Extensive atherosclerosis associated with mobile thrombus in the left carotid bulb in an elderly

A case of extensive atherosclerosis in an 88-year-old, chronic heavy smoker, associated with mobile thrombus in the left carotid bulb is presented. This patient also suffered from chronic obstructive pulmonary disease (COPD) and hypertension. He was fully worked up and confirmed as a case of the mobile thrombus attached to the plaque in the left carotid bulb by echocardiography and carotid Doppler. Thrombolysis of a large, mobile clot poses a theoretical risk of stroke worsening from incomplete fibrinolysis. He was prescribed anticoagulants and has been doing fine till the last follow-up. The importance of preventing premature atherosclerosis in the next generations is also discussed. We report this case to create awareness about this preventable malady and treatment options.

Multi-mode images to assess posterior circulation ischemic stroke caused by bilateral vertebral artery dissection based on vascular ultrasound: A case report / 中国脑血管病杂志

The etiology of posterior circulation ischemic stroke caused by bilateral vertebral artery dissection ( VAD) is often difficult to detect. In this study, the authors report a case of posterior circulation ischemic stroke with a history of excessive back elevation of the neck. The dissection of bilateral vertebral arteries was detected by carotid Doppler ultrasonography and further confirmed by magnetic resonance imaging and high-resolution magnetic resonance imaging. After 6 months of standard administration of dual antiplatelet therapy, recanalization of the bilateral vertebral artery was achieved. It proves that the early diagnosis and standardized medical treatment of VAD can significantly improve patients' prognosis.

Feasible study of carotid artery Doppler ultrasound blood flow measurement during chest compression cardiopulmonary resuscitation / 中华危重病急救医学

Objective To determine the feasibility of ultrasound to measure blood flow on patients with chest compression cardiopulmonary resuscitation (CPR), and to find out a real-time, noninvasive hemodynamic evaluation method. Methods A prospective study was conducted. All adult patients undergoing CPR admitted to Department of Emergency and intensive care unit (ICU) of Zhengzhou People＇s Hospital from May 2016 to November 2018 were enrolled. The blood flow over the right carotid arteries during chest compressions was recorded with a bedside ultrasound machine. The peak systolic flow velocity (PSV) and end diastolic flow velocity (EDV) of carotid artery were recorded at 1 minute after the start of CPR and 1 minute before the end of CPR. The mean compression frequency during the whole recovery period was recorded, the rate of compression reaching the standard was evaluated by ultrasound (the rate of compression 100-120 times/min was defined as up to standard), and the interruption time of compression was calculated retrospectively according to the ultrasound image data recorded during CPR. Results Thirty-nine patients were enrolled, and 21 patients were successfully rescued, with a successful rate of 53.8%, the time of restoration of spontaneous circulation (ROSC) was (10.9±5.3) minutes. The time from CPR to retrieve an ultrasound image was 1.1-4.9 minutes, with an average of (2.5±1.2) minutes. Satisfactory ultra-sonographic images were obtained in 28 patients during the whole course of chest compression. The acquisition rate was 71.8% (28/39). In the process of compression, if the frequency of compression was less than 100 times/min or the velocity of carotid artery dropped (PSV < 30 cm/s), the chest compressors should be reminded and corrected in time. The PSV at 1 minute after CPR start of 28 patients with satisfactory ultrasound images was (62.9±18.5) cm/s, and the EDV was (13.9±3.5) cm/s, the PSV at 1 minute before the end of CPR was (55.4±18.4) cm/s, and the EDV was (12.9±3.7) cm/s. There was no significant difference in above parameters between the two time points (both P > 0.05), suggesting that satisfactory resuscitation effect was achieved in the whole process of CPR. The compression frequency of 28 patients was 100-149 times/min with an average of (117±47) times/min. The rate of compression with standard was 85.7% (24/28), and the total interruption time of compression accounted for 4.4% of all compression time (25.9 minutes/587.2 minutes). Conclusion Ultrasound measurement of common carotid artery blood flow during CPR has the advantage of real-time and non-invasive, and it is feasible in clinical work.

