Transcranial Doppler Examination Research Articles

Transcranial Doppler screening in sickle cell disease: The implications of using peak systolic criteria.

To compare time average maximum mean velocity (TAMV) and peak systolic velocity (PSV) criteria of Trans Cranial Doppler (TCD) in their ability to predict abnormalities on magnetic resonance imaging (MRI)/magnetic resonance angiogram (MRA) in patients with sickle cell disease. A retrospective evaluation was performed of the outcomes in all patients with a Transcranial Doppler examination at our institution since the implementation of the hospital picture archiving and communication system (PACS) system in January 2003 through December 2012. All ultrasound imaging exams were performed by the same technologist with a 3 MHz transducer. Inclusion criteria was based upon the Transcranial Doppler procedure code in our PACS which had an indication of sickle cell disease in the history. The patient's age and gender along with the vessel with the highest time averaged mean velocity as well as the highest peak systolic velocity was recorded for analysis. A subset of the study cohort also had subsequent MR imaging and Angiograms performed within 6 mo of the TCD examination. MRI results were categorized as having a disease related abnormality (vessel narrowing, collateral formation/moya-moya, or abnormal fluid attenuation inversion recovery signal in parenchyma indicative of prior stroke) or normal. The MRI results formed the comparison standards for TCD exams in evaluating intracranial injury. Sensitivity and specificity for the two TCD criteria (TAMV and PSV) were calculated to determine which could be a better predictor for intracranial vasculopathy /clinically occult strokes. The study cohort for our institution was 110 patients with a total of 291 TCD examinations. These patients had a mean age of 7.6 years with a range from 2-18 years of age. Sixty-two of the 110 patients (56%) had two or more TCD exams. Thirty-seven patients (34%) had at least one MRI following a TCD examination. Of the 291 TCD examinations, 46 (16%) were conditional or abnormal by TAMV criteria. One hundred and sixteen (40%) were conditional or abnormal by PSV criteria. All studies that were abnormal by TAMV were also abnormal by PSV criteria. Seventy of the 116 (60%) studies which were conditional or abnormal by peak systolic criteria would not have been identified by time averaged mean maximum velocity criteria. The most frequent location of highest velocity measurement was noted to be in the middle cerebral artery regardless of whether it was measured by PSV or TAMV. From the 37 patients having one or more MRIs, 43 MRI exams were performed within 6 mo of a TCD examination. Twenty two (51%) MRIs had a disease related abnormality reported. When evaluating conditional or abnormal exams by PSV criteria against follow-up MRI/MRA, the sensitivity was 73% [16/(16 + 6)] and specificity was 81% [17/(4 + 17)]. When evaluating conditional or abnormal exams by TAMV criteria by follow-up MRI/MRA as the gold standard, the sensitivity was 41% [9/(9 + 13)] and the specificity was 100% [21/(21 + 0)]. In using conditional or abnormal criteria from PSV and TAMV to predict abnormalities on follow-up MRI/MR Angiogram, PSV was more sensitive (73% vs 41%) while TAMV was more specific (100% vs 81%). Based on the data obtained at our institution and using the assumption that the best screening test is the one with the highest sensitivity, the peak systolic velocity could be the measurement of choice for TCD screening.

Teleneurosonology: A Novel Application of Transcranial and Carotid Ultrasound

To demonstrate the technical feasibility of interfacing transcranial Doppler (TCD) and carotid "duplex" ultrasonography (CUS) peripherals with telemedicine end points to provide real-time spectral waveform and duplex imaging data for remote review and interpretation. We performed remote TCD and CUS examinations on a healthy, volunteer employee from our institution without known cerebrovascular disease. The telemedicine end point was stationed in our institution's hospital where the neurosonology examinations took place and the control station was in a dedicated telemedicine room in a separate building. The examinations were performed by a postgraduate level neurohospitalist trainee (M.N.R.) and interpreted by an attending vascular neurologist, both with experience in the performance and interpretation of TCD and CUS. Spectral waveform and duplex ultrasound data were successfully transmitted from TCD and CUS instruments through a telemedicine end point to a remote reviewer at a control station. Image quality was preserved in all cases, and technical failures were not encountered. This proof-of-concept study demonstrates the technical feasibility of interfacing TCD and CUS peripherals with a telemedicine end point to provide real-time spectral waveform and duplex imaging data for remote review and interpretation. Medical diagnostic and telemedicine devices should be equipped with interfaces that allow simple transmission of high-quality audio and video information from the medical devices to the telemedicine technology. Further study is encouraged to determine the clinical impact of teleneurosonology.

