Cerebral Artery Peak Systolic Velocity Research Articles

Remote ischemic conditioning for acute stroke patients treated with thrombectomy.

ObjectiveRemote ischemic conditioning (RIC) has been demonstrated to be safe and feasible for patients with acute ischemic stroke (AIS), as well as for those receiving intravenous thrombolysis. We assessed the safety and feasibility of RIC for AIS patients undergoing endovascular treatment (ET).MethodsWe conducted a pilot study with patients with AIS who were suspected of having an emergent large‐vessel occlusion in the anterior circulation and who were scheduled for ET within 6 hours of ictus. Four cycles of RIC were performed before recanalization, immediately following recanalization, and once daily for the subsequent 7 days. The primary outcome was any serious RIC‐related adverse events.ResultsTwenty subjects, aged 66.1 ± 12.1 years, were recruited. No subject experienced serious RIC‐related adverse events. The intracranial pressure, cranial perfusion pressure, mean arterial pressure, heart rate, middle cerebral artery peak systolic flow velocity, and pulsatility index did not change significantly before, during, or after the limb ischemia (P > 0.1 for all). Of 80 cycles, 71 (89%) were completed before recanalization and 80 (100%) were completed immediately after recanalization; 444 of 560 cycles (78%) were completed within 7 days posttreatment. No patients had to stop RIC because it affected routine clinical managements. Six subjects (30%) experienced intracerebral hemorrhage, which was symptomatic in one case (5%). At the 3‐month follow‐up, 11 subjects (55%) had achieved functional independence, and two subjects (10%) died.Interpretation RIC appears to be safe and feasible for patients with AIS undergoing ET. Investigations are urgently needed to determine the efficacy of RIC in this patient population.

Factors associated to early intrauterine fetal demise after laser for TTTS by preoperative fetal heart and Doppler ultrasound.

To determine the prognostic value of fetal Doppler and echocardiographic parameters for intrauterine fetal demise (IUFD) within 24hours and within 1week after laser coagulation in monochorionic pregnancies complicated by twin-twin transfusion syndrome. This retrospective study correlated the preoperative hemodynamic and echocardiography parameters to the outcome in fetuses with twin-twin transfusion syndrome undergoing laser therapy. One hundred and twelve laser coagulations were performed between February 2006 and June 2015. The total (single and double) IUFD rate was 27.7%. Further, 59% of IUFD occurred within 24hours and 74.4% occurred within 1week after laser. The following were associated to IUFD within 24hours: the middle cerebral arterial pulsatility index in the donor, abnormal umbilical artery (UA) end diastolic flow, increased middle cerebral artery peak systolic velocity, and right ventricular myocardial performance index (RV-MPI) z-score in the recipient. For IUFD within 1week were the pulsatility index in the donor UA and the recipient abnormalities in UA, ductus venosus, middle cerebral artery-peak systolic velocity, and RV-MPI z-score. Following laser was early IUFD that was associated with Doppler findings suggesting donor cerebroplacental redistribution, and recipient overload cardiomyopathy, such as abnormal ductus venosus and UA Dopplers as well as an increase of RV-MPI.

Fetal middle cerebral artery Doppler to time intrauterine transfusion in red-cell alloimmunization: a randomized trial.

To evaluate whether Doppler measurement of middle cerebral artery peak systolic velocity (MCA-PSV) for timing subsequent intrauterine transfusions (IUTs) in fetuses that had undergone one IUT for anemia secondary to red-cell alloimmunization is non-inferior to timing based on expected decrease in fetal hematocrit (Hct) or fetal hemoglobin level, without compromising infant hemoglobin at birth. This was an international, pragmatic multicenter randomized controlled trial. Women with a pregnancy complicated by fetal anemia secondary to red-cell alloimmunization (due to any antibody alone or in combination), as indicated by the need to undergo a single IUT, were eligible for inclusion. Women were randomized to the determination of timing of further transfusion(s) by Doppler measurement of MCA-PSV (MCA-PSV Group), with a serial upward trend of values >1.5 multiples of the median considered indicative of the need for another IUT, or timing of transfusion by a decrease in fetal Hct (fetal Hct Group), with subsequent IUTs timed according to an estimated fall in fetal Hct of 1% per day or fetal hemoglobin of 0.3 g/dL per day, to maintain fetal hemoglobin level between 7 and 10 g/dL. The primary outcome was infant hemoglobin level measured at birth. A total of 71 women were randomized, 36 to the MCA-PSV Group and 35 to the fetal Hct Group. Median gestational age at randomization was 30.3 weeks, the majority of women were Caucasian and non-smokers, 9.9% of women had Kell alloimmunization, and 14% of fetuses were hydropic at their first IUT. No statistically significant differences between the two treatment groups were observed with regard to mean hemoglobin levels at birth (MCA-PSV Group, 10.36 ± 3.82 g/dL vs fetal Hct Group, 12.03 ± 3.14 g/dL; adjusted mean difference -1.56 g/dL (95% CI, -3.24 to 0.13 g/dL); P = 0.070), or the number of IUTs performed after randomization (MCA-PSV Group, 1.75 ± 1.79 vs fetal Hct Group 1.80 ± 1.32; adjusted relative risk 0.88 (95% CI, 0.61-1.26); P = 0.474). There was no statistically significant difference between the two groups with respect to the risk of adverse infant outcomes related to alloimmunization or procedure-related complications. Both Doppler measurement of MCA-PSV and estimation of the decrease in fetal Hct or hemoglobin can be used to determine the timing of second and subsequent IUTs in fetuses with red-cell alloimmunization. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Rh Isoimmunized Pregnancy—Do Maternal Antibody Titre Always Correlate with the Fetal Affection? A Non-Invasive Management

This case is of Rh -ve 2nd gravida having antibody titre detected 1:2 at 8 weeks of 2nd pregnancy. Serial antibody titre carried out along with clinical examination. Fetal monitoring was done by assessing MCA-PSV (Middle cerebral artery peak systolic velocity) and CTG (Cardiotocograph) when required. Pregnancy was terminated when the titre reached 1:512 at 34 wks of pregnancy with abnormal MCA-PSV values. Neonate just had begun to show sign of anaemia & haemolysis at birth.

Middle Cerebral Artery Doppler Changes following Fetal Transfusion Performed with and without Fetal Anesthesia.

The objective of this study was to test the association between fetal intravenous anesthesia and the change in middle cerebral artery peak systolic velocity (MCA-PSV) in patients undergoing intrauterine transfusion (IUT) for suspected fetal anemia. We retrospectively examined data from all patients who underwent IUT via umbilical cord route from 2007 to 2016. We calculated the change of the MCA-PSV multiple of median (MoM) as the difference in MCA-PSV MoM between the pre- and immediate postoperative measurements for the first IUT. The change in MCA-PSV MoM was compared between those who did and did not receive fetal anesthesia using Kruskal-Wallis' testing. Of 62 patients, 37 (59.7%) received intravenous fetal anesthesia and 25 (40.3%) did not. The change in MCA-PSV MoM did not differ between those who did and did not receive fetal anesthesia (median: 0.57 [interquartile range, IQR: +0.42 to +0.76] vs. median 0.57 [IQR: +0.40 to +0.81], p = 1.000). The relationship remained insignificant when stratifying by gestational age, length of procedure, initial MCA-PSV, and when excluding hydropic fetuses. Among women undergoing IUT, there was no evidence that the use of fetal anesthesia was associated with a change in the pre- versus postoperative change in MCA-PSV MoM.

Unusual Rhesus Antibodies as a Cause for Fetal Isoimmunisation

AbstractHemolytic disease of the newborn due to Rh isoimmunisation in a Rhesus D (Rh-D) negative mother with an Rh-D positive fetus is a well recognised entity. Although antibody to Rh-D antigen (anti-D antibody) was once the major cause of hemolytic disease of the fetus and newborn (HDFN), widespread adoption of antenatal and postnatal prophylactic anti-D immunoglobulin administration has resulted in a marked decrease in the prevalence of allo-immunisation due to the Rh-D antigen during pregnancy. However, at the same time, the maternal allo-immunisation to other red cell Rhesus antigens became more evident as a cause for HDFN, since no prophylactic immunoglobulins are available to prevent the formation of these antibodies. The authors report a case of a pregnant woman with AB negative blood group and positive indirect Coombs test (ICT) with rising middle cerebral artery peak systolic velocity (MCA-PSV) on follow up visits. Fetus required intrauterine transfusion. Fetal cord blood sampling revealed the fetus to be B negative and the direct Coombs test (DCT) was positive. On further testing, maternal serum was found to be positive for anti-D, anti-C and anti-G antibodies. Postnatally, the baby required double volume exchange transfusion. The authors highlight the importance of irregular antibody screening for women with obstetric history suggestive of HDNF. This could help in diagnosis and successful treatment of the affected fetus.