Variability of peripheral arterial peak velocity predicts fluid responsiveness in patients with septic shock / 中华危重病急救医学

Objective To explore the accuracy of fluid responsiveness assessment by variability of peripheral arterial peak velocity and variability of inferior vena cava diameter (ΔIVC) in patients with septic shock. Methods A prospective study was conducted. The patients with septic shock undergoing mechanical ventilation (MV) admitted to intensive care unit (ICU) of Beijing Electric Power Hospital from January 2016 to December 2017 were enrolled. According to sepsis bundles of septic shock, volume expansion (VE) was conducted. The increase in cardiac index (ΔCI) after VE ≥ 10% was defined as liquid reaction positive (responsive group), ΔCI < 10% was defined as the liquid reaction negative (non-responsive group). The hemodynamic parameters [central venous pressure (CVP), intrathoracic blood volume index (ITBVI), stroke volume variation (SVV), ΔIVC, variability of carotid Doppler peak velocity (ΔCDPV), and variability of brachial artery peak velocity (ΔVpeak-BA)] before and after VE were monitored. The correlations between the hemodynamic parameters and ΔCI were explored by Pearson correlation analysis. Receiver operating characteristic (ROC) curve was plotted to analyze the predictive value of all hemodynamic parameters on fluid responsiveness. Results During the study, 74 patients with septic shock were included, of whom 9 were excluded because of peripheral artery stenosis, recurrent arrhythmia or abdominal distension influencing the ultrasound examination, and 65 patients were finally enrolled in the analysis. There were 31 patients in the responsive group and 34 in the non-responsive group. SVV, ΔIVC, ΔCDPV and ΔVpeak-BA before VE in responsive group were significantly higher than those of the non-responsive group [SVV: (12.3±2.4)% vs. (9.2±2.1)%, ΔIVC: (22.3±5.3)% vs. (15.5±3.7)%, ΔCDPV: (15.3±3.3)% vs. (10.3±2.4)%, ΔVpeak-BA: (14.5±3.3)% vs. (9.6±2.3)%, all P < 0.05]. There was no significant difference in CVP [mmHg (1 mmHg = 0.133 kPa): 7.5±2.5 vs. 8.2±2.6] or ITBVI (mL/m2: 875.2±173.2 vs. 853.2±192.0) between the responsive group and non-responsive group (both P > 0.05). There was no significant difference in hemodynamic parameter after VE between the two groups. Correlation analysis showed that SVV, ΔIVC, ΔCDPV, and ΔVpeak-BA before VE showed significant linearity correlation with ΔCI (r value was 0.832, 0.813, 0.854, and 0.814, respectively, all P < 0.05), but no correlation was found between CVP and ΔCI (r = -0.342, P > 0.05) as well as ITBVI and ΔCI (r = -0.338, P > 0.05). ROC curve analysis showed that the area under ROC curve (AUC) of SVV, ΔIVC, ΔCDPV, and ΔVpeak-BA before VE for predicting fluid responsiveness was 0.857, 0.826, 0.906, and 0.866, respectively, which was significantly higher than that of CVP (AUC = 0.611) and ITBVI (AUC = 0.679). When the optimal cut-off value of SVV for predicting fluid responsiveness was 11.5%, the sensitivity was 70.4%, and the specificity was 94.7%. When the optimal cut-off value of ΔIVC was 20.5%, the sensitivity was 60.3%, and the specificity was 89.7%. When the optimal cut-off value of ΔCDPV was 13.0%, the sensitivity was 75.2%, and the specificity was 94.9%. When the optimal cut-off value of ΔVpeak-BA was 12.7%, the sensitivity was 64.8%, and the specificity was 89.7%. Conclusions Ultrasound assessment of ΔIVC, ΔCDPV, and ΔVpeak-BA could predict fluid responsiveness in patients with septic shock receiving mechanical ventilation. ΔCDPV had the highest predictive value among these parameters.

Carotid doppler ultrasonography evaluation in patients with stroke

Introduction: Stroke is defined as rapid onset of focal neurological deficit resulting from diseases of cerebral vasculature and its contents. Community surveys in India have shown a crude prevalence rate for hemiplegia in the range of 200 per 100,000 persons, nearly 1.5% of all urban hospital admission, 4.5% of all medical and around 20% of neurological cases. The aim of the study: To determine the usefulness of doing Carotid Doppler Ultrasonography as a screening procedure in predicting the chance of developing stroke in persons having risk factors for stroke. Materials and methods: The study was conducted in Department of Medicine, Government Dharmapuri Medical College, Dharmapuri in December 2017 to January 2018. In this study, patients who were admitted with a history of sudden onset of neurological illness are subjected to CT scan brain. Among the patients who had suffered an ischemic stroke in the anterior circulation are selected and they were further evaluated. Results: Hypertension was present equally in 58% of the males and females studied. Hence this study confirmed that hypertension is one of the major risk factors for the development of stroke and control of hypertension will reduce the risk of developing stroke. In this study diabetes as a risk factor was present in 89% of females and 41% of males. Hence this study observed that patients with diabetes are at increased risk for all forms of ischemic stroke and also are more likely to have hypertension and hyperlipidemia. Information from other studies also suggests that higher total and low-density lipoprotein (LDL) cholesterol levels are associated with an increased risk of ischemic stroke. Conclusion: Carotid Doppler Ultrasonography cannot substitute for angiography as the sole preoperative tests for Carotid endarterectomy. However, it can be used as a screening test for the detection of the asymptomatic Carotid disease in patients with risk factors for stroke.

Prevalence of carotid artery stenosis in neurologically asymptomatic patients undergoing coronary artery bypass grafting for coronary artery disease: Role of anesthesiologist in preoperative assessment and intraoperative management.

Objective(s): This study aimed to determine the prevalence of carotid artery stenosis (CAS) due to atherosclerosis in neurologically asymptomatic patients undergoing coronary artery bypass grafting (CABG) for coronary artery disease (CAD). It contemplated a greater role for the cardiac anesthesiologist in the perioperative management of such patients with either previously undiagnosed carotid artery disease or towards re-assessment of severity of CAS. Design: Prospective, observational clinical study. Setting: Operation room of a cardiac surgery centre of a tertiary teaching hospital. Participants: A hundred adult patients with New York Heart Association (NYHA) classification I to III presenting electively for CABG. Interventions: All patients included in this study were subjected to ultrasonic examination by means of acarotid doppler scan to access for presence of CAS just prior to induction of general anesthesia. Measurements and Main Results: Based on parameters measured using carotid doppler, the presence of CAS was defined using standard criteria. The prevalence of CAS was found to be as high as 38% amongst the patients included in our study. The risk factors for CAS were identified to be advanced age, history of smoking, diabetes mellitus, dyslipidaemia and presence of a carotid bruit. Conclusion: This study points towards the relatively wide prevalence of carotid artery disease in neurologically asymptomatic patients undergoing CABG for CAD in the elective setting. It highlights the need to routinely incorporate carotid ultrasonography in the armamentarium of the cardiac anesthesiologist as standard of care for all patients presenting for CABG.

Colour Doppler Study of Extracranial Carotid Arteries in Stroke.

The current observational study was conducted to evaluate the morphology of extracranial parts of carotid arteries by colour doppler in patients of stroke and to assess the peak systolic velocity ratio of internal carotid artery/common carotid artery and its utility in diagnosis of the carotid arterial disease. Duplex ultrasound is an inexpensive, non-invasive method that can provide functional and anatomical information about vessel stenosis and plaque morphology. It is a sensitive method for detection of atherosclerotic plaque and provides considerable information about the extent and severityof plaque as well as the resulting diminution of arterial lumen.The study of Colour Doppler of carotid arteries was carried on 35 patients presenting with stroke. The data gathered included grey scale and Doppler findings of common carotid, internal carotid and external carotid arteries. In this study, the commonest lesion found was the atherosclerotic plaque. Most common risk factor for increased intima -media thickness of carotid vessel is found in patients with history of smoking > 10 years. Atheromatous plaque was most commonly found in the left carotid and bilateral system (41.1%). Most common site for atheromatous plaque was found to be carotid bifurcation (48.5%). Significant stenosis (i.e. >40%) was found in 24(64%) of the cases. Peak systolic velocity ratio showed significant stenosis in 24 (68.5%) of patients. The role of carotid Doppler in detecting the site and morphology of atherosclerotic plaque with quantifying the amount of stenosis is very welljustified. In addition carotid Doppler can also be used to assess the prognosis in potential symptomatic and asymptomatic patients with one or the other risk factors for cerebrovascular disease.

