Dr. Frank Rasulo U.O. Neurorianimazione Università di Brescia alutazione con TCD LA NEUROSONOLOGIA...

Dr. Frank RasuloU.O. Neurorianimazione

Università di Brescia

alutazione con TCD V

LA NEUROSONOLOGIA NELL’AMBITO DELLE

NEUROSCIENZE:

Primo Corso teorico praticoBRESCIA

12-13 NOVEMBRE 2010U.O. NeurorianimazioneSpedali Civili di Brescia

asospasmo cerebrovascolare V

VASOSPASM

INTRACRANIAL HYPERTENSION

CEREBRAL CIRCULATORY ARREST

AUTOREGULATION

STENOSIS

SUBARACHNOID HEMORRHAGE HEAD TRAUMA

STROKE

BRAIN DEATH

TCD in the ICU TCD in the ICU

SSVD Neurorianimazione ,Spedali Civili, Brescia,Dr. FRANK RASULOTCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

http://www.spedalicivili.brescia.it/






Day Vessel layer Pathological change

1–8 Adventitia Increase in inflammatory cells (plasma cells, lymphocytes, mast cells, and connective tissue)

Media Muscle necrosis and corrugation of elastica

Intima Thickening with endothelial swelling and vacuolisation, opening of interendothelial tight unctions

9–60 Intima Proliferation of smooth muscle leads progressive intimal thickening

Histopathological events in vasospasm

Definition of vasospasm

FV

CBF








Definition of hyperemia

CBF

FV








Hagen-Poiseuille Law of laminar flow

CBFCBF








Indice di Lindegaard

ICAe

ACM

FVm

FVmLI ..

Vasospasmo Iperemia

ICAe

ACM

FVm

FVmLI ..

I.L. Vasospasmo vs Iperemia

<3 Iperemia

3-6 Vasospasmo moderato (25-50%)

>6 Vasospasmo grave (>50%)

ICAe

ACM

FVm

FVmLI ..








Gold Standard

VASOSPASM & ANGIOGRAPHY VASOSPASM & ANGIOGRAPHY








ANGIOGRAPHYANGIOGRAPHY








39 (1.3%) neurologic complications in 2,899 procedures; 20 (0.7%) transient5 (0.2%) reversible14 (0.5%) permanent (strokes)

NEUROLOGIC COMPLICATIONS OF CEREBRAL ANGIOGRAPHYA retrospective study of complication rate and patient risk factors

AM Leffers, A Wagner. Acta Radiologica 41 (2000) 204-210

ANGIOGRAPHYANGIOGRAPHY








0

250

200

TCD and Vasospasm TCD and Vasospasm








An inverse relationship between vessel diameter and TCD velocities Aaslid et al.

FVm > 120 cm/s = mild vasospasm FVm > 200 cm/s = severe vasospasm

Comparison of TCD with angiography for detection of vasospasm

FVm < 120 cm.sec - < 25% narrowing

FVm 120-200 cm.sec - 25-50% narrowing

FVm < 200 cm.sec - > 50% narrowingAaslid et alSloan et alVora et alLindegaard et al

Correlation between FVm and angiographic lumen diameter of MCA










Sensitivity &

Specificity









Assessment: Transcranial Doppler ultrasonography Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology

M. A. Sloan, et al: NEUROLOGY 2004;62:1468-1481

“to review the use of TCD for diagnosis”


http://www.caip.rutgers.edu/~sinder/Cfd/Images/anim_jet_vmag.mpg







INDICATION SENSITIVITY (%)

SPECIFICITY (%) REFERENCE STANDARD

Vasospasm after Spontaneous Subarachnoid Hemorrhage

Conventional angiography

Intracranial ICA 25-30 83-91

MCA 39-94 70-100

ACA 13-71 65-100

VA 44-100 82-88

Vasospasm after Spontaneous SAH

BA 77-100 42-79

PCA 48-60 78-87









INDICATION SENSITIVITY (%)

SPECIFICITY (%) REFERENCE STANDARD

Vasospasm after Spontaneous Subarachnoid Hemorrhage

69 83 Conventional angiography

Intracranial ICA 100 97

MCA 100 93

ACA 71 85

Vasospasm after Spontaneous SAH

TCCD and Vasospasm TCCD and Vasospasm Courtesy of Andrea Rigamonti








Predicting Outcome after Traumatic Brain Injury:Development and International Validation of Prognostic

Scores Based on Admission CharacteristicsEwout W. Steyerberg et al., PLoS Medicine August 2008 | Volume 5 | Issue 8 | e165

Head injury patients with SAH have a worse prognosis than patients without SAH or Vasospasm.

TCD and post-traumatic SAHTCD and post-traumatic SAH








TCD and post-traumatic SAHTCD and post-traumatic SAH

63% tSAH 15% VSP

INDICATION SENSITIVITY (%) SPECIFICITY (%) REFERENCE STANDARD

Vasospasm after Traumatic Subarachnoid Hemorrhage

Conventional angiography

Data on sensitivity, specificity and predictive value of TCD for VSP after tSAH are needed.

CT evidence of SAH following closed head injury occurs in up to 63% of patients

Lee JH Martin NA

focal DID ?








Vasospasm-related DIDs were the major cause of bad outcome. DID’s occured in 20–30% of SAH pts. within 3–14 days after bleed.

TCD & Delayed Ischemic Deficits (DID) TCD & Delayed Ischemic Deficits (DID)

Ability of TCD to predict onset of DID’s following SAH

Kassell NF et al.

8 of 21 patients with SAH developed DID. Good correlation between TCD and DID.

Sekhar et al.








TCD monitoring and Clinical Decision MakingAfter Subarachnoid Hemorrhage

MJ. McGirt et al. J Stroke Cerbrovasc Disease. March 2003

“TCD-defined vasospasm preceded the neurological deficit in 64%, therefore earlier intervention might reduce the incidence of vasospasm-related stroke.”


What about the other 36% ?








ILLUSTRATIVE CASE

SAH - rupture of a left MCA aneurysm.

Day 0 - Fully conscious, with no neurological

deficits, after.

However, primary THRT impairment was observed on the side of surgery.

Xenon-CT also demonstrated regional impairment of autoregulation.

Day 4 - Developed delayed weakness of the right upper limb as the left MCA FV increased.

The symptom improved with time

THRT predicted the occurrence of DID SSVD Neurorianimazione ,Spedali Civili, Brescia,Dr. FRANK RASULOTCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE







Regions of cerebral ischemia are not always associated with territories of maximal vasospasm.


Positron Emission Tomographic Cerebral Perfusion DisturbancesAnd Transcranial Doppler Findings Among Patients With

Neurological Deterioration After Subarachnoid Hemorrhage

Pawan S. Minhas et al. Neurosurgery 52: 1017-1024, 2003








The accuracy of TCD to detect vasospasm in patients with aneurysmal subarachnoid hemorrhage

L.Mascia et al. Intensive Care Medicine 2003

MFv threshold > 160 cm/s

TCD Delayed Ischemic Deficits (DID) TCD Delayed Ischemic Deficits (DID)









Rapid rise in Fvm in a few days High Lindegaard ratio








Dr. Frank Rasulo U.O. Neurorianimazione Università di Brescia alutazione con TCD LA NEUROSONOLOGIA...

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