Brain MRI/MRA Findings after Hydroxyurea Treatment in Children with Sickle Cell Anemia

Background: Up to 40% of children with sickle cell anemia (SCA) will have abnormalities on brain imaging due to their hematologic disorder, much of which is subclinical. Common abnormalities on brain magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) include leukoencephalopathy from microvascular ischemic insult and vascular stenosis from endothelial damage. Silent cerebral ischemic insults are progressive; further neurologic abnormalities, including overt stroke, are more common among children with ischemic findings on MRI compared to children without them. Furthermore, poor performance on neuropsychological testing, lower IQ, and higher rates of grade retention are common in children with SCA and cerebral ischemic disease. The effect of hydroxyurea treatment on the development and progression of vascular stenosis and leukoencephalopathy is unclear. This study aimed to longitudinally evaluate the development of intracerebral abnormalities through serial MRI/MRA in children with SCA (HbSS and HbSβ0-thalassemia) who receive long-term therapy with hydroxyurea.Methods: Children with SCA and no prior history of overt stroke enrolled in the Hydroxyurea Study of Long-Term Effects (HUSTLE NCT00305175) underwent brain MRI/MRA, transcranial doppler (TCD) examinations, and laboratory evaluations immediately before hydroxyurea initiation and after 3 and 6 years of treatment to maximum tolerated dose. MRI/MRAs were reviewed for the presence or absence of vascular stenosis and leukoencephalopathy. Leukoencephalopathy was defined as white matter T2 hyperintensity. Proportions of abnormal MRI/MRA findings were compared between baseline and 3 years and baseline and 6 years using McNemar’s test and the Wilcoxon-Mann-Whitney exact test was used to explore associations with laboratory parameters.Results: Forty-six children with SCA, mean age 9.4 years (range 1-17.3), had an MRI/MRA at baseline and 3 years post-initiation of hydroxyurea. Ten children had an additional MRI/MRA after 6-years of hydroxyurea therapy. Frequencies of leukoencephalopathy and vascular stenosis are shown in the table. Prevalence of leukoencephalopathy before hydroxyurea therapy was higher than that reported in the literature for untreated children with SCA of similar age. There were no significant differences between baseline imaging findings and those at 3 and 6 years.Table:Prevalence of leukoencephalopathy and vascular stenosis at baseline, 3 and 6 yearsBaseline (n=47) Median age 9.6 years (range 1.0 to 17.3)3 years (n=46) Median age 13.1 years (range 4.4 to 21.1)6 years (n=10) Median age 14.5 years (range 8.3 to 18.3)Leukoencephalopathy27 (57.4%)28 (60.9%)*5 (50%)*Stenosis3 (6.4%)1 (2.2%)*0*all p>0.05Children with leukoencephalopathy at baseline and 3 years were older than those without (mean 10.7 vs. 7.7 years, p=0.01; 10.5 vs. 7.5 years, p=0.02 respectively). Lower HbF at baseline was associated with the presence of leukoencephalopathy at year 3 (median HbF 4.6% vs. 12.4%, p=0.008), but there was no association between HbF at 3-years and the presence of leukoencephalopathy at 3-years (median HbF 16.4% vs. 13.2%, p=0.55). When stratified by age, these findings were similar. TCD velocities and other hematologic parameters were not associated with MRI/MRA abnormalities. The small number of vascular stenosis cases precluded further analyses of this outcome.Conclusions: In this longitudinal study, children treated with hydroxyurea for 3-6 years did not demonstrate an increased frequency of vascular stenosis or leukoencephalopathy on brain MRI/MRA during treatment. Older age at hydroxyurea initiation and lower pre-hydroxyurea HbF percentage were associated with the presence of leukoencephalopathy at baseline and 3-years. These findings suggest that hydroxyurea may mitigate the expected progression of vascular stenosis and leukoencephalopathy in children with SCA, and that this therapy should be initiated early on, before the development of cerebrovascular disease, particularly among those with a low HbF percentage. DisclosuresOff Label Use: hydroxyurea for children with sickle cell disease.