Discordant intrauterine transfusion in dichorionic twin pregnancy with Rh isoimmunization

Discordant intrauterine transfusion (IUT) in twin pregnancy with Rh isoimmunization is uncommon and complicated. We report a gravida 3, para 2 woman with a dichorionic diamniotic (DCDA) twin pregnancy and two fetuses received discordant transfusions. Middle cerebral artery peak systolic velocity (MCA-PSV) was used to evaluate the anemic degree in each foetus. IUT was performed 3 times in twin A and 4 times in twin B to reverse foetal anaemia. Transfusions were distinct due to the different tolerance to IUT, and the procedure could be continued in one foetus even if the other one underwent complications. Two male babies were born at 36 weeks of gestation and were given different treatments after birth. Twins were subsequently healthy after 2 years of follow up.The discordant IUT was due to the different tolerance to transfusion in the DCDA twins. Zygosity is important for the management and treatment of haemolytic anaemia in twin pregnancies.

Middle cerebral artery Doppler reference centile charts for the prediction of fetal anemia in a population from India.

To construct reference charts for the fetal middle cerebral artery (MCA) peak systolic velocity (PSV,) and the corresponding cord blood hemoglobin values at 24-40weeks of pregnancy for the identification of fetal anemia. In a cross-sectional study, 300 women with a pregnancy duration of 24-40weeks planned for delivery within 72hours underwent a Doppler study of the MCA and cord blood hemoglobin estimation at delivery. Regression analysis was used to construct reference charts. The validity of the charts was assessed in 40 fetuses from Rhesus-isoimmunized pregnancies. The MCA PSV and hemoglobin values increased with advancing gestational age. Multiples of the median (MOM) were calculated and reference charts were constructed for mild anemia (MCA PSV 1.29 MOM; hemoglobin 0.8 MOM), moderate anemia (MCA PSV 1.50 MOM; hemoglobin 0.6 MOM), and severe anemia (MCA PSV 1.55 MOM; hemoglobin 0.5 MOM). In the validation sample, the hemoglobin value estimated on the basis of the MCA PSV corresponded with the actual hemoglobin range in 90% of the fetuses. The sensitivity was 92% and the specificity was 95%. The constructed charts are suitable for the evaluation of fetal anemia in the regional population.

EP20.04: Diagnostic indices of MCA PSV for fetal severe anemia in MCDA twin pregnancy

To examine the diagnostic indices of fetal middle cerebral artery peak systolic velocity (MCA PSV) above 1.55 multiples of the median(MoM) Doppler velocimetry for the identification of fetal severe anemia in monochorionic diamniotic (MCDA) twin pregnancies. Study population consisted of 178 MCDA twin fetuses who underwent MCA PSV Doppler velocimetry within 7 days of delivery between gestational age (GA) of 24 and 38 weeks at Seoul National University Hospital between 2005 and February 2017. Fetuses with chromosomal abnormalities, major congenital anomalies or intrauterine demise were excluded. We examined the frequency of severe fetal anemia according to the presence of an increased fetal MCA PSV (≥1.55 MoM). Severe anemia was defined in the presence of hemoglobin concentration < 0.55 MoM in umbilical cord blood at the time of delivery. An increased MCA PSV (≥1.55 MoM) was present in 8.4% of study population and severe anemia was present in 2.2%. Diagnostic indices of an increased MCA PSV (≥1.55 MoM) for the identification of severe anemia were as follows: sensitivity 100% (4/4), specificity 93.7% (163/14), positive predictive value (PPV) 26.7% (4/15) and negative predictive value 100% (163/163). However, PPV at GA 30 weeks or more was only 12.5%, while that at GA less than 30 weeks was 42.9%. The sensitivity and specificity of an increased MCA PSV (≥1.55 MoM) for the identification of severe anemia in MCDA twin pregnancies are very high. However, PPV of that is much lower in cases with GA 30 weeks or more than in those with GA less than less than 30 weeks among MCDA twin pregnancies. EP20.04: Table 1. Middle cerebral artery peak systolic velocity (MCA PSV) Doppler velocimetry in the prediction of fetal severe anemia

