good evidence of feasibility from multiple studies. Where sufficient bandwidth and high quality components were used, diagnostic accuracy was slightly reduced by image transmission. There was evidence of clinical utility in remote hospitals and low-resource settings, although reliability was infrequently reported. Further exploratory research is required to determine minimum requirements for image quality, bandwidth, frame rate and to assess diagnostic accuracy. Clinical trials in remote settings are justifiable. Telecommunication options will depend on local requirements; no one system conveys universal advantages. The methodological quality of research in this field must improve: studies should be designed to minimise bias, and must include details of their methods to allow replication. Analysis of cost effectiveness and sustainability should be provided.
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Affiliation(s)
| | - Leila Eadie
- Centre for Rural Health, University of Aberdeen, Inverness, Scotland, United Kingdom
| | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Inverness, Scotland, United Kingdom
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16
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Forgó B, Tárnoki ÁD, Tárnoki DL, Littvay L, Fagnani C, Stazi MA, Meneghetti G, Medda E, Farina F, Baracchini C. Investigation of circle of Willis variants and hemodynamic parameters in twins using transcranial color-coded Doppler sonography. Int J Cardiovasc Imaging 2018; 34:1419-1427. [PMID: 29675634 DOI: 10.1007/s10554-018-1359-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/16/2018] [Indexed: 11/30/2022]
Abstract
Morphological and hemodynamic variations of the circle of Willis (CW) may have an important impact on cerebrovascular events. However, the environmental and genetic influence remains unclear. For this reason we studied the variations and hemodynamic parameters of the CW in twins using transcranial color-coded sonography (TCCS). Sixty-four twins, 19 monozygotic (MZ) and 13 dizygotic (DZ) pairs from the Italian Twin Registry (average age 45.0 ± 13.7 years) underwent TCCS and risk factor assessment. We examined CW morphology and recorded peak systolic velocity (PSV), end-diastolic velocity (EDV) and pulsatility index (PI). Raw heritability was determined for hemodynamic parameters, whereas concordance and discordance rates were calculated for CW morphological variants. A normal CW anatomy was observed in the majority of MZ and DZ twins (76.5% and 92.3%, respectively). The most frequent variant was a missing anterior cerebral artery (ACA). There was no significant difference in the prevalence of most CW variants depending on the zigosity. Concordance rates were low regarding the presence of variant CW anatomy both in MZ and DZ groups (0.14 and 0.00, respectively). Women had a significantly higher PI in vertebral arteries (VA) and in the right ACA (p = 0.01, p = 0.02 and p < 0.01, respectively). An inverse correlation was observed between hemodynamic parameters and age. Morphological variants of the CW do not seem to be heritable; they are most likely determined by environmental factors. In contrast, hemodynamic parameters of the CW are moderately heritable and this might have implications in the management and prevention of cerebrovascular diseases.
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Affiliation(s)
- Bianka Forgó
- Department of Radiology, Semmelweis University, Üllői Street 78/A, Budapest, 1082, Hungary.
| | - Ádám Domonkos Tárnoki
- Department of Radiology, Semmelweis University, Üllői Street 78/A, Budapest, 1082, Hungary.,Hungarian Twin Registry, Erdélyi Street 29, Budapest, 1212, Hungary
| | - Dávid László Tárnoki
- Department of Radiology, Semmelweis University, Üllői Street 78/A, Budapest, 1082, Hungary.,Hungarian Twin Registry, Erdélyi Street 29, Budapest, 1212, Hungary
| | - Levente Littvay
- Central European University, Nádor Street 9, Budapest, 1051, Hungary
| | - Corrado Fagnani
- Centre for Behavioural Sciences and Mental Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Maria Antonietta Stazi
- Centre for Behavioural Sciences and Mental Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Giorgio Meneghetti
- Department of Neurosciences, University of Padua School of Medicine, via Giustiniani 5, 35128, Padua, Italy
| | - Emanuela Medda
- Centre for Behavioural Sciences and Mental Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Filippo Farina
- Department of Neurosciences, University of Padua School of Medicine, via Giustiniani 5, 35128, Padua, Italy
| | - Claudio Baracchini
- Department of Neurosciences, University of Padua School of Medicine, via Giustiniani 5, 35128, Padua, Italy
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17
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Venturelli PM, Brunser AM, Gaete J, Illanes S, López J, Olavarría VV, Reccius A, Brinck P, González F, Cavada G, Lavados PM. Reliability of Hand-Held Transcranial Doppler with M-mode Ultrasound in Middle Cerebral Artery Measurement. J Med Ultrasound 2017; 25:76-81. [PMID: 30065464 PMCID: PMC6029317 DOI: 10.1016/j.jmu.2016.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 12/06/2016] [Indexed: 11/13/2022] Open
Abstract
Purpose To determine the intra- and interrater agreement of mean flow velocity (MFV) and pulsatility index (PI) measurement in middle cerebral arteries, assessed by transcranial Doppler (TCD) with M-mode. Methods Masked experienced neurosonologists performed TCD with M-mode using handheld probe in healthy adult volunteers. The Bland–Altman method for concordance and intraclass correlation coefficient were used. Results Seventy-seven healthy volunteers and seven raters participated (3 on regular TCD shift and 4 off-shift). The intrarater absolute mean difference between measurements was 5.5 cm/s [95% confidence interval (CI), 4.7–6.3] for MVF and 0.073 (95% CI, 0.063–0.083) for PI. The difference between MFV measurements was significantly higher in off-shift raters (p = 0.015). The interrater absolute mean difference between measurements was 6.5 cm/s (95% CI, 5.5–7.5) for MVF and 0.065 (95% CI, 0.059–0.071) for PI. No influence was found for the middle cerebral artery side, volunteer’s sex, or age, and there was no significant difference between raters. The intraclass correlation coefficient was 82.2% (95% CI 77.8–85.6) and 72.9% (95% CI 67.4–77.6) for MFV and PI, respectively. Conclusions There exists good intra- and interrater agreement in MFV and PI measurements using M-mode TCD. These results support the use of this noninvasive tool and are important for clinical and investigational purposes.
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Affiliation(s)
- Paula Muñoz Venturelli
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,NMH, The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Alejandro M Brunser
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Javier Gaete
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,Servicio de Neurología, Hospital Clínico de Magallanes, Punta Arenas, Chile
| | - Sergio Illanes
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Javiera López
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Verónica V Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Andrés Reccius
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,Centro de Pacientes Críticos y Departamento de Neurología, Clínica Las Condes, Chile
| | - Pablo Brinck
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Francisca González
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Gabriel Cavada
- Departamento Científico Docente, Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile.,Facultad de Medicina, Universidad de los Ande, Santiago, Chile
| | - Pablo M Lavados
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,Departamento de Ciencias Neurológicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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18
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Pontes-Neto OM, Cougo P, Martins SCO, Abud DG, Nogueira RG, Miranda M, Castro-Afonso LHD, Rebello LC, Caldas JGMP, Bazan R, Bezerra DC, Rezende MT, Freitas GRD, Longo A, Magalhães P, Carvalho JJFD, Montalverne FJ, Lima FO, Andrade GH, Massaro AR, Oliveira-Filho J, Gagliardi R, Silva GS. Brazilian guidelines for endovascular treatment of patients with acute ischemic stroke. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:50-56. [DOI: 10.1590/0004-282x20160174] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 08/10/2016] [Indexed: 11/22/2022]
Abstract
ABSTRACT These guidelines are the result of a joint effort from writing groups of the Brazilian Stroke Society, the Scientific Department of Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Stroke Network and the Brazilian Society of Diagnostic and Therapeutic Neuroradiology. Members from these groups participated in web-based discussion forums with predefined themes, followed by videoconference meetings in which controversies and position statements were discussed, leading to a consensus. This guidelines focuses on the implications of the recent clinical trials on endovascular therapy for acute ischemic stroke due to proximal arterial occlusions, and the final text aims to guide health care providers, health care managers and public health authorities in managing patients with this condition in Brazil.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Gabriel R. de Freitas
- Universidade Federal Fluminense, Brasil; Instituto D'Or de Pesquisa e Ensino, Brasil
| | | | | | | | | | | | | | | | | | | | - Gisele Sampaio Silva
- Universidade Federal de São Paulo, Brasil; Hospital Israelita Albert Einstein, Brasil
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19
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Olavarría VV, Arima H, Anderson CS, Brunser A, Muñoz-Venturelli P, Billot L, Lavados PM. Statistical analysis plan of the head position in acute ischemic stroke trial pilot (HEADPOST pilot). Int J Stroke 2016; 12:211-215. [PMID: 27742914 DOI: 10.1177/1747493016674955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The HEADPOST Pilot is a proof-of-concept, open, prospective, multicenter, international, cluster randomized, phase IIb controlled trial, with masked outcome assessment. The trial will test if lying flat head position initiated in patients within 12 h of onset of acute ischemic stroke involving the anterior circulation increases cerebral blood flow in the middle cerebral arteries, as measured by transcranial Doppler. The study will also assess the safety and feasibility of patients lying flat for ≥24 h. The trial was conducted in centers in three countries, with ability to perform early transcranial Doppler. A feature of this trial was that patients were randomized to a certain position according to the month of admission to hospital. Objective To outline in detail the predetermined statistical analysis plan for HEADPOST Pilot study. Methods All data collected by participating researchers will be reviewed and formally assessed. Information pertaining to the baseline characteristics of patients, their process of care, and the delivery of treatments will be classified, and for each item, appropriate descriptive statistical analyses are planned with comparisons made between randomized groups. For the outcomes, statistical comparisons to be made between groups are planned and described. Results This statistical analysis plan was developed for the analysis of the results of the HEADPOST Pilot study to be transparent, available, verifiable, and predetermined before data lock. Conclusions We have developed a statistical analysis plan for the HEADPOST Pilot study which is to be followed to avoid analysis bias arising from prior knowledge of the study findings. Trial registration The study is registered under HEADPOST-Pilot, ClinicalTrials.gov Identifier NCT01706094.
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Affiliation(s)
- Verónica V Olavarría
- 1 Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Medicina Interna, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Hisatomi Arima
- 2 Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.,3 The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Craig S Anderson
- 3 The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,4 Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Alejandro Brunser
- 1 Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Medicina Interna, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Paula Muñoz-Venturelli
- 1 Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Medicina Interna, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,3 The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Laurent Billot
- 3 The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Pablo M Lavados
- 1 Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Medicina Interna, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,5 Departamento de Ciencias Neurológicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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20
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Gupta D, Sharma A, Uchino K, Alexandrov AV, Khan K, Shuaib A, Saqqur M. Accuracy of National Institutes of Health Stroke Scale Score in Predicting the Site of Arterial Occlusion in Acute Stroke: A Transcranial Doppler Study. J Stroke Cerebrovasc Dis 2016; 25:2109-15. [PMID: 27468661 DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 06/03/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND In acute stroke, it is crucial to assess for intracranial large-vessel occlusion and site of occlusion. The National Institutes of Health Stroke Scale score (NIHSSS) is the frequently used clinical tool to predict the site of arterial occlusion. In this study we aimed to determine the following: (1) if there is a correlation between the site of occlusion and the NIHSSS at presentation (bNIHSSS); and (2) if there is a bNIHSSS cutoff which can distinguish proximal occlusions (PO) from distal occlusions (DO). METHODS Up to 313 patients from CLOTBUST data bank with demonstrable intracranial arterial occlusion and having received intravenous recombinant tissue plasminogen activator (rt-PA) were included. Occlusions were classified as PO (terminal internal carotid artery, M1 segment of middle cerebral artery [M1 MCA], and basilar artery) or DO (M2 MCA, anterior cerebral artery, posterior cerebral artery, and vertebral artery). RESULTS By univariate analysis, bNIHSSS, thrombolysis in brain ischemia (TIBI) flow grade before rt-PA, degree of recanalization after rt-PA, and modified Rankin Scale score at 3 months were significantly different between various sites of occlusion. By univariate analysis, a higher bNIHSSS, lower TIBI flow grade, and lower ASPECTS (Alberta Stroke Program Early CT Score) differentiated PO from DO. Lower TIBI flow grade and higher bNIHSSS differentiated PO from DO by logistic regression analysis. No single NIHSSS cutoff with acceptable sensitivity and specificity could be derived to differentiate PO from DO. CONCLUSIONS Although NIHSSS are higher in PO, there is no satisfactory NIHSSS cutoff which differentiates PO from DO. A vascular imaging or transcranial doppler should be obtained to determine the site of arterial occlusion in acute stroke.
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Affiliation(s)
- Deepak Gupta
- Stroke Program, Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Arvind Sharma
- Stroke Program, Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ken Uchino
- Cerebrovascular Center, Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Khurshid Khan
- Stroke Program, Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ashfaq Shuaib
- Stroke Program, Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Maher Saqqur
- Stroke Program, Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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21
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Italian symptomatic intracranial atherosclerosis study (ISIDE) : A multicenter transcranial ultrasound evaluation. Neurol Sci 2016; 37:1645-51. [PMID: 27365086 DOI: 10.1007/s10072-016-2642-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/17/2016] [Indexed: 01/26/2023]
Abstract
There are currently no data available on the prevalence of symptomatic intracranial atherosclerosis (ICAS) in Italy. The aim of this prospective, multicenter, hospital-based, transcranial ultrasound study was to establish the prevalence of ICAS among patients hospitalized with acute ischemic stroke. At 11 stroke centers across Italy, patients consecutively admitted for their first ever acute ischemic stroke were assessed prospectively over a 24-month period either with transcranial color-coded Doppler sonography (TCCS) or transcranial Doppler (TCD) according to validated criteria. ICAS was diagnosed when there was an evidence of a cerebral infarction in the territory of a ≥50 % stenosis detected by TCCS/TCD and confirmed by magnetic resonance angiography or computed tomography angiography. A total of 1134 patients were enrolled, 665 of them (58.6 %) men, with a mean age of 71.2 ± 13.3 years. ICAS was recorded in 99 patients (8.7 % of the whole sample, 8.9 % among Caucasians), most commonly located in the anterior circulation (63 of 99, 5.5 %). After adjusting for potential confounders, multivariate analysis identified carotid/vertebral ≥50 % stenosis [odds ratio (OR) 2.59, 95 % (confidence interval) CI 1.77-6.33; P = 0.02] and hypercholesterolemia (OR 1.38, 95 % CI 1.02-1.89; P = 0.02) as being independently associated with ICAS. ICAS is a surprisingly relevant cause of ischemic stroke in Italy, identified in almost 9 % of first-ever stroke patients. It is more prevalent in the anterior circulation and independently associated with hemodynamically significant cervical vessel atherosclerosis and hypercholesterolemia. These findings support the systematic use of transcranial ultrasound to identify ICAS in patients presenting with acute ischemic stroke and in cases with ≥50 % cervical vessel stenoses.
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22
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Brunser AM, Mansilla E, Hoppe A, Olavarría V, Sujima E, Lavados PM. The Role of TCD in the Evaluation of Acute Stroke. J Neuroimaging 2016; 26:420-5. [DOI: 10.1111/jon.12334] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 12/23/2015] [Accepted: 12/25/2015] [Indexed: 11/26/2022] Open
Affiliation(s)
- Alejandro M. Brunser
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
| | - Eloy Mansilla
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
| | - Arnold Hoppe
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
| | - Verónica Olavarría
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
| | - Emi Sujima
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
| | - Pablo M. Lavados
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago; Facultad de Medicina Clínica Alemana - Universidad del Desarrollo; Santiago Chile
- Department of Neurological Sciences, Faculty of Medicine; Universidad de Chile; Santiago Chile
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23
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Brunser AM, Muñoz Venturelli P, Lavados PM, Gaete J, Martins S, Arima H, Anderson CS, Olavarría VV. Head position and cerebral blood flow in acute ischemic stroke patients: Protocol for the pilot phase, cluster randomized, Head Position in Acute Ischemic Stroke Trial (HeadPoST pilot). Int J Stroke 2016; 11:253-9. [DOI: 10.1177/1747493015620808] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rationale Few proven interventions exist for acute ischemic stroke (AIS), and most are expensive and restricted in applicability. Lying flat ‘head down’ positioning of AIS patients has been shown to increase by as much as 20%, mean cerebral blood flow velocities (CBFV) measured by transcranial Doppler (TCD) but whether this translates into clinical improvement is uncertain. Aim To determine if the lying flat position increases mean CBFV in the affected territory as compared to the sitting up position in AIS patients. Methods and design Head Position in Acute Ischemic Stroke Trial (HeadPoST pilot) is a cluster randomized (clusters being months), assessor-blinded end-point, phase IIb trial, where consecutive adults with anterior circulation AIS within 12 h of symptom onset are positioned to a randomized position for 48 h with TCD performed serially. Study outcomes Primary outcome is mean CBFV on TCD at 1 and 24 h after positioning. Secondary outcomes include: serious adverse events, neurological impairment at seven days, and death and disability at 90 days. Sample size estimates Assuming an increase of 8.3 (SD 11.4) cm/s in average of mean CBFV when tilted from 30° to 0°, 46 clusters are required (92 patients in total) to detect a 20% increase of mean CBFV with 90% power and 5% level of significance. Conclusion HeadPoST pilot is a cluster randomized multicenter clinical trial investigating the effect of head positioning on mean CBFV in anterior circulation AIS.
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Affiliation(s)
- Alejandro M Brunser
- Vascular Neurology Program, Neurology Service, Department of Internal Medicine, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Paula Muñoz Venturelli
- Vascular Neurology Program, Neurology Service, Department of Internal Medicine, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
- The George Institute for Global Health, University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Pablo M Lavados
- Vascular Neurology Program, Neurology Service, Department of Internal Medicine, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
- Department of Neurological Sciences, Universidad de Chile, Santiago, Chile
| | - Javier Gaete
- Servicio de Neurología, Hospital Clínico Dr. Lautaro Navarro Avaria, Punta Arenas, Chile
| | - Sheila Martins
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Hisatomi Arima
- The George Institute for Global Health, University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Craig S Anderson
- The George Institute for Global Health, University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Verónica V Olavarría
- Vascular Neurology Program, Neurology Service, Department of Internal Medicine, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
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24
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Preprocedure change in arterial occlusion in acute ischemic stroke patients undergoing endovascular treatment by computed tomographic angiography. Am J Emerg Med 2015; 33:631-4. [DOI: 10.1016/j.ajem.2015.01.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 01/28/2015] [Accepted: 01/29/2015] [Indexed: 11/16/2022] Open
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25
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Herzberg M, Boy S, Hölscher T, Ertl M, Zimmermann M, Ittner KP, Pemmerl J, Pels H, Bogdahn U, Schlachetzki F. Prehospital stroke diagnostics based on neurological examination and transcranial ultrasound. Crit Ultrasound J 2014; 6:3. [PMID: 24572006 PMCID: PMC3996057 DOI: 10.1186/2036-7902-6-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 02/07/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Transcranial color-coded sonography (TCCS) has proved to be a fast and reliable tool for the detection of middle cerebral artery (MCA) occlusions in a hospital setting. In this feasibility study on prehospital sonography, our aim was to investigate the accuracy of TCCS for neurovascular emergency diagnostics when performed in a prehospital setting using mobile ultrasound equipment as part of a neurological examination. METHODS Following a '911 stroke code' call, stroke neurologists experienced in TCCS rendezvoused with the paramedic team. In patients with suspected stroke, TCCS examination including ultrasound contrast agents was performed. Results were compared with neurovascular imaging (CTA, MRA) and the final discharge diagnosis from standard patient-centered stroke care. RESULTS We enrolled '232 stroke code' patients with follow-up data available in 102 patients with complete TCCS examination. A diagnosis of ischemic stroke was made in 73 cases; 29 patients were identified as 'stroke mimics'. MCA occlusion was diagnosed in ten patients, while internal carotid artery (ICA) occlusion/high-grade stenosis leading to reversal of anterior cerebral artery flow was diagnosed in four patients. The initial working diagnosis 'any stroke' showed a sensitivity of 94% and a specificity of 48%. 'Major MCA or ICA stroke' diagnosed by mobile ultrasound showed an overall sensitivity of 78% and specificity of 98%. CONCLUSIONS The study demonstrates the feasibility and high diagnostic accuracy of emergency transcranial ultrasound assessment combined with neurological examinations for major ischemic stroke. Future combination with telemedical support, point-of-care analysis of blood serum markers, and probability algorithms of prehospital stroke diagnosis including ultrasound may help to speed up stroke treatment.
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Affiliation(s)
- Moriz Herzberg
- Department of Neurology, University of Regensburg, Community District Hospital, Universitätsstr.84, Regensburg 93053, Germany
| | - Sandra Boy
- Department of Neurology, University of Regensburg, Community District Hospital, Universitätsstr.84, Regensburg 93053, Germany
| | - Thilo Hölscher
- Department of Radiology and Neuroscience, University of California San Diego, San Diego, CA, USA
| | - Michael Ertl
- Department of Neurology, University of Regensburg, Community District Hospital, Universitätsstr.84, Regensburg 93053, Germany
| | - Markus Zimmermann
- Department of Emergency Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Karl-Peter Ittner
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | | | - Hendrik Pels
- Department of Neurology, Krankenhaus der Barmherzigen Brüder Regensburg, Regensburg, Germany
| | - Ulrich Bogdahn
- Department of Neurology, University of Regensburg, Community District Hospital, Universitätsstr.84, Regensburg 93053, Germany
| | - Felix Schlachetzki
- Department of Neurology, University of Regensburg, Community District Hospital, Universitätsstr.84, Regensburg 93053, Germany
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Pérez de la Ossa N, Carrera D, Gorchs M, Querol M, Millán M, Gomis M, Dorado L, López-Cancio E, Hernández-Pérez M, Chicharro V, Escalada X, Jiménez X, Dávalos A. Design and Validation of a Prehospital Stroke Scale to Predict Large Arterial Occlusion. Stroke 2014; 45:87-91. [DOI: 10.1161/strokeaha.113.003071] [Citation(s) in RCA: 299] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
We aimed to develop and validate a simple prehospital stroke scale to predict the presence of large vessel occlusion (LVO) in patients with acute stroke.
Methods—
The Rapid Arterial oCclusion Evaluation (RACE) scale was designed based on the National Institutes of Health Stroke Scale (NIHSS) items with a higher predictive value of LVO on a retrospective cohort of 654 patients with acute ischemic stroke: facial palsy (scored 0–2), arm motor function (0–2), leg motor function (0–2), gaze (0–1), and aphasia or agnosia (0–2). Thereafter, the RACE scale was validated prospectively in the field by trained medical emergency technicians in 357 consecutive patients transferred by Emergency Medical Services to our Comprehensive Stroke Center. Neurologists evaluated stroke severity at admission and LVO was diagnosed by transcranial duplex, computed tomography, or MR angiography. Receiver operating curve, sensitivity, specificity, and global accuracy of the RACE scale were analyzed to evaluate its predictive value for LVO.
Results—
In the prospective cohort, the RACE scale showed a strong correlation with NIHSS (
r
=0.76;
P
<0.001). LVO was detected in 76 of 357 patients (21%). Receiver operating curves showed a similar capacity to predict LVO of the RACE scale compared with the NIHSS (area under the curve 0.82 and 0.85, respectively). A RACE scale ≥5 had sensitivity 0.85, specificity 0.68, positive predictive value 0.42, and negative predictive value 0.94 for detecting LVO.
Conclusions—
The RACE scale is a simple tool that can accurately assess stroke severity and identify patients with acute stroke with large artery occlusion at prehospital setting by medical emergency technicians.