Cilostazol Decreases Cerebral Arterial Pulsatility in Patients with Mild White Matter Hyperintensities: Subgroup Analysis from the Effect of Cilostazol in Acute Lacunar Infarction Based on Pulsatility Index of Transcranial Doppler (ECLIPse) Study

Background: The Effect of Cilostazol in Acute Lacunar Infarction Based on Pulsatility Index of the Transcranial Doppler (ECLIPse) study showed a significant decrease in the transcranial Doppler (TCD) pulsatility index (PI) with cilostazol treatment at 90 days after acute lacunar infarction. The aim of the present study was to perform a subgroup analysis of the ECLIPse study in order to explore the effect of cilostazol in acute lacunar infarction based on cerebral white matter hyperintensities (WMH) volume. Methods: The ECLIPse study was a multicenter, randomized, double-blind, placebo-controlled trial that evaluated the difference between the efficacy of cilostazol and a placebo to reduce the PI in patients with acute lacunar infarction using serial TCD examinations. The primary outcome was changes in the PIs of the middle cerebral artery (MCA) and basilar artery at 14 and 90 days from the baseline TCD study. For this subgroup analysis, using semi-automated computerized software, the WMH volume was measured for those subjects for whom fluid-attenuated inversion recovery (FLAIR) images were available. Results: Of the 203 patients in eight hospitals in the ECLIPse study, 130 participants from six hospitals were included in this subgroup analysis. Cilostazol was given to 63 patients (48.5%) and placebo to 67 patients (51.5%). All baseline characteristics were well balanced across the two groups, and there were no significant differences in these characteristics except in the changes of PI from the baseline to the 90-day point. There was a significant decrease of TCD PIs at 90-day study from baseline in the cilostazol group (p = 0.02). The mean WMH volume was 11.57 cm³ (0.13-68.45, median 4.86) and the mean MCA PI was 0.95 (0.62-1.50). The changes in PIs from the baseline to 14 days and to 90 days were 0.09 (-0.21 to 0.33) and 0.10 (-0.22 to 0.36). While there were no significant correlations between WMH volume and the changes in PIs, a trend of inverse correlation was observed between the WMH volume and the changes in PIs from the baseline to the 90-day point. For the subgroup analysis, the WMH volume was dichotomized based on its median value (4.90 cm³). Cilostazol decreased the TCD PIs significantly at the 90-day point in patients with WMH volumes ≤4.9 cm³ (p = 0.002). Significant treatment effects were observed in the cilostazol group. Conclusions: This study showed that cilostazol decreased cerebral arterial pulsatility in patients with WMH. Our findings indicate the unique effect of cilostazol in small vessel disease (SVD), especially in patients with mild WMH changes. Further clinical trials focusing on WMH volume and clinical outcomes are required to assess the unique efficacy of cilostazol in SVD.

Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members.

Sickle cell disease (SCD) is a life-threatening genetic disorder affecting nearly 100,000 individuals in the United States and is associated with many acute and chronic complications requiring immediate medical attention. Two disease-modifying therapies, hydroxyurea and long-term blood transfusions, are available but underused. To support and expand the number of health professionals able and willing to provide care for persons with SCD. Databases of MEDLINE (including in-process and other nonindexed citations), EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, TOXLINE, and Scopus were searched using prespecified search terms and keywords to identify randomized clinical trials, nonrandomized intervention studies, and observational studies. Literature searches of English-language publications from 1980 with updates through April 1, 2014, addressed key questions developed by the expert panel members and methodologists. Strong recommendations for preventive services include daily oral prophylactic penicillin up to the age of 5 years, annual transcranial Doppler examinations from the ages of 2 to 16 years in those with sickle cell anemia, and long-term transfusion therapy to prevent stroke in those children with abnormal transcranial Doppler velocity (≥200 cm/s). Strong recommendations addressing acute complications include rapid initiation of opioids for treatment of severe pain associated with a vasoocclusive crisis, and use of incentive spirometry in patients hospitalized for a vasoocclusive crisis. Strong recommendations for chronic complications include use of analgesics and physical therapy for treatment of avascular necrosis, and use of angiotensin-converting enzyme inhibitor therapy for microalbuminuria in adults with SCD. Strong recommendations for children and adults with proliferative sickle cell retinopathy include referral to expert specialists for consideration of laser photocoagulation and for echocardiography to evaluate signs of pulmonary hypertension. Hydroxyurea therapy is strongly recommended for adults with 3 or more severe vasoocclusive crises during any 12-month period, with SCD pain or chronic anemia interfering with daily activities, or with severe or recurrent episodes of acute chest syndrome. A recommendation of moderate strength suggests offering treatment with hydroxyurea without regard to the presence of symptoms for infants, children, and adolescents. In persons with sickle cell anemia, preoperative transfusion therapy to increase hemoglobin levels to 10 g/dL is strongly recommended with a moderate strength recommendation to maintain sickle hemoglobin levels of less than 30% prior to the next transfusion during long-term transfusion therapy. A strong recommendation to assess iron overload is accompanied by a moderate strength recommendation to begin iron chelation therapy when indicated. Hydroxyurea and transfusion therapy are strongly recommended for many individuals with SCD. Many other recommendations are based on quality of evidence that is less than high due to the paucity of clinical trials regarding screening, management, and monitoring for individuals with SCD.

Impact of time to treatment on tissue-type plasminogen activator-induced recanalization in acute ischemic stroke.

Although tissue-type plasminogen activator (tPA) efficacy depends on time, it is unknown whether its effect on recanalization is time dependent. Information about likelihood of successful recanalization as a function of time to treatment may improve patient selection for advanced reperfusion strategies. We aimed to identify the impact of time to treatment on tPA-induced recanalization in patients with acute ischemic stroke. Consecutive patients with intracranial acute occlusion treated with intravenous tPA underwent transcranial Doppler examination before and 1 hour after tPA administration. Patients were categorized according to occlusion localization in proximal and distal occlusion. Sequential analysis of recanalization according to time to treatment was performed for every 30-minute cutoff point. Overall (n=508), 54.3% had proximal and 45.7% had distal occlusion. Median time to treatment was 171.4±61.9 minutes, and 5.9% were treated >270 minutes. Recanalization occurred in 36.1% of patients. There was no linear association between time to treatment and time to recanalization, but sequential analysis showed that patients treated >270 minutes had a lower recanalization rate. Lower National Institutes of Health Stroke Scale score on admission (odds ratio [OR], 0.305; 95% confidence interval [CI], 0.1-0.933) and time to treatment ≤270 minutes (OR, 0.995; 95% CI, 0.99-0.999) emerged as independent predictors of recanalization. In patients with proximal occlusion, 41.8% recanalized. Time to treatment >90 minutes was associated with lower recanalization rate. However, only younger age (OR, 0.975; 95% CI, 0.952-0.999) and lower baseline National Institutes of Health Stroke Scale score (OR, 0.921; 95% CI, 0.855-0.993) independently predicted recanalization. In distal occlusion patients, male sex was the only independent predictor of recanalization (OR, 0.416; 95% CI, 0.195-0.887). None recanalized >270 minutes. The effect of tPA on recanalization may decrease over time. Treatment >270 minutes predicted lack of recanalization, especially in distal occlusions.

Comparison of Two Contrast Agents for Right-to-Left Shunt Diagnosis with Contrast-Enhanced Transcranial Doppler

We compared two contrast agents, agitated saline and agitated saline with blood, with respect to their efficacy in the diagnosis of right-to-left shunt with contrast-enhanced transcranial Doppler. Three hundred thirty Chinese patients underwent examinations with one of four different methods in random order: (i) 9 mL agitated saline solution with 1 mL air without the Valsalva maneuver (ASwoVM); (ii) 9 mL agitated saline solution with 1 mL air with the Valsalva maneuver (ASwVM); (iii) 9 mL agitated saline solution, 1 mL air and a drop of the patient's blood without the Valsalva maneuver (ASbwoVM); and (iv) 9 mL agitated saline solution, 1 mL air and a drop of the patient's blood, with the Valsalva maneuver (ASbwVM). Rates of detection were 11.5%, 17.9%, 16.7% and 23.6% for the ASwoVM, ASwVM, ASbwoVM, and ASbwVM examinations, respectively. The embolus track numbers for these examinations were 4.0 ± 1.83, 11.5 ± 6.2, 10.5 ± 4.9 and 33.7 ± 14.9, respectively. There were significant differences between the four groups (all comparisons, p < 0.001). For contrast-enhanced transcranial Doppler examinations, the agitated saline/blood agent yielded better rates of diagnosis of right to-left shunt than did the agitated saline alone.