EP20.01: In utero partial exchange transfusion (iPET) combined with in utero blood transfusion (IT) for treatment of twin anemia polycythemia sequence

Twin anemia-polycythemia sequence (TAPS) is an infrequent complication of monochorionic twin gestations. Diagnosis is established by prenatal Doppler assessment of middle cerebral artery peak systolic velocity (MCA-PSV). A staging system is proposed based on MCA-PSV. At this time, an optimal prenatal treatment method is not known. We report 3 pregnancies, one spontaneous and 2 product of assisted reproductive technology, managed in our centre with in utero partial exchange transfusion (iPET) combined with in utero blood transfusion (IT). Once the diagnosis is established, the polycythemic twin underwent partial exchange transfusion. After iPET is completed, the anemic fetus had IT during the same session. The volume to be replaced for iPET is calculated utilising previously established formulas for newborns, based on ultrasound estimated fetal weight. Following iPET, IT is performed for the anemic fetus, either intraperitoneal or intravascular route. At the end of iPET, target hematocrit was 50% for the polycythemic twin. Following IT, target hematocrit was 40% for the anemic twin. Median gestational age at diagnosis was 26.1 weeks [range:24.6 – 27.6 weeks]. At the time of diagnosis, 2 cases were at stage 2 and 1 case was at stage 4. Duration between diagnosis and delivery was median 2.5 weeks [range:1 – 11.5 weeks]. Delivery indications were worsening fetal status, premature preterm rupture of membranes, and preterm labour. iPET combined with IT is feasible for the treatment of TAPS and it appears to prolong pregnancy. EP20.01: Table 1. GA gestational age, Dx diagnosis, IVF in vitro fertilisation, TTTS Twin–twin transfusion syndrome, iPET partial exchange transfusion, Del delivery, PPROM preterm premature rupture of membranes, PTL preterm labour

EP20.02: Diagnostic performance of middle cerebral artery peak systolic velocity for fetal severe anemia in advanced gestational age of monochorionic diamniotic twin pregnancy

EP20.02: Diagnostic performance of middle cerebral artery peak systolic velocity for fetal severe anemia in advanced gestational age of monochorionic diamniotic twin pregnancy

OP21.02: Assessment of relationship between fetal middle cerebral artery peak systolic velocity and umbilical vein blood gas values in diabetic pregnancies

OP21.02: Assessment of relationship between fetal middle cerebral artery peak systolic velocity and umbilical vein blood gas values in diabetic pregnancies

Appearance of Abnormal Cardiothoracic Ratio of Fetuses with Hemoglobin Bart's Disease: Life Table Analysis.

Objective To determine the timeline of the first appearance of an increased CT ratio of fetuses with hemoglobin (Hb) Bart's disease. Materials and Methods A prospective longitudinal study was conducted on pregnancies at risk for fetal Hb Bart's disease. Sonographic markers including cardiothoracic (CT) ratio and middle cerebral artery peak systolic velocity (MCA-PSV) were serially assessed and recorded from the first trimester. The definite diagnosis of fetal Hb Bart's disease based on DNA analysis (CVS), or fetal Hb typing (HPLC; cordocentesis) was performed at the first appearance of an increased CT ratio. Results Of 275 pregnancies at risk, 64 fetuses were finally proven tobe affected and life table analysis was performed. Most affected fetuses showed an increased CT ratio in late first trimester and early second trimester, with median time of the first appearance at 13weeks and all affected fetuses were detected at 23 weeks or less. The CT ratio yielded a sensitivity of 100 % at a gestational age of 23 weeks with afalse-positive rate of 8 %. MCA-PSV appeared later than CT ratio. Only 9.4 % of affected cases developed abnormal MCA-PSV before an increased CT ratio. Conclusion The timeline of the first appearance of an increased CT ratio of fetuses with Hb Bart's disease was established. This may help us identify Hb Bart's disease among fetuses at risk in earlier gestation and proper schedules for serial ultrasound could be made more effectively.

