Higher Pulsatility Index Research Articles

EP16.18: Pregnancy association of abnormal Doppler indices with inherited thrombophilia

Thrombophilia reflects a hypercoagulable condition with an increased thrombogenic potential during pregnancy. The most frequent causes of inherited thrombophilia are the factor V Leiden mutation and the prothrombin gene mutation. Repetitively, it has been hypothesised that thrombophilic mutations associate an increased risk of thrombosis at the low flow maternal-placental interface resulting in placenta-mediated complications, such as miscarriage, fetal loss, pre-eclampsia, fetal growth impairment, and abruption. Our prospective study aimed to determine the impact of thrombophilic mutations on second and third trimester umbilical and uterine artery Doppler parameters. Four hundred and forty-eight pregnant women were tested for the presence of factor V Leiden mutation, prothrombin gene mutation and also for a series of minor thrombophilic mutations. Each patient included in the study has been examined by ultrasound corresponding to its gestational age with the measurement of umbilical and uterine artery velocity. The measured parameters (pulsatility index and resistivity index) were interpreted consistent with gestational age nomograms. The incidence of factor V Leiden mutation was 10.4% in the studied group and the incidence of the prothrombin gene mutation was 4.46%; 11 cases (2.4%) expressed both major mutation. In 6.6% of cases corresponding to second trimester pregnancies with factor V Leiden mutation an increased pulsatility index of umbilical artery was found and 11% of these cases had a high pulsatility index of the uterine artery. For the cases with both major thrombophilic mutations present, Doppler parameters were increased in 4 from 6 cases. Even if inherited thrombophilia is not considered a major risk factor for most adverse pregnancy outcomes, Doppler assessment of fetal status is imperative for high-risk population. In our study, the impact of thrombophilia on Doppler indices was modest and limited to major mutations.

Cerebral Hemodynamics in Mild Cognitive Impairment: A Systematic Review.

The incidence of dementia is projected to rise over the coming decades, but with no sensitive diagnostic tests available. Vascular pathology precedes the deposition of amyloid and is an attractive early target. The aim of this review was to investigate the use of cerebral hemodynamics and oxygenation as a novel biomarker for mild cognitive impairment (MCI), focusing on transcranial Doppler ultrasonography (TCD) and near-infrared spectroscopy (NIRS). 2,698 articles were identified from Medline, Embase, PsychINFO, and Web of Science databases. 306 articles were screened and quality assessed independently by two reviewers; 26 met the inclusion criteria. Meta-analyses were performed for each marker with two or more studies and limited heterogeneity. Eleven studies were TCD, 8 NIRS, 5 magnetic resonance imaging, and 2 positron/single photon emission tomography. Meta-analyses showed reduced tissue oxygenation index, cerebral blood flow and velocity, with higher pulsatility index, phase and cerebrovascular resistance in MCI compared to controls. The majority of studies found reduced CO2 reactivity in MCI, with mixed findings in neuroactivation studies. Despite small sample sizes and heterogeneity, meta-analyses demonstrate clear abnormalities in cerebral hemodynamic and oxygenation parameters, even at an early stage of cognitive decline. Further work is required to investigate the use of cerebral hemodynamic and oxygenation parameters as a sensitive biomarker for dementia.

Clinical study of monitoring of transcranial Doppler ultrasonography to seriously illed children with cerebral dysfunction

Objective To investigate the application value of transcranial Doppler ultrasonography(TCD) in critically ill children with cerebral dysfunction. Methods We detected the cerebral blood flow parameters[systolic velocity(Vs), mean velocity(Vm), end of diastolic velocity(Vd), pulsatility index(PI), resistance index(RI)] of middle cerebral artery in cerebral dysfunction group(n=20) and control group(no cerebral dysfunction, n=20), and observed the differences of those parameters between two groups.Children in cerebral dysfunction group were also divided into groups according to Glasgow Coma Score(GCS) and prognosis.The differences of each TCD parameter in diverse groups divided by GCS and by prognosis were analysed.Children in cerebral dysfunction group were checked TCD everyday until TCD parameters were normal.The relation between the days of TCD parameters′ reaching normal and GCS, duration of disorder of consciousness with correlation analysis were analysed. Results Vs, PI, RI in cerebral dysfunction group were higher than those in control group, while Vd was lower (P<0.05). (2)PI in the group of GCS less than 6 points(0.91±0.21) was higher than that in group of GCS 7-13 points(0.83±0.14)(P<0.05). The other parameters between two groups of GCS less than 6 points and GCS 7-13 points were not significantly indistinctive.Between the good prognosis group and the bad prognosis group, there were no significant differences in all parameters.(3) The days of TCD parameters′ reaching normal were negatively correlated with GCS(r=-0.653, P<0.01), but positively correlated with the duration of disorder of consciousness(r=0.923, P<0.01). Conclusion The cerebral hemodynamics of children with cerebral dysfunction is abnormal, the more serious cerebral dysfunction, the higher PI and the longer time for regaining normal TCD parameters.Constantly monitoring TCD could reflect the changes of cerebral hemodynamics and is valuable to assess the state of illness and prognosis. Key words: Seriously cerebral dysfunction; Transcranial Doppler ultrasonography; Children,

