Endarterectomía carotídea en paciente con estenosis aórtica crítica. Importancia de la anestesia regional y del neuromonitoreo / Carotid endarterectomy in a patient with critical aortic stenosis. Importance of regional anesthesia and transoperative neurological monitoring

Resumen: La estenosis carotídea (EC) ocurre en 13% de los pacientes con estenosis valvular aórtica (EVA). El riesgo de evento vascular cerebral (EVC), en los pacientes con EC significativa sometidos a cirugía valvular cardíaca, puede aumentar hasta 11%. Someter a un paciente con EVA crítica y fracción de eyección del ventrículo izquierdo (FEVI) disminuida a endarterectomía carotídea es todo un reto anestésico, cuyo principal objetivo es evitar la hipotensión y el bajo gasto cardíaco. La anestesia regional es una opción para estos pacientes. Presentamos el caso de un hombre de 70 años con diagnóstico de EC significativa y EVA crítica con disfunción ventricular izquierda, al que se realizó endarterectomía carotídea con bloqueo del plexo cervical superficial por alto riesgo de colapso circulatorio. Dicha estrategia anestésica permitió mantener al paciente despierto durante la cirugía, al valorar continuamente su estado neurológico. Asimismo, se documentaron los cambios transoperatorios en el NIRS (Near-infrared spectroscopy) cerebral y Doppler transcraneal (DTC), los cuales se correlacionaron con el estado clínico del paciente. En un segundo tiempo se hizo cambio valvular aórtico sin complicaciones. En este caso destaca la importancia de la anestesia regional y el monitoreo neurológico con Doppler transcraneal, en pacientes sometidos a endarterectomía carotídea con alto riesgo quirúrgico por EVA crítica.

Abstract: Carotid stenosis occurs in 13% of patients with aortic valve stenosis. The risk of stroke in patients with significant carotid stenosis undergoing heart valve surgery may increase to 11%. Proposing a patient with critical aortic valve stenosis and left ventricular dysfunction to carotid endarterectomy is an anesthetic challenge, where the objective is to avoid hypotension and low cardiac output. Regional anesthesia is an option for these patients. Due to the high incidence of intraoperative stroke during carotid endarterectomy, continuous neurological monitoring is of relevance. We present the case of a 70-year-old man diagnosed with significant carotid stenosis and critical aortic valve stenosis and left ventricular dysfunction who underwent carotid endarterectomy with superficial cervical plexus block due to a high risk of circulatory collapse. In addition, this anesthetic strategy made it possible to keep the patient awake during surgery, and to continuously assess their neurological status. Likewise, transoperative changes in brain NIRS and transcranial Doppler were documented, which correlated with the patient's clinical status. In a second time, aortic valve replacement was performed without complications. This case highlights the importance of regional anesthesia and neurological monitoring in patients undergoing carotid endarterectomy with high surgical risk due to critical aortic valve stenosis.

Encuesta sobre usos y prácticas de Doppler transcraneal en pacientes neurocríticos en unidades de cuidados intensivos pediátricos de Argentina / Survey on the use and practice of transcranial Doppler ultrasound in neurocritical patients in pediatric intensive care Units in Argentina

Introducción. El uso del Doppler transcraneal (DTC) en pacientes neurocríticos se reporta cada vez más en las terapias intensivas pediátricas. El objetivo de esta encuesta es conocer los usos y prácticas del DTC en la atención neurocrítica y el proceso de formación del personal que realiza el estudio. Materiales y métodos. Encuesta a profesionales de 23 unidades de terapia intensiva pediátrica de Argentina. Resultados. Porcentaje de respuesta del 86 %. Se utilizó en sospecha de muerte encefálica (n = 20), trauma de cráneo (n = 16) y accidente cerebrovascular (n = 16). El intensivista pediátrico es quien realiza los estudios (n = 13/20). Los encuestados utilizan el Doppler para decidir conductas y tratamientos, comenzar el proceso de evaluación de muerte encefálica, solicitar tomografía de cerebro y manejar la presión de perfusión cerebral con vasopresores. Conclusión. Todos los encuestados utilizan los hallazgos del DTC para guiar tratamientos o conductas. La mitad de los encuestados está poco conforme con la capacitación recibida.

Introduction. The use of transcranial Doppler (TCD) ultrasoundin neurocritical patients is reported to be increasingly common in pediatric intensive care units. The objective of this survey was to know about the use and practice of TCD ultrasound in neurocritical care and the training process of staff members performing it. Materials and methods. Survey administered to providers from 23 pediatric intensive care units of Argentina. Results. The percentage of response was 86%. TCD ultrasound was used for suspected brain death (n = 20), head injury (n = 16), and stroke (n = 16). Pediatric intensivists perform the test (n = 13/20). Surveyed participants use TCD ultrasound to decide on treatment and management, start brain death assessment, request brain computed tomography, and manage cerebral perfusion pressure with vasopressors. Conclusion. All surveyed participants use TCD ultrasound findings to guide management or treatments. Half of surveyed participants are little satisfied with their training.