OP18.11: Assessment of correlation between fetal middle cerebral artery peak systolic velocity and brain apparent diffusion coefficient in IUGR

OP18.11: Assessment of correlation between fetal middle cerebral artery peak systolic velocity and brain apparent diffusion coefficient in IUGR

EP16.03: The role of middle cerebral artery Doppler in the detection of fetal anemia in pregnancy with decreased perception of fetal movements

To analyse the role of middle cerebral artery (MCA) peak systolic velocity (PSV) in the prediction of severe fetal anemia in pregnancies with decreased perception of fetal movements and to compare it with standard cardiotocographic and biophysical assessment. This a prospective interventional study including all women with a viable singleton pregnancy who complain of reduced perception of fetal movements. Women participating were evaluated as per routine care with fetal biophysical profile assessment and these results were reported as usual. Additionally the middle cerebral artery peack sistolic velocity and the cerebroplacental ratio were assessed and the results were noted. Cytofluorimetric test for fetomaternal hemorrhage was performed if this condition was suspected. Overall we recruited 74 women who complain of decreased perception of fetal movements. Gestational age at admission was 34 ± 4 weeks and only two of these fetuses were small for gestational age (2.7 %). The cardiotocogram was non reactive in 4 cases (5.4%). Among these pregnancies the cerebral Doppler was abnormal only in one case (1.7%) and the cardiotocogram was reassuring for this patient. After an emergency Caesarean section performed at 31 weeks because of the suspected fetal anemia (peak systolic velocity < 1.4 MoM) a very anemic neonate was born. The most accurate predictor of fetal anemia was fetal MCA-PSV. CTG was sometimes abnormal but the pattern was frequently nonspecific and it was normal in the anemic fetus. We suggest to include fetal cerebral Doppler in the evaluation of patients with decreased fetal movements, particularly in those cases with ambiguous results of biophysical testing.

Analysis of Hemodynamic Changes in Early Stage after Carotid Stenting by Transcranial Doppler—A Preliminary Study

Cerebral hyperperfusion syndrome or hemodynamic instability, caused by the hemodynamic changes, often occur within 6hr after carotid artery stenting (CAS) The postprocedure cerebral hemodynamic change in the early phase, <6hr after CAS, is largely unknown. In this study, we evaluated the cerebral hemodynamic changes in patients after CAS using transcranial Doppler (TCD). From January 2013 to July 2014, medical records of 61 patients who underwent CAS were reviewed retrospectively. Among them, 44 patients had TCD examination before CAS, 1-2 and 3-4hr after CAS. In the TCD examination, middle cerebral artery (MCA) peak systolic velocity (PSV) and pulsatility index (PI) on the ipsilateral and contralateral sides were measured. Blood pressure, MCA PSV, and PI data were collected and analyzed from the 44 patients who had valid TCD examinations. Blood pressure was 148.4±14.5mm Hg before CAS: 124.5±13.8mm Hg 1-2hr after CAS, and 121.6±12.6mm Hg 3-4hr after CAS. On the ipsilateral side, the MCA PSV increased from 85.7±22.8cm/s before CAS to 101.1±27.1cm/s (19.9%, P<0.001) 1-2hr after CAS, and 99.7±27.0cm/s (18.2%, P<0.001) 3-4hr after CAS. There was no significant difference in MCA PSV between 1-2 and 3-4hr after CAS (P=0.200). The PI increased from 0.871±0.167 before CAS to 0.941±0.205 (P=0.022) 1-2hr after CAS, and 0.954±0.218 (P=0.010) 3-4hr after CAS. On the contralateral side, there was no statistically significant PSV increase in the MCA following CAS. CAS may induce a significant increase in PSV and PI in the ipsilateral MCA within 4hr. The MCA PSV increased significantly higher than that on the contralateral side. The PSV had no significant change between 1-2 and 3-4hr after CAS.