Intraoperative graft verification in coronary surgery.

Transit-time flow measurement (TTFM) is a reliable method to check the graft function intraoperatively in coronary surgery. The given parameters are: Mean Graft Flow (MGF); Pulsatility Index (PI) and Insufficiency Ratio (%BF). Some cutoffs of these parameters have been identified as predictors for unfair 1-y clinical outcome: mean graft flow (MGF) less than 20 ml/min and high pulsatility index greater than 5. Other cutoffs have been found as related to postoperative angiography: MGF 15 ml/min or less and pulsatility index at least 3 (sensitivity 94%; specificity 61%); MGF less than 15 ml/min and pulsatility index greater than 3 for left coronary artery or pulsatility index greater than 5 for right coronary artery (sensitivity 96%; specificity 77%); MGF 15 ml/min or less and pulsatility index at least 5.1 left coronary artery (sensitivity 98%; specificity 26%). Hence, with the need to improve the diagnostic accuracy of TTFM, high-resolution epicardic coronary ultrasound module has been added to graft flow evaluation providing 2D ultrasound imaging (either in short-axis or long-axis) and color-flow mapping, allowing an accurate morphological evaluation of body graft and anastomosis. An intraoperative method aimed to verify coronary grafts should be easy to handle, not time consuming, minimally invasive, easily meaningful and relatively cheap; in addition, it should offer objective parameters more than qualitative criteria. We herein report the results of our experience with intraoperative graft verification with TTFM and high-resolution imaging along with a systematic review of the literature in this field with the aim to provide a road map to be followed.

Vertebral artery terminating in posterior inferior cerebellar artery: A normal variation with clinical significance.

A vertebral artery (VA) terminating in a posterior inferior cerebellar artery (PICA) is often considered to be a normal variation associated with VA hypoplasia. We aimed to investigate the clinical significance of this cerebrovascular variant. A total of 80 patients with clinically evident cerebrovascular events in posterior circulation were examined by duplex sonography and magnetic resonance angiography (MRA). Eighty healthy subjects who had MRA check-up were recruited as controls. PICA termination of the VA (PICA-VA) was identified as the VA not communicating with the basilar artery (BA) but ending into a PICA. We compared the prevalence of PICA-VA and associated hemodynamic parameters between the patients with and without PICA-VA, and investigated their relationships with VA hypoplasia. The prevalence of PICA-VA was higher in the patient group than in the controls (18.7% vs. 6.3%, p = 0.015). Most measurements (73.3%) of PICA-VA did not fit the criteria of VA hypoplasia. In comparison with the non-PICA-terminating group, the PICA-VA has a smaller diameter (3.7 ± 0.7 mm vs. 3.0 ± 0.5 mm, p < 0.001), lower mean velocity (241 ± 100 mm/sec vs. 164 ± 88 mm/sec, p < 0.01), and higher pulsatility index (1.3 ± 0.5 vs. 1.9 ± 0.6, p < 0.001). Moreover, a smaller diameter of the BA (3.2 ± 0.5 mm vs. 2.5 ± 0.9 mm, p = 0.004) and the posterior cerebral artery (PCA) (2.0 ± 0.1 mm vs. 1.6 ± 0.1 mm, p = 0.006) were also noted in the PICA-VA group. The higher prevalence of PICA-VA in the patient group with smaller diameter of VA, BA and PCA reflected its clinical significance, suggesting that PICA-VA may have a detrimental impact on cerebral hemodynamics. However, the sample is small, and further studies are needed with larger sample size for confirmation.