Cerebral hemodynamic characteristics of acute mountain sickness upon acute high-altitude exposure at 3,700 m in young Chinese men.

PurposeWe aimed at identifying the cerebral hemodynamic characteristics of acute mountain sickness (AMS).MethodsTranscranial Doppler (TCD) sonography examinations were performed between 18 and 24 h after arrival at 3,700 m via plane from 500 m (n = 454). A subgroup of 151 subjects received TCD examinations at both altitudes.ResultsThe velocities of the middle cerebral artery, vertebral artery (VA) and basilar artery (BA) increased while the pulsatility indexes (PIs) and resistance indexes (RIs) decreased significantly (all p < 0.05). Velocities of BA were higher in AMS (AMS+) individuals when compared with non-AMS (AMS−) subjects (systolic velocity: 66 ± 12 vs. 69 ± 15 cm/s, diastolic velocity: 29 ± 7 vs. 31 ± 8 cm/s and mean velocity, 42 ± 9 vs. 44 ± 10 cm/s). AMS was characterized by higher diastolic velocity [V d_VA (26 ± 4 vs. 25 ± 4, p = 0.013)] with lower PI and RI (both p = 0.004) in VA. Furthermore, the asymmetry index (AI) of VAs was significantly lower in the AMS + group [−5.7 % (21.0 %) vs. −2.5 % (17.8 %), p = 0.016]. The AMS score was closely correlated with the hemodynamic parameters of BA and the V d_VA, PI, RI and AI of VA.ConclusionAMS is associated with alterations in cerebral hemodynamics in the posterior circulation rather than the anterior one, and is characterized by higher blood velocity with lower resistance. In addition, the asymmetry of VAs may be involved in AMS.

104 Transcranial Doppler-detected Emboli Can Be Differentiated Between Solid And Gaseous Emboli During Transcatheter Aortic Valve Implantation And This Has Implications For Neuroprotective Strategies

BackgroundTranscatheter aortic valve implantation (TAVI) is known to carry a relatively high stroke risk, at least in part related to embolisation from the valve and aorta. The number of emboli...

Does the sex of acute stroke patients influence the effectiveness of rt-PA?

BackgroundWomen have been reported to show more frequent recanalization and better recovery after intravenous (IV) recombinant tissue plasminogen activator (rt-PA) treatment for acute stroke compared with men. To investigate this we studied a series of stroke patients receiving IV rt-PA and undergoing acute transcranial doppler (TCD) examination.MethodsAcute stroke patients received IV rt-PA and had acute TCD examination within 4 hours of symptom onset at 4 major stroke centers. TCD findings were interpreted using the Thrombolysis in Brain Ischemia (TIBI) flow grading system. The recanalization rates, and poor 3-month outcomes (modified Rankin scale >2) of men and women were compared using the chi-square test. Multiple regression analysis was used to assess sex as a predictor of recanalization and poor 3-month outcome after controlling for age, baseline NIH Stroke Scale (NIHSS), time to treatment, hypertension, and blood glucose.Results369 patients had TCD examinations before or during IV rt-PA treatment. The 199 (53.9%) men and 170 (46.1%) women had mean ages of 67 ± 13 and 70 ± 14 years, respectively. The sexes did not differ significantly in baseline stroke severity, time to TCD examination, or time to thrombolysis. Of the men, 68 (34.2%) had complete recanalization, 58 (29.1%) had partial recanalization, and 73 (36.6%) had no recanalization. Of the women, 53 (31.2%) had complete recanalization, 46 (27%) had partial recanalization, and 71 (41.8%) had no recanalization (p = 0.6). Multiple regression analyses showed no difference between the sexes in recanalization rate, time to recanalization, or clinical outcome at 3 months.ConclusionsIn our study; sex is not a significant predictor of recanalization rate, time to recanalization or 3-month outcome in stroke patients following IV rt-PA.Trial registrationData from CLOTBUST trial Clinicaltrails.gov Identifier: NCT01240356.