Ocular and Systemic Manifestation of Amaurosis Fugax: Six-Year Observational Study

PURPOSE: To investigate the prevalence of ocular and systemic disease causing amaurosis fugax and to discuss the ocular and systemic manifestation of each disease. METHODS: Consecutive patients who had amaurosis fugax were retrospectively studied from 2007 to 2013. Carotid evaluation using Doppler was performed in all patients. Ocular and medical histories were taken and bilateral ophthalmic evaluation performed. RESULTS: This study included 35 patients. The mean age of patients was 63 years and 27 patients were male; 29 unilateral and 6 bilateral eyes were involved. Associated systemic disease included hypertension (54.3%) and diabetes mellitus (34.2%). The most frequent cause of amaurosis fugax was retinal artery occlusion (28.6%) followed by ocular ischemic syndrome (22.9%), other vascular diseases (11.4%), and retinal vein occlusion (5.7%). The remaining 31.4% patients with amaurosis fugax had no vascular disease. Clinically significant stenosis of the internal carotid artery was observed in 16 patients (45.7%) and 6 of these patients (37.5%) had retinal artery occlusion disease. CONCLUSIONS: Prevalence and clinical manifestation of amaurosis fugax is very complex. Patients with transient visual disturbance are at risk for retinal artery occlusion, ocular ischemic syndrome and other diseases which cause visual loss. Therefore, careful history taking and urgent systemic and ophthalmic evaluations should be performed.

Results of Carotid Doppler and Lipid Profiles in Patients with Ocular Ischemic Disease

PURPOSE: To analyze the findings of carotid Doppler and lipid profiles in patients with ischemic ocular disease and as well as the risk and correlation between cardiovascular and ischemic ocular diseases. METHODS: We analyzed the intima-media thickness (IMT) and existence of vascular stenosis using carotid Doppler and blood lipid profiles of the study patients diagnosed with anterior ischemic optic neuropathy (AION group, n = 45), central retinal vein occlusion (CRVO group, n = 34), central retinal artery occlusion (CRAO group, n = 23), or ocular ischemic syndrome (OIS group, n = 27). The study patients who visited Chonbuk National University Hospital from January, 2010 to June, 2013 were compared with healthy control (control group, n = 107). RESULTS: The average age of the study patients was 60.0 +/- 14.1 years and 56.1 +/- 9.1 years for the controls. Ipsilateral common carotid artery-IMT was thicker in the OIS and CRAO groups than the control group (p < 0.01 and <0.01, respectively). The number of patients with carotid stenosis was highest in the OIS group (n = 17, 62.9%) followed by the CRAO group (n = 5, 21.7%), CRVO group (n = 2, 5.9%), and AION group (n = 1, 2.2%). No significant stenosis was found in the control group. Total blood cholesterol was not significantly different between the study patients and controls. Low-density lipoprotein cholesterol was higher in every patient group than the control group (p < 0.01, <0.01, <0.05 and <0.01, respectively). CONCLUSIONS: The ischemic ocular disease likely precedes carotid artery disease and dyslipidemia. Therefore, general examinations such as carotid Doppler, lipid profile and risk factor evaluations are needed in patients with ischemic ocular disease.

Ultrasound Study of Atherosclerotic Changes in Carotid Vessels and Role of Certain Factors which Increase the Incidence of Atherosclerosis

Atherosclerosis is supposed to be causing number of deaths due to coronary artery stenosis and major inability in the shape of hemipleagias involving carotid arteries, which is called stroke or vascular accident. In this study, evaluation of the factors causing increased incidence of carotid artery atherosclerosis is done. Ultrasound has unique capability to visualise vessel wall in vivo. This important arterial pathophysiolgy detected with B-mode sonography is arthrosclerosis and plaque formation. Atherosclerotic plaque is represented sonographically by echogenic material that thickens the intimal reflection and encroaches onto the arterial lumen and produces flow void. The study was carried out with 375 patients who were attending the medical, surgical and diabetic departments of Santhiram Medical College, Nandyal for attributable neurological signs. All the cases were examined with SIEMENS SONOLINE G-50 ultrasound machine using the 7.5–10 MHz linear array transducer. All examinations are done with the Doppler angle of 60 degree and sample volume of 1–5 mm[2,5]. All four vessels, i.e., common carotid, internal carotid, external carotid and vertebral arteries of both sides are evaluated both longitudinally and transversely. Following parameters are observed on both real time and frozen images. Intima-media thickness, patent lumen diameter, residual lumen diameter, dimensions of the plaque, peak systolic velocity, systolic velocity ratio (carotid index), diastolic velocity ratio and percentage of diameter stenosis.