PS-02-001 Cardiometabolic risk and female sexuality: Focus on clitoral vascular resistance

... The relationship between sexual and cardiovascular health in women is not well defined. Clitoral colour Doppler ultrasound (CDU) with assessment of pulsatility index (PI), reflecting resistance to blood flow, has been proposed as an objective measurement of sexual functioning. The aim of the present study was to investigate the associations between clitoral PI and cardiometabolic risk factors, sexual and intrapsychic parameters and self-perception of body image. Seventy-one adult heterosexual women in a stable relationship attending our clinic for sexual dysfunction were consecutively recruited. Patients underwent a physical, laboratory and clitoral CDU examination, and completed the Female Sexual Function Index (FSFI), the Middlesex Hospital Questionnaire (MHQ) and the Body Uneasiness Test (BUT). Clitoral PI was positively correlated with body mass index (BMI) (r=0.441, p<0.0001), waist circumference (r=0.474, p<0.0001), glycaemia (r=0.300, p=0.029), insulin (r=0.628, p=0.002), HOMA index (r=0.605, p=0.005), triglycerides (r=0.340, p=0.011), total cholesterol (r=0.346, p=0.010) and LDL cholesterol (r=0.334, p=0.016). All the relationships, with the exception of glycaemia, retained statistical significance after adjusting for age, smoking habit and years of menopause (p<0.0001 for BMI, waist circumference and triglycerides; p<0.05 for all the other associations). At ANCOVA, after adjusting for confounders, women with obesity or metabolic syndrome (MetS) showed significantly higher PI values (F=17.79, p=0.001; F=7.37, p=0.019, for obesity and MetS, respectively). In particular, a stepwise increase of PI was found as a function of increasing MetS components (β=0.434; p=0.007). Clitoral PI was negatively associated with FSFI arousal (β=-0.321, p=0.014) and satisfaction scores (β=-0.289, p=0.026) and positively associated with somatized anxiety symptoms (MHQ-S), even after adjusting for age, smoking habit, years of menopause and current use of psychiatric medication (β=0.354, p=0.011). A positive association was also observed between PI and BUT Positive symptom distress index (PSDI) (β=0.322, p=0.039) and BUT-B dislike of womb, genitals and breast (β=0.538, p<0.0001; β=0.642, p<0.0001; β=0.549, p<0.0001, respectively). After introducing waist circumference as a further covariate, the associations between clitoral PI and BUT-PSDI, dislike of womb, genitals and breast retained statistical significance (p=0.038 for PSDI and p<0.0001 for the dislike of womb, genital and breast, respectively).

Regional Patterns of Pulsatility Index and Wall Shear Stress Across Cerebral Circulation of Adolescents with High Insulin Resistance

BackgroundInsulin resistance (IR) is associated with altered arterial stiffness, blood flow, and shear stress patterns in the peripheral circulation of middle‐aged and older diabetic and non‐diabetic hypertensive populations. Both altered blood flow and shear stress patterns may contribute to the elevated risk of cerebrovascular disease in IR populations. The aim of this study was to determine if adolescents (12–18yrs) with high IR (indexed as High Homeostatic Model Assessment of IR, HOMA‐IR) display early signs of cerebrovascular dysfunction. We hypothesized that young adolescents with a high HOMA‐IR would exhibit increased stiffness and decreased shear patterns in cerebral conduit arteries.Methods2 healthy controls (17±3) and 3 IR subjects (14±1) underwent a single 4D Flow MRI scan (scan time ~ 5min, no contrast given) to quantify cerebral blood flow (CBF), pulsatility index (PI) and wall shear stress (WSS) in extracranial and intracranial conduit arteries. 11 arteries were analyzed: middle cerebral (MCA) x2, anterior cerebral (ACA) x2, posterior cerebral (PCA) x2, vertebral (VA) x2, internal carotid (ICA) x2, and basilar. PI was calculated for each artery as [(CBFmax − CBFmin)/CBFmean]. WSS was measured by segmenting the vascular tree from PC angiograms and calculating the velocity gradient at the vessel wall using 4D flow MRI data over ~3 voxel. Due to voxel limitations, the PCA value is exploratory. Total CBF was calculated as the sum of both ICA and both VA. Significance was determined using a two‐tail Welch's t‐test.ResultsIndividuals with IR displayed higher HOMA‐IR (IR 5.3±0.2, Ctrl, 3.3±0.3, p=0.02), BMI (kg•m2; IR 28±2, Ctrl 19±4, p=0.03) and fasting insulin (μU/mL; IR 25±4, Ctrl 13±0, p=0.04), but fasting glucose was not different (mg/dL; IR 79±4, Ctrl 93±5, p=0.07). PI was not different between groups among the 11 conduit arteries. However, there was a trend for higher PI in the IR group in the left PCA and right VA. Resting WSS did not differ between Ctrl and IR among the 11 conduit arteries. Similarly, total resting CBF was not different between Ctrl and IR (mL/min; IR 811±115, Ctrl 735±79, p=0.64).ConclusionPI or WSS were similar in 11 conduit arteries of cerebral circulation in adolescent controls compared to IR. These data indicate IR does not cause measurable arterial stiffening or altered total cerebral blood flow patterns. Therefore, the pathogenic arterial characteristics observed in middle‐aged adults with IR may be linked to the duration and/or severity of IR in association with other known vascular pathological processes linked to aging.Support or Funding InformationThis research was made possible by the National Science Foundation Grant #HRD‐1500138 (UW‐Madison WiscAMP‐BD program) and UW Graduate School Pilot Funding.

