Blood Flow Volume Measurement in Cervical and Intracranial Arteries using Quantitative Magnetic Resonance Angiography and Duplex Sonography (Bocaccia) - A Prospective Observational Study.

PURPOSE: Cerebral blood flow volume is an important factor for the accurate diagnosis of neurovascular diseases and treatment indication. This study aims to assess correlations of blood flow volume measurements in cervical and intracranial arteries between duplex sonography and quantitative magnetic resonance angiography (qMRA). MATERIALS AND METHODS: Consecutive patients with suspicion of cerebral vascular pathology underwent qMRA and duplex sonography of cervical and intracranial arteries with measurement of blood flow volume in bilateral common (CCA), internal (ICA) and external carotid arteries, vertebral and basilar arteries, middle, anterior, posterior cerebral and posterior communicating arteries using 2 different ultrasound machines. Ten patients underwent all examinations twice. Correlations between blood flow volume measurements were evaluated using Spearman's correlation coefficient and inter-class correlation coefficient (ICC). RESULTS: In total, 21 subjects (15 males, mean age: 56.3 ± 6.2 years) were included in the study. Duplex sonography inter-investigator correlation was excellent (ICC = 0.972, p < 0.0001) as well as intra-investigator correlations of both qMRA and duplex sonography (ICC ˃ 0.990, p < 0.0001). Mostly high correlations were recorded between qMRA and duplex sonography in particular cervical arteries but only low to moderate correlations were obtained for intracranial arteries. The mean differences between blood flow volume measurements were 10.9 ±â€Š8.1 % in the CCA and its branches when using qMRA and 15.0 ±â€Š11.9 % when using duplex sonography, 13.5 ±â€Š11.8 %/35.4 ±â€Š34.2 % in the ICA siphon and its branches when using qMRA/duplex sonography, and 24.1 ±â€Š19.7 %/44.9 ± 44.0 % in both vertebral arteries and the basilar artery when using qMRA/duplex sonography. CONCLUSION: Duplex sonography as well as qMRA allow for highly reproducible measurement of blood flow volume in cervical and intracranial arteries in routine clinical practice.

Factors influencing quality of life in patients followed in the neurosonology laboratory for carotid stenosis.

BACKGROUND: Quality of life (QoL) is one of the main endpoints in stroke prevention or acute stroke treatment studies. The aim of the current study was to identify risk factors affecting the QoL of patients with carotid stenosis in stroke prevention. METHODS: Self-sufficient patients (50-80 years of age) with ≥20% carotid artery stenosis followed in the neurosonology laboratory, and without any severe illnesses within the last 12 months, dementia, or psychiatric disorders were selected for the study after signing informed consent. Patients completed two standardized QoL questionnaires (WHOQoL-BREF and EQ-5D-3 L) and a visual pain scale, provided covariate variables (medication, age, gender, education, and social situation), and the blood pressure and body mass indexes were recorded. Logistic regression (forward stepwise method) was used to identify factors affecting the individual domains of QoL questionnaires. RESULTS: Of the 584 consecutive patients, 502 met the inclusion criteria and 344 completely filