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Assessing ischemic etiology and mechanism during the acute phase of an ischemic stroke is crucial in order to tailor and monitor appropriate treatment and determine prognosis. Cervical Duplex Ultrasound (CDU) has evolved since many years as an excellent screening tool for the evaluation of extracranial vasculature. CDU has the advantages of a low c...
Context in source publication
Context 1
... Kingdom Joint recommendations [47] further propose peak systolic ICA to end diastolic CCA ratio (referred as St Mary's ratio) as the more robust index enabling grading in deciles [48]. Table 2 summarizes these criteria. Of note, given that the PSV measured in the CCA may vary along the length of the artery [49], distal CCA measurement should be made within 2 cm of the bifurcation at a point where the vessel still has a uniform diameter. ...Citations
... Psychogios et al. 23 pointed out that the main clinical manifestation of carotid artery stenosis is abnormal hemodynamic changes in the internal carotid artery. When the stenosis of the carotid artery occurs, arterial RI and PI increase abnormally, normal blood circulation in the body is obstructed, and the brain experiences varying degrees of ischemia and hypoperfusion, resulting in a slowdown in blood flow velocity. ...
Objective: To explore the evaluation value of intracranial magnetic resonance angiography (MRA) combined with carotid ultrasound (CU) in patients with cerebral infarction (CI). Methods: A retrospective analysis was conducted on 122 patients with CI who underwent intracranial MRA combined with CU examination in Shengzhou People’s Hospital from January 2021 to October 2022. Vascular stenosis rate and CU parameters of patients with different degrees of nerve damage (ND) and size of CI lesion were analyzed. Results: The rate of vascular stenosis and ultrasound parameters significantly varied between patients with different degrees of ND and different sizes of CI lesion. Spearman test showed a significant positive correlation between vascular stenosis, pulsatile index (PI), and resistance index (RI) with the degree of ND and the size of CI lesions in patients. There was a significant negative correlation between peak systolic velocity (PSV) and end-diastolic velocity (EDV) and the degree of ND and the size of CI lesions (P<0.05). Conclusions: Intracranial MRA combined with CU can clarify the vascular stenosis and hemodynamic characteristics of patients with CI, and the combined approach closely correlates with the characteristics of CI, which can be used for disease assessment. doi: https://doi.org/10.12669/pjms.40.6.9312 How to cite this: Guo X, Sun L. The evaluation value of intracranial magnetic resonance angiography combined with carotid ultrasound in cerebral infarction. Pak J Med Sci. 2024;40(6):1140-1145. doi: https://doi.org/10.12669/pjms.40.6.9312 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
... In addition, CDUS may offer important information regarding arterial wall thickening (a "macaroni" sign), lumen stenosis, flow pattern, and blood flow directions [23,66]. ...
Unlabelled:
Non-atherosclerotic aortic arch pathologies (NA-AAPs) and anatomical variants are characterized as rare cardiovascular diseases with a low incidence rate, below 1 case per 2000 population, but enormous heterogeneity in terms of anatomical variants, i.e., Takayasu disease (TAK) and fibromuscular dysplasia (FMD). In specific clinical scenarios, NA-AAPs constitute life-threatening disorders.
Methods:
In this study, 82 (1.07%) consecutive patients with NA-AAPs (including 38 TAKs, 26 FMDs, and 18 other AAPs) out of 7645 patients who underwent endovascular treatment (EVT) for the aortic arch and its side-branch diseases at a single institution between 2002 and 2022 were retrospectively reviewed. The recorded demographic, biochemical, diagnostic, operative, and postoperative factors were reviewed, and the functional outcomes were determined during follow-up. A systematic review of the literature was also performed.
Results:
The study group comprised 65 (79.3%) female and 17 (21.7%) male subjects with a mean age of 46.1 ± 14.9 years. Overall, 62 (75.6%) patients were diagnosed with either cerebral ischemia symptoms or aortic arch dissection on admission. The EVT was feasible in 59 (72%) patients, whereas 23 (28%) patients were referred for medical treatment. In EVT patients, severe periprocedural complications occurred in two (3.39%) patients, including one periprocedural death and one cerebral hyperperfusion syndrome. During a median follow-up period of 64 months, cardiovascular events occurred in 24 (29.6%) patients (5 deaths, 13 ISs, and 6 myocardial infarctions). Repeated EVT for the index lesion was performed in 21/59 (35.6%) patients, including 19/33 (57.6%) in TAK and 2/13 (15.4%) in FMD. In the AAP group, one patient required additional stent-graft implantation for progressing dissection to the iliac arteries at 12 months. A baseline white blood count (odds ratio [HR]: 1.25, 95% confidence interval [CI]: 1.11-1.39; p < 0.001) was the only independent prognostic factor for recurrent stenosis, while a baseline hemoglobin level (HR: 0.73, 95%CI: 0.59-0.89; p = 0.002) and coronary involvement (HR: 4.11, 95%CI: 1.74-9.71; p = 0.001) were independently associated with a risk of major cardiac and cerebral events according to the multivariate Cox proportional hazards regression analysis.
Conclusions:
This study showed that AAPs should not be neglected in clinical settings, as it can be a life-threatening condition requiring a multidisciplinary approach. The knowledge of prognostic risk factors for adverse outcomes may improve surveillance in this group of patients.
... However, Doppler ultrasound is the most commonly used imaging modality for evaluating SA stenosis, either directly (by evaluating the SA) or indirectly (by evaluating the vertebral artery) [8], due to its cost-effective and noninvasive features. Doppler ultrasound has been frequently used in the intertransverse segment of the vertebral artery (VA) to obtain spectral Doppler waveform of the VA and determine if the blood flow is antegrade or retrograde in the VA [9][10][11][12][13]. The waveforms of VA on Doppler ultrasound were classified into five types, each correlating with a certain degree of SA stenosis [14,15]. ...
Objectives:
To investigate the value of subtypes of completely reversed flow (CRF) waveform in vertebral artery (VA) on Doppler ultrasound in differentiation occlusion from severe stenosis of the ipsilateral proximal subclavian artery (SA).
Methods:
A total of 357 patients with CRF in the VA on Doppler US were reviewed retrospectively. Among them, 49 patients (mean age, 68.2 ± 7.8 years) confirmed by digital subtraction angiography (DSA) were included. According to the status of diastolic flow, the CRF was divided into continuous CRF (CCRF, n = 27) and intermittent CRF (ICRF, n = 22). The correlation of subtypes of CRF waveform and VA parameters with the severity of SA stenosis was evaluated. The severity of SA stenosis was determined by DSA.
Results:
Of those 49 patients, SA occlusion was observed in 33 patients (67%, occlusion group) and severe stenosis in 16 patients (33%, stenosis group). The subtypes of CRF waveforms showed a significant between-group difference (p = 0.005). CCRF exhibited an accuracy of 85.2% (23/27) in diagnosing SA occlusion. The diameter of the target VA with ICRF showed a significant between-group difference (p = 0.041). The target VA diameter ≥ 3.8 mm in ICRF achieved an accuracy of 81.8% (18/22), and its combination with CCRF achieved an accuracy of 83.7% (41/49) in the differentiation of SA occlusion from severe stenosis.
Conclusions:
Subtypes of CRF in VA can help to differentiate SA occlusion from severe stenosis. CCRF has higher accuracy in diagnosing SA occlusion. The CCRF waveform plus VA diameter in ICRF is more accurate for differentiating SA occlusion from severe stenosis.
... 6 The latter can be diagnosed by the direct visualization of intimal flap, pseudolumen, or hypoechoic vessel wall thickening, especially when contralateral atherosclerosis is absent. 29 The distinction between total carotid artery occlusion and near-occlusion is often challenging and highly operator depended. A recent study comprising 548 patients that underwent carotid artery ultrasound and CTA showed that ultrasound had a specificity of 99% (95% confidence interval [CI]: 99%-100%) but a sensitivity of only 22% (95% CI: 14%-30%) for detecting near-occlusions. ...
The clinical manifestations of proximal (extracranial) internal carotid artery occlusions (pICAOs) may range from asymptomatic to acute, large, and devastating ischemic strokes. The etiology and pathophysiology of the occlusion, intracranial collateral status and patient’s premorbid status are among the factors determining the clinical presentation and outcome of pICAOs. Rapid and accurate diagnosis is crucial and may be assisted by the combination of carotid and transcranial duplex sonography, or a computed tomography/magnetic resonance angiography (CTA/MRA). It should be noted that with either imaging modalities, the discrimination of a pseudo-occlusion of the extracranial internal carotid artery (ICA) from a true pICAO may not be straightforward. In the absence of randomized data, the management of acute, symptomatic pICAOs remains individualized and relies largely on expert opinion. Administration of intravenous thrombolysis is reasonable and probably beneficial in the settings of acute ischemic stroke with early presentation. Unfortunately, rates of recanalization are rather low and acute interventional reperfusion therapies emerge as a potentially powerful therapeutic option for patients with persistent and severe symptoms. However, none of the pivotal clinical trials on mechanical thrombectomy for acute ischemic stroke randomized patients with isolated extracranial large vessel occlusions. On the contrary, several lines of evidence from non-randomized studies have shown that acute carotid endarterectomy, or endovascular thrombectomy/stenting of the ICA are feasible and safe, and pοtentially beneficial. The heterogeneity in the pathophysiology and clinical presentation of acute pICAOs renders patient selection for an acute interventional treatment a complicated decision-making process. The present narrative review will outline the pathophysiology, clinical presentation, diagnostic challenges, and possible treatment options for pICAOs.
... It is important to obtain multiple spectral analyses of each vessel, including the pre-stenotic and the post-stenotic area, in addition to the area of stenosis itself, to appreciate indirect hemodynamic effects of the stenosis [9]. Intima media thickness on 2-dimensional grey scale imaging, of more than 1 mm was considered abnormal in the common carotid arteries [10]. ...
Objectives: Cervical duplex ultrasonography (CDU) is a simple, non-invasive, portable technique, that provides valuable high-quality visual information about the integrity of the carotid and vertebral vessels, plaque morphology and flow hemodynamics. CDU is useful in the assessment and follow up of patients with cerebrovascular disease as well as other conditions like inflammatory vasculitis, carotid artery dissection and carotid body tumours. CDU is inexpensive and invaluable in smaller centres. Methods: CDU was performed in all patients in both longitudinal and transverse planes in the out-patient clinic. Brightness mode (B-mode) and Doppler waveforms were obtained. Relevant findings were presented. Results: CDU provides real time visualisation of plaque characteristics and follow up, hemodynamic characteristics in Takayasu arteritis, visualisation of dissection. Conclusion: With availability of MR/CT angiography, CDU can be an adjuvant in follow up, triage and early bed-side diagnosis of the vascular diseases. We present our experience with CDU in the out-patient clinics in this pictorial essay.
Background. Hemodynamic disturbances in the vertebral arteries often lead to neurological imbalances. Assessing blood flow parameters in different parts of the vertebral arteries can help predict the development of serious neurological diseases and promptly carry out appropriate treatment and preventive measures. Purpose. To determine quantitative parameters of blood flow in the vertebral arteries in young people with atlantoaxial instability using functional tests in triplex mode. Materials and methods. In triplex mode, blood flow was recorded in the V2 and V3 segments of the vertebral arteries (VA) in 41 young patients. Maximum systolic velocity (Vs), end-diastolic velocity (Vd), resistive index (RI), pulsatility index (PI), and minute volume of blood flow (Vvol) were assessed. These hemodynamic parameters were measured in a straight head position during functional tests. Result. The RI value in the left VA was the highest in contralateral turning (CLT) of the head: 0.71±0.03, which is statistically (p
A 73-year-old male with a recent finding of pericardial effusion and syncope was evaluated with point of care ultrasound for recurrent effusion. A thickened left ventricle and recurrent pericardial effusion were found. Unexpectedly, on scanning the inferior vena cava (IVC), extensive portal venous gas was identified, a finding previously described as a “meteor shower”. Subsequent imaging by computed tomography (CT) identified gastric edema and peri-gastric vessel gas as the source of the portal gas, attributed to a large bezoar. The bezoar was later classified as a phytobezoar and the patient was found to have both cardiac and gastrointestinal manifestations of light chain amyloidosis. The gastrointestinal amyloidosis predisposed the patient to bezoar formation owing to associated dysmotility, a rare complication of an unusual manifestation of systemic amyloid.
Zusammenfassung
Hintergrund Der Artikel gibt einen Überblick über die aktuellen diagnostischen Einsatzmöglichkeiten sonographischer Anwendung in der neurologischen Intensivmedizin.
Methoden Selektive Literaturrecherche mit kritischer Beurteilung ab dem Jahr 1984 sowie nationaler und internationaler Leitlinien sowie Expertenmeinung.
Ergebnisse Neben der raschen validen Abklärung akuter Schlaganfälle bieten verschiedene neurosonografische Monitoring-verfahren gerade in der Intensivmedizin spezifische Vorteile wie die beliebig häufige Wiederholbarkeit am Patientenbett selbst und die Darstellung in Echtzeit. Innovative Entwicklungen machen die Neurosonografie auch wissenschaftlich zu einem interessanten Gebiet.
Schlussfolgerung Die neurosonografische Diagnostik nimmt seit Jahren einen wichtigen Stellenwert in der neurologischen Intensivmedizin ein. Weitere Anstrengungen sind notwendig, um die Verbreitung der Methode zu fördern und durch wissenschaftliche Evidenz zu stärken.
Backgroud
Patients with atrial fibrillation (AF) and oral anticoagulation (OAC) failure may benefit from left atrial appendage closure (LAAC), however, the evidence is scarce. We report outcomes of LAAC in patients with OAC failure compared to those with classic indications of OAC contraindications.
Methods
Prospective registry of LAAC with Amplatzer or WATCHMAN device followed by dual antiplatelet therapy (DAPT) was analyzed (05.2014–11.2019). The study group included patients with OAC failure defined as stroke/TIA/PE/LAA thrombus (n = 39) during OAC, whereas the control group patients with OAC contraindications (n = 156). Structured follow-up at 3, 6 and 12 months was done.
Results
The study group compared to controls was younger [73 (IQR, 62–77) vs 74 (IQR, 68–81) years, P = 0.046], with higher CHA2DS2-VASc [5.0 (IQR, 3.0–6.0) vs 4.0 (IQR, 3.0–5.0), P = 0.001)], lower HAS-BLED [2.0 (IQR, 1.0–3.0) vs 3.0 (IQR, 2.0–3.0), P = 0.006] and similar proportion of WATCHMAN implantations (43.6% vs 44.2%, P = 1.000). The reduction from CHA2DS2-VASc predicted to observed annual stroke/TIA/PE rate was markedly smaller in the study vs control group (14% vs 77%) with 10.3% vs 1.9% stroke/TIA/PE respectively (P = 0.031). The reduction from HAS-BLED predicted to observed annual major nonprocedural bleeding rate was higher (100% vs 7.4%) with 0.0% vs 5.1% major bleedings respectively (P = 0.361). The device-related thrombosis remained similar (13.2% vs 11.3%, P = 0.778).
Conclusions
Patients after LAAC for OAC failure and unremarkable prior bleeding history presented with high residual stroke and low bleeding risks. Therefore concomitant long-term OAC or prolonged DAPT should strongly be considered in this population.