Two-dimensional sonographic and Doppler changes in the uteri of bitches according to breed, estrus cycle phase, parity, and fertility

This study aimed to evaluate the two-dimensional and Doppler ultrasonographic features of bitches' uteri according to breed, cycle phase, parity and fertility during the follicular and early diestrus phases. Thirty-nine pubertal bitches were divided into groups according to breed, parity, and fertility. Sonographic assessments started from the first day of vaginal bleeding and were performed weekly for a month. The diameter of the uterine body was measured longitudinally and the uterine characteristics observed sonographically were evaluated. The resistivity index (RI) and pulsatility index (PI) of the uterine artery were calculated and the spectral morphology analyzed subjectively. The uterine diameter increased from proestrus to the diestrus regardless of the breed or parity. Multiparous bitches of both breeds had higher uterine diameters than nulliparous bitches, except Fila Brasileiro bitches in estrus. In diestrus and proestrus, the uterine diameters were significantly the largest for multiparous bitches, followed by the primiparous bitches and smallest for nulliparous bitches. The uterine diameter was larger in Fila Brasileiro females than in French Bulldogs during estrus and diestrus. The RI did not differ during the different phases of the cycle for the same breed. However, the RI was higher in nulliparous and primiparous Fila Brasileiro females compared to French Bulldog females. Within Fila Brasileiro, multiparous bitches showed lower RI than nulliparous and primiparous bitches. Higher PI values were found during proestrus. All multiparous French Bulldog bitches had greater PI than nulliparous bitches, while multiparous Fila bitches had lower PI. Nulliparous and primiparous Fila bitches had larger PI larger than bitches with the same reproductive status of the breed French Bulldog. Infertile bitches had higher RI and PI than bitches considered fertile during the initial estrus and diestrus. Triphasic and types A, C, and D spectral morphologies were found in females who did not gestate; while pregnant females showed spectral morphologies of type B, C and D. Hence, it was concluded that the breed, the phase of estrus cycle and pregnancy history should be considered when studies the uterine artery flow during estrus and early diestrus using investigations such as Doppler assessment, which can be an important tool in diagnosing fertility in dogs.

Prediction of Intrauterine Growth Restriction in High Pulsatility Index of Uterine Artery

Prediction of Intrauterine Growth Restriction in High Pulsatility Index of Uterine Artery

The correlation between cerebral arterial pulsatility and cognitive dysfunction in Alzheimer's disease patients

BackgroundPotential role of vascular dysfunction has been suggested in the pathogenesis of Alzheimer's disease (AD). Previous cross-sectional studies have demonstrated relations between abnormal transcranial Doppler (TCD) parameters and cognitive impairment. We aimed to investigate the associations between longitudinal changes of TCD parameters and cognitive decline in patients with AD. MethodsWe have enrolled patients with mild to moderate AD who aged 60 to 79years. Mean flow velocity and pulsatility index (PI) of anterior (ACA), middle (MCA), and posterior (PCA) cerebral arteries were evaluated. Cognitive functions were assessed using mini-mental state examination (MMSE), clinical dementia rating sum of boxes (SOB), and Alzheimer's Disease Assessment Scale (ADAS-cog), which was further categorized as praxis, language, and memory subscores. TCD and cognitive assessments were followed up 1year later, and the longitudinal changes (Δ) between the baseline and follow-up measurements were evaluated. ResultsA total of 51 patients completed the follow-up evaluations (baseline age 71.5years, MMSE 21.2). In the baseline evaluations, high PI values of ACA and MCA were associated with poor MMSE score, ADAS-cog total, memory, and praxis subscores. After 1year, the increases of ACA and MCA PI were correlated with the aggravation of ADAS language subscore, and ΔACA PI was also correlated with ΔSOB. The decrease in mean flow velocity of ACA was associated with aggravation of ADAS-cog praxis score. ConclusionsThere was significant correlation between longitudinal changes of TCD parameters and cognitive dysfunction in patients with mild to moderate AD. Serial assessment of TCD may provide useful information regarding to the disease progression.

Impact of Hemorheology Assessed by the Microchannel Method on Pulsatility Index of the Common Carotid Artery in Patients With Type 2 Diabetes Mellitus.

BackgroundType 2 diabetes mellitus is known to be closely associated with the risk of ischemic stroke. Recent clinical studies have reported that a high pulsatility index (PI) of the cerebral or carotid artery, which is estimated by ultrasonography, also reflects a risk of ischemic stroke. This cross-sectional study aimed to clarify the impact of hemorheology assessed by the microchannel method on the PI of the common carotid artery (CCA) in patients with type 2 diabetes mellitus in terms of the primary prevention of ischemic stroke.MethodsIn total, 349 outpatients on treatment for type 2 diabetes mellitus (131 men and 218 women; mean age ± standard deviation: 65 ± 11 years) with no history of cardiovascular events, including ischemic stroke, were enrolled. The whole blood passage time (WBPT) as a marker of hemorheology and the PI of CCA were measured using commercial devices, and their relationships to various clinical parameters were examined.ResultsA significant positive correlation was observed between WBPT and the PI of CCA (r = 0.49, P < 0.001). Furthermore, multivariate analysis revealed that patients with high WBPT (≥70 s) had significantly higher risk (odds ratio: 5.2; 95% confidence interval: 2.4 - 9.2; P < 0.001) of being detected with a high PI of CCA (≥ 2) than those with low WBPT (≤ 52.0 s).ConclusionThe results of this study indicated that WBPT was an important determination factor for the PI of CCA, suggesting that an increase in WBPT can potentially predict the incidence of ischemic stroke in patients with type 2 diabetes mellitus.

Association between uterine artery Doppler blood flow changes and arterial wall elasticity in pregnant women

Introduction: Uterine artery (UtA) Doppler velocimetry changes and increased arterial stiffness are associated with preeclampsia. We aimed to investigate the relation between UtA velocimetry changes and arterial stiffness in pregnant women.Methods: Doppler velocimetry and photoplethysmographic digital pulse wave analysis (DPA) were performed in 173 pregnant women in the second or the third trimester, where UtA Doppler pulsatility index (PI), diastolic notching, and UtA score (UAS) combining notching and high PI were calculated. DPA stiffness parameters representing large arteries were ejection elasticity index (EEI) and b/a, small arteries dicrotic index (DI) and d/a, and global stiffness the aging index (AI).Results: One hundred and thirty women had normal Doppler and 43 had diastolic notching, of whom nine had high PI. DI indicated increased stiffness in small arteries when notching was present (p = 0.044) and showed a significant but weak correlation to UAS (p = 0.025, tau 0.12). EEI and b/a indicated increased large artery stiffness (p ≤0.014), d/a small artery stiffness (p = 0.023), and AI a systemic stiffness (p = 0.040) when high PI.Conclusion: High UtA PI was associated with increased systemic arterial stiffness, whereas notching was related to increased stiffness in small arteries only. This indicates pathophysiological differences between the two Doppler parameters.

In utero origin of sex-related differences in future cardiovascular disease.

BackgroundThere are sex differences in the risk of development of cardiovascular disease (CVD). According to the developmental origins of health and disease paradigm (DOHaD), CVD originates in fetal life. This study examines fetal sex differences in cardiovascular development in utero.MethodsIn 1028 pregnant women, we assessed fetal circulation using pulsed wave Doppler examinations between 28 and 34 weeks gestation. To test associations between fetal sex and fetal circulation measurements, linear regression models were used adjusting for fetal size, gestational age, and fetal heart rate.ResultsA higher pulsatility index in the ductus venosus was observed in male fetuses compared to female fetuses (difference 0.02, 95 % CI 0.01; 0.05) with a lower E/A ratio of the tricuspid (difference −0.01, 95 % CI −0.03; −0.00) and mitral (difference −0.02, 95 % CI −0.03; −0.01) valves. This was mainly determined by differences in the E wave of the tricuspid and mitral valves (differences −1.02, 95 % CI −1.81; −0.24 and −1.28, 95 % CI −2.11; −0.46, respectively). Also in males, a lower peak systolic velocity was seen in the pulmonary artery (difference −1.33, 95 % CI −2.63; −0.03) with a similar lower trend regarding peak systolic velocity in the ascending aorta.ConclusionsMale fetuses exhibit an increased preload and reduced afterload conditions compared to females. While it is difficult to relate these measurements to exact cardiac function, our findings strongly suggest that the known differences in cardiovascular performance between the sexes already start in utero.

Cardiometabolic Risk and Female Sexuality: Focus on Clitoral Vascular Resistance

IntroductionThe relation between sexual and cardiovascular health in women is not well defined. Clitoral color Doppler ultrasound (CDU) with assessment of the pulsatility index (PI), reflecting resistance to blood flow, has been proposed as an objective measurement of sexual functioning. AimTo investigate associations between clitoral PI and cardiometabolic risk factors, sexual and intrapsychic parameters, and self-perception of body image. MethodsSeventy-one adult heterosexual women in a stable relationship attending our clinic for sexual dysfunction were consecutively recruited. Main Outcome MeasuresPatients underwent physical, laboratory, and clitoral color Doppler ultrasound examinations and completed the Female Sexual Function Index, the Middlesex Hospital Questionnaire, and the Body Uneasiness Test (BUT). ResultsClitoral PI was positively correlated with body mass index (r = 0.441, P < .0001), waist circumference (r = 0.474, P < .0001), glycemia (r = 0.300, P = .029), insulin (r = 0.628, P = .002), homeostatic model assessment index (r = 0.605, P = .005), triglycerides (r = 0.340, P = .011), total cholesterol (r = 0.346, P = .010), and low-density lipoprotein cholesterol (r = 0.334, P = .016). All relations, with the exception of glycemia, retained statistical significance after adjusting for age, smoking habit, and years since menopause (P < .0001 for body mass index, waist circumference, and triglycerides; P < .05 for all other associations). Analysis of covariance, after adjusting for confounders, showed that women with obesity or metabolic syndrome (MetS) showed significantly higher PI values (obesity: F = 17.79, P = .001; MetS: F = 7.37, P = .019). In particular, a stepwise increase of PI was found as a function of increasing MetS components (β = 0.434, P = .007). Clitoral PI was negatively associated with Female Sexual Function Index arousal (β = −0.321, P = .014) and satisfaction (β = −0.289, P = .026) scores and positively associated with Middlesex Hospital Questionnaire somatized anxiety symptoms, even after adjusting for age, smoking habit, years since menopause, and current use of psychiatric medication (β = 0.354, P = .011). A positive association also was observed between PI and the BUT positive symptom distress index (β = 0.322, P = .039) and BUT for dislike of the womb, genitals, and breast (β = 0.538, P < .0001; β = 0.642, P < .0001; β = 0.549, P < .0001, respectively). After introducing waist circumference as another covariate, the associations between clitoral PI and the BUT positive symptom distress index and BUT dislike of the womb, genitals, and breast retained statistical significance (P = .038 for positive symptom distress index; P < .0001 for dislike of womb, genitals, and breast). ConclusionClitoral vascular resistance is positively associated with MetS (in particular insulin resistance), decreased sexual arousal, body image concerns, and increased somatized anxiety symptoms. Further studies are needed to establish whether treatment of metabolic abnormalities might improve clitoral color Doppler ultrasound indices and sexual outcomes.

Blood Pressure, Carotid Flow Pulsatility, and the Risk of Stroke: A Community-Based Study.

High blood pressure is a major cause of cardiovascular events, and carotid flow pulsatility may be associated with cardiovascular events. However, the combined effect of blood pressure and flow pulsatility on the development of stroke remains unclear. Therefore, we investigated the combined influence of central blood pressure and pulsatility index (PI) on the incidence of stroke. Baseline data from 2033 adults (≥30 years) without stroke history in the Cardiovascular Disease Risk Factor Two-Township Study were linked to incident stroke. Common carotid flow PI was calculated by peak systolic velocity, end-diastolic velocity, and mean vessel velocity, which were measured in the common carotid artery. Hazard ratios for the risk of total stroke resulting from high central systolic blood pressure (CSBP) and high PI were calculated with Cox proportional hazard models. Over a median follow-up of 9.81 years, 132 people incurred stroke events. The incidence rates of stroke were 1.3, 6.4, and 13.2 per 1000 person-years for tertile groups of CSBP (P for trend<0.05) and 4.3, 7.0, and 9.4 per 1000 person-years for tertile groups of PI (P for trend<0.05). Compared with the first tertile of CSBP, hazard ratios were 4.88 (95% confidence interval, 2.29-10.43) for the second tertile and 10.42 (5.05-21.53) for the third tertile. Hazard ratios of PI were 2.18 (1.39-3.42; third tertile) and 1.64 (1.02-2.63; second tertile) compared with the first tertile. The individuals with a high CSBP and high PI had a 13-fold higher stroke risk compared with those with low CSBP and low PI (13.2; 1.75-99.71) after adjusting for age, sex, and traditional cardiovascular risk. CSBP and common carotid PI jointly and independently predicted future stroke. Carotid flow pulsatility may play an important role in the development of stroke.

Increased arterial pulsatility and progression of single subcortical infarction.

We investigated the association of clinical, laboratory, sonographic and imaging parameters, in the progression of single subcortical infarctions. Consecutive 169 patients with lacunar (n = 89) and striatocapsular infarctions (n = 80) in the middle cerebral artery (MCA) territory with nonstenotic MCAs were recruited and examined for stroke progression. The pulsatility index (PI) was measured by transcranial Doppler from ipsilateral M1. The striatocapsular infarction group exhibited more stroke progression. The patients with progressive lacunar infarctions had more diabetes, higher HbA1c levels, and higher initial National Institutes of Health Stroke Scale (NIHSS) scores, and the patients with progressive striatocapsular infarctions had more hypertension, higher cholesterol levels, and higher NIHSS scores. The MCA PI was higher in the lacunar infarction patients with progression (0.99 ± 0.19 vs. 0.90 ± 0.14, p = 0.048), while the striatocapsular infarction patients did not differ according to progression. From a multivariate analysis, higher MCA PI were independently associated with lacunar infarction progression (by 0.1 increase, OR 1.51; 95% CI 1.06-2.15; p = 0.024). Higher pulsatility was associated with progression in lacunar infarction. PI measured by transcranial Doppler sonography might reflect downstream arterial resistance and vascular/paravascular perfusion status and be a possible indicator of stroke progression. • Higher pulsatility index was observed in progression group of lacunar infarction patients. • Higher pulsatility index seemed to be associated with progression in lacunar infarction patients. • Differences in the factors associated with stroke progression suggest different underlying pathophysiologies.

55 Prediction of subtypes of pre-eclampsia in high-risk women

Introduction Pre-eclampsia (PE) is a heterogeneous pregnancy-specific disorder. Prediction of different subtypes may require different strategies. Early identification of high-risk women would allow closer surveillance and application of preventive measures. Objectives To evaluate first-trimester biomarkers, mean arterial pressure (MAP), and pulsatility index (PI) of uterine artery (Uta) for the prediction of PE and its early- and late-onset forms (EOPE delivery Methods We studied a subcohort of 257 high-risk women with biomarker and blood pressure measurements available at 11 0/7–13 6/7 weeks of gestation. Placental growth factor (PlGF), human chorionic gonadotropin (hCG), hyperglycosylated hCG (hCG-h), hCG-beta and pregnancy associated plasma protein A (PAPP-A). Doppler ultrasound measurement was available at the same time point from 217 women (83.7%). The results are presented as multiples of the medians (MoMs). The binary logistic regression was used to evaluate univariate associations. Multivariable prediction models were built using regularized logistic regression with L1/L2-norm. Cross validation was used to select regularization variables and separately to assess model fit. Three separate models were fitted for all outcomes. The first model included only background variables and mean arterial pressure in the first trimester (model 1), then biomarkers (model 2) and MoM of mean PI of Uta was added (model 3). Areas under ROC (receiver operating characteristics) curves (AUC) were determined for all models and compared using R package pROC. Results Nine women developed EOPE (3.5%) and 25 LOPE (13.2%). In univariate analyses low PlGF, high MAP and high Uta PI were associated with PE. Women with EOPE had lower PlGF [median 0.73 MoM (IQR 0.63–0.83) vs. 1.22 (IQR 0.98–3.88) p = 0.02] and higher MAP [mean 104.3 (SD 15.0) mmHg vs. 95.4 (SD 11.5) mmHg p = 0.03] than women without EOPE. %hCG-h MoM was lower [median 0.76 (IQR 0.64–0.89) MoM vs. 1.02 (IQR 0.71–1.46) MoM p = 0.02] and MAP was higher [mean 101.0 (SD 14.5) mmHg vs. 95.0 (SD 11.2) mmHg p = 0.01] in the LOPE group than in those women that had not LOPE. The best multivariable models for PE, EOPE and LOPE are presented in Table 1. Download : Download high-res image (197KB) Download : Download full-size image Conclusions In univariate analyses low PlGF, high MAP and Uta PI were associated with pre-eclampsia. Women with EOPE had lower PlGF and higher MAP than women without EOPE and women with LOPE had lower %hCG-h and higher MAP than women without LOPE. In multivariable regression analyses the ROC values presented in this study did not meet requirements of a clinically useful screening test after validation.

Cerebral perfusion alterations and cognitive decline in critically ill sepsis survivors

Introduction: We investigated the association between cerebral perfusion perturbations in sepsis with possible cognitive decline (CD) after patients’ discharge from the intensive care unit (ICU).Methods: We studied 28 patients with sepsis and Lawton’s Instrumental Activities of Daily Living scale (IADL) scores ≥5 who were discharged from a university ICU institution. We evaluated cerebral circulatory parameters (pulsatility index (PI) and cerebral blood flow index (CBFi) was calculated based on the measured velocity of the middle cerebral artery. Use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) test was performed daily, and either the Mini Mental State Examination test (MMSE) or Clock Drawing test was performed at ICU discharge. CD was categorized as persistent coma, positive CAM-ICU test at discharge, MMSE <24, or an abnormal Clock test.Results: Patients had a median pre-ICU IADL score of 6.3 (95% CI 5.9–6.7). Fourteen patients (50%) had CD at discharge. Two were in persistent coma despite sepsis resolution. Information recall was the most affected mental function of the other 12 patients. Only on the first day, patients with CD had higher PI and lower CBFi compared to those without CD (2.2 ± 0.7 vs. 1.4 ± 0.5, p = 0.02; 363 ± 170 vs. 499 ± 133, p = 0.03, respectively). Multivariable analysis revealed delirium, but not PI, as an independent prognostic factor for CD (OR: 29.62, 95%CI 1.91–458.01, p = 0.01).Conclusion: Delirium, but not cerebral perfusion alterations, is an independent risk factor for cognitive impairment in septic patients who were discharged from the ICU.

First Trimester Screening for Pre-eclampsia and Fetal Growth Restriction

AbstractThis paper is an analysis of the effectiveness of various first trimester markers in detecting uteroplacental insufficiency. The various parameters used for screening in 3373 women were uterine artery pulsatility index (PI) &gt;90th percentile, maternal characteristics, mean arterial pressure (MAP), PAPP-A lower than 0.5 MoM, and PlGF test. Adverse pregnancy outcomes related to uteroplacental insufficiency, namely low birth weight, fetal loss, delivery before 36 weeks (due to abnormal fetal Doppler or oligohydramnios), and hypertension were assessed. Adverse outcomes were found in 37 % of patients who had high uterine PI, in 52 % of cases that had a positive risk after inclusion of maternal characteristics, MAP, and uterine artery Doppler, 55 % of women with low PAPP-A values, 85 % in cases that had both low PAPP-A values and high uterine artery PI, in all the cases positive for early onset pre-eclampsia (PE), and in 65 % of cases positive for late onset PE after inclusion of all parameters mentioned above with PlGF testing. Hence, PlGF test had the maximum detection rate for early onset PE. However, the predictive efficacy for detection of PE and fetal growth restriction (FGR) is quite good when PAPP-A is combined along with first trimester risk prediction using maternal characteristics, MAP, and uterine artery PI. The adverse outcomes were very minimal in the screen negative group, thus first trimester screening for PE and FGR definitely helps in triaging patients earlier in pregnancy giving the advantage of adding low-dose aspirin and increasing surveillance in screen positive group which would help us in minimizing adverse perinatal outcomes.

Cerebral hemodynamics in patients with cirrhosis

Cirrhosis causes a decrease in cerebral blood flow because of a hyperdynamic circulatory state. We aimed to study the cerebral hemodynamic parameters in patients with decompensated cirrhosis and their relationship to the Child-Pugh and Model for End-Stage Liver Disease (MELD) scores. We used transcranial Doppler to investigate the cerebral hemodynamic parameters, namely the mean flow velocity of the middle cerebral artery, pulsatility index (PI), and resistive index (RI), in 50 patients who had decompensated cirrhosis and in a control group of 50 healthy people. We also investigated their relationship to the Child-Pugh and MELD scores. Patients with cirrhosis had a lower mean flow velocity than those in the control group. Further, patients with cirrhosis had higher PI and RI values. There was a positive correlation between PI and the Child-Pugh score. In addition, there was a positive correlation among PI, RI, and the MELD score. The RI values of patients with ascites were higher than those of patients without ascites. Cerebral autoregulation might be impaired in patients with cirrhosis. Cerebral resistance proportionally increases to disease severity. There was a positive correlation among PI, RI, and MELD scores, which means that transcranial Doppler might be useful not only in the follow-up of the severity of the disease but also in determining the survival of these patients.