Transcranial Doppler Parameters Research Articles

Transcranial doppler (TCD) in predicting outcomes following successful mechanical thrombectomy of large vessel occlusions in anterior circulation: a systematic review and meta-analysis

BackgroundTranscranial Doppler (TCD) is a non-invasive, bedside tool that allows for real-time monitoring of the patient’s hemodynamic status following mechanical thrombectomy (MT). This systematic review and meta-analysis aims to evaluate...

A prospective pilot study of gut microbiome in cerebral vasospasm and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

A recent systematic review indicated that gut–microbiota–brain axis contributes to growth and rupture of intracranial aneurysms. However, gaps were detected in the role of intestinal microbiome in cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage (aSAH). This is the first pilot study aiming to test study feasibility and identify differences in gut microbiota between subjects with and without CVS following aSAH. A prospective nested case–control pilot study with 1:1 matching was conducted recruiting subjects with aSAH: cases with CVS; and controls without CVS based on the clinical picture and structured bedside transcranial Doppler (TCD). Fecal samples for microbiota analyses by means of 16S rRNA gene amplicon sequencing were collected within the first 96 h after ictus. Operational taxonomic unit tables were constructed, diversity metrics calculated, phylogenetic trees built, and differential abundance analysis (DAA) performed. At baseline, the groups did not differ significantly in basic demographic and aneurysm-related characteristics (p > 0.05). Alpha-diversity (richness and Shannon Index) was significantly reduced in cases of middle cerebral artery (MCA) vasospasm (p < 0.05). In DAA, relative abundance of genus Acidaminococcus was associated with MCA vasospasm (p = 0.00013). Two butyrate-producing genera, Intestinimonas and Butyricimonas, as well as [Clostridium] innocuum group had the strongest negative correlation with the mean blood flow velocity in anterior cerebral arteries (p < 0.01; rho = − 0.63; − 0.57, and − 0.57, respectively). In total, 16 gut microbial genera were identified to correlate with TCD parameters, and two intestinal genera correlated with outcome upon discharge. In this pilot study, we prove study feasibility and present the first preliminary evidence of gut microbiome signature associating with CVS as a significant cause of stroke in subjects with aSAH.

A Clinical Model predicting the 90-Day Prognosis after Mechanical Thrombectomy in Patients with Acute Ischemic Stroke: A Retrospective Study.

Mechanical thrombectomy (MT) is usually recommended for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) within the time window (6 hours after the disease onset). However, poor prognosis in acute great vascular occlusive stroke after MT, which is not an uncommon occurrence, can be attributed to an absence of appropriate postoperative monitoring. Transcranial Doppler (TCD) ultrasound and quantitative electroencephalography (QEEG) offer the advantages of fast, convenient, and bedside examinations compared with conventional imaging techniques. We aimed to analyze the predictive performance of clinical factors, Transcranial Doppler (TCD) ultrasound and quantitative electroencephalography (QEEG) for the prognosis of patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) at 90 days after discharge. Patients achieved revascularization through MT performed within 6 hours after the onset of AIS due to LVO were included. We use the data to build four predictive models of prognosis and compared the predictive performance measured by the area under the curve, sensitivity, and specificity. A total of 74 patients were included in the study. Among them, 47 patients had a poor prognosis (63.5%) on discharge, and 45 patients had a poor prognosis (60.8%) at 90 days after discharge. Independent predictors of poor prognosis at 90 days after discharge were identified as follows: age, NIHSS score on admission, PI on the affected/healthy side, and RAP. Among the four models built, AUC was the highest (reaching 0.831) when age was combined with NIHSS score on admission, TCD parameters (VD on the affected side, PI on the affected/healthy side), and QEEG parameter (RAP) for prognostic prediction. However, AUC of the four predictive models did not differ significantly (P>0.05). Age, NIHSS score on admission, TCD parameters, and QEEG parameter were independent predictors of the prognosis at 90 days after discharge in patients receiving MT for AIS due to LVO in the anterior circulation. The model combining the above four parameters may be helpful for prognostic prediction in such patients.

Comparison of Change in the Pulsatility Index before and after Ventriculoperitoneal Shunt Surgery in Adult Patients with Hydrocephalus

Background and Aim: In hydrocephalus patients, after ventriculoperitoneal (VP) shunt, decrease in pulsatility index (PI) correlates with decrease in ventricle size. Also, increase in PI is noted in obstructed or malfunctioning VP shunts. However, previous studies were either done in infants and children or included patients of all age groups. Our aim was to compare PI before and after successful VP shunt surgery in adult patients and also the trend of transcranial Doppler (TCD) parameters for 3 days after surgery. Materials and Methods: A prospective, observational study was done in 20 adult patients undergoing VP shunt. Clinical features, vitals, Evans index, and TCD parameters were noted in the preoperative period. A computed tomography (CT) head was repeated 4–6 h after surgery, and the position of ventricular end of shunt was confirmed and Evans index was calculated. The vitals and TCD parameters were noted at same time and for the next 2 days. Repeated measures analysis of variance (ANOVA) and paired t-test were uses for statistical analysis. Results: A total of 18 patients were included for statistical analysis. The mean preoperative PI was 1.19 ± 0.24 and the postoperative PI after surgery was 0.97 ± 0.17, 0.97 ± 0.23, and 0.94 ± 0.21 (P = 0.0039) on postoperative day (POD) 1 (POD1), POD2, and POD3, respectively. The mean preoperative value of Evans index was 0.37 ± 0.06 and there was statistically significant (P = &lt; 0.001) reduction to 0.33 ± 0.07 after VP shunt surgery. The change in PI and change in Evans index were found to be positively correlated (r = 0.34 and P = 0.0013). Conclusions: The decrease in PI after VP shunt surgery correlates with decrease in ventricular size. Any increase in PI in the postoperative period should raise the suspicion of malfunctioning of VP shunt.

Transcranial Doppler Sonography in Acute Viral Encephalitis with Special Reference to Dengue Encephalitis

Abstract Introduction: Acute viral encephalitis syndrome including dengue encephalitis (DE) is an important tropical illness with a guarded prognosis. The cerebral blood flow may be affected in acute viral encephalitis. Transcranial Doppler (TCD) sonography can quantitatively determine intracranial vascular flow dynamics in acute viral encephalitis. Aim: We aimed to investigate the intracranial blood flow characteristics in patients with DE and compare with nondengue acute viral encephalitis patients. Materials and Methods: In this prospective study, all the cases of acute viral encephalitis including dengue were enrolled over 18 months and followed up at 3 months. TCD was performed to determine the mean velocity pulsatility index (PI) and resistive index (RI) across the middle cerebral artery, anterior cerebral artery, posterior cerebral artery (PCA), vertebral artery, and basilar artery and compared it among dengue versus nondengue group as well as outcome at 3 months. Results: Out of 39 patients, 19 were diagnosed with DE, whereas 20 patients suffered from the nondengue group. The elevated PI and RI in the left PCA were found to statistically significant (P = 0.001 and 0.008, respectively) in the DE group. There was no significant difference in any other TCD indices in any other vessel among both the groups. In addition, an initial low Glasgow Outcome Scale (GOS) and higher brain imaging abnormality were significantly associated with poor GOS of &lt;5 in both the groups. Conclusion: An elevated PI and RI of PCA could be an important initial TCD parameter in DE. TCD parameters did not affect the outcome of acute viral encephalitis.

Intracranial Pressure and Cerebral Hemodynamics in Infants Before and After Glenn Procedure.

This prospective cohort study aimed to investigate changes in intracranial pressure (ICP) and cerebral hemodynamics in infants with congenital heart disease undergoing the Glenn procedure, focusing on the relationship between superior vena cava pressure and estimated ICP. A single-center prospective cohort study. The study was conducted in a cardiac center over 4 years (2019-2022). Twenty-seven infants with congenital heart disease scheduled for the Glenn procedure were included in the study, and detailed patient demographics and primary diagnoses were recorded. Transcranial Doppler (TCD) ultrasound examinations were performed at three time points: baseline (preoperatively), postoperative while ventilated (within 24-48 hr), and at discharge. TCD parameters, blood pressure, and pulmonary artery pressure were measured. TCD parameters included systolic flow velocity, diastolic flow velocity (dFV), mean flow velocity (mFV), pulsatility index (PI), and resistance index. Estimated ICP and cerebral perfusion pressure (CPP) were calculated using established formulas. There was a significant postoperative increase in estimated ICP from 11 mm Hg (interquartile range [IQR], 10-16 mm Hg) to 15 mm Hg (IQR, 12-21 mm Hg) postoperatively (p = 0.002) with a trend toward higher CPP from 22 mm Hg (IQR, 14-30 mm Hg) to 28 mm Hg (IQR, 22-38 mm Hg) postoperatively (p = 0.1). TCD indices reflected alterations in cerebral hemodynamics, including decreased dFV and mFV and increased PI. Intracranial hemodynamics while on positive airway pressure and after extubation were similar. Glenn procedure substantially increases estimated ICP while showing a trend toward higher CPP. These findings underscore the intricate interaction between venous pressure and cerebral hemodynamics in infants undergoing the Glenn procedure. They also highlight the remarkable complexity of cerebrovascular autoregulation in maintaining stable brain perfusion under these circumstances.

Effect of continuous 2MHz transcranial ultrasound as an adjunct to tenecteplase thrombolysis in acute anterior circulation ischemic stroke patients: an open labeled non-randomized clinical trial.

The treatment of acute ischemic stroke has improved in last few decades. While meta-analyses of several trials have established the safety and efficacy of Intravenous (IV) Tenecteplase thrombolysis, concomitant continuous transcranial doppler (TCD) ultrasound administration has not been assessed in any clinical trial. The aim of this study was to determine the effects of continuous 2MHz TCD ultrasound during IV Tenecteplase thrombolysis for Middle cerebral artery (MCA) stroke. A total of 19 patients were included, 13 received TCD ultrasound and 6 sham TCD with IV Tenecteplase. TCD spectrum and difference in Pre and post TCD parameters were measured. Asymptomatic hemorrhagic transformation of infarct wasseen in two patients. There was no mortality or clinical worsening in thesonothrombolysis group as against sham sonothrombolysis group. Median of peak systolic velocity wasincreased in both thesonothrombolysis (P = 0.0002) and sham sonothrombolysis group (P-value = 0.001). The difference in change in mean flow velocity between two groups, sonothrombolysis (11cm/sec)and sham sonothrombolysis (3.5cm/sec) were also significantly different (P = 0.014). This pilot work has established safety of continuous 30min TCD application along with IV Tenecteplase thrombolysis and it concludes thatconcomitant 2MHz TCD ultrasound administration significantly increased the MCA blood flow compared to chemothrombolysis alone.CTRI Registered Number: CTRI/2021/02/031418.

Propofol effects over intracranial pressure waveform and cerebral hemodynamics: A case report

Introduction: Few reports have been dedicated on assessing cerebral hemodynamics (CH) and intracranial compliance (ICC) in non-primary neurological patients. Objective: The present study aims to observe the anesthetic influence of propofol on CH and ICC using noninvasive monitoring techniques in the immediate postoperative period. Methodology: This is a case report in which CH and ICC were assessed noninvasively using transcranial Doppler (TCD) and a skull deformation sensor (B4C) respectively, in the immediate postoperative period of a patient just after cardiac revascularization. After exclusion of volemic depletion, TCD and B4C parameters indicated reduction in cerebral blood flow what would be attributed to propofol infusion during surgery. After endovenous additional volume administration and arterial pressure elevation, TCD and B4C parameters improved. Final Considerations: It was possible observing cerebrovascular influences of propofol in the immediate postoperative period, by means of neurological ancillary techniques. Noninvasive neuromonitoring is a way to assess changes in brain physiology that may occur subtly and influence in non-primary neurological patients outcomes.

Optimizing the prediction of sepsis-associated encephalopathy with cerebral circulation time utilizing a nomogram: a pilot study in the intensive care unit.

Sepsis-associated encephalopathy (SAE) is prevalent in intensive care unit (ICU) environments but lacks established treatment protocols, necessitating prompt diagnostic methods for early intervention. Traditional symptom-based diagnostics are non-specific and confounded by sedatives, while emerging biomarkers like neuron-specific enolase (NSE) and S100 calcium-binding protein B (S100B) have limited specificity. Transcranial Doppler (TCD) indicators, although is particularly relevant for SAE, requires high operator expertise, limiting its clinical utility. This pilot study aims to utilize cerebral circulation time (CCT) assessed via contrast-enhanced ultrasound (CEUS) as an innovative approach to investigate the accuracy of SAE prediction. Further, these CCT measurements are integrated into a nomogram to optimize the predictive performance. This study employed a prospective, observational design, enrolling 67 ICU patients diagnosed with sepsis within the initial 24 h. Receiver operating characteristic (ROC) curve analyses were conducted to assess the predictive accuracy of potential markers including NSE, S100B, TCD parameters, and CCT for SAE. A nomogram was constructed via multivariate Logistic Regression to further explore the combined predictive potential of these variables. The model's predictive performance was evaluated through discrimination, calibration, and decision curve analysis (DCA). SAE manifested at a median of 2 days post-admission in 32 of 67 patients (47.8%), with the remaining 35 sepsis patients constituting the non-SAE group. ROC curves revealed substantial predictive utility for CCT, pulsatility index (PI), and S100B, with CCT emerging as the most efficacious predictor, evidenced by an area under the curve (AUC) of 0.846. Multivariate Logistic Regression identified these markers as independent predictors for SAE, leading to the construction of a nomogram with excellent discrimination, substantiated by an AUC of 0.924 through bootstrap resampling. The model exhibited satisfactory concordance between observed and predicted probabilities, and DCA confirmed its clinical utility for the prompt identification of SAE. This study highlighted the enhanced predictive value of CCT in SAE detection within ICU settings. A novel nomogram incorporating CCT, PI, and S100B demonstrated robust discrimination, calibration, and clinical utility, solidifying it as a valuable tool for early SAE intervention.

Exploring Cerebral Perfusion Transcranial Doppler Parameters in Patients Admitted to Combined Medical Surgical Intensive Care Unit

Introduction: Encephalopathy, a common complication in Intensive Care Unit (ICU) patients, is often linked to poor outcomes. Transcranial Doppler (TCD), a non-invasive tool assesses cerebral perfusion via the Pulsatility Index (PI), Resistivity Index (RI), and Time-Averaged Peak (TAP) or Mean Flow Velocity (MFV). These parameters may offer insights into cerebral perfusion and outcomes in encephalopathic patients. Aim: To describe the PI, RI of the Middle Cerebral Artery (MCA), and MFV or TAP measured by TCD in patients admitted to the ICU, comparing those with and without encephalopathy at the time of admission. Materials And Methods: This cross-sectional observational study was conducted from January 2019 to November 2020, in a combined medical-surgical ICU of a tertiary care hospital, involving 45 enrolled patients. Patients were evaluated within 24 hours of admission and subsequently every 24 hours until ICU discharge, death, or discharge against medical advice. Bilateral Middle cerebral artery TCD studies were conducted using a 1-5 MHz phased array probe or TCD mode through the transtemporal window. The PI, RI, and MFV were measured on both sides, with the higher value used for analysis, and all statistical analyses were performed using Statistics and Data 13 software. Results: In the present study, 88% (n=40) of patients had encephalopathy (GCS&lt;15 and RAAS less than or more than 0). The mean APACHE II score was 19 (14-25), indicating severe illness with a predicted mortality of 30-40%. Patients with encephalopathy had significantly higher APACHE II scores compared to those without (19.5 (16-25) vs 10 (4-19)). Although there was a trend towards a higher Pulsatility Index in encephalopathic patients at admission (1.11±0.378 vs 1.07±0.12, p=0.81), PI, RI, and TAP values did not significantly differ in non-survivors (1.12±0.49 vs 1.11±0.33, p=0.750). Persistent encephalopathy was associated with a trend towards higher PI at admission (1.05±0.24 vs 1.16±0.46; p=0.756), and a moderate correlation was found between decreasing PI and improvement in GCS (rho=-0.489, p=0.001). Conclusions: PI, RI, and TAP at the time of admission were not found to be associated with occurrence and recovery of encephalopathy as well as mortality. The trend of change in PI moderately correlated with improvement in GCS suggesting the importance of trends rather than absolute values.

Transcranial Doppler ultrasonography in bacterial meningitis: A systematic review.

Bacterial meningitis remains a global threat due to its high mortality. It is estimated that >1.2 million cases of bacterial meningitis are reported annually. Intracranial vasculopathy is an important, under-documented complication, easily detected by transcranial Doppler (TCD) ultrasonography. Following the PRISMA Guidelines, we reviewed the utility of TCD in bacterial meningitis. This is a systematic review of observational studies on the use of TCD in patients with CSF-proven bacterial meningitis. Characteristic changes in TCD parameters along the course of the disease, correlation of TCD findings with neuroimaging, and functional outcomes were evaluated. Nine studies were included with a total of 492 participants (mean age of 42). The most common TCD finding was intracranial arterial stenosis of the MCA (50%-82%) and ischemia (33%) was the predominant neuroimaging finding. The presence of an abnormal TCD finding increased the risk of poor outcomes as high as 70%. Patients diagnosed with bacterial meningitis who underwent TCD show alterations in cerebral blood flow, correlating with imaging findings and poor outcomes. It aids in the diagnosis of its sequelae and can predict the prognosis of its outcome. TCD is a cost-effective, reliable modality for diagnosing vasculopathy associated with bacterial meningitis. It may prove useful in our armamentarium of management. Large prospective studies with long-term follow-up data may help establish the use of TCD in bacterial meningitis.

Transcranial Doppler Sonography in Children with Congenital Heart Disease Undergoing Cardiac Catheterization

Background Children with congenital heart disease (CHD) are at high risk for neurodevelopmental disabilities. Acute neurologic complications, such as seizures, transient ischemic attack, intracranial hemorrhage, and ischemic stroke might occur in the setting of cardiac surgery and cardiac catheterization. Cardiac catheterization is important in the diagnosis and assessment of hemodynamic function in children with congenital heart disease. The incidence of neurologic complications (occurring within 48 hours) in interventional cardiac catheterization is significantly higher than those in diagnostic. Objective The Aim of this study is to evaluate the effect of cardiac catheterization on TCD Commented [RM1]: transcranial doppler (TCD) in children with congenital heart disease. Methods This is a prospective study. 40 children were enrolled; at Children’s hospital, Ain Shams University over 6 months. TCD parameters, clinical data, neurologic examination were done before and after cardiac catheterization. Results In the present study, 33 patients (82.5%) had interventional catheter and 7 (17.5%) had diagnostic catheter. Middle cerebral artery TCD parameters of the patients in the diagnostic group showed lower peak systolic (PS), and time average mean of the maximal velocities (TAMX), also called mean velocity, before catheterization and lower PS, end diastolic (ED), and TAMX post catheterization. All patients showed statistically significant lower TAMX post catheterization. Conclusion Cardiac catheterization lower middle cerebral artery time average mean of the maximal velocities in children with congenital heart disease. This impairment in blood flow might be a risk for cerebrovascular diseases in this population.

Transcranial Doppler After Successful Endovascular Revascularization and Hospitalization Outcomes

Background Almost half of large‐vessel occlusion strokes have unfavorable outcomes despite successful endovascular therapy. We aim to investigate whether postrevascularization cerebral hemodynamics, determined by transcranial Doppler (TCD), associate with hospitalization outcomes in this population. Methods The current observational cohort study analyzed 155 patients with successfully revascularized anterior circulation large‐vessel occlusion stroke (mean age, 68.3±15.4 years; 55% women) who had TCD within 48 hours from endovascular therapy. TCD parameters (mean flow velocity, peak systolic velocity, and pulsatility index) were recorded at the ipsilateral middle cerebral artery, and blood flow signals were categorized using the Thrombolysis in Brain Ischemia grades into normal (grade 5), stenotic (grade 4), or dampened (grade ≤3). Hospitalization outcomes comprised favorable discharge modified Rankin Scale score (0–2), favorable discharge destination (home or acute inpatient rehabilitation), and in‐hospital mortality. Logistic regression models adjusted for age, initial National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT [Computed Tomography] Score were fit to determine TCD findings in association with study outcomes. Results Abnormal TCD‐derived blood flow was found in 54 (35%) cases, including 35 (23%) with Thrombolysis in Brain Ischemia grade 4 and 19 (12%) with Thrombolysis in Brain Ischemia grade ≤3. Overall, 31% had favorable discharge modified Rankin Scale score, 65% had favorable destination, and 14% died. Thrombolysis in Brain Ischemia grade ≤3 was associated with lower likelihood of both favorable discharge modified Rankin Scale score (adjusted odds ratio [OR], 0.09 [95% CI, 0.01–0.81]) and favorable destination (adjusted OR, 0.22 [95% CI, 0.07–0.71]). Mean flow velocity and peak systolic velocity were not associated with study outcomes. Conversely, increased pulsatility index was inversely associated with favorable destination (adjusted OR, 0.34 [95% CI, 0.13–0.87]). Conclusions TCD after successful endovascular therapy identified abnormal blood flow in one‐third of cases. Dampened flow and markers of increased microvascular resistance were associated with unfavorable hospitalization outcomes. TCD could provide valuable prognostic information in this population and identify potential therapeutic targets.

The Effect of Pharmacologically Induced Blood Pressure Manipulation on Cardiac Output and Cerebral Blood Flow Velocity in Patients with Aneurysmal Subarachnoid Hemorrhage.

Vasopressors are used in patients with subarachnoid hemorrhage (SAH) to increase blood pressure with the idea of reversing the ischemic process. The current study is designed to evaluate the changes in systemic and cerebral hemodynamics, including cerebral blood flow autoregulation, at different pharmacologically augmented blood pressure levels using norepinephrine in patients with spontaneous aneurysmal SAH following surgery. This prospective observational study was carried out in patients with ruptured anterior circulation aneurysms who underwent surgical clipping and required norepinephrine infusion. Postoperatively, when the treating physician decided to start a vasopressor, norepinephrine infusion was started at 0.05 µg/kg/min. The infusion rate was increased by 0.05 µg/kg/min every 5 minutes to achieve a 20% and then 40% increase in the systolic blood pressure (SBP). When the blood pressure stabilized at each level for 5 minutes, hemodynamic and transcranial doppler (TCD) parameters in the middle cerebral artery (MCA) were recorded. Peak systolic, end-diastolic, and mean flow velocities in the MCA increased with targeted blood pressure increase in the hemispheres with impaired autoregulation and not in the hemispheres with intact autoregulation. The interaction of changes in TCD flow velocities between hemispheres with and without intact autoregulation was significant (p < 0.001). Cardiac output changes following norepinephrine infusion were not significant (p = 0.113). Hypertensive therapy with norepinephrine increases cerebral blood flow velocity only when autoregulation is impaired, an effect that is desirable in patients with focal cerebral ischemia following SAH. Lakshmegowda M, Muthuchellapan R, Sharma M, Ganne SUR, Chakrabarti D, Muthukalai S. The Effect of Pharmacologically Induced Blood Pressure Manipulation on Cardiac Output and Cerebral Blood Flow Velocity in Patients with Aneurysmal Subarachnoid Hemorrhage. Indian J Crit Care Med 2023;27(4):254-259.

Transcranial Doppler ultrasonography in tuberculous meningitis: A systematic review.

Tuberculous (TB) meningitis is a common type of central nervous system infection, and may cause multifocal cerebral infarctions due to the involvement of cerebral vasculature. This systematic review aims to review and synthesize the utility of transcranial Doppler (TCD) in TB meningitis. This is a systematic review of observational studies on the use of TCD in patients diagnosed to have TB meningitis. Study outcomes included changes in TCD parameters during stages of TB meningitis, frequency of neurologic complications (such as hydrocephalus, vasculopathy, and cerebral infarction), correlation of TCD findings with neuroimaging, and functional outcomes. Five studies were included with a total of 141 participants, with ages from 4 months to 75 years. The most common neurologic complication was hydrocephalus (87.1%), cerebral infarction (29.2%), and arterial stenosis (26.3%). There was increased mean flow velocity (MFV) most commonly in the middle cerebral artery in the early stage of TB meningitis, and decreased MFV in the advanced disease stage. TCD findings of stenosis were well correlated with CT or MR angiogram. Among patients with hydrocephalus, pulsatility indices were significantly decreased after ventriculoperitoneal shunting. A considerable proportion of patients with TB meningitis develop cerebral hemodynamic disturbances which lead to cerebral ischemia and affect clinical outcomes. TCD is a reliable tool for the diagnosis of vasculopathy and increased intracranial pressure and can thus help monitor disease progression and treatment response. Future studies with larger populations and longer follow-ups are recommended to determine the association of TCD findings with functional outcomes.

Correlation between transcranial Doppler parameters and parenchymal intracranial pressure in an experimental model of cerebral rebleeding

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Updating the role of transcranial Doppler in prediction and prevention of stroke in correlation to the regularity of blood transfusion in Egyptian children with sickle cell anemia

BackgroundThe Sickle cell disease (SCD) is a hemoglobinopathy that is recessively inherited commonly among people of Equatorial African, Saudi Arabian, and Mediterranean ancestry. It is characterized by chronic hemolytic anemia and intermittent vaso-occlusive events. The stroke is a common complication of SCD, which occurs in approximately 7% of children with SCD. The Transcranial Doppler ultrasonography is the only noninvasive examination that provides a reliable evaluation of intracranial blood flow patterns in real time with no need for sedation of the patient. The TCD can identify children with the highest risk of the first-ever stroke and those in need of prophylactic blood transfusion, as the blood transfusion is not in the protocol of management of SCD till now but just after complication occurrence. So, it is important to know if the chronicity and the regularity of the transfusion are useful or not.ResultsSixty-nine patients diagnosed with sickle cell disease, recruited from the pediatric hematology outpatient clinic, over a period of 7 months, with age 2–13 years, examined by transcranial Doppler ultrasound. 44.9% of them were on regular blood transfusion, 39.1% occasionally transfused and 15.9% never transfused. Transcranial Doppler parameters of the cerebral arteries, namely TAMAX, PSV, were correlated with the frequency of transfusion and with (STOP) classification of the stroke risk. The Doppler parameters were also correlated with the different clinical parameters. The right MCA PSV and left DICA PSV were significantly higher among patients who were never transfused before. The Right DICA TAMAX was significantly higher among patients on regular transfusion, and the left DICA TAmax was significantly higher among patients who were never transfused before. Patients with high risk of stroke were diagnosed at a significantly older age. Regarding the laboratory parameters, platelets were significantly lower and total and direct bilirubin was significantly higher among the high stroke risk patients.ConclusionsThe regularity of the blood transfusion is extremely important in the stroke prevention. The most important velocities that may act as indicators for the risk are TAMAX of both DICAs and PSV of RT MCA & LT DICA.

Correlation of Obesity and Overweight with Cervical Vascular Function Among Healthy Populations.

PurposeTo study the effects of obesity and overweight on carotid vascular function among healthy populations by carotid ultrasound (CAU) and transcranial Doppler (TCD).Materials and MethodsBasic clinical characteristics, CAU and TCD parameters were collected from recruited healthy individuals. Firstly, all participants were divided into three groups: normal, overweight and obese. Then, the variability of basic clinical characteristics and lipids between the three groups was calculated. Subsequently, CAU and TCD parameters were compared between the three groups. Finally, the correlation between body mass index (BMI) and neck vascular function was analyzed.ResultsA total of 613 healthy participants were included, of whom 241 were normal, 264 were overweight, and 108 were obese. Overweight and obesity significantly decreased systolic, diastolic and mean flow velocities in the basilar, vertebral and internal carotid arteries, but had no effect on pulsatility index. In addition, BMI was significantly negatively correlated with systolic, diastolic, and mean flow velocities in the basilar, vertebral, and internal carotid arteries, and remained correlated after adjusting for other factors. There was no effect of overweight and obesity on carotid plaques.ConclusionOur study revealed that overweight and obesity decreased carotid vascular flow velocity and showed a decreasing trend in vascular flow velocity with increasing BMI. Overweight and obesity appear to have no effect on carotid plaques.

Role of Nimodipine and Milrinone in Delayed Cerebral Ischemia

The role of nimodipine and milrinone in the management of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) was studied using clinical and TCD (transcranial Doppler) parameters. In this prospective observational study, patients with DCI after aneurysmal SAH presenting between November 2020 and June 2021 who were treated by either intra-arterial nimodipine (IAN) or intravenous milrinone (IVM) were included after excluding patients in whom both IAN and IVM had been given or mechanical angioplasty was performed. Twelve-hourly TCD was performed during the course of the therapy. Clinical improvement and the development of new brain infarcts were also assessed. A P value <0.05 was considered statistically significant. Thirty-four patients fulfilled the inclusion criteria (IVM, 13/34 [38%]; IAN, 21/34 [62%]); patients in the IVM group (vs. IAN group) had poorer median Glasgow Coma Scale score (12 vs. 13), poorer motor response (<M6 response, 5/13 [38%] vs. 5/21 [24%]; P= 0.36) and higher grades (modified Fisher grade ≥3) of SAH (12/13 [92%] vs. 8/21 [86%]; P= 0.56). More patients in the IAN group (vs. IVM group) showed clinical improvement (17/21 [81%] vs. 10/13 [77%]; P= 0.77), development of new infarcts (15/21 [71%] vs. 7/13 [54%]; P= 0.29] and discharged to home (13/21 [62%] vs. 6/13 [46%]; P= 0.36) with less mortality (1/21 [9%] vs. 4/13 [23%]; P= 0.037). On TCD analysis, both IAN and IVM protocols showed similar effects in middle cerebral artery vasospasm; however, IAN proved better over time. In group-effect analysis, the IAN protocol was significantly better in anterior cerebral artery and posterior cerebral artery vasospasm compared with IVM protocol. In this single-center small study, patients in the IAN group had significantly less mortality compared with the IVM group in the management of DCI after aneurysmal SAH.

Neutrophil Extracellular Traps and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage.

IMPORTANCE:Myeloperoxidase (MPO)-DNA complexes, biomarkers of neutrophil extracellular traps (NETs), have been associated with arterial and venous thrombosis. Their role in aneurysmal subarachnoid hemorrhage (aSAH) is unknown.OBJECTIVES:To assess whether serum MPO-DNA complexes are present in patients with aSAH and whether they are associated with delayed cerebral ischemia (DCI).DESIGN, SETTING, AND PARTICIPANTS:Post-hoc analysis of a prospective, observational single-center study, with de novo serum biomarker measurements in consecutive patients with aSAH between July 2018 and September 2020, admitted to a tertiary care neuroscience ICU.MAIN OUTCOMES AND MEASURES:We analyzed serum obtained at admission and hospital day 4 for concentrations of MPO-DNA complexes. The primary outcome was DCI, defined as new infarction on brain CT. The secondary outcome was clinical vasospasm, a composite of clinical and transcranial Doppler parameters. We used Wilcoxon signed-rank-test to assess for differences between paired measures.RESULTS:Among 100 patients with spontaneous subarachnoid hemorrhage, mean age 59 years (sd ± 13 yr), 55% women, 78 had confirmed aSAH. Among these, 29 (37%) developed DCI. MPO-DNA complexes were detected in all samples. The median MPO-DNA level was 33 ng/mL (interquartile range [IQR], 18–43 ng/mL) at admission, and 22 ng/mL (IQR, 11–31 ng/mL) on day 4 (unpaired test; p = 0.015). We found a significant reduction in MPO-DNA levels from admission to day 4 in patients with DCI (paired test; p = 0.036) but not in those without DCI (p = 0.17). There was a similar reduction in MPO-DNA levels between admission and day 4 in patients with (p = 0.006) but not in those without clinical vasospasm (p = 0.47).CONCLUSIONS AND RELEVANCE:This is the first study to detect the NET biomarkers MPO-DNA complexes in peripheral serum of patients with aSAH and to associate them with DCI. A pronounced reduction in MPO-DNA levels might serve as an early marker of DCI. This diagnostic potential of MPO-DNA complexes and their role as potential therapeutic targets in aSAH should be explored further.