Doppler Criteria Research Articles

Role of clipping in aneurysmal subarachnoid hemorrhage: a post hoc analysis of the Earlydrain trial

The choice between clipping and coiling of ruptured cerebral aneurysms in subarachnoid hemorrhage (SAH) remains controversial. The recently published Earlydrain trial provides the opportunity to analyze the latest clip-to-coil ratio in German-speaking countries and to evaluate vasospasm incidence and explorative outcome measures in both treatment modalities. We performed a post hoc analysis of the Earlydrain trial, a multicenter randomized controlled trial investigating the use of an additional lumbar drain in aneurysmal SAH. The decision whether to clip or to coil the ruptured aneurysm was left to the discretion of the participating centers, providing a real-world insight into current aneurysm treatment strategies. Earlydrain was performed in 19 centers in Germany, Switzerland, and Canada, recruiting 287 patients with aneurysmal SAH of all severity grades. Of these, 140 patients (49%) received clipping and 147 patients (51%) coiling. Age and clinical severity based on Hunt-Hess/WFNS grades and radiological criteria were similar. Clipping was more frequently used for anterior circulation aneurysms (55%), whereas posterior circulation aneurysms were mostly coiled (86%, p < 0.001). In high-volume recruiting centers, 56% of patients were treated with clipping, compared to 38% in other centers. A per-year analysis showed a stable and balanced clipping/coiling ratio over time. Regarding vasospasm, 60% of clipped versus 43% of coiled patients showed elevated transcranial Doppler criteria (p = 0.007), reflected in angiographic vasospasm rates (51% vs. 38%, p = 0.03). In contrast to the Earlydrain main results establishing the superiority of an additional lumbar drain, explorative outcomes after clipping and coiling measured by secondary infarctions, mortality, modified Rankin Score, Glasgow Outcome Scale Extended, or Barthel-Index showed no significant differences after discharge and at six months. In clinical practice, aneurysm clipping is still a frequently used method in aneurysmal SAH. Apart from a higher rate of vasospasm in the clipping group, an exploratory outcome analysis showed no difference between the two treatment methods. Further development of periprocedural treatment modalities for clipped ruptured aneurysms to reduce vasospasm is warranted.

Impact of intracranial atherosclerosis burden on vasospasm risk and outcomes in aneurysmal subarachnoid hemorrhage

BackgroundCerebral vasospasm is a well-known complication after aneurysmal subarachnoid hemorrhage (aSAH) and occurs more commonly in younger patients. We hypothesized that intracranial atherosclerosis, which is seen predominantly in older patients, affects vasospasm risk. We sought to determine association between intracranial atherosclerosis burden with vasospasm and outcomes in aSAH. MethodsWe retrospectively reviewed a cohort of consecutive patients with aSAH admitted to a Comprehensive Stroke Center between 2016 and 2023. Intracranial atherosclerosis burden was quantified by using modified Woodcock (MW) score on CT angiograms. Vasospasm was defined based on transcranial Doppler (TCD) criteria. Poor outcome was defined as 3-month modified Rankin Scale 3–6. ResultsWe reviewed 392 patients and included 302 (mean age 56.8 years [SD 13.3], 65 % female and 70 % white) in the final analysis. MW scores were measured with excellent intra-rater and inter-rater reliability (Cohen's kappa coefficient 0.9 and 0.83 respectively) ranging from 0 to 3 (mean 0.59, SD 0.83) with higher scores in older patients (beta coefficient 0.019, 95 % CI 0.009–0.028; p < 0.001). Higher MW calcification score was associated with lower risk of vasospasm (OR 0.52 per point increase, 95 % CI 0.36–0.78; p = 0.001). There was an inverse correlation between MW scores and severity of vasospasm (beta coefficient −0.29, 95 % CI −0.48, −0.1; p = 0.003). However, MW score was not independently associated with poor functional outcome (p = 0.62). ConclusionsIntracranial atherosclerosis is a potential mechanism for lower TCD-based vasospasm in older patients with aSAH; however, it may not impact functional outcomes. Larger prospective studies are needed to confirm our findings.

