Color-coded Duplex Sonography Research Articles

Transcranial color-coded duplex sonography reliably identifies intracranial vasculopathy in adult patients with sickle cell disease.

In order to prevent stroke, screening for disease-related intracranial vasculopathy using Doppler ultrasound is recommended in sickle-cell disease (SCD) children. How to screen such vasculopathy in adults remains largely unknown. The objective of this study was to assess whether transcranial color-coded duplex sonography (TCCD) is sensitive and specific enough to identify SCD adult patients with vasculopathy, compared with magnetic resonance angiography (MRA). Sickle cell disease adults followed in referral centers at high risk of vasculopathy were included in this study. Transcranial color-coded duplex sonography examination and 3-D time-of-flight MRA were performed on the same day. On MRA, vasculopathy was defined by the presence of at least one ≥50% arterial stenosis. On TCCD, vasculopathy was defined by a time-averaged mean of the maximum velocity (TAMx) stenotic/prestenotic ratio ≥ 3, an occlusion, or a Moyamoya pattern. Vasculopathy was also considered as present when TAMx ratio could not be calculated because of the presence of severe cervical lesions. Among 80 included patients, quality of MRA was insufficient in three patients. Among the 38 patients with vasculopathy on MRA, 37 had a vasculopathy according to TCCD criteria: TAMx ratio ≥ 3 or intracranial occlusion in 33 patients and cervical lesion in four patients. A Moyamoya pattern was identified with TCCD in all 17 patients with Moyamoya on MRA. Sensitivity and specificity of TCCD toidentify patients with ≥50% vasculopathy on MRA were (n=37/38) 97% and(n=28/34) 82%, respectively. Positive and negative predictive values were (n=37/43) 86% and (n=28/29) 97%, respectively. Note, TCCD may be used to identify SCD adult patients with vasculopathy.

Do-It-Yourself Preoperative High-Resolution Ultrasound-Guided Flap Design of the Superficial Circumflex Iliac Artery Perforator Flap (SCIP).

The superficial circumflex iliac artery perforator (SCIP) flap is a well-documented, thin, free tissue flap with a minimal donor site morbidity, and has the potential to become the new method for resurfacing moderate-size skin defects. The aim of this study is to describe an easy, reliable, systematic, and standardized approach for preoperative SCIP flap design and perforator characterization, using color-coded duplex sonography (CCDS). A list of customized settings and a straightforward algorithm are presented, which are easily applied by an operator with minimal experience. Specific settings for SCIP flap perforator evaluation were investigated and tested on 12 patients. Deep and superficial superficial circumflex iliac artery (SCIA) branches, along with their corresponding perforators and cutaneous veins, were marked individually with a permanent marker and the anatomy was verified intraoperatively. From this, a simplified procedure for preoperative flap design of the SCIP flap was developed. Branches could be localized and evaluated in all patients. A preoperative structured procedure for ultrasonically guided flap design of the SCIP flap is described. A 100% correlation between the number and emergence points of the branches detected by preoperative CCDS mapping and the intraoperative anatomy was found.

Intraoperative angiography in carotid artery reconstruction-Pathological findings, reliability and importance of the procedure

ZielDer Wert der intraoperativen Angiographie und deren Ad-hoc-Beurteilung im Hinblick auf operationstechnische Unzulänglichkeiten soll geprüft werden.MethodeInsgesamt 523 konsekutive A.-cartotis-Thrombendarteriektomie(TEA)-Patienten mit intraoperativer Kontrollangiographie, postoperativer Duplexsonographie und retrospektiver Zweitbeurteilung der Angiographie wurden in die Auswertung einbezogen.ErgebnisseIn der retrospektiven Zweitbeurteilung der Angiographie wurden 23 (4,4%) Verschlüsse oder hochgradige Stenosen der Arteria carotis communis (ACC) oder Arteria carotis interna (ACI) im Operationsbereich (12/2,3%) bzw. in der Abstrombahn (distale extrakranielle und intrakranielle ACI, A. cerebri media [ACM]) detektiert (11/2,1%), wohingegen bei der intraoperativen Ad-hoc-Beurteilung nur 13 (2,5%) derartige Pathologien beschrieben worden waren (7/1,3% im Operationsbereich, 6/1,1% in der Abstrombahn; p=0,002). Duplexsonographisch wurden postoperativ bei 50 von 505 untersuchten Patienten (10,1%) operationstechnische Unzulänglichkeiten lokal detektiert, was signifikant mehr war als in der Angiographie (p<0,001). In den meisten Fällen handelte es sich um nicht okkludierende/nicht hochgradig stenosierende Intima-Media-Ablösungen (19), Nahteinziehungen (13) und Kinkings/Kalibersprünge am distalen Patchende (14). Nahteinziehungen und Kinkings/Kalibersprünge waren mit einer linksseitigen TEA (adjustierte OR: 2,4; 95%-KI: 1,1‑5,1), einer Operation ohne Patch (adjustierte OR: 16,6; 95%-KI: 1,3–215,0) und der Verwendung eines Dacron- vs. Polytetrafluorethylen-Patch (adjustierte OR: 3,0; 95%-KI: 1,4–6,6) assoziiert.SchlussfolgerungBei der Ad-hoc-Beurteilung der intraoperativen Kontrollangiographie kann eine nicht unerhebliche Zahl auch okkludierender und hochgradig stenosierender Pathologien übersehen werden (zur Detektion nicht okkludierender und nicht hochgradig stenosierender operativer Unzulänglichkeiten methodisch nicht geeignet – Ausweich: postoperative Duplexsonographie).

Training novice users to assess stroke aetiology in remote settings using transcranial ultrasound: pilot study.

Emergency care delivery to patients in remote and rural areas is limited by diagnostic restrictions and long transport times to major centres of care. People with suspected acute stroke living long distances from a hospital are unlikely to receive time-critical reperfusion therapy for these reasons. Basic brain imaging assessing blood flow in the major intracranial arteries could facilitate such care in remote settings. A 3-hour training package for novice transcranial ultrasound users has been piloted on a small group of volunteers to investigate whether they could acquire transcranial ultrasound images and video clips to potentially allow remote interpretation and optimise pre-hospital management of acute stroke. A pilot training project was set up in a university setting in Inverness, Scotland. Volunteer clinicians and students of nursing or medicine with no practical experience in transcranial ultrasound were recruited. Participants received three 1-hour training sessions combining theoretical aspects and hands-on practice on healthy volunteers provided by a qualified neurologist with more than 2 years of experience in transcranial ultrasound. Transcranial greyscale and colour-coded duplex sonography was performed to visualise midline structures and major intracranial vessels, and to measure blood flow velocity in the middle cerebral artery, followed by an unsupervised assessment. Qualitative analysis of the anonymised feedback from participants on the training experience and its potential application was also performed. A total of 11 volunteers were recruited in the current pilot study. The average time to complete transcranial ultrasound assessment was approximately 40 minutes. The brain midline and cerebral peduncles were correctly labelled by 64% (7/11) and 91% (10/11) of volunteers, respectively. Participants demonstrated a good performance in detecting major intracranial vessels. The correct labelling rate for the middle cerebral artery was 73% (8/11), and 64% (7/11) for the anterior and posterior cerebral arteries. There was agreement between the trainer and the participants on rating the quality of scans as assessed using a visual analogue scale. All participants gave positive feedback on the provided training and time allocated for each session. Generally, volunteers thought that operating the ultrasound machine and the probe simultaneously was difficult. It was also suggested that further follow-up training, with possible supervision, would be useful to retain the acquired skills. Transcranial ultrasound scans of a quality to allow expert interpretation can be acquired by inexperienced transcranial ultrasound operators after receiving a brief training. This could potentially be used by medical staff working in remote and rural areas to facilitate acute care for stroke patients, but further work with a larger sample is needed.

One-Year Aerobic Exercise Reduced Carotid Arterial Stiffness and Increased Cerebral Blood Flow in Amnestic Mild Cognitive Impairment.

Central arterial stiffness and brain hypoperfusion are emerging risk factors of Alzheimer's disease (AD). Aerobic exercise training (AET) may improve central arterial stiffness and brain perfusion. To investigate the effects of AET on central arterial stiffness and cerebral blood flow (CBF) in patients with amnestic mild cognitive impairment (MCI), a prodromal stage of AD. This is a proof-of-concept, randomized controlled trial that assigned 70 amnestic MCI patients into a 12-month program of moderate-to-vigorous AET or stretching-and-toning (SAT) intervention. Carotid β-stiffness index and CBF were measured by color-coded duplex ultrasonography and applanation tonometry. Total CBF was measured as the sum of CBF from both the internal carotid and vertebral arteries, and divided by total brain tissue mass assessed with MRI to obtain normalized CBF (nCBF). Episodic memory and executive function were assessed using standard neuropsychological tests (CVLT-II and D-KEFS). Changes in cardiorespiratory fitness were measured by peak oxygen uptake (VO2peak). Total 48 patients (29 in SAT and 19 in AET) were completed one-year training. AET improved VO2peak, decreased carotid β-stiffness index and CBF pulsatility, and increased nCBF. Changes in VO2peak were associated positively with changes in nCBF (r = 0.388, p = 0.034) and negatively with carotid β-stiffness index (r = -0.418, p = 0.007) and CBF pulsatility (r = -0.400, p = 0.014). Decreases in carotid β-stiffness were associated with increases in cerebral perfusion (r = -0.494, p = 0.003). AET effects on cognitive performance were minimal compared with SAT. AET reduced central arterial stiffness and increased CBF which may precede its effects on neurocognitive function in patients with MCI.

Effect of low-intensity extracorporeal shock wave therapy on diabetic erectile dysfunction: Randomised control trial.

This study aimed to assess the effectiveness of low-intensity extracorporeal shockwave therapy (Li-ESWT) in the management of erectile dysfunction in diabetic patients with mixed vasculogenic and neurogenic causes as confirmed by nerve conduction and Doppler studies. This randomised controlled trial included 42 patients 41-55years of age with a confirmed diagnosis of erectile dysfunction and diabetic polyneuropathy. They were randomly allocated to one of two groups: shock wave group (n=21) treated with Li-ESWT plus pelvic floor muscle training and control Group (n=21) treated with pelvic floor muscle exercise and sham therapy by a shock wave. The erectile function was scored according to the five-item version of the International Index of Erectile Function (IIEF-5). Colour-coded duplex sonography was used for the evaluation of penile perfusion of the two cavernous arteries. The assessment was done before and three months after treatment. IIEF-EF increased significantly in the study group (p<.001), but not in the control group (p=.194). Peak systolic velocity increased significantly in the two groups; however, the post-treatment peak systolic velocity was significantly higher in the study group compared to the control group (p<.001, for both arteries).

Recurring paroxysmal positional vertigo: evaluation of the vascular factor.

SUMMARYTo evaluate the effective incidence of vascular factor in the recurrence of benign paroxysmal positional vertigo (BPPV), we studied 50 subjects, 32 affected by idiopathic recurrent BPPV (study group) and 18 healthy subjects (control group). All subjects underwent complete otoneurological balance and haemodynamic evaluation by extracranial colour-coded duplex sonography (ECCS) of vertebral arteries (VA) with indication of arterial flow in ml/min, and retinal fluorangiography (FAG). The ECCS of 19 patients (59.3%) within the study group presented a reduction in vertebral arterial flow, exceeding the limits established by normative values (< 100 ml/min). In all cases, the same side was affected by BPPV, emphasised by vertebral hypoperfusion. The remaining 13 patients (40.6%) showed an arterial vertebral flow entirely within the normative values. The FAG excluded qualitative alterations of the cerebral microcirculation. The ECCS demonstrated that 59.3% of the study group showed a significant reduction in vertebral arterial flow ipsilateral to the semicircular canal affected by BPPV. This increased to 68.75% when the flow difference (D) between both the vertebral arteries were considered and reached 71.8% when vascular risk factors were evaluated. We conclude that reduced perfusion of the vestibular structures makes an already critical situation even more difficult, which can eventually develop into labyrinth suffering. The absence of fluorangiographic signs suggests that the labyrinthine neuroepithelium is much more sensitive to hypoperfusion than the retina. We hypothesise that this ischaemic situation could degenerate utricular macula, otolith detachment, leading to the development of recurrent BPPV. This risk situation for the labyrinth can also be revealed by the evaluation of three parameters: presence of vascular risk factors, reduction of vertebral flow < 100 ml/min and the difference in flow between the 2 vertebral arteries > 29 ml/min.

Prevalence of Mimics and Severe Comorbidity in Patients with Clinically Suspected Transient Global Amnesia

Background: Transient global amnesia (TGA) is a syndrome featuring acute anterograde amnesia as the most striking clinical symptom. Its etiology is still a matter of debate. Most neurological guidelines allow the diagnosis on the basis of clinical criteria only; a more extensive evaluation is recommended only for patients with “red flags” like severe headache, nausea or vomiting, or metabolic abnormalities. The aim of our study was to assess the frequency of a severe underlying disease or alternative diagnoses (mimics) in patients fulfilling the clinical criteria. Methods: We evaluated the medical records and the imaging data of an unselected consecutive cohort of patients with suspected TGA over a 7-year period. All patients were hospitalized and received a neurological workup including brain imaging, color-coded duplex sonography of the brain supplying arteries, electroencephalography, and laboratory studies of blood and (in selected cases) cerebrospinal fluid. Results: 163 patients with 166 episodes of suspected TGA were hospitalized (3 patients twice). After the workup, the diagnosis of TGA was confirmed in 148/166 (89.2%) episodes (“simple TGA”). Eighteen patients (10.8%) either had an alternative diagnosis or a severe comorbidity that was assumed to have had an impact on the occurrence of the amnestic episode (“complicated TGA/mimic”). The most important differential diagnosis was stroke (11 patients, 6.6% of all TGA suspects and 61.1% of the complicated TGA/mimic group). Other mimics were transient epileptic amnesia (2 patients) and steroid-induced delirium (1 patient). Important comorbidities that had not been obvious at the time of presentation were severe sleep apnea (2 patients), triptan overuse (1 patient), and an involuntary amlodipine intoxication during TGA. Conclusion: As approximately every tenth patient with suspected TGA either had an alternative diagnosis or a severe comorbidity, which had not been obvious at the time of admission, we consider in-patient treatment of all suspected TGA cases as appropriate, preferably in the setting of a stroke unit, as ischemic stroke was the by far most important diagnosis mimicking TGA.

Apolipoproteins A1 and B and their ratio in acute ischemic stroke patients with intracranial and extracranial arterial stenosis: an Egyptian study

BackgroundApolipoprotein A1 and B and their ratio are considered a better biomarker for cardiovascular diseases than a lipid profile, but this previous finding is not proved to cerebrovascular ischemic diseases. The aim of this study is to assess the relation between apolipoprotien A1 and B and their ratio to intra- and extracranial carotid atherosclerosis in patients with ischemic acute stroke.Methods90 Egyptian patients with acute ischemic stroke are included in the study, and they have been classified into 3 groups: group 1 includes 30 patients with intracranial stenosis, group 2 includes 30 patients with extracranial arterial stenosis, and group 3 includes 30 patients with non-arterial stenosis. Patients were subjected to clinical assessment, routine laboratory measures, and Color-Coded Duplex Sonography for extracranial and intracranial arteries. The measurement of serum levels of apolipoproteins A1 and B was done using enzyme-linked immuno-sorbent assay (ELISA).ResultsA statistically significant difference was found between patient groups as regards the frequency of abnormal serum LDL-cholesterol (p = 0.04), being elevated in patients with extracranial stenosis (p = 0.01). There was a significant difference between patients groups as regards the frequency of abnormal serum HDL-cholesterol (p = 0.02), being lower in patients with extracranial stenosis. High Apo B/A1 ratio was an independent risk factor for intracranial arterial stenosis (p = 0.045). An abnormal elevation of serum LDL cholesterol was an independent risk factor of extracranial arterial stenosis (p = 0.021).ConclusionApo B/A1 ratio is an independent risk factor for intracranial arterial stenosis, while serum LDL cholesterol is an independent risk factor for extracranial arterial stenosis. Apo B/A1 ratio and serum LDL cholesterol are reliable serum biomarkers for cranial arterial stenosis in acute ischemic stroke patients.

Characteristics of cerebral hemodynamics in patients with chronic brain ischemia

Background. Literature sources report conflicting results regarding the severity of clinical symptoms of hydrocephalus (HC) and their association with cerebral arterial blood flow (CABF); most studies do not show a direct relationship, while some suggest a link between clinical severity and progressive decrease in CABF. The study of hemodynamic changes in the brain of patients with chronic brain ischemia (CBI), elucidation of their relationship with cognitive impairments helps to improve diagnostic approaches and optimize the prognosis of the disease. The purpose of this study is to investigate the state of cerebral hemodynamics and to establish its relationship with changes in cognitive functions in patients with CBI and HC. Materials and Methods. A comprehensive examination of 110 patients with CBI and HC was performed. The localization of the HC and results of Montreal Cognitive Test (MoCA scale) were taken into account. Computed tomography of the brain was performed with subsequent determination of morphometric parameters and indices. The state of cerebral blood flow and structural changes of blood vessels were studied using transcranial color-coded duplex ultrasonography (TCCS) of intracranial vessels and extracranial divisions. Microsoft Excel 2011 and Statistica were used for statistical processing of the results. Results. It was found that there was a significantly larger diameter of both common carotid arteries (CCA), thickness of complex intima\media (CIM), maximum systolic velocity (Vs), velocity at the end of the diastolic cycle (Vd), as well as peripheral resistance (IR) in left CCA (p &lt;0,05) in patients with CBI and HC compared with patients with CBI without HC. Significantly larger diameter of left internal carotid artery (ICA), Vs, Vd and IR was revealed; Vs and Vd in the right ICA; Vd in the extracranial devision of vertebral artery (VA) in patients with HC. A significant relationship was found between the following blood flow parameters and the values of the MoCA scale: Vs MCA/MoCA (r = 0,45, p &lt;0,05), Vs ACA/MoCA (r = 0,38, p &lt;0.05), ICA diameter/MoCA (r = -0,51, p &lt;0,05). It was found that the diameter of CCA and the thickness of CIM were significantly larger in patients with CBI with internal HC in comparison with patients with CBI with external HC (p &lt;0,01). Vs and Vd in patients with internal hydrocephalus were significantly lower, and IR was significantly higher compared with patients with external hydrocephalus (p &lt;0,01). The diameter of ICA and IR in patients with CBI with internal HC was significantly higher, and Vs was significantly lower compared with patients with CBI and external HC (p &lt;0,01). Significantly different values were found in Vs and IR meanings in middle cerebral artery (MCA) and Vs in anterior cerebral artery (ACA) in patients with CBI with internal HC compared with patients with CBI with external HC.Conclusions. Functional parameters of blood flow and structural changes of cerebral arteries in patients with CBI with concomitant hydrocephalus differed significantly from those in patients without hydrocephalus and depended on the type and severity of hydrocephalus. ICA occlusion, ICA stenosis &gt;50%, and intracranial venous stasis were significantly more common in patients with severe and moderate HC compared with those with mild HC. A weak relationship was found between the structure of carotid arteries and blood flow in intracranial arteries in patients with CBI and HC. There was a significant relationship between blood flow indices and the values of the MoCA scale, which indicated the effect of changes in the vessels of the anterior circular basin on the cognitive functions and the lack of such connection with blood flow indices in vertebrobasilar basin.

Evaluation of the interrater and intermethod agreement of the German multiparametric ultrasound criteria for the grading of internal carotid artery stenosis

PurposeThe interdisciplinary German guidelines for the diagnosis and treatment of internal carotid artery stenosis (ICAS) recommend a multiparametric approach for the sonographic grading of extracranial ICAS. The aim of this study is to evaluate the interrater and intermethod agreement of this elaborated sonographic approach with different angiographic modalities.MethodsPatients with extracranial ICAS were examined twice with colour-coded duplex sonography (CDS) by two experienced vascular neurologists. Each of the ten criteria and the resulting stenotic value were assessed. Grading of ICAS based on the multiparametric ultrasound criteria was compared with different angiography modalities (magnetic resonance angiography (MRA), computed tomography angiography (CTA), digital subtraction angiography (DSA)).ResultsSeventy-four consecutive patients with 91 extracranial ICAS were recruited from our stroke unit and neurovascular outpatient clinic. Interrater agreement for each single ultrasound criterion ranged from moderate to excellent (for the peak systolic velocity). Concerning the absolute stenotic value of ICAS, an excellent agreement between both ultrasound examiners with an ICC of 0.91 (range 0.87–0.94; p < 0.001) was found. In 96% of ICAS, the difference between the stenotic values was ≤ 10%. Intermethod agreements between CDS and DSA, CTA, and MRA were also good for both sonographers.ConclusionStrictly adhering to the multiparametric “DEGUM ultrasound criteria”, we found an excellent interrater agreement and a good intermethod agreement compared with angiography for the sonographic grading of extracranial ICAS. Thus, multiparametric CDS is in particular suitable for the follow up of extracranial ICAS even when examinations are done by different sonographers.

Feasibility study of preoperative microvessel evaluation and characterization in perforator flaps using various modes of color-coded duplex sonography (CCDS).

Color-coded duplex sonography (CCDS) is useful for perforator flap design showing the highest sensitivity in identifying microvessels. This prospective study evaluates the feasibility of different ultrasound (US) modes applied by the microsurgeon in daily practice suggesting quantifiable reference values. Twenty-four patients aged between 17 and 68 years (mean 43.3 ± 14.2 years) with 18 anterolateral thigh (ALT) and 6 superficial circumflex iliac artery (SCIP) flaps were included. Indications were traumatic (n = 12), infectious (n = 6), ischemic (n = 4), or tumor-associated defects (n = 2). Different US modes were evaluated regarding applicability using multifrequency linear probes (5-15 MHz). Vessels diameter, peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were measured. Preoperative results were correlated to intraoperative findings. In the examined patient group with 24 perforator flaps a 100% correlation was seen when comparing perforators detected with CCDS/PD with intraoperative findings using optimized US settings. Sensitivity, PPV, and accuracy of CCDS were 100% respectively. Mean PSV of 16.99 ± 6.07 cm/s, mean EDV of 5.01 ± 1.84 cm/s and RI of 0.7 ± 0.07 were measured in microvessels (PW-mode). CCDS proved to be superior compared to PD in correct diameter assessment showing a mean diameter of 1.65 ± 0.45 mm, compared to PD-mode 1.31 ± 0.24 mm. Mean PSV and EDV were higher in ALT than in SCIP flaps, RI was slightly higher in SCIP flaps (p > .05). There were no significant differences in size of different flaps' perforators (p > .05). CCDS represents a highly valuable tool in the daily practice of free flap reconstructions using optimized low flow US settings and multifrequency linear probes.

Evaluation of Contrast-enhanced Transcranial Color-coded Duplex Sonography (CE-TCCD) Applied in Stroke Patients with Intracranial Collateral Circulation.

CE-TCCD was applied to 70 patients (51 males and 19 females) who presented with ischemic symptoms, to detect the openness of the anterior communicating artery (ACoA) and posterior communicating artery (PCoA) of the Willis ring before Computed Tomography angiography (CTA) or Magnetic Resonance Angiography (MRA) examination. The results from CETCCD is used to compare with CTA/MRA result to verify the diagnostic efficacy. Forty-one communicating artery openings were detected by CE-TCCD, among which 37 were PCoA and 4 were ACoA. Among the 70 patients, 23 of 70 patients indicated severe stenosis within intracranial and/or extracranial arteries. Eighteen out of the 23 patients showed collateral circulation, accounting for 78.3% (18/23). Moderate stenosis were 23 cases in total, in which 7 cases showed collateral circulation, accounting for 30.4% (7/23). Slight stenosis were 24 cases in total, none of which showed collateral circulation. In the stroke patients with limited bone windows, CE-TCCD can evaluate intracranial collateral circulation.