Abstract T P170: Risk Stratification in Acute Ischemic Stroke by Transcranial Doppler in a Multiethnic Population: Role of Microembolic Signal

Background: The role of microembolic signal (MES) detected by transcranial Doppler sonography in the acute phase of a stroke remains controversial in the medical literature. The prevalence of MES in the various sources of arterial brain embolism in patients in developing countries has been poorly studied. We investigated the prevalence of MES and whether MES detection is of proven use for risk stratification in the Brazilian population Methods: This was a transversal study with 45 ischemic stroke patients in acute phase at the Stroke Unit in a Brazilian hospital. All patients underwent monitoring of the middle cerebral arteries by transcranial doppler for at least 30 minutes. The examiner who conducted the monitoring was unaware of the risk stratification of the patient(single blinded). Then the record of the examination was independently analyzed by two neurologists to identify the MES. Prior to monitoring, risk stratification was carried out for all patients by complementary examinations. The independent variables were: age, NIHSS at admission, time of ictus, symptomatic carotid disease (stenosis &gt; 60%), atrial fibrillation, intracranial stenosis, diseases of small arteries and other cardioembolic sources. The outcome was the presence or absence of MES with independent variables. The relationship between admission variables and MES was analyzed by Fisher’s Exact Test and logistic regression to estimate the odds ratio with significance defined as p&lt;0.05. Results: The prevalence of MES was 10%. A significant correlation was found between ictus &lt; 24 hours before transcranial Doppler examination (p=0.04; OR=5.0) and symptomatic carotid disease (p=0.03; OR=15.6) with presence of MES. There was no statistical correlation between age (p=1.0), intracranial stenosis (p=1.0), atrial fibrillation (p=0.55), diseases of small arteries (p=0.56), other cardioembolic sources (p=0.55), and the association with atrial fibrillation and symptomatic carotid disease (p=1.0). Conclusions: MES detection showed higher correlation with symptomatic carotid disease and the precocity of monitoring in relation to time of ictus too. There was no relationship found between cardioembolic source and atrial fibrillation.

Reliability and sensitivity of transcranial Doppler in the prediction of recurrence in ischemic stroke

ObjectivesThis study was designed to evaluate the role of serial transcranial Doppler (TCD) examinations in the prediction of early recurrence in acute cerebral ischemia (ACI).BackgroundIn patients with ACI, either transient ischemic attack or acute ischemic stroke, the risk of early recurrence is significant. TCD enables the examination of hemodynamic patterns of intracranial circulation blood flow. After transient ischemic attack or acute ischemic stroke, developing cerebral flow hemodynamics is related to the stroke outcome.Materials and methodsA prospective trial was performed on 60 patients with the first ever or second-time ACI affecting the anterior circulation territory. A diagnostic work up including full clinical examination, routine laboratory tests, brain computed tomography, and TCD examination were performed to evaluate the risk factors of recurrence. Patients were followed up by clinical and TCD examination for 90 days after ischemia (days 2, 7, 30, and 90) to detect clinical and hemodynamic evidences of correlated with early recurrence.ResultsPatients were divided into two groups [group A with early recurrence (n = 12) and group B without early recurrence (n = 48)]. Diabetes mellitus, atrial fibrillation, and a history of cerebrovascular ischemia were found to be significantly associated with early recurrence of ischemia (P < 0.05). Initial TCD parameters showed that about 75% of the study patients had an abnormally increased mean arterial flow velocity (MFV) of the intracranial artery supplying the affected vascular territory. Group A patients tended to have a higher MFV (M = 77 ± 11.7) than group B patients (M = 66.47 ± 15.3) with significant effect (P < 0.05). Microembolic signals were detected in 10/12 patients (83%) with early recurrence, showing a significant relationship (P < 0.001).ConclusionOur results indicate that TCD parameters of intracranial hemodynamics, especially increasing MFV of the affected intracranial arteries and detection of microembolic signals, are of predictive value in risk stratification of early recurrence in patients with ACI.

RETRACTED ARTICLE: Systematic study of cilostazol on secondary stroke prevention: a meta-analysis