Коагуляційні характеристики пуповинної крові при затримці росту плода

Fetal growth restriction (FGR) is a common complication of pregnancy associated with severe perinatal consequences, a significant part of which is hemorrhagic and thrombotic disorders. Fetuses with FGR have thrombocytopenia, platelet dysfunction, and distortion of standard coagulation tests. There are few studies of the coagulation system in such newborns in vivo in the literature. Аim - to assess the relationship between the Doppler criteria of FGR and the kinetic manifestations of umbilical artery blood coagulation and fibrinolysis according to rotational thromboelastometry. Materials and methods. Prenatal Doppler parameters and postpartum kinetic parameters of blood coagulation and fibrinolysis in 118 newborns from singleton births were analyzed: the Group I - 67 newborns with FGR; the Group II - 51 full-term newborns from healthy mothers. Results. A significant decrease in the uterine and umbilical arteries resistance and blood flow velocity in FGR cases has been established. Thromboelastometric tests in the umbilical cord blood of the Group I newborns showed faster than in the Group II the blood clot formation, its greater firmness and delayed fibrinolysis. Comparison using rank correlation showed a relationship of average strength between the velocity of blood flow in the umbilical cord arteries and the blood clot firmness. Correlation between blood flow velocity in the midbrain and uterine arteries and coagulation indicators are weak. Conclusions. Reduced resistance index in the middle cerebral artery of fetuses with FGR indicates reduced resistance in these vessels, which should be regarded as signs of decentralization of fetal circulation. The blood of newborns with FGR is dominated by the processes of increased coagulation and slowing down of fibrinolysis, regardless of the date of birth. An increase in the pulsation index in the umbilical cord arteries during pregnancy can be considered a prognostically favorable hemodynamic characteristic in FGR. The study was carried out in accordance with the principles of the Helsinki Declaration. The research protocol was approved by the Local Ethics Committee of the institution mentioned in the work. The authors declare that there is no conflict of interest.

Abstract WP139: Impact of Intracranial Atherosclerosis Burden on Vasospasm Risk and Outcomes in Aneurysmal Subarachnoid Hemorrhage

Background: Cerebral vasospasm is a well-known complication after aneurysmal subarachnoid hemorrhage (aSAH) and occurs more commonly in younger patients. We hypothesized that intracranial atherosclerosis, which is seen predominantly in older patients, affects vasospasm risk in aSAH. We sought to determine association between intracranial atherosclerosis burden with vasospasm and outcomes in aSAH. Design/Methods: We performed a retrospective study of a prospectively collected cohort of consecutive patients with aSAH admitted to a Comprehensive Stroke Center between July 2016 and April 2023. Intracranial atherosclerosis burden was quantified by using modified Woodcock (MW) score on CT angiograms measured by trained assessors. Vasospasm was defined based on transcranial Doppler (TCD) criteria. Worse outcome was defined as 3-month modified Rankin Scale 4-6. Univariable and multivariable logistic regression were used to test the association of predictors with outcomes. Results: We reviewed 302 cases of aSAH (mean age 56.8 years [SD 13.3], 65% female and 70% white). Cerebral vasospasm was reported in 46% of patients and was more common in younger patients (OR 0.91 for each year increase, 95% CI 0.89-0.94; p&lt;0.001). MW scores were measured with excellent intra-rater and inter-rater reliability (Cohen’s kappa coefficient 0.9 and 0.83 respectively) ranging from 0 to 3 (median 0, IQR 0-1) with higher scores in older patients (beta coefficient 0.019, 95% CI 0.009-0.028; p&lt;0.001). Higher MW calcification score was associated with lower risk of vasospasm (odds ratio 0.52 per point increase, 95% CI 0.36-0.78; p=0.001). There was an inverse correlation between MW scores and severity of vasospasm (beta coefficient -0.29, 95% CI -0.48, -0.1; p=0.003). However, MW score was not independently associated with worse functional outcome (p=0.62) when adjusted for age, Hunt and Hess grades, modified Fisher scores. Conclusions: Intracranial atherosclerosis is a potential mechanism for lower vasospasm rate in older SAH patients, however, it may not impact functional outcome. This may suggest intracranial atherosclerosis may affect TCD velocities without any clinical correlation. Larger prospective studies are needed to confirm our findings.

Abstract WP123: Accuracy of Cisternal Score in Predicting Cerebral Vasospasm Risk in Aneurysmal Subarachnoid Hemorrhage: A Post Hoc Analysis of a Single Center Study

Background: Cisternal score (CISCO), which is calculated based on quantification of blood clot in basal cisterns, has been shown to have good accuracy in predicting ventriculoperitoneal shunt requirement in patients with aneurysmal subarachnoid hemorrhage (aSAH). We hypothesized that CISCO is superior to modified Fisher score (mFS) in predicting vasospasm, a common complication associated with worse outcomes in aSAH, as it better quantifies blood clot burden in the basal cisterns. Design/Methods: We performed a post hoc analysis of a retrospective study of a cohort of consecutive patients with aSAH admitted to an academic center from 2016 through 2021. Data was collected prospectively as part of a quality improvement project. Cerebral vasospasm was defined based on transcranial Doppler criteria. CISCO, as previously described, was constructed based on quantification of blood clot thickness in the basal cisterns (interpeduncular, ambient, crural, prepontine, interhemispheric cisterns, and bilateral Sylvian fissures) on admission head CT scans. Receiver operating characteristics (ROC) curve analysis was performed to compare accuracy of CISCO with mFS in predicting vasospasm. Results: We included 176 patients with aSAH who had radiographic assessments with complete clinical data. Mean age was 54.9 years [SD 12.8] and 57% were female. Cerebral vasospasm was observed in 30% of patients. CISCO ranged from 0 to 10 with a median of 3 [IQR 1-5]. Higher CISCO was associated with higher risk of vasospasm (odds ratio 1.29 per point increase, 95% CI 1.17-1.49; p=0.001). ROC curve analysis revealed that CISCO had higher accuracy in predicting vasospasm compared to mFS but the difference was not significant (AUC 0.67, 95% CI 0.59-0.76 vs 0.60, 95% CI 0.52-0.68; p=0.10). Conclusions: CISCO has comparable accuracy with mFS score in predicting vasospasm in aSAH. Improvement in quantification methods using fully automated volumetric measurement techniques may further enhance its accuracy in predicting vasospasm in aSAH in future. Larger studies are needed to test this hypothesis and to explore the utility of using CISCO in clinical practice.

Diagnostic performance of spectral Doppler in acute appendicitis with an equivocal Alvarado score.

This study aims to evaluate the added value of duplex Doppler examination to the routinely graded compression grayscale ultrasound (US) for patients with suspected acute appendicitis (AA) in correlation with surgical management outcomes. The study lasted from January 2020 to March 2021. Throughout that period, patients who had suspected appendicitis were included with a visible appendix in the grayscale US. These patients were categorized clinically based on Alvarado's score. They underwent graded compression grayscale US of the appendix and duplex Doppler study. Subsequently, they were assigned for non-contrast multislice computed tomography (MSCT) according to Alvarado's score and underwent either emergency appendicectomy or conservative clinical management afterward. A Student's t-test was used to determine if there were significant differences in the mean values between the groups. The diagnostic performance of spectral Doppler US for the diagnosis of AA was depicted. Eighty-four patients with visualized color flow in the appendicular Doppler US were enrolled, with 60 (71.4%) having AA, and 24 (28.6%) not having appendicitis. Spectral Doppler criterion of PSV greater than 8.6 cm/s demonstrated a high sensitivity of 91.67% and specificity of 77.78% for patients with Alvarado score ranging from 4 to 7, and appendiceal MOD ranging from 6 to 8 mm, while a discriminatory criterion of RI greater than 0.51 had a high sensitivity of 100% and a relatively lower specificity of 66.67%. The patients with AA have significantly higher point PSV and point RI values than those without AA and are especially useful in equivocal patients whose MODs and Alvarado scores are in the diagnostically equivocal ranges of 6-8 mm and 4-7, respectively, with the point PSV and RI demonstrating negative predictive value 87.5% and 100%.

The Flow Volume and Resistance Index of Patent Arteriovenous Fistulas, With Proper Function, Compared to Unhealthy Arteriovenous Fistulas, Using Spectral Doppler

Objective: This study was designed to use sonography and evaluate arteriovenous fistulas (AVFs) in dialysis patients. The aim was to determine criteria for distinguishing between patent AVFs with proper function (healthy) and unhealthy AVFs. Materials and Methods: This study enrolled 106 dialysis patients with an AVF. All fistulas were evaluated using spectral Doppler and grayscale sonography, assessing parameters such as draining vein diameter, distance of the venous vein from the skin surface, feeding artery diameter, presence of thrombosis, and fistula stenosis. Subsequently, Doppler criteria such as flow volume (FV) and resistance index (RI) were measured and compared between healthy and unhealthy AVFs. Results: This cohort’s spectral Doppler findings demonstrated lower FV and higher RI, in unhealthy AVFs, compared to healthy ones (283.5 ± 101.26 mL/min vs 1383.43 ± 756.76 mL/min; P = .006) and (0.55 ± 0.33 vs 0.37 ± 0.14; P = .004) respectively. Conclusion: The spectral Doppler and grayscale sonographic imaging made it possible to evaluate AVF performance and determine its quality. In this cohort, a decreased FV, increased RI, and decreased draining vein diameter were observed in unhealthy AVFs. These results would suggest that sonographers and clinicians should pay close attention to these parameters when assessing the function of an AVF, for patients undergoing hemodialysis.

Management of late-onset fetal growth restriction: pragmatic approach.

There is limited prospective evidence to guide the management of late-onset fetal growth restriction (FGR) and its differentiation from small-for-gestational age. The aim of this study was to assess prospectively a novel protocol in which ultrasound criteria were used to classify women with suspected late FGR into two groups: those at low risk, who were managed expectantly until the anticipated date of delivery, and those at high risk, who were delivered soon after 37 weeks of gestation. We also compared the outcome of this prospective cohort with that of a historical cohort of women presenting similarly with suspected late FGR, in order to evaluate the impact of the new protocol. This was a prospective study of women with a non-anomalous singleton pregnancy at ≥ 32 weeks' gestation attending a tertiary hospital in London, UK, between February 2018 and September 2019, with estimated fetal weight (EFW) ≤ 10th centile, or EFW > 10th centile in addition to a decrease in fetal abdominal circumference of ≥ 50 centiles compared with a previous scan, umbilical artery Doppler pulsatility index > 95th centile or cerebroplacental ratio < 5th centile. Women were classified as low or high risk based on ultrasound and Doppler criteria. Women in the low-risk group were delivered by 41 weeks of gestation, unless they subsequently met high-risk criteria, whereas women in the high-risk group (EFW < 3rd centile, umbilical artery Doppler pulsatility index > 95th centile or EFW between 3rd and 10th centiles (inclusive) with abdominal circumference drop or abnormal Dopplers) were delivered at or soon after 37 weeks. The primary outcome was adverse neonatal outcome and included hypothermia, hypoglycemia, neonatal unit admission, jaundice requiring treatment, suspected infection, feeding difficulties, 1-min Apgar score < 7, hospital readmission and any severe adverse neonatal outcome (perinatal death, resuscitation using inotropes or mechanical ventilation, 5-min Apgar score < 7, metabolic acidosis, sepsis, and cerebral, cardiac or respiratory morbidity). Secondary outcomes were adverse maternal outcome (operative delivery for abnormal fetal heart rate) and severe adverse neonatal outcome. Women managed according to the new protocol were compared with a historical cohort of 323 women delivered prior to the implementation of the new protocol, for whom management was guided by individual clinician expertise. Over 18 months, 321 women were recruited to the prospective cohort, of whom 156 were classified as low risk and 165 were high risk. Adverse neonatal outcome was significantly less common in the low-risk compared with the high-risk group (45% vs 58%; adjusted odds ratio (aOR), 0.6 (95% CI, 0.4-0.9); P = 0.022). There was no significant difference in the rate of adverse maternal outcome (18% vs 24%; aOR, 0.7 (95% CI, 0.4-1.2); P = 0.142) or severe adverse neonatal outcome (3.8% vs 8.5%; aOR, 0.5 (95% CI, 0.2-1.3); P = 0.153) between the low- and high-risk groups. Compared with women in the historical cohort classified retrospectively as low risk, low-risk women managed under the new protocol had a lower rate of adverse neonatal outcome (45% vs 58%; aOR, 0.6 (95% CI, 0.4-0.9); P = 0.026). Appropriate risk stratification to guide management of late FGR was associated with a reduced rate of adverse neonatal outcome in low-risk pregnancies. In clinical practice, a policy of expectantly managing women with a low-risk late-onset FGR pregnancy at term could improve neonatal and long-term development. Randomized controlled trials are needed to assess the effect of an evidence-based conservative management protocol for late FGR on perinatal morbidity and mortality and long-term neurodevelopment. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The Comparison of Pulsatility Index, Resistance Index, and Diameter of the Temporal, Carotid, and Vertebral Arteries During Active Migraine Headaches to Non-Headache Intervals

Objective: Migraine is a debilitating disease affecting a large number of young people. In this study, he aim was to assess the extracranial arteries during migraine headaches and non-headache headache intervals using sonography. Materials and Methods: The study enrolled 210 patients with confirmed migraine headaches. The vertebral arteries, superficial temporal arteries, internal carotid arteries (ICAs), and common carotid arteries were assessed using a sonographic method. Grayscale and spectral doppler criteria, such as the diameter of arteries, peak systolic velocity (PSV), and pulsatility index (PI), during migraine headaches and non-headache headache intervals were measured. Results: Assessing the vertebral and external carotid arteries, a significant difference was observed between the diameter of the arteries during active headaches and that during non-headache headache periods. The mean PSV of ICA during active headaches was 60.05 cm/s, which was lower than that during non-headache headache periods, which was 69.35 cm/s ( P = .016). Conclusion: In this cohort’s migraine headaches, the diameter of the superficial temporal artery and ICA are increased and the diameter of the vertebral artery is decreased. Decreased PSV of the vertebral artery in contrast with increased PSV of the temporal artery is seen during headaches. These diagnostic findings may be useful in predicting migraine headaches and should be replicated with other patients.

Impact of Circle of Willis Anatomical Variations on Outcomes in Aneurysmal Subarachnoid Hemorrhage (P7-5.027)

<h3>Objective:</h3> We sought to determine the association between circle of Willis (CoW) anatomical variations and outcomes in aneurysmal subarachnoid hemorrhage (aSAH) patients. <h3>Background:</h3> The impact of CoW anatomical variations on vasospasm risk and functional outcome in patients with aSAH is poorly understood. <h3>Design/Methods:</h3> We performed a retrospective study on a single center cohort of patients with aSAH admitted to an academic center between 2015 and 2022. After reviewing imaging, we classified CoW variants into 4 categories: 1) incomplete anterior segments if either proximal anterior cerebral or anterior communicating arteries were absent or hypoplastic (with a 1mm diameter cutoff), 2) incomplete posterior segments if posterior communicating or proximal posterior cerebral arteries were absent or hypoplastic; 3) complete CoW; 4) others. Outcomes include vasospasm based on transcranial Doppler (TCD) criteria and poor functional outcome defined as modified Rankin Scale 4–6 at 3 months post discharge. Binary logistic regression analysis was used to test the association of each CoW variant with outcomes. <h3>Results:</h3> We included 178 patients with aSAH (mean age 55.9 years [SD 13.6], 56% female). Eighty percent of patients had incomplete CoW and they were older than those with complete CoW (mean age 57.4 [SD12.7] vs 49.9 [15.4]; p=0.003). Incomplete posterior segments were seen in 73% of patients. The presence of incomplete anterior segments was more common in females (11% vs 1%; p=0.01) and it was associated with vasospasm (OR 2.39, 95% CI 1.02–5.63; p=0.042), but not with poor functional outcome (p=0.89). There was no association between incomplete posterior segments and vasospasm risk (p=0.29) or poor functional outcome (p=0.93). <h3>Conclusions:</h3> Anatomical variations of the CoW may affect TCD findings but did not appear to be associated with poor outcomes. Larger prospective studies are needed to explore clinical significance of CoW variants in aSAH patients. <b>Disclosure:</b> Scott Moody has nothing to disclose. Mr. Pham has nothing to disclose. Mr. Ozcan has nothing to disclose. Miss Haripottawekul has nothing to disclose. Dr. Subramaniam has nothing to disclose. Dr. Reznik has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Morrison Mahoney. The institution of Dr. Reznik has received research support from NIDUS. The institution of Dr. Furie has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Janssen/BMS. The institution of Dr. Furie has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for ACTICOR. Dr. Furie has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for BMJ/JNNP. The institution of Dr. Furie has received research support from NINDS. Dr. Yaghi has nothing to disclose. Dr. Mahta has nothing to disclose.

Прогнозирование риска неблагоприятных перинатальных исходов у беременных с задержкой роста плода

Objective. Development of additional Doppler criteria for predicting the risk of adverse perinatal outcomes in pregnant women with fetal growth restriction (FGR) Patients and methods. 161 patients with singleton pregnancies were examined: 100 women were diagnosed with АПК, and 31 women had fetuses that were low in weight by gestational age; The control group consisted of 30 patients with normal fetal growth. Ultrasound, in addition to fetometry, included Doppler sonography of blood flow in the uterine arteries, umbilical arteries and the fetal middle cerebral artery. The cerebroplacental ratio (CPR) and cerebro-placental-uterine ratio (CPUR) were determined. Reference values of CPUR in patients with FGR have been developed. Results. The ROC analysis in 100 patients with FGR showed that using of CPUR predict a high risk of adverse perinatal outcomes with a sensitivity of 60% and a specificity of 82%. The positive predictive value of CPUR was 91% (83% for CPR). In pregnant women with severe FGR (&lt;3rd centile), the positive prognostic value was – 97%, the highest values were founded in patients with an early phenotype – 100% (with late – 93%). Conclusion. CPUR has a high prognostic significance in relation to the risk of adverse perinatal outcomes in patients with FGR, which indicates the using this indicator along with CPR in the examination of patients with low fetal weight. Key words: fetal growth restriction, early phenotype, late phenotype, cerebro-placental ratio, cerebro-placental-uterine

Association of asymptomatic cerebral vasospasm with outcomes in survivors of aneurysmal subarachnoid hemorrhage

BackgroundCerebral vasospasm (cVSP) is a common complication in aneurysmal subarachnoid hemorrhage (aSAH) and is associated with worse outcomes. However, clinical significance of asymptomatic cVSP is poorly understood. We sought to determine the association of asymptomatic cVSP with functional outcome and hospital length of stay (LOS). MethodsWe performed a retrospective study of a prospectively collected cohort of patients with aSAH who survived hospitalization at an academic center between 2016 and 2021. We defined cVSP based on transcranial Doppler criteria. Multivariate logistic and multiple linear regression analyses were used to determine the association of asymptomatic cVSP with poor functional outcome (defined as modified Rankin scale 3-6 at 3 months after discharge) and hospital length of stay (LOS). ResultsThe cohort consisted of 201 aSAH patients with a mean age 54.9 years (SD 13.6) and 60% were female. One hundred nine patients (54%) experienced cVSP, of whom 43 patients (39%) were asymptomatic. Patients with asymptomatic cVSP were younger (mean 50.5 years [SD 10.6] vs 61 years [SD12.5]; p < 0.001) and had longer ICU LOS (median 13 days [IQR12-20] vs median 12 days [IQR9-15], p = 0.018) compared to those without cVSP. However, after adjusting with other variables asymptomatic cVSP was not associated with longer ICU or hospital LOS. Asymptomatic cVSP was not associated with poor outcome either (p = 0.14). ConclusionAsymptomatic cVSP, which was more common in younger patients, was neither associated with poor functional outcome nor hospital LOS. Larger prospective studies are needed to assess the significance of asymptomatic cVSP on long-term outcomes.

Ультразвуковая оценка морфологии и тяжести митральной недостаточности

The article describes in detail the mechanisms of anatomical and functional changes in the mitral valve that cause its insufficiency. Modern recommendations on diagnostic criteria and assessment of the severity of mitral regurgitation are given. Attention is drawn to the need for an integrated approach to diagnosis, integrating data on morphological changes in the valve, Doppler criteria and the degree of hemodynamic disorders

Abstract TP141: Impacts Of Dysnatremia On Outcomes In Aneurysmal Subarachnoid Hemorrhage

Disturbances in serum sodium levels are common following aneurysmal subarachnoid hemorrhage (aSAH) and may lead to increased morbidity, mortality, and poor functional outcomes. This study aims to examine the relationship between abnormal sodium levels following aSAH and patient outcomes. A retrospective cohort study of consecutive patients with aSAH who were admitted to an academic referral center between 2015 and 2021 was performed. Dysnatremia was categorized as either mild or moderate-severe and patients were sorted accordingly. Multivariable logistic regression was used to test the association of any dysnatremia and outcomes, including modified Rankin Scale (mRS) at 3 months after discharge, vasospasm (based on transcranial Doppler criteria), delayed cerebral ischemia (DCI) and refractory hydrocephalus requiring ventriculoperitoneal shunt. Multiple linear regression was used to test the association of hospital length of stay and dysnatremia (categorical variables). We included 320 patients (mean age 57.8 years (SD 14.3), 61% female, 70% white). Hyponatremia was seen in 58% for a median of 3 days [IQR 1-6], with moderate-severe hyponatremia occurring in 5%. Hypernatremia was observed in 49% for a median of 5 days [IQR 2-8], 56% of whom had moderate-severe hypernatremia. Of 156 hypernatremic patients, 80% were treated with hypertonic saline for cerebral edema. Hypernatremia was independently associated with a higher odds of vasospasm (OR 1.75, 95% CI 1.02-303, p =0.04) when adjusted for Hunt and Hess grades, cerebral edema and modified Fisher scales. There was no independent association between any dysnatremia and mRS, DCI or refractory hydrocephalus. Hospital length of stay was longer in patients with hypernatremia (8.11 more hospital days, 95% CI 5.4-10.8; p &lt;0.001) independent of age, Hunt and Hess grades, modified Fisher scales and hospital complications, including cerebral edema, vasospasm, DCI and refractory hydrocephalus. In conclusion, although dysnatremia may not directly affect functional outcome, hypernatremia may prolong hospital length of stay by increasing risk of cerebral vasospasm. These findings underscore the importance of judicious use of hypertonic saline and avoidance of hypernatremia in aSAH patients.