Estudio con ultrasonido doppler color en la caracterización de la enfermedad aterosclerotica carotidea oclusiva sintomática / Study with color doppler ultrasound in the characterization of symptomatic carotid atherosclerotic occlusive disease

Objective: To determine the association between risk factors and atherosclerosis in the carotid arteries in occlusive cerebrovascular disease. Method: A prospective, descriptive, cross-sectional study in 274 patients with clinical and CT diagnosis ofischemic ictus was conducted. Examination by the means of carotid artery color Doppler ultrasound was performed in the study Group. Results and Conclusions: The mean age of patients was 68.7 years anda male predominance (54.1 percent) was reported. Arterial hypertension, which was present in 214 patients (78.1 percent), constituted the most prevalent atherogenic risk factor, followed by age over 60 years (75.9 percent), and smoking (58 percent). The atherothrombotic and cardioembolic origins were predominant (54 percent and 19.7 percent, respectively), followed by lacunar (13.9 percent), and undetermined origin (11.3 percent). Atherosclerotic involvement occurs bilaterally with a predominance of the right axis, appearing low shear stress areas as the sites of the greatest severity.

Objetivo: Determinar la asociación entre los factores de riesgos y la aterosclerosis de las arterias carótidas, en la enfermedad cerebrovascular oclusiva. Método: Se realizó un estudio prospectivo, descriptivo y transversal en 274 pacientes con diagnóstico clínico y tomográfico de ictus isquémico, realizándoles estudio con ultrasonido Doppler color carotídeo. Resultados y Conclusiones: La edad media de los pacientes fue 68,7años. Se observó predominio de sexo masculino (54,1 por ciento). EI factor de riesgo aterogénico que predominó fue HTA, presente en 214 (78.1 por ciento), seguido por edad mayor de 60 (75.9 por ciento) y tabaquismo (58 por ciento). El origen aterotrombótico y cardioembólico fueron predominantes (54 y 19.7 por ciento respectivamente), seguidos por el lacunar (13.9 por ciento) y el origen indeterminado (11.3 por ciento). La afectación aterosclerótica ocurre bilateralmente, con un predominio del eje derecho, siendo las zonas de bajo shear stress los sectores de mayor severidad.

Transthoracic Echocardiography and Carotid Doppler Ultrasound for Detection of Cardiac and Carotid Artery Disease in Patients with Acute Retinal Artery Obstruction

We reviewed the medical records of patients with acute retinal artery obstruction (RAO) and evaluated the importance of transthoracic echocardiography (TTE) and carotid Doppler ultrasound in determining causes of cardiac and carotid artery origin in RAO. A retrospective case study conducted in the Department of Ophthalmology, Inha University Hospital, Korea comprised 26 patients presenting with acute RAO who underwent systemic evaluation, TTE and carotid Doppler ultrasound between June 1, 1997 and December 31, 2003. Among these 26 patients, abnormal cardiac findings were detected in 12 (46%) and abnormal carotid findings in 4 (15%). Furthermore, other risk factors for RAO were found in 2 (8%) and stroke broke out within 7 months after experiencing RAO in 4 (15%) of the 26 patients. In patients with acute RAO, TTE and carotid Doppler ultrasound play an important role in pinpointing the origins of retinal emboli. It is thought that TTE and carotid Doppler ultrasound may be essential examinations for determining the underlying cause, planning treatment strategies, and preventing stroke and death.