BackgroundTo study the efficacy and safety of cilostazol on ischemic stroke prevention and treatment, systematic reviews of related clinical randomized controlled trials were analyzed.MethodsWe searched the main databases for eligible trials including literature from January 1966 to November 2012 in MEDLINE, reports from 1980 to November 2012 in EMBASE, and all the studies published in EBSCO, Springer, Ovid, and Cochrane library citations. We also searched for keywords, including cilostazol and aspirin. RewMan 5.0 software was used to conduct the meta-analysis.ResultsOur search yielded five eligible trials. The effects of cilostazol and aspirin on ischemic stroke prevention and treatment were almost equal (combined odds ratio (OR) 0.78, 95% confidence interval (CI) (0.59, 1.04)). Additionally, both magnetic resonance angiography (MRA) and transcranial Doppler (TCD) examination showed that cilostazol could significantly decrease the incidence of intracranial artery stenosis exacerbation (MRA: combined OR 0.22, 95% CI (0.07, 0.68); TCD: combined OR 0.17, 95% CI (0.05, 0.51)). In terms of adverse reactions, there were slightly fewer incidences of major bleeding with cilostazol than with aspirin (combined OR 0.38, 95% CI (0.24, 0.60)), and there was no difference in the number of heart palpitations between cilostazol and aspirin. However, the incidence of gastrointestinal disorders, dizziness, and headaches caused by cilostazol was greater.ConclusionsCilostazol might be a more effective and safer alternative to aspirin for patients with ischemic stroke. Further studies are required to confirm whether cilostazol is a suitable therapeutic option for secondary stroke prevention in larger cohorts of patients with ischemic stroke.

Transcranial doppler ultrasonography in children with sickle cell anemia: Clinical and laboratory correlates for elevated blood flow velocities

Transcranial Doppler (TCD) sonography of major cerebral arteries is now recommended for routine screening for stroke risk in children with sickle cell disease (SCD). We performed TCD studies on children with sickle cell anemia (SCA) seen at the pediatric hematology clinic over a period of 2 years. TCD scans were repeated yearly in children with normal flow velocities and every 3 months in children with elevated velocities. Findings were correlated with clinical variables, hematologic indices, and arterial oxygen saturation. Predictors of elevated velocities were identified by multiple linear regressions. We enrolled 237 children and performed a total of 526 TCD examinations. Highest time-averaged maximum flow velocities were ≥170 cm/s in 72 (30.3%) cases and ≥200 cm/s in 20 (8.4%). Young age, low hematocrit, low hemoglobin, and arterial oxygen desaturation <95% showed significant correlations with presence of increased cerebral flow velocities. Low hematocrit, low hemoglobin concentration, young age, and low arterial oxygen desaturation predicted elevated cerebral blood flow velocities and, invariably, increased stroke risk, in children with SCA. Children who exhibit these features should be given high priority for TCD examination in the setting of limited resources.

Power M‐Mode Transcranial Doppler Examination of the Ophthalmic Artery in Pregnancy

Our aim was to describe the standard operating procedure for transcranial Doppler investigation of the ophthalmic artery in pregnancy, determine the interobserver and intraobserver variability using power M-mode technology, and review the existing literature. Accordingly, 27 healthy pregnant or immediately postpartum women were enrolled and underwent transcranial Doppler investigation of the ophthalmic artery using power M-mode technology. Good interobserver and intraobserver variability was observed for both, especially with respect to the clinically important indices. Transcranial Doppler power M-mode examination of the ophthalmic artery is easy and reproducible and holds a great deal of potential for investigation in pregnancy.

Post-intervention TCD examination may be useful to predict outcome in acute ischemic stroke patients with successful intra-arterial intervention

Background and purposeSome acute stoke patients have a poor outcome despite successful arterial recanalization. We hypothesized that transcranial Doppler (TCD) findings from the rescued artery might predict poor outcome in patients with recanalization. MethodsAcute stroke patients treated with internal carotid artery or middle cerebral artery (MCA) occlusions with follow-up TCD examination after intra-arterial (IA) intervention were retrospectively analyzed. Only patients with at least a Thrombolysis In Myocardial Infarction (TIMI) flow grade ≥2 in the MCA territory were included. Mean flow velocity (MFV) and pulsatility index (PI) of the rescued MCA were obtained by TCD. Poor clinical outcome was defined as in-hospital death or decompressive craniectomy. ResultsAmong 50 patients, there were 8 (16%) in the Poor Outcome group and 42 (84%) in the Non-poor Outcome group. TCD was conducted at a median of 1day (interquartile range, 1–1) after IA therapy. Although MCA MFV was not different between the two groups, MCA PI was significantly higher in the Poor Outcome group than in the Non-poor Outcome group (1.3 [1.1–1.7] vs. 0.8 [0.7–1.1], p=0.002). After adjusting for the National Institutes of Health Stroke Scale score on admission, the Alberta Stroke Programme Early Computed Tomography score, a past history of coronary artery disease and the Thrombolysis In Brain Ischemia grade, MCA PI was an independent predictor of poor outcome (odds ratio: 1.71, 95% confidence interval: 1.10–2.66, p=0.017). ConclusionFollow-up TCD examination after IA intervention in acute stroke patients may predict poor outcome beyond angiographic residual TIMI flow.