Abstract TP166: Association Of Hemoglobin Trend And Outcome In Aneurysmal Subarachnoid Hemorrhage

Introduction: Anemia has been linked to delayed cerebral ischemia and worse outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, the association of hemoglobin (Hb) trend on outcomes has not been well studied. We sought to determine predictors of Hb trend and its association with outcomes in aSAH. Methods: We conducted a retrospective cohort study of consecutive patients with aSAH who were admitted to an academic center from 2016 through 2021. Multiple linear regression analysis was used to identify factors associated with Hb difference from admission to discharge (continuous variable). Binary logistic regression analysis was used to test the association of Hb values (on admission, discharge, trend and difference from admission to discharge) with outcome measures including vasospasm (based on transcranial Doppler criteria) and worse functional outcome defined as modified Rankin scale (mRS) 4-6 at 3 months after discharge. Results: We included 312 patients with confirmed aneurysmal etiology (mean age 57 years, SD13.6; 62% female; 70% white). Mean Hb on admission was 13.5 g/dl (SD 1.7) and on discharge was 11.1 g/dl (SD 2). Forty-three patients (14%) required blood transfusions. Greater Hb drop from admission to discharge was independently associated with higher risk of vasospasm (OR 1.16, 95% CI 1.02-1.30; p=0.018) but not worse outcome after adjustment for age, sex, Hb on admission, Hunt and Hess grades, modified Fisher scales. Predictors of Hb drop on multiple linear regression analysis were lower Hb on admission (beta=0.61, p&lt;0.001), longer ICU length of stay (0.5 mg/dl drop per 10 days, p&lt;0.001), female sex (beta=0.66, p=0.008) and higher Hunt and Hess grades (beta=0.34 per grade, p=001). Conclusions: Greater hemoglobin drop was associated with higher risk of vasospasm but unlike lower Hb at discharge, it was not associated with worse outcome. Further studies are needed to use Hb trend to guide transfusion threshold in these patients.

Abstract TP113: Association Of External Ventricular Drain Duration And Outcomes In Aneurysmal Subarachnoid Hemorrhage

Introduction: Hydrocephalus is a common complication following aneurysmal subarachnoid hemorrhage (aSAH) and is usually treated with external ventricular drain (EVD). However, there is no consensus on EVD weaning process and duration of cerebrospinal fluid (CSF) drainage. We aimed to determine association of EVD duration and outcomes. Methods: We performed a retrospective cohort study of consecutive patients with aSAH who were admitted to an academic referral center between 2016 and 2021. Binary logistic regression was used to test the association of EVD duration (continuous variable) and outcomes including functional outcome defined as modified Rankin scale of 4-6 at 3 months after discharge and requirement for ventriculoperitoneal shunt (VPS) placement. Multiple linear regression analysis was used to test the association of EVD duration and hospital length of stay (both continuous variables) Results: Of 316 patients with aSAH, 253 patients received external ventricular drain (EVD) on admission for symptomatic hydrocephalus and we included survivors (n=204) in final analysis. (mean age 57.9 years (SD 13.8), 62% female, 71% white). VPS was placed in 15% (30/204) prior to hospital discharge. Duration of EVD was longer in patients with worse functional outcome (median 18 days [IQR 13.5-23] vs 12 days [IQR 8-19); p=0.006). EVD wean was interrupted in 39% of survivors (80/204) due to persistent hydrocephalus (61%) and asymptomatic vasospasm (19%) based on transcranial Doppler criteria. Longer EVD duration was associated with higher VPS requirement (odds ratio 1.17 per day, 95% CI 1.09-1.26; p&lt;0.001) after adjustment for age, aneurysm related factors, Hunt and Hess grades, modified Fisher scales and delayed cerebral ischemia. EVD related complications such as infections (2%) and tract hemorrhage (9%) were non-significantly higher in patients with longer EVD duration. (p=0.070) Longer EVD duration was associated with longer hospital length of stay (0.88 more days, 95% CI 0.73-1.04; p&lt;0.001) independent of aSAH complications. Conclusions: Longer EVD duration can be associated with worse outcomes and higher need for VPS placement and longer hospital length of stay. Further studies are needed to justify early VPS placement in selected patients.

The utility of spectral Doppler evaluation of acute appendicitis.

The use of spectral Doppler, peak systolic velocity (PSV), and resistive index (RI) imaging criteria to improve the accuracy of acute appendicitis diagnosis is hypothesized. Graded compression ultrasound was performed for suspected patients. The spectral Doppler evaluation was conducted while observing the appendix. A total of 152 patients (82 males and 70 females, ages 4-63years, mean age of 24.5years) were examined using the spectral Doppler waveform between 2018 and 2019. RI and PSV values of patients with and without appendicitis were compared to histopathologic findings. SPSS 26 was used to analyze the data, including using descriptive statistics and measures of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Appendicitis was confirmed in 95 patients (62.5%) and rejected in 57 patients (37.5%). For the diagnosis of appendicitis, the area under the curve (AUC) of receiver operating characteristic (ROC) for RI (0.92 with 95% confidence interval (CI): 0.88, 0.97; P = 0.001) and PSV (0.96, with 95% CI: 0.93, 1.00; P = 0.001) was calculated. The discriminatory RI ≥ 0.49 demonstrated high sensitivity (90.5%) and low specificity (86%), and the discriminatory PSV ≥ 9.6cm/s had high specificity (94.7%) and sensitivity (94.7%) for appendicitis. By incorporating spectral Doppler criteria into routine graded compression ultrasound, the diagnostic accuracy of acute appendicitis was increased. In comparison, high PSV and RI values of the appendix with a cut-off point of 9.6cm/s and 0.49 differ significantly between positive and negative appendectomy patients.