Follow-up of children with sickle cell anemia screened with transcranial Doppler and enrolled in a primary prevention program of ischemic stroke

ABSTRACT Background: Stroke is a serious complication of sickle cell anemia (SCA). The transcranial Doppler (TCD) is the risk-screening tool for ischemic strokes. The objective of the study was to describe the clinical progression of children with SCA who presented with high risk for stroke by TCD or relevant changes by magnetic resonance angiography (MRA) and underwent the regular transfusion program (RTP) and/or hydroxyurea (HU) treatment between 2007 and 2018. Method: This was a neonatal retrospective/prospective cohort study with children born between 1999 and 2014 with the homozygotic form (HbSS) or Sβ0-thalassemia who underwent TCD at least once. Results: Of the 718 children screened during this period, 675 had HbSS and 43 Sβ0-thalassemia. In 54 children (7.5%), all with HbSS, a high-risk TCD (n = 45) or, when the TCD was inconclusive, an MRA with cerebral vasculopathy (n = 9) was used for detection. Of these, 51 started the RTP and the families of three refused treatment. Of the 43 children with a highrisk TCD who initiated the RTP, 29 (67.4%) reverted to low risk. In 18 of them (62%), HU was started at the maximum tolerated dose (MTD) before transfusion discontinuation. None of these 29 patients had a stroke. Eight children (18.6%) maintained a high-risk TCD, even using the RTP/HU and two had a stroke. Conclusions: The TCD was confirmed as a viable tool for tracking patients with a risk for stroke. The RTP was effective in preventing the primary event. New strategies are necessary to prevent stroke using HU and new drugs, in addition to bone marrow transplantation.

Cerebrovascular changes in neuro-Behcet's disease and neuropsychiatric lupus by transcranial Doppler ultrasonography and magnetic resonance imaging

ABSTRACT Introduction: Transcranial Doppler ultrasonography (TCD) is a technique that allows measurement of blood flow from the basal intracerebral vessels. It is relatively inexpensive, non-invasive, can be performed at the bedside, and allows monitoring in acute emergency settings and for prolonged periods with a high temporal resolution, making it ideal for studying the haemodynamics within the intracranial arteries in neuro-Behcet's disease (NBD) and neuro-psychiatric lupus (NPSLE). Our aim was to assess the cerebral haemodynamic patterns in patients with NBD and NPSLE using TCD, while brain lesions were examined using magnetic resonance imaging (MRI). Material and methods: Case-control prospective study of 30 neuro-Behcet's disease patients, 25 neuro-psychiatric lupus patients and 26 healthy age-matched volunteers. All patients and healthy controls were examined by TCD. Only the groups of patients underwent cranial magnetic resonance imaging (MRI). Results: Transcranial Doppler (TCD) values for middle cerebral artery (MCA), anterior cerebral artery (ACA), posterior cerebral artery (PCA), vertebral artery (VA) and basilar artery (BA) in NBD, NPSLE and control groups were measured. The results showed that there was a significant decrease in mean blood flow velocities in all the arteries examined in NBD and NPSLE patients. There was also a significant increase in the pulsatile index of PCA, VA and BA between NBD and NPSLE patients. The same results were obtained when comparing NBD versus controls. However, there was no significant difference between the NPSLE patients and the control group. The MRI lesions described were parenchymal lesions in 14 patients (46.7%), and vascular lesions in 4 patients (13.3%). Vascular lesions co-existed with parenchymal lesions (mixed lesion). Parenchymal lesions were in white matter (40%), thalamus (26.7%), brain stem (26.7%) and cerebellum (20%). While, in NPSLE, 23 patients were normal (92%) and only two patients had a vascular lesion (8%). Conclusion: There was a significant decrease in mean blood flow and a significant increase in the pulsatile index among both NBD and NPSLE patients, according to the TCD values.

Evaluación de la hemodinamia cerebral mediante ecografía Doppler transcraneal en pacientes con preeclampsia/eclampsia / Evaluation of cerebral hemodynamics by transcranial Doppler ultrasound in patients with preeclampsia/eclampsia / Avaliação da hemodinâmica cerebral por ultrassonografia Doppler transcraniana em pacientes com pré-eclâmpsia/eclâmpsia

Resumen: Introducción: preeclampsia, la complicación más común del embarazo, ocasiona más de 76,000 muertes maternas al año, principalmente por complicaciones neurológicas. La alteración en la vasorregulación cerebral es clave en la patogénesis de dichas complicaciones. La ecografía Doppler transcraneal (EDT) evalúa el flujo de las principales arterias cerebrales, pero se desconocen los cambios que presentan las pacientes con preeclampsia/eclampsia. Objetivo: descripción de los cambios en el flujo sanguíneo cerebral evaluados mediante EDT en pacientes con preeclampsia/eclampsia. Material y métodos: se realizó EDT a las pacientes con diagnóstico de preeclampsia y/o eclampsia atendidas de forma consecutiva en la Unidad de Cuidados Intensivos del Hospital Civil de Guadalajara, del 01 de marzo de 2019 al 01 de marzo de 2021 y grupo control de embarazadas sanas; describimos el patrón de flujo de las arterias cerebrales anterior, media, posterior y arteria basilar. Resultados: Ochenta pacientes, 50 con preeclampsia/eclampsia y 30 embarazadas sanas, edad 23 ± 6.7, 50% primigestas, 34.8 ± 4.3 semanas de gestación. La presión de perfusión cerebral de las arterias cerebrales media derecha > 74 mmHg (sensibilidad 0.88, especificidad 0.86, ABC 0.92) y anterior derecha > 69 mmHg (sensibilidad 0.89, especificidad 0.93, ABC 0.92) tuvieron la mayor asociación con preeclampsia/eclampsia. El índice de flujo sanguíneo de las arterias cerebrales posteriores tuvo asociación significativa con eclampsia (p = 0.02), ABC: 0.695 (p = 0.009), punto de corte ≥ 34.6 cm/s (sensibilidad 1.0, especificidad 0.43, OR 26). Conclusiones: un incremento generalizado de la presión de perfusión es el hallazgo más común en preeclampsia/eclampsia. Aumento en el índice de flujo sanguíneo en las arterias cerebrales posteriores se asocia a complicaciones neurológicas graves en pacientes con preeclampsia.

Abstract: Introduction: preeclampsia, the most common complication of pregnancy, leads to > 76,000 maternal deaths annually, mainly due to neurological complications. An alteration in cerebral vasoregulation is key in the pathogenesis of these complications. Transcranial Doppler Ultrasound (TCD) evaluates the flow of the main cerebral arteries and could help to predict the development of preeclampsia/eclampsia and its complications. Objective: to determine the most frequent cerebral blood flow changes in preeclampsia/eclampsia. Material and methods: we prospectively analyzed by TCD patients with preeclampsia/eclampsia on admission to the ICU. Results: Eighty patients, 50 with preeclampsia/eclampsia and 30 healthy pregnant women, age 23 ± 6.7, 50% primigravida, 34.8 ± 4.3 weeks gestation. Cerebral perfusion pressure of right middle cerebral arteries > 74 mmHg (sensitivity 0.88, specificity 0.86, AUC 0.92) and right anterior cerebral arteries > 69 mmHg (sensitivity 0.89, specificity 0.93, AUC 0.92), had the highest association with preeclampsia/eclampsia. Posterior cerebral artery blood flow index had significant association with eclampsia (p = 0.02), AUC 0.695 (p = 0.009), with a cut-off ≥ 34.6 cm/s (sensitivity 1.0, specificity 0.43, OR 26). Conclusions: a generalized increase in perfusion pressure is the most common finding in preeclampsia/eclampsia. Hyper flow in the posterior cerebral arteries may predict severe neurological complications.

Resumo: Introdução: a pré-eclâmpsia, complicação mais comum da gravidez, causa mais de 76,000 mortes maternas anualmente, principalmente devido a complicações neurológicas. A vasorregulação cerebral alterada é fundamental na patogênese dessas complicações. A ultrassonografia Doppler transcraniana (DTC) avalia o fluxo das principais artérias cerebrais, as alterações que os pacientes com pré-eclâmpsia/eclâmpsia apresentam são desconhecidas. Objetivo: descrição das alterações do fluxo sanguíneo cerebral avaliados por DTC em pacientes com pré-eclâmpsia/eclâmpsia. Material e métodos: DTC foi realizado em pacientes com diagnóstico de pré-eclâmpsia e/ou eclâmpsia tratados consecutivamente na unidade de terapia intensiva do Hospital Civil de Guadalajara, de 1o de março de 2019 a 1o de março de 2021 e um grupo controle de gestantes saudáveis; descrevemos o padrão de fluxo das artérias cerebrais anterior, média, posterior e da artéria basilar. Resultados: 80 pacientes, 50 com pré-eclâmpsia/eclâmpsia e 30 gestantes saudáveis, idade 23 ± 6.7, 50% primíparas, 34.8 ± 4.3 semanas de gestação. A pressão de perfusão cerebral das artérias cerebrais médias direitas > 74 mmHg (sensibilidade 0.88, especificidade 0.86, AUC 0.92) e anterior direita > 69 mmHg (sensibilidade 0.89, especificidade 0.93, AUC 0.92), teve a maior associação com pré-eclâmpsia/eclâmpsia. O índice de fluxo sanguíneo das artérias cerebrais posteriores, teve associação significativa com eclâmpsia (p = 0.02), AUC: 0.695 (p = 0.009), ponto de corte ≥ 34.6 cm/s (sensibilidade 1.0, especificidade 0.43, OR 26). Conclusões: Um aumento generalizado da pressão de perfusão é o achado mais comum na pré-eclâmpsia/eclâmpsia. O aumento da taxa de fluxo sanguíneo nas artérias cerebrais posteriores está associado a complicações neurológicas graves em pacientes com pré-eclâmpsia.

Relation between transcranial doppler findings, neuroimaging and functional state in the first days of acute cerebrovascular accidents- hemorrhagic and ischemic in patients admitted to the Ardabil city hospital during 2015-2016

Background: Cerebrovascular accident (CVA) is the third leading cause of death in the United States. Considering the diagnostic and clinical value of sonography of extra cranial vessels of the brain, identifying findings obtained from patients suspected of having CVA and Transient Ischemic Attack (TIA) and their prevalence is of great importance. The aim of this study was to investigate the relation between TCD finding, neuroimaging and functional state of ischemic and hemorrhagic CVA patients.Methods: This was a cross-sectional study that has been done on 100 stroke patients admitted to Ardabil city hospital from March 2015 to March 2016. Patients underwent to CT-scan, doppler sonography, and TCD. The obtained data were analyzed by statistical methods in SPSS version 21.Results: The mean age of the patients was 66.3±11 years and 53% were women. High blood pressure, history of heart disease, smoking, and diabetes were the major risk factors in the present study. Fifty eight percent of the patients had moderate to severe disability in their functional status. Atheroma plaques, intima-media thickening, and the change of speed in the external carotid artery were most frequent in doppler sonography investigations. There was no significant correlation between the obtained results from TCD and the functional status of the patients.Conclusions: Considering the non-significant correlation between TCD results and the functional state of the patients in this study, for exactly study of this topic, study the TCD of patients on several different days and after starting treatment is essential.

Chronic transfusion therapy effectiveness as primary stroke prophylaxis in sickle cell disease patients

Abstract Introduction About 10% of sickle cell anemia patients will have ischemic stroke. Adams showed stroke incidence reduction in children receiving monthly erythrocyte transfusions by reducing transcranial Doppler (TCD) velocities. Since then, chronic transfusion is recommended as primary stroke prophylaxis. This study aims to assess the effectiveness of chronic transfusions as stroke prophylaxis. Method Retrospective study, reviewing medical records from 15 sickle cell anemia patients undergoing chronic transfusion. Data collected were age, sex, adverse reactions, stroke, hemoglobin, reticulocytes, ferritin, HbS and TCD values (baseline, after 12 and 24 months of treatment). Results The mean age was 118.67 ± 41.40 months; six patients experienced allergic reactions. No stroke was recorded. One patient had alloimmunization. There was a decrease in the HbS rate and an increase in hemoglobin values in the first 12 months. Values were maintained after 24 months, but with no improvement of data. Before treatment, the mean HbS rate was 75.18%±11.69; after 12 months, 41.63 ± 14.99 and after 24 months, 43.78 ± 10.6. Thirteen patients initiated chelation after 12 months from the beginning of chronic transfusions and ferritin decline after 24 months. Pre-transfusional TCD velocities were 204.28 ± 9.41 cm/s (right) and 198.85 ± 33.37 cm/s (left). After a 12-month treatment, these values were 158.5 ± 28.89 cm/s and 157.62 ± 34.43 cm/s, respectively, and this reduction was statistically significant (p = 0.002 right and p = 0.02 left). After 24 months, these values were 149.63 ± 26.95 cm/s (right) and 143.7 ± 32.27 cm/s (left). Conclusion Significant reduction of TCD velocity occurred after treatment with chronic transfusion in sickle cell anemia patients, leading to a normal or conditional test and reducing stroke risk in all but one patient.

Magnetic resonance angiography and transcranial Doppler ultrasound findings in patients with a clinical diagnosis of vertebrobasilar insufficiency

OBJECTIVE: To evaluate the findings of magnetic resonance angiography (MRA) and transcranial Doppler ultrasound (TCD) in patients with a clinical diagnosis of vertebrobasilar insufficiency (VBI). METHOD: From our outpatient neurotology clinic, we selected patients (using the criteria proposed by Grad and Baloh) with a clinical diagnosis of VBI. We excluded patients with any definite cause for vestibular symptoms, a noncontrolled metabolic disease or any contraindication to MRA or TCD. The patients in the study group were sex- and age-matched with subjects who did not have vestibular symptoms (control group). Our final group of patients included 24 patients (study, n=12; control, n=12). RESULTS: The MRA results did not demonstrate significant differences in the findings between our study and control groups. TCD demonstrated that the systolic pulse velocity of the right middle cerebral artery, end diastolic velocity of the basilar artery, pulsatility index (PI) of the left middle cerebral artery, PI of the right middle cerebral artery, and PI of the basilar artery were significantly higher in the study group than in the control group, suggesting abnormalities affecting the microcirculation of patients with a clinical diagnosis of VBI compared with controls. CONCLUSION: MRA failed to reveal abnormalities in patients with a clinical diagnosis of VBI compared with controls. The PI of the basilar artery, measured using TCD, demonstrated high sensitivity (91%) and specificity (91%) for detecting clinically diagnosed VBI.

A case of dural arteriovenous fistula suspected temporal arteritis and literature review / 中国脑血管病杂志

Dural arteriovenous fistula is a rare subtype of intracranial arteriovenous malformation, accounting for 10%-15% of all intracranial vascular malformations, with the characteristic of pathological anastomosis between the dural branch of the dural artery or intracranial artery and dural vein, or meningeal vein, or cortical vein. In this paper, a patient with headache suspected of temporal arteritis was analyzed retrospectively. Ultrasonography showed that arteriovenous fistula supplied by bilateral branches of the superficial temporal artery of the external carotid artery is likely. Finally, a dural arteriovenous fistula was diagnosed using digital subtraction angiography. The case shows that patients with headaches should also pay attention to other rare diseases causing headaches excepted for the temporal arteritis in practice.

Análisis de las lesiones encefálicas en resonancia magnética en pacientes con señales transitorias de alta intensidad detectadas por Doppler transcraneal / Analysis of Encephalic Lesions in Magnetic Resonance Imaging in patients with High Intensity Transient Signals detected on Transcranial Doppler

Resumen Objetivo: Describir los hallazgos en resonancia magnética (RM) de encéfalo en pacientes menores de 65 años que fueron estudiados por Doppler transcraneal (DTC) con contraste de microburbujas, con antecedentes de accidente cerebrovascular (ACV) criptogénico y sospecha de foramen oval permeable (FOP). Materiales y métodos: Este estudio transversal retrospectivo incluyó pacientes de ambos sexos, menores de 65 años. Resultados: Nuestra muestra (n = 47, 47% masculino y 53% femenino, edad media de 42 años) presentó señales transitorias de alta intensidad (HITS, por su sigla en inglés) positivo en el 61,7% y HITS-negativo en el 38,3%. En pacientes HITS-positivo, predominaron las lesiones a nivel de las fibras en U subcorticales, únicas o múltiples con distribución bilateralmente simétrica. En pacientes con HITS moderados, predominaron las lesiones en el territorio vascular de la circulación posterior. Conclusión: En pacientes menores de 65 años con ACV criptogénico y lesiones en fibras en U subcorticales, únicas o múltiples con distribución bilateral y simétrica, debe tenerse en cuenta un FOP como posible causa de dichas lesiones.

Abstract Objectives: To analyze the findings on brain magnetic resonance imaging (MRI) in patients less than 65 years of age with history of cryptogenic stroke and suspected patent foramen ovale (PFO) who were studied with Contrast-Transcranial Doppler. Materials and Methods: This transversal retrospective study included both, men and women less than 65 years of age. Results: Our sample (n = 47, 47% male and 53% female, average age 42 years old) had High Intensity Transient Signals (HITS)-positive in 61.7% and HITS-negative in 38.3%. In HITS-positive patients, lesions were predominantly located on the subcortical U fibers, lone or multiple bilateral symmetric distributions. In patients with moderate-severity HITS, the posterior circulation was the most affected. Conclusion: In patients less than 65 years of age with cryptogenic stroke with lesions affecting the subcortical U fibers, with unique or multiple bilateral symmetric distributions, a PFO should be considered as an underlying cause.

Estrategias para el empleo optimizado de la neuroimagenología en pacientes con traumatismo encéfalo craneano: puesta al día / Strategies for the optimized use of neuroimaging in patients with head trauma cranial: update

INTRODUCTION: Introduction of current neuroimaging technologies has been essential for the agile and effective diagnosis of cranial brain injuries. However, for various reasons there is a tendency to indiscriminate use. A review of the topic was made aimed at providing an update on the recommended strategies for the optimized use of these technologies. Material and method: A review of the topic of the last five years was made, using the Medline / Pubmed and SciELO platforms of complete articles, in English and Spanish. We also included relevant articles, published in previous years, located in previous bibliographic reviews carried out by the authors. CONCLUSIONS: Routine study with CT scan in all patients with head trauma is not cost effective, should be used in patients with Glasgow less than 15 points or in those with Glasgow of 15 points and risk factors of intracranial injury. Its use as a form of neuromonitoring is similarly useful, but on a selective basis. Magnetic Resonance Imaging is especially useful in the mediate or late periods of cranial trauma, in patients with clinical tomographic incongruences, very useful to establish prognosis in diffuse traumas and intracranial complications. Neurosonology is a useful tool for therapeutic decision.

Predictive value of transcranial doppler ultrasound for cerebral small vessel disease in elderly patients / Valor preditivo do ultrassom doppler transcraniano para doença de pequenos vasos em pacientes idosos

ABSTRACT Objective: To investigate the predictive value of transcranial Doppler (TCD) ultrasound for cerebral small vessel disease in elderly patients. Methods: Transcranial Doppler ultrasound and magnetic resonance imaging (MRI) were performed on 184 elderly patients with cerebral small vessel disease. The relationship of clinical characteristics and TCD ultrasound parameters with severe white matter lesions (WMLs) in MRI were investigated by univariate analysis and multivariate analysis. Results: The univariate analysis showed that age, left middle cerebral artery (MCA) mean flow velocity, right MCA mean flow velocity and mean MCA pulsatility index were significantly correlated with severe WMLs (p < 0.05). The multivariate logistic regression analysis showed that only age (odds ratio: 1.21; 95%CI: 1.10-1.36; p < 0.01) and MCA pulsatility index (dominance ratio: 1.13; 95%CI: 1.06-1.80; p = 0.02) were significantly correlated with severe WMLs. The analysis of TCD ultrasound parameters showed that when the cut-off for MCA pulsatility index was 1.04, it could identify severe WMLs. The area under the curve was 0.70 (95%CI: 0.60-0.80). The sensitivity and specificity were 63.0% and 72.0%, respectively. The positive and negative predictive values were 35.4% and 86.6%, respectively. Conclusion: The MCA pulsatility index in TCD ultrasound is significantly correlated with severe WMLs; and TCD ultrasound can guide selective MRI for the detection of WMLs.

RESUMO Objetivo: Investigar o valor preditivo do ultrassom de Doppler transcraniano (TCD) para doença de pequenos vasos (SVD) em pacientes idosos. Métodos: ultrassonografia de TCD e ressonância magnética (RM) foram realizadas em 184 idosos portadores de SVD cerebral. As relações das características clínicas e os parâmetros ultrassonográficos do TCD com lesão grave de substância branca (WML) no desempenho da RM foram investigados por análise univariada e análise multivariada. Resultados: A análise univariada mostrou que, a idade, a velocidade média de fluxo (MFV) da artéria média cerebral (MCA) esquerda, a MFV da MCA direita e o índice de pulsatilidade (PI) médio estiveram significativamente relacionados à WML grave (P <0,05). A análise de regressão logística multivariada mostrou que apenas a idade (razão de chances: 1,21; IC95%: 1,10-1,36; P <0,01) e o PI da MCA (razão de dominância: 1,13; IC 95%: 1,06-1,80; P = 0,02) estiveram significativamente relacionados a WML grave. A análise dos parâmetros ultrassonográficos do TCD mostrou que, quando o ponto de corte do IP do MCA foi 1,04, ele pôde identificar à WML grave. A área sob a curva foi de 0,70 (IC 95%: 0,60-0,80). A sensibilidade e especificidade foram de 63,0% e 72,0%, respectivamente. Os valores preditivos positivos e negativos foram de 35,4% e 86,6%, respectivamente. Conclusão: O PI da MCA na ultrassonografia do TCD está significativamente relacionado à WML grave. A ultrassonografia TCD pode orientar a ressonância magnética seletiva para detecção da WML.

Progress in the diagnosis and treatment of sepsis-associated encephalopathy / 解放军医学杂志

Sepsis-associated encephalopathy (SAE) is a diffuse brain dysfunction caused by sepsis, characterized by no central nervous system infection. The main clinical manifestations are the changes of mental state and consciousness level, which were associated with sepsis. The early clinical manifestations of SAE are not specific and can not be diagnosed in time, resulting in prolonged hospitalization, increased disability rate, higher mortality, and cognitive dysfunction after discharge. Currently, the commonly used auxiliary diagnostic methods of SAE include assessment of the conscious state, biochemical examination, electrophysiological examination and neuroimaging studies. This paper reviews the diagnostic methods and treatments of SAE, so as to deepen the understanding of SAE and improve the level of clinical diagnosis and treatments of SAE.

The clinical significance of transcranial Doppler in early diagnosis of sepsis-associated encephalopathy / 中华内科杂志

Objective@#To investigate the clinical significance of transcranial Doppler (TCD) in early diagnosis of sepsis-associated encephalopathy(SAE).@*Methods@#Septic patients admitted to the intensive care unit(ICU) were recruited at Xiangya Hospital, Central South University from July 2015 to March 2016. Clinical data and TCD parameters during 24 hours after admission were collected. All patients were screened for delirium using the confusion assessment method for the intensive care unit (CAM-ICU) twice a day. The gold standard of the diagnosis of SAE was positive CAM-ICU evaluation. Patients were divided into SAE group and the non-SAE group. TCD data including systolic velocity (Vs), diastolic velocity (Vd), mean velocity (Vm), pulsatility index (PI) and resistant index (RI) were analyzed to determine the optimal diagnostic cut-off value.@*Results@#A total of 43 patients were enrolled including 12 in SAE group and 31 in non-SAE group. Vm and Vd were lower in SAE group [Vm: (53.50±12.22) cm/s vs. (61.68±9.63) cm/s, P<0.05; Vd: (33.42±10.87) cm/s vs. (43.16±7.84) cm/s, P<0.01] but PI and RI were significant higher in SAE group[PI:(1.16±0.2) vs. (0.90±0.15), P<0.01;RI:(0.65±0.08) vs. (0.56±0.06), P<0.01] than in non-SAE group. The cut-off values of Vs, Vm, Vd, PI and RI for the diagnosis of SAE were 112cm/s, 55.50cm/s, 34.50cm/s, 1.16, 0.65, respectively, with the relevant sensitivities of 19.4%, 83.9%, 93.5%, 58.3%, 58.3% and the specificities of 100.0%, 50.0%, 58.3%, 96.8%, 96.8%, respectively. The diagnostic AUC of Vd, PI and RI were 0.741, 0.808 and 0.808 respectively.@*Conclusions@#The parameter changes of TCD suggest that the pathogenesis of SAE is related to cerebral hypoperfusion, TCD is a helpful method for the early diagnosis of SAE.

Clinical follow-up study on the treatment of middle cerebral artery stenosis with balloon-expandable stent: 67 cases analysis / 中国实用内科杂志

OBJECTIVE: To discuss the clinical efficacy and safety of balloon-expandable stent in the treatment of symptomatic atherosclerotic cerebral artery stenosis in the middle cerebral artery(MCA), and to assess the appropriate methods of postoperative follow-up auxiliary examination. METHODS: A total of 67 patients with symptomatic atherosclerotic cerebral artery stenosis in the MCA were treated with balloon-expandable stent. The clinical data and follow-up data were collected and then analyzed retrospectively.RESULTS: the success rate of the surgical treatment with balloon-expandable stent was 98.51%(66/67). The incidence of symptomatic perioperative complications was 4.48%(3/67). All patients received clinical follow-up, and the auxiliary examination methods of the internal condition lesion of the stent included transcranial Doppler(TCD) or digital subtraction angiography(DSA). The incidence of in-stent restenosis or occlusion was 8.96%(6/67), and the consistency rate of stent restenosis or occlusion between TCD and DSA was75.00%, and the incidence of symptomatic in-stent restenosis or occlusion was 2.99%(2/67). It was found that there were two patients with recurrent stroke in cerebrovascular stent related region but without in-stent restenosis, and within 1 year of follow-up, the incidence of symptomatic stroke in stent-associated areas after operation was 10.44%(7/67). CONCLUSION: The treatment with balloonexpandable stent for symptomatic MCA stenosis has good clinical effect. The incidence of perioperative complications is low and the incidence of stroke in stent-associated areas after operation is low. TCD is an effective way of follow-up after the arterial stenting in the brain, which can play a role in the early detection of the in-stent restenosis, and its consistency with DSA is high.

Whole body ultrasound in the operating room and intensive care unit / 대한마취과학회지

Whole body ultrasound can be used to improve the speed and accuracy of evaluation of an increasing number of organ systems in the critically ill. Cardiac and abdominal ultrasound can be used to identify the mechanisms and etiology of hemodynamic instability. In hypoxemia or hypercarbia, lung ultrasound can rapidly identify the etiology of the condition with an accuracy that is equivalent to that of computed tomography. For encephalopathy, ocular ultrasound and transcranial Doppler can identify elevated intracranial pressure and midline shift. Renal and bladder ultrasound can identify the mechanisms and etiology of renal failure. Ultrasound can also improve the accuracy and safety of percutaneous procedures and should be currently used routinely for central vein catheterization and percutaneous tracheostomy.

Fístula Carótido Cavernosa. Utilidad del ultrasonido Doppler en el diagnóstico / Cavernous carotid fistula. Utility of Doppler ultrasound in diagnosis

Resumen Introducción: Las fístulas carótido cavernosas son malformaciones vasculares infrecuentes que generan un shunt arteriovenoso patológico que compromete el funcionamiento ocular. El diagnóstico definitivo se establece a través de una arteriografía cerebral. Sin embargo, su carácter invasivo limita su uso en el seguimiento. El objetivo de este trabajo es ilustrar el valor del estudio con ultrasonido doppler transcraneal para el diagnóstico y describir los parámetros de flujo que pudieran modificarse. Pacientes: Se realizó una revisión retrospectiva de las historias clínicas de los pacientes atendidos con diagnóstico de fistula carótido cavernosa en la unidad de ictus del Hospital CQ Hermanos Ameijeiras de La Habana, entre enero de 2005 y mayo de 2014. Se recogieron variables demográficas y de la enfermedad, así como los resultados de los estudios de imagen y ultrasonido. Resultados: Se describen las características clínicas e imagenológicas de tres enfermos en los que se confirmó el diagnóstico. En los dos pacientes con comunicaciones directas, se registró un aumento de la velocidad media de flujo en la vena oftálmica, arterializada, con disminución de la pulsatilidad; sumado a aumento en la velocidad de pico diastólico en la arteria carótida interna ipsilateral a la fístula. En el paciente con la fístula indirecta los cambios fueron menos marcados. Conclusión: El estudio con ultrasonido fue de utilidad en el diagnóstico de las fístulas carótido cavernosa. Mostró diferencias en parámetros de flujo que pueden servir para clasificar las fistulas.

Abstract Introduction: Carotid cavernous fistulas are infrequent vascular malformations that generate a pathological arteriovenous shunt, which compromises ocular function. The definitive diagnosis is established by cerebral arteriography. However, its invasive nature limits its use in follow-up. The aim of this work is to illustrate the value of the study with transcranial doppler ultrasound for the diagnosis of cavernous carotid fistulas and to describe the flow parameters that could be modified. Patients: A retrospective review of the clinical histories of the patients treated with a diagnosis of cavernous carotid fistula was carried out in the stroke unit of the Hermanos Ameijeiras Hospital in Havana, between January 2005 and May 2014. Demographic and disease variables were collected, as well as the results of imaging and ultrasound studies. Results: We describe the clinical and imaging characteristics of three patients in whom carotid cavernous fistula was confirmed. In the two patients with direct communications, an increase of the mean flow velocity in the ophthalmic vein, arterialized, with decrease in pulsatility were registered; in addition to an increase in the diastolic peak velocity in the internal carotid artery ipsilateral to the fistula. In the patient with the indirect fistula the changes were less marked. Conclusion: The ultrasound study was useful in the diagnosis of carotid cavernous fistulas, showing differences in the flow parameters that can be used to classify the fistulas.

Genetic, laboratory and clinical risk factors in the development of overt ischemic stroke in children with sickle cell disease

ABSTRACT Cerebrovascular disease, particularly stroke, is one of the most severe clinical complications associated with sickle cell disease and is a significant cause of morbidity in both children and adults. Over the past two decades, considerable advances have been made in the understanding of its natural history and enabled early identification and treatment of children at the highest risk. Transcranial Doppler screening and regular blood transfusions have markedly reduced the risk of stroke in children. However, transcranial Doppler has a limited positive predictive value and the pathophysiology of cerebrovascular disease is not completely understood. In this review, we will focus on the current state of knowledge about risk factors associated with ischemic stroke in patients with sickle cell disease. A search of PubMed was performed to identify studies. Full texts of the included articles were reviewed and data were summarized in a table. The coinheritance of alpha-thalassemia plays a protective role against ischemic stroke. The influence of other genetic risk factors is controversial, still preliminary, and requires confirmatory studies. Recent advances have established the reticulocyte count as the most important laboratory risk factor. Clinical features associated with acute hypoxemia as well as silent infarcts seem to influence the development of strokes in children. However, transcranial Doppler remains the only available clinical prognostic tool to have been validated. If our understanding of the many risk factors associated with stroke advances further, it may be possible to develop useful tools to detect patients at the highest risk early, improving the selection of children requiring intensification therapy.

Clinical characteristics of patients with cryptogenic stroke and patent foramen ovale / 第二军医大学学报

Objective To investigate the clinical characteristics of patients with cryptogenic stroke and patent foramen ovale (PFO). Methods The clinical features, imaging findings and therapeutic outcomes of 51 patients with cryptogenic stroke and PFO, who received treatment in Stroke Center of Changhai Hospital of Navy Medical University (Second Military Medical University) between Sep. 2013 and Jan. 2018, were retrospectively analyzed. Results Of the 51 cases, 41 were male and 10 were female; and the mean age was (53.92±14.83) years (ranging from 21 to 84 years). Diffusion weighted imaging (DWI) showed that 46 patients developed new infarction including 20 cases (43.5%) of single lesion and 26 cases (56.5%) of multiple lesions, of which 15 cases (57.7%) involved single arterial territory and 11 cases (42.3%) involved two or more arterial territories (4 cases of bilateral anterior circulation, and 7 cases of both the anterior and posterior circulations). Thirty-seven patients underwent contrast-enhanced transcranial Doppler (cTCD) examination, which showed that 31 cases (83.8%) had microbubble sign (air microbubble emboli of 4 cases looked like raindrops or curtains). In 50 patients undergoing transesophageal echocardiography (TEE) examination, 49 cases (98.0%) were accompanied with PFO. Nine patients received intravenous thrombolysis. In secondary prevention, 18 patients received single antiplatelet therapy, 12 dual antiplatelet therapy, 8 anticoagulation therapy, and 13 PFO closure+single antiplatelet therapy. One patient with single antiplatelet therapy had recurrent ischemic stroke, 2 patients with dual antiplatelet therapy had recurrent ischemic stroke, and the patients with percutaneous closure of PFO had no recurrent stroke. Conclusion The infarction of cryptogenic stroke with PFO involves single or multiple arterial territories, cTCD and TEE have high positive diagnosis rate for PFO, and the patients with selective antithrombotic therapy and PFO closure have a low risk of recurrent stroke.