Duplication of the Middle Cerebral Artery: A Potential Pitfall for Transcranial Doppler Examination

Duplication of the Middle Cerebral Artery: A Potential Pitfall for Transcranial Doppler Examination

Intracranial Hemodynamic Stabilization Patterns After Stenting of Severe Stenosis in the Proximal Internal Carotid Artery

To evaluate intracranial hemodynamic stabilization patterns after carotid artery stenting (CAS) in patients having variable collateral developments before CAS. The hemodynamic and angiographic data of 62 patients (58 men; mean age 68.0±8.4 years) who underwent CAS for unilateral proximal internal carotid artery stenosis were analyzed. The patients had transcranial Doppler examinations before and at 1 and 90 days after CAS. Patients were classified according to pre-CAS mean blood flow velocity (MBFV) of the ipsilateral middle cerebral artery (MCA): low (<30 cm/s; n=17), normal (30 to 48 cm/s; n=26), or high (>48 cm/s; n=19). The collaterals from contralateral anterior and/or posterior circulations prior to CAS, the stabilization pattern of MBFV, and the pulsatility index (PI) after CAS were compared across the 3 groups. The presence of collaterals was lowest in the low MBFV group (17.6% of patients) than in the normal (38.5%) or high (68.4%) MBFV groups (p=0.008). The low MBFV group exhibited an increase in MBFV and PI in the ipsilateral MCA at 1 and 90 days after CAS (p<0.05). By contrast, the high MBFV group exhibited a decrease in MBFV and no change in PI in the ipsilateral MCA up to 90 days after CAS (p<0.05). The normal MBFV group showed an increase in MBFV at post-CAS day 1 but a subsequent decrease at 90 days and an increase in PI in the ipsilateral MCA at 1 and 90 days post-CAS (p<0.05). The pattern of post-CAS intracranial hemodynamic stabilization differs according to the pre-CAS MBFV in the ipsilateral MCA.

Current Management of Sickle Cell Anemia

Proper management of sickle cell anemia (SCA) begins with establishing the correct diagnosis early in life, ideally during the newborn period. The identification of affected infants by neonatal screening programs allows early initiation of prophylactic penicillin and pneumococcal immunizations, which help prevent overwhelming sepsis. Ongoing education of families promotes the early recognition of disease-released complications, which allows prompt and appropriate medical evaluation and therapeutic intervention. Periodic evaluation by trained specialists helps provide comprehensive care, including transcranial Doppler examinations to identify children at risk for primary stroke, plus assessments for other parenchymal organ damage as patients become teens and adults. Treatment approaches that previously highlighted acute vaso-occlusive events are now evolving to the concept of preventive therapy. Liberalized use of blood transfusions and early consideration of hydroxyurea treatment represent a new treatment paradigm for SCA management.

Computed Tomography and Transcranial Doppler Findings in Acute and Subacute Phases of Intracerebral Hemorrhagic Stroke

The hematoma volume is an important determinant of outcome and a predictor of clinical deterioration in patients with intracerebral hemorrhage (ICH). Our goal was to evaluate alterations in the cerebral circulation, in respect to hemorrhage and edema volume changes, using transcranial Doppler (TCD). Twenty patients with acute supratentorial ICH were examined. Brain, hematoma, and edema volumes were calculated from CT scans performed at admission and 2 weeks later. Data were compared with those obtained from bilateral TCD recordings of the middle cerebral arteries. During TCD examination, blood flow velocities did not change, cerebral perfusion pressure (CPP) and resistance area product (RAP) decreased (P = .006, P = .002) while cerebral blood flow index (CBFI) remained constant on the affected side. Although hemorrhage volume did not correlate with RAP in the acute phase, correlation was found in the subacute phase (r = -.44, P = .04). TCD monitoring sensitively demonstrates the hemodynamic change caused by ICH but the severity of the changes does not correlate with the volume of the ICH in acute stage. The CPP, RAP, and CBFI values are more sensitive parameters than the absolute velocity values, therefore they contribute more to the understanding of hemodynamic changes developed after spontaneous ICH.