Integrated 2D Doppler indices of uteroplacental and fetal blood flow in diagnosis of intrauterine hypoxia

Relevance . Intrauterine hypoxia associated with placental disorders is a significant factor of ante-, intra- and postnatal fetal and newborn death. Despite clinical examination of pregnant women using ultrasound and cardiotocography, cases of intrauterine hypoxia often remain undetected prenatally. Clinical manifestation of placental disorders and intrauterine hypoxia are associated with pathological changes of blood flow resistance in the uterine, placental and fetal vessels. A combined Doppler assessment of blood flow in the uterine, placental and fetal vessels could improve detection of intrauterine hypoxia. The aim of the study was to assess the prognostic significance of integrated 2D Doppler indices of uteroplacental and fetal blood flow for the detection of fetal hypoxia in the 3rd trimester and to predict unfavorable perinatal outcomes. Materials and Methods. The outcomes of pregnancy of 48 women with fetal hypoxia delivered at 29 - 40 gestational weeks (study group), and 21 women who gave birth to healthy full-term infants (control group) were retrospectively analyzed. On the eve of delivery all women had 2D Doppler assessment of the uterine arteries, umbilical arteries, and fetal middle cerebral artery with an assessment of the cerebro-placental ratio, umbilical-cerebral ratio and cerebro-placental-uterine ratio. Results and Discussion . Analysis of the obtained values of cerebro-placental-uterine ratio, cerebro-placental ratio and umbilical-cerebral ratio showed the benefit from use of integrated 2D Doppler indices in the diagnosis of fetal hypoxia at 29 - 40 gestations weeks and in predicting complications in newborns. The high sensitivity of the cerebro-placental-uterine ratio (90.5%) makes it possible to effectively use this index for the diagnosis of intrauterine hypoxia. Conclusion. Pathological cerebro-placental-uterine ratio 2.44 is a clinically significant 2D Doppler criterion that predicts a high risk of asphyxia, respiratory distress syndrome, hypotrophy, and perinatal hypoxic-ischemic encephalopathy. Lower values of the cerebro-placental ratio and umbilical-cerebral ratio sensitivity (77.1% and 81.3%, respectively) limit their use for the diagnosis of fetal hypoxia as compared with cerebro-placental-uterine ratio.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Extracranial Cerebrovascular System.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Extracranial Cerebrovascular System.

Cerebral vasospasm in children with subarachnoid hemorrhage: frequency, diagnosis, and therapeutic management.

The present study explores the frequency, diagnostic approach, and therapeutic management of cerebral vasospasm in a cohort of children with moderate-to-severe traumatic and nontraumatic subarachnoid hemorrhage (SAH). This was a single-center retrospective study performed over a 10-year period, from January 2010 to December 2019. Children aged from one month to 18years who were admitted to the pediatric or adult intensive care unit with a diagnosis of SAH were eligible. Cerebral vasospasm could be suspected by clinical signs or transcranial Doppler (TCD) criteria (mean blood flow velocity > 120cm/s or an increase in mean blood flow velocity by > 50cm/s within 24h) and then confirmed on cerebral imaging (with a reduction to less than 50% of the caliber of the cerebral artery). Eighty patients aged 8.6years (3.3-14.8years, 25-75th centiles) were admitted with an initial Glasgow Coma Scale score of 8 (4-12). SAH was nontraumatic in 21 (26%) patients. A total of 14/80 patients (18%) developed cerebral vasospasm on brain imaging on day 6 (5-10) after admission, with a predominance of nontraumatic SAH (12/14). The diagnosis of cerebral vasospasm was suspected on clinical signs and/or significant temporal changes in TCD monitoring (7 patients) and then confirmed on cerebral imaging. Thirteen of 14 patients with vasospasm were successfully treated using a continuous intravenous infusion of milrinone. The Pediatric Cerebral Performance Category score at discharge from the intensive care unit was comparable between children with vasospasm (score of 2 [1-4]) vs. children without vasospasm (score of 4 [2-4]) (p = 0.09). These findings indicate that cerebral vasospasm exists in pediatrics, particularly after nontraumatic SAH. The use of TCD and milrinone may help in the diagnostic and therapeutic management of cerebral vasospasm.