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27
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Guan J, Zhou Q, Ouyang H, Zhang S, Lu Z. The diagnostic accuracy of TCD for intracranial arterial stenosis/occlusion in patients with acute ischemic stroke: the importance of time interval between detection of TCD and CTA. Neurol Res 2013; 35:930-6. [PMID: 23816352 DOI: 10.1179/1743132813y.0000000230] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Jingxia Guan
- Department of NeurologyRenmin Hospital of Wuhan University, China
| | - Qin Zhou
- Department of NeurologyRenmin Hospital of Wuhan University, China
| | - Huangqing Ouyang
- Department of RadiologyRenmin Hospital of Wuhan University, China
| | - Shaofeng Zhang
- Department of NeurologyRenmin Hospital of Wuhan University, China
| | - Zuneng Lu
- Department of NeurologyRenmin Hospital of Wuhan University, China
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28
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Mattioni A, Brazzelli M, Cenciarelli S, Mazzoli T, Del Sette M, Gandolfo C, Marinoni M, Finocchi C, Saia V, Eusebi P, Sandercock PAG, Ricci S. Transcranial Doppler sonography for detecting stenosis or occlusion of intracranial arteries in people with acute ischaemic stroke. Hippokratia 2013. [DOI: 10.1002/14651858.cd010722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alessia Mattioni
- ASL 1 dell' Umbria; UO Neurologia; Via Luigi Angelini 10 Città di Castello Perugia Italy 06012
| | - Miriam Brazzelli
- University of Edinburgh; Division of Clinical Neurosciences; Bramwell Dott Building, Western General Hospital Crewe Road Edinburgh UK EH4 2XU
| | - Silvia Cenciarelli
- ASL 1 dell' Umbria; UO Neurologia; Via Luigi Angelini 10 Città di Castello Perugia Italy 06012
| | - Tatiana Mazzoli
- ASL 1 dell' Umbria; UO Neurologia; Via Luigi Angelini 10 Città di Castello Perugia Italy 06012
| | - Massimo Del Sette
- Università di Genova; Dipartimento Neuroscienze, Oftalmologia e Genetica; Via De Toni 5 Genova Italy 16132
| | - Carlo Gandolfo
- Università di Genova; Dipartimento Neuroscienze, Oftalmologia e Genetica; Via De Toni 5 Genova Italy 16132
| | - Marinella Marinoni
- University of Florence; Department of Neurosciences; Viale Morgagni, 85 Florence Italy 50134
| | - Cinzia Finocchi
- Università di Genova; Dipartimento Neuroscienze, Oftalmologia e Genetica; Via De Toni 5 Genova Italy 16132
| | - Valentina Saia
- University of Florence; Department of Neurosciences; Viale Morgagni, 85 Florence Italy 50134
| | - Paolo Eusebi
- Regional Health Authority of Umbria; Epidemiology Department; Via Mario Angeloni 61 Perugia Umbria Italy 06124
| | - Peter AG Sandercock
- University of Edinburgh; Division of Clinical Neurosciences; Bramwell Dott Building, Western General Hospital Crewe Road Edinburgh UK EH4 2XU
| | - Stefano Ricci
- ASL 1 dell' Umbria; UO Neurologia; Via Luigi Angelini 10 Città di Castello Perugia Italy 06012
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29
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Topcuoglu MA, Unal A, Arsava EM. Advances in transcranial Doppler clinical applications. ACTA ACUST UNITED AC 2013; 4:343-58. [PMID: 23496150 DOI: 10.1517/17530059.2010.495749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Diagnostic neurosonology techniques including transcranial Doppler (TCD), transcranial color Doppler imaging (TCDI) and power motion-mode (PMD) TCD provide information about various aspects of cerebrovascular status such as microemboli detection, dynamic autoregulation and long-duration real-time monitoring of flow characteristics. Although most of the information provided cannot be obtained by any other imaging methodology, and is critical in clinical decision-making in the care of various neurovascular diseases, these modalities are widely underutilized. Increasing the familiarity to neurosonological techniques is of crucial importance. AREAS COVERED IN THIS REVIEW After briefly reviewing TCD, TCDI and PMD techniques, classical features are summarized and recent developments in the clinical neurosonology applications with specific interest in the neurovascular disorders. WHAT THE READER WILL GAIN Practical perspectives of ultrasound evaluation of intracranial arterial status in various neurovascular diseases including sickle cell vasculopathy and vasospasm are reviewed in detail. Pearls on the neurosonological monitoring of acute ischemic stroke and increased intracranial pressure increase is provided. Standards of cerebral microembolism detection, right to left shunts diagnosis and cerebral autoregulation assessment are discussed methodologically. Future perspectives of therapeutic neurosonology including sonothrombolysis, microbubble-ultrasound-mediated gene and drug delivery into the brain, and alteration of the brain-blood barrier permeability are summarized. TAKE HOME MESSAGE Suitable with future medicine, neurosonology brings imaging to the bedside, which enables the treating physician to monitor a given intervention in real time. A non-invasive neurosonology-guided treatment of various diseases could be possible in the near future. The first and foremost step in gaining mastery in this very fruitful field is beginning to use it.
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Affiliation(s)
- Mehmet Akif Topcuoglu
- Hacettepe University Hospitals, Department of Neurology, Neurological Intensive Care Unit, 06100, Sihhiye, Ankara, Turkey +90 312 3051806 ; +90 312 3093451 ;
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30
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Tsivgoulis G, Vadikolias K, Heliopoulos I, Katsibari C, Voumvourakis K, Tsakaldimi S, Boutati E, Vasdekis SN, Athanasiadis D, Al-Attas OS, Charalampidis P, Stamboulis E, Piperidou C. Prevalence of symptomatic intracranial atherosclerosis in Caucasians: a prospective, multicenter, transcranial Doppler study. J Neuroimaging 2012; 24:11-7. [PMID: 22818110 DOI: 10.1111/j.1552-6569.2012.00707.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 12/09/2011] [Accepted: 01/13/2012] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND There are limited data available regarding symptomatic intracranial atherosclerosis (SIA) prevalence in Caucasians. We sought to investigate SIA prevalence among Caucasian patients hospitalized with acute cerebral ischemia (ACI) in a prospective, multicenter Transcranial Doppler sonography (TCD) study. METHODS Consecutive patients with ACI were prospectively evaluated with TCD over a 24-month-period. The previously validated criteria of SONIA trial were used for detection of >50% intracranial stenosis with TCD. Brain angiography was performed to confirm the diagnosis in cases with abnormal TCD findings. SIA was diagnosed when there was evidence of a cerebral infarction in the territory of the stenotic artery (identified by TCD and confirmed by Magnetic resonance angiography [MRA]/Computed tomography angiography [CTA]). RESULTS A total of 467 consecutive patients with ACI (60.4% men, mean age 58 ± 14 years) were evaluated. SIA was documented in 43 patients (9.2%; 95%CI: 6.9%-12.2%). The most common SIA location was M1MCA (34.9%) followed by TICA (18.8%). Diabetes mellitus (OR: 4.25, 95%CI: 2.18-8.26; P < .001) and hypertension (OR: 2.41, 95%CI: 1.02-5.67; P = .045) were independently associated with SIA on multivariate models adjusting for potential confounders. CONCLUSIONS SIA was identified in almost 10% of patients admitted with symptoms of ACI. These preliminary findings support further collaborative initiatives among stroke physicians to increase the yield of SIA detection in Caucasian patients with ACI.
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Affiliation(s)
- Georgios Tsivgoulis
- Department of Neurology, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece; Second Department of Neurology, School of Medicine, University of Athens, Attikon Hospital, Athens, Greece
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Aoki J, Kimura K, Iguchi Y, Shibazaki K, Kobayashi K, Sakai K, Sakamoto Y. A combined TCD and MRA screening for significant siphon portion of internal carotid artery (S-ICA) stenosis. J Neuroimaging 2011; 22:172-6. [PMID: 21223433 DOI: 10.1111/j.1552-6569.2010.00567.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We investigated whether combined transcranial Doppler (TCD) and magnetic resonance angiography (MRA) can diagnose significant stenosis (s-stenosis) of the siphon portion of the internal carotid artery (S-ICA) on digital subtraction angiography (DSA). METHODS TCD criteria cut-off peak systolic blood-flow velocity of 75 cm/s or mean blood-flow velocity of 50 cm/s, with both values more than 30% higher than in the contralateral S-ICA. MRA criterion was defined as a ≥50% signal reduction of the column width. Combined TCD and MRA criteria were fulfillment of both TCD and MRA criteria. RESULTS Among 295 vessels, seven (2%) had s-stenosis on DSA. Using TCD criteria, 16 vessels (5%) were identified to have s-stenosis, of which six (38%) had s-stenosis on DSA (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV] were .86, .97, .38, and .99). Using MRA criteria, 17 (6%) vessels were s-stenosis, of which seven (41%) had s-stenosis on DSA. Sensitivity, specificity, and NPV were 1.00, .97, and 1.00; however, PPV was low (.41). Combined TCD and MRA criteria identified six (2%) vessels as having s-stenosis, all were s-stenosis on DSA (PPV was 1.00). CONCLUSION Combined TCD and MRA examinations have similar diagnostic power to DSA.
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Affiliation(s)
- Junya Aoki
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan.
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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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