Abnormal Systemic Findings in Patients with Acute Retinal Artery Occlusion

PURPOSE: Analyzing the systemic abnormal findings of acute retinal artery occlusion, to investigate what kinds of systemic evaluation must be performed in patients with acute retinal artery occlusion. METHODS: Thirty-three patients who had been diagnosed as acute retinal artery occlusion from July 1996 to June 2001 at Kyungpook National University Hospital were evaluated. Routine blood test, carotid doppler ultrasonography, echocardiography, routine anticoagulation study and antithrombin III assay were performed and serum protein S and protein C levels of these patients were checked. RESULTS: Seventeen of 33 were diagnosed as central retinal artery occlusion, 2 as ophthalmic artery occlusion, 10 as branch retinal artery occlusion, 4 as cilioretinal artery occlusion. Sixteen of 33 patients (48%) had abnormal findings on these systemic evaluation. Twenty-two patients had carotid doppler ultrasonography. Twelve of these 22 patients (54%) had atherosclerotic plaque in their carotid artery, and hemodynamically significant carotid stenosis (> or =60% of lumen) was found in six patients (27%). Only one patient had decreased serum levels of protein S and protein C. Two patients had abnormal findings of echocardiography. One patient had elevated serum hemoglobin and hematocrit, and so he was transferred to department of hematology and diagnosed as secondary polycythemia (Table 2). CONCLUSIONS: Many patients with acute retinal artery occlusion had various systemic disease. So, it is suggested that systemic evaluation of acute retinal artery occlusion be performed.

Clinical Study of Potential Embolic Sources in Patients with Ischemic Cerebrovascular Diseases

BACKGROUND: The etiologies of ischemic cerebrovascular diseases are various-thrombosis or artery to artery embolism, cardiogenic embolism and lipohyalinosis. In the past embolic cerebral infarct was thought to occur uncommonly. But these days substantial portion of patients have been found to have potential embolic sources by transesophageal echo cardiography and carotid duplex doppler. As transesophageal echocardiography has a high yield for identification of potential sources of cardiac embolism in patients with ischemic cerbrovascular diseases, its use has been increasing. In Korea an increasing number of patients with ischemic cerebrovascular diseases have been examined by transesophageal echocardiography since 1990. But in all the previous studies transesophageal echocardiographic evaluation has been confined to the patients with high probability of embolic cerebral infarct. All kinds of ischemic cerebrovascular diseases patients have never been examined by transesophageal echocardiography and carotid duplex doppler and the prevalence of potential embolic sources in Korean ischemic cerebrovascular disease patients is not known. The aim of this study was to evaluate the prevalence of potential cardiovascular embolic sources by transesophageal echocardiography and carotid duplex doppler in unselected patients with ischemic cerebrovascular diseases. METHODS: We evaluated all kinds of ischemic cerebrovascular diseases patients admitted from 1994. 9. 1. until 1995 9. 31. to the Departments of Neurology and Internal Medicine of Kangnam General Hospital. We evaluated them by transesophageal echocardiography, carotid doppler, brain CT(or brain MRI). A significant carotid stenosis was defined as a duplex scandetected lesion producing at least 50% vessel narrowing. The following echocardiographic findings were defined prospectively as potential cardiac sources of embolism : atrial appendage or left atrial cavity thrombus, spontaneous echocardiographic contrast, atrial septal aneurysm, interatrial shunt, ventricular aneurysm, ventricular thrombus, myxomatous mitral valve and protruding atherosclerotic plaque in the ascending aorta or transverse aortic arch. RESULTS: Of 64 patients admitted during the study period, 30 were excluded(Three patients were critically ill, and twenty seven patients refused diagnostic work-up.). Thorough diagnostic work-up was performed in 34 patients. Transesophageal echocardiographic positive findings were present in six patients(17.6%). Of them four(4/34, 11.7%) had spontaneous echo contrast, two(2/34, 5.8%) had left atrial thrombi, one(1/34, 2.9%) had ascending aorta atheroma. Eleven patients(11/34, 32.3%) had abnormalities in carotid doppler study. Five patients(5/34, 14.7%) had abnormalities both in transesophageal echocardiography and carotid doppler study. CONCLUSIONS: The results suggest that among ischemic cerebrovascular diseases patients substantial portion of patients have potential embolic sources. The prevalence of potential embolic sources in Korea may be higher than previously expected. Because the relative small number of the patients studied make it difficult to generalize the results, further studies with a large number of patients are needed.