Evaluation of cerebrovascular reactivity by ultrasonography in type 2 diabetic patients with hypertension*

BACKGROUNDCerebrovascular reactivity (CVR) reflects cerebrovascular reserve capacity, and cerebrovascular reactivity damage prognosticates a very high risk of stroke. OBJECTIVETo evaluate CVR by detecting the increase rate of blood flow volume of middle cerebral artery (MCA) before and after breathholding in diabetic patients with hypertension, and observe the effects of hypertension on cerebrovascular reserve capacity of diabetic patients. DESIGNControlled observation. SETTINGSDepartment of Function, Affiliated Hospital of Hebei University; Department of Special Diagnosis, the 202 Hospital of Chinese PLA. PARTICIPANTSInpatients or outpatients with type 2 diabetes mellitus (DM) or primary hypertension admitted to Departments of Gastroenterology and Cardiology, Affiliated Hospital of Hebei University and the 202 Hospital of Chinese PLA from April to December 2004 were involved in this experiment. Inclusive criteria: type 2 DM met the criteria of the report on diabetes diagnosis announced in 1999 by WHO expert committee, totally 88 patients were involved. Primary hypertension met the diagnosis criteria announced in 1999 by WHO/ISH, totally 42 patients were involved. Another group of 43 concurrent subjects who received physical examination served as controls. According to the disease condition, the involved patients were assigned into 3 groups: DM group (only diabetic patients), hypertension group (only hypertension patients) and DM complicated with hypertension group (diabetic patients with hypertension). Informed consent for the examination was obtained from all the involved subjects. METHODSBefore MCA of subjects was detected, bilateral carotid artery was routinely detected by high-frequency ultrasonography. Subjects were rejected when stenosis rate of unilateral internal carotid artery or common carotid artery ≥ 70%. Vessels were expanded with transcranial color Duplex Doppler by breath holding test for detecting vascular reactivity. Hypercapnia was created by BHT. The mean velocity and diameter of blood flow were detected under the quiescent condition and 25 s after breath holding with transcranial color-coded duplex sonography. The volume of blood flow of MCA was calculated according to the following formula: Volume of blood flow of MCA (mL/ min) = (the diameter of blood flow /2)2 × π × mean blood flow velocity × 60. The increase rates of mean blood flow velocity and blood flow volume of patients with hypercapnia were calculated as compared with under the quiescent condition to evaluate cerebrovascular reactivity. MAIN OUTCOME MEASURESMean blood flow velocity, blood flow diameter and MCA blood flow volume as well as the increase rates of them. RESULTSAmong the 173 participates, 103 patients and 39 healthy controls were involved in the final analysis, and the other 31 dropped out due to not accomplishing the examination, (1)Comparison of blood flow parameter of MCA under the quiescent condition: The mean blood flow velocity of DM complicated by hypertension group was significantly higher than that of DM group (P < 0.05) and control group (P < 0.05); The blood flow diameter of DM complicated by hypertension group was significantly smaller than that of control group (P < 0.01). Under the quiescent condition, significant difference was not found in the intergroup comparison of blood flow volume of MCA. (2) Comparison of increase rate of blood flow parameter: In the DM group, hypertension group. DM complicated by hypertension group and control group, the increase rate of mean blood flow velocity of was (29.34±4.50) %, (29.35±4.35) %, (26.68±4.99) % and (30.99±3.54) %, respectively, the increase rate of blood flow volume of MCA was (35.32±5.08) %, (35.36±6.16) %, (31.78±7.11) % and (37.26±4.17) %, respectively, and the increase rate of blood flow diameter was (2.29±1.09) %, (2.27±0.95) %, (1.97±1.05) % and (2.36±0.46) %, respectively. The increase rate of mean blood flow velocity and that of blood flow volume of MCA in the DM complicated by hypertension group were significantly lower than those in the other 3 groups (P < 0.05). CONCLUSIONCVR is markedly lowered and cerebrovascular reserve capacity is damaged in diabetic patients with hypertension.

Progression of Large Vessel Disease in Patients With Giant Cell Arteritis-Associated Ischemic Stroke: The Role of Vascular Imaging: A Case Series.

Giant cell arteritis (GCA) can cause ischemic stroke (IS) due to the involvement of the internal carotid and vertebral arteries. The aim of our study is to describe the pattern of stroke recurrence in patients with GCA-related IS and the role of vascular imaging in the follow-up of these patients. We conducted an observational study of 2417 consecutive patients diagnosed with IS and admitted to our hospital from January 2012 to December 2018. We reviewed patients with GCA-related IS and the relationship of erythrocyte sedimentation rate, C-reactive protein, vascular status, and clinical course. We found 4 patients with GCA-related IS among 2417 IS patients: 1 woman (25%); median age, 77.3 years (67-85 years). Mean follow-up was 3.6 years. Initial vascular workup showed vertebral artery stenosis in all of them and internal carotid artery stenosis in 2 patients. All patients were started on treatment with full-dose prednisone, associated with methotrexate in 2 cases. Follow-up color-coded duplex sonography disclosed progression of arterial stenoses in 3 patients who suffered a recurrent IS (days after index stroke; mean, 27.67 [SD, 10.97]) despite normal C-reactive protein and erythrocyte sedimentation rate values. Vascular imaging, especially with color-coded duplex sonography, could play a role in the follow-up of patients with GCA-related IS and identify those patients with higher risk of recurrent stroke.

Assessment of celiac artery compression using color-coded duplex sonography.

Median arcuate ligament syndrome (MALS) is a rare condition due to compression of the celiac artery (CA) by an anatomically abnormal median arcuate ligament. With ultrasonography (US) as first-line diagnostic modality in patients with unclear abdominal pain, there is limited data on its diagnostic performance in MALS. To investigate the value of CA peak systolic velocity (PSV) in the workup of patients with suspected MALS. Patients with diagnosis of MALS between 2009 and 2019 were referred by Department of Visceral Surgery after clinical and gastroenterological workup. Diagnosis was confirmed by surgery or further cross-sectional imaging. B-mode US findings and PSV in the CA during various respiratory states were compared between patients with a final MALS diagnosis and patients not meeting the diagnostic criteria. Patients with proven MALS (n = 10) had higher median CA PSV during normal inspiratory breath-hold (239 [IQR, 159-327] vs. 138 [IQR, 116-152] cm/s; p < #x003C;< #x200A;0.001), and expiratory breath-hold (287 [IQR, 191-412] vs. 133 [IQR, 115-194] cm/s; p < #x003C;< #x200A;0.001) compared to patients without MALS (n = 26). CA PSV in both inspiratory breath-hold (AUC 0.88, 95% CI 0.77-1.00) and expiratory breath-hold (AUC 0.89, 95% CI 0.78-1.00) was of diagnostic value for confirming MALS. The best diagnostic performance (100% sensitivity, 80% specificity) was found for the combination of CA PSVexpiration+2.4·PSVinspiration>550cm/s . Since results on optimal cutoff values are inconsistent, a combination of CA PSVs during breathing maneuvers may help to diagnose or rule out MALS.

Radial artery occlusion after cardiac catheterization and impact of medical treatment.

Background: The transradial artery approach is the preferred access for cardiac catheterization according to current guidelines. However, the most common complication is radial artery occlusion (RAO). Despite the rare indication for surgical reopening, the occluded radial artery is not available for further procedures or as a potential bypass graft. Still, treatment regimens for RAO are scarce. We now determined whether the addition of antithrombotic to antiplatelet therapy improves the rate of partial or complete regain of patency in RAO following transradial cardiac catheterization in a retrospective analysis. Patients and methods: In a two-center tertiary referral hospital retrospective analysis 4135 files of patients who had undergone transradial catheterization were screened for documented RAO. 141 patients were identified and 138 patients with complete information on the medical regimen and ultrasound examinations for a maximum of 3 months were included in the analysis, whereas 3 patients were excluded due to missing or incomplete follow-up information. Results: 3.3% of all patients that had undergone transradial catheterization featured an oligosymptomatic RAO, confirmed by color-coded duplex sonography. 21% of patients with additional anticoagulation regained full patency vs. 9% without additional anticoagulation (p=0.07). 40% of patients with anticoagulation featured a partial or full regain of patency vs. 16% of patients without additional anticoagulation for a maximum of 3 months treatment (p=0.006). No major bleedings were reported during the follow-up visits. Conclusions: RAO remains a rare complication of cardiac catheterization. The addition of antithrombotic therapy for 3 months appears to safely improve the partial or even full regain of radial patency in case of postinterventional RAO.

Contrast-enhanced ultrasound (CEUS) reliably rules out neoplasm in developmental renal pseudotumor.