Fetal hydrops and middle cerebral artery Doppler in prediction degree of fetal anemia and the best timing for therapy

To determine the role of fetal multiples of the median of middle cerebral artery peak systolic velocity (MoM MCA-PSV), in predicting the degree of fetal anemia for determination of the best timing for the second intrauterine intravascular transfusion (IUIVT) in hydropic fetuses with Rh alloimmunization. Prospective study of 30 monofetal pregnancies with maternal Rh D alloimmunization and hydrops fetalis, from 2005 to 2012 that underwent first and second IUIVT were assessed. Thirty IUIVT were performed at 26.9 weeks (standard deviation, SD 4.3). Mean interval to the second procedure was 11.23 (SD 6.21) days and average hematocrit decline rate was 1.45%/day. The study did not demonstrated statistical significance between MCA-MoM-3 before the second IUIVT, and the mean decline rate in fetal hematocrit levels (expressed in percentage/day) r = 0.220; p = 0.242, and between MCA-MoM-3 and the time interval between both procedures (T) r = -0.157; p = 0.408. The measurements fetal MoM-MCA before every IUIVT cannot be useful as predictor for the best timing for the next IUIVT, but it can be useful in predicting severity of fetal anemia.

Personalized treatment with immunoadsorption and intravenous immunoglobulin in a case of severe Rh alloimmunization during pregnancy unresponsive to plasma – exchange

IntroductionDespite prophylaxis, a small proportion of RhD-negative women may develop anti-D antibodies after a sensitizing event occurring during pregnancy or delivery of a D-positive baby. Intrauterine transfusion (IUT) is the treatment of choice in case of fetal anemia, but it cannot be performed early during pregnancy. Combined treatment with therapeutic plasma-exchange (TPE) and intravenous immunoglobulin (IVIG) can avoid or delay IUT. Immunoadsorption (IA) could represent a more effective treatment in selected cases. Case reportWe report a D-negative female with a history of induced abortion and hydrops fetalis, referred at 8 weeks of gestation with a high anti-D titer. Despite implementing a TPE-IVIG protocol, the patient experienced a spontaneous abortion. At the beginning of her fourth pregnancy, only after a partially effective intensive TPE course, cycles of IA-IVIG were performed. Despite a suboptimal response on the anti-D titer, Doppler ultrasonographic measurements of the fetal middle cerebral artery peak systolic velocity first showed evidence of anemia at 30 weeks of gestation and a IUT was required. After the IUT, anemia persisted with a subsequent dramatic rise in titer, requiring an emergent cesarean section. The infant subsequently underwent successful treatment with IVIG, phototherapy and exchange transfusion and was discharged 7 weeks later without neurological deficits. DiscussionThe treatment of high titer anti-D antibodies during pregnancy may require a multidisciplinary approach with utilization of different apheresis strategies in order to have a successful pregnancy outcome.

Accuracy of Middle Cerebral Artery Doppler Assessment between 34 and 37 Weeks in Fetuses with Red Cell Alloimmunization

Background: The Doppler measurement of middle cerebral artery peak systolic velocity (MCA-PSV) is considered the gold standard for the noninvasive detection of moderate to severe anemia. However, the accuracy of this test has not been evaluated so far, specifically beyond 34 weeks. Objectives: To assess the accuracy of MCA-PSV to detect moderate to severe fetal anemia and to identify risk factors associated with false-positive and false-negative MCA-PSV values after 34 weeks. Study Design: We studied a retrospective cohort of 150 pregnant women with severe alloimmunization who delivered between 2010 and 2014 and correlated MCA-PSV and fetal or neonatal hemoglobin levels. Results: Sensitivity to predict severe anemia was 69%, with a false-negative rate of 3.6%. When MCA Doppler assessment was normal, the identification of serosal effusions increased the detection rate of severe fetal anemia to 94%, with a false-negative rate of 0.8%. False-positive MCA-PSV measurements were more frequent in fetuses with 1 previous intrauterine transfusion (p = 0.0002), but were not associated with MCA resistance index, intrauterine growth restriction and fetal heart rate. Conclusions: Between 34 and 37 weeks, sensitivity of MCA-PSV Doppler assessment alone is 69% and increases to 94% when also considering signs of hydrops. False-positive MCA-PSV measurements are more frequent in case of former fetal transfusion.

Guidelines on transfusion for fetuses, neonates and older children.

Guidelines on transfusion for fetuses, neonates and older children.