Renal pseudotumors appear as benign cortical hypertrophies and are typically assessed by contrast-enhanced computed tomography or magnetic resonance imaging to rule out malignancy. To investigate whether contrast-enhanced ultrasound (CEUS) can rule out renal neoplasm and thus potentially reduce cross-sectional imaging and further follow-up in these patients. Thirty-two patients with presumption of developmental renal pseudotumor on CEUS between June 2011 and July 2019 were retrospectively analyzed. All patients were examined with a standardized renal US protocol including B-mode, color-coded duplex sonography (CCDS), and CEUS by an experienced radiologist (EFSUMB level 3). Images were retrospectively interpreted in consensus by two highly experienced radiologists. Histopathological reports, cross-sectional imaging findings, and clinical course (treatment response, long-term imaging follow-up) were defined as standard of reference. CEUS correctly identified 8/9 neoplastic lesions and missed one oncocytoma within the 32 included patients. Irregular vessel structure (88.9% vs. 13.0%, P = 0.007) and hyperenhancement (66.6% vs. 17.4%, P = 0.031) on CEUS were more common in neoplasm compared to developmental pseudotumors reaching statistical significance. Compared with the standard of reference, CEUS had 89% sensitivity (95% confidence interval [CI] 57-98), 96% specificity (95% CI 80-99), a positive predictive value of 89% (95% CI 57-98), and a negative predictive value of 96% (95% CI 79-99) for ruling out renal malignancy in developmental pseudotumors. CEUS is a safe and fast method to rule out neoplasm in the diagnostic work-up of renal pseudotumors. In conjunction with B-mode and CCDS, CEUS has the potential to reduce further (invasive) diagnostic procedures.

Classification of Intracranial Stenoses: Discrepancies between Transcranial Duplex Sonography and Computed Tomography Angiography

Transcranial color-coded duplex sonography (TCCS) and computed tomography angiography (CTA) are widely used to identify intracranial stenoses (ISs). We assessed concordance of IS grading between TCCS and CTA and proposed new TCCS criteria for severe IS ≥70%. One hundred two stroke patients (70 ± 13 y) with TCCS-identified IS were included. TCCS and CTA were performed within 24 h after admission. TCCS peak systolic velocity cutoffs for <50%/50%–69% stenoses were ≥155/≥220 cm/s (middle cerebral artery [MCA]-M1), ≥100/≥140 cm/s (MCA-M2), ≥120/≥155 cm/s (anterior cerebral artery [ACA]-A1), ≥100/≥145 cm/s (posterior cerebral artery [PCA]-P1 and PCA-P2), ≥90/≥120 cm/s (vertebral artery [VA]-V4) and ≥100/≥140 cm/s (basilar artery [BA]). Criteria for ≥70% stenoses were, despite variable flow velocities, post-stenotic flow alterations and/or leptomeningeal collateral flow. One hundred seventy-seven ISs were detected by TCCS. The number and grade (<50%/50%–69%/≥70%) of ISs were MCA 70 (39/19/12), BA 24 (9/11/4), ACA 21 (14/7/0), PCA 49 (29/15/5) and VA 13 (2/6/5). IS localization was confirmed by CTA in 84 of 177 cases (48%): MCA, 41/70 (59%); BA, 16/24 (67%); ACA 2/21, (10%); PCA, 17/49 (35%); VA, 8/13 (62%). Concordance between TCCS and CTA grading was (<50%/50%–69%/≥70%) 17%/19%/77%. TCCS and CTA exhibited substantial differences in the detection and grading of IS. Higher concordance rates for severe stenosis support our proposed TCCS criteria.

A comparative study of preoperative color-coded Duplex ultrasonography versus handheld audible Dopplers in ALT flap planning.

The anterior lateral thigh (ALT) flap's vascular variability can lead to complications. Thus, the accuracy of numerous planning modalities has been studied. The clinical relevance of competing mapping methods, however, remains unknown. Therefore, we compared the impact of color-coded Duplex ultrasonography and handheld audible Dopplers on surgical efficacy and flap safety. Forty-four ALT flaps were included in this comparative retrospective monocentric study. Twelve patients received Duplex scans and 32 flaps were designed using Dopplers only. Patient, defect, and flap characteristics of both groups were analyzed. The effect of either planning method on the primary outcome variables - flap harvest and operative times (HT, OT), course of perforator dissection, incidence of flap loss, emergent re-explorations, and donor-site revisions - was then assessed. Patient, defect, and flap characteristics were comparable between both groups, including flap size (Doppler: 134 ± 73 cm2 , Duplex: 131 ± 65 cm2 , p = .90). There was no flap loss. Emergent re-explorations (Doppler: 4/32, Duplex: 1/12, p = .70) and donor-site revisions (Doppler: 2/32, Duplex: 1/12, p = .81) were equally distributed. Duplex rendered septal perforator dissection 10 times more likely (Chi-Square = 8.9, p = .003, OR = 9.7), reaching 50% (n = 6/12), as opposed to only 9% in the Doppler cohort (n = 3/32). This allowed for highly significant HT and OT reductions of 89 minutes, respectively (p < .01): from 255 and 383 min (Doppler) to 166 and 294 min (Duplex). Preoperative Duplex significantly reduces harvest and operative times of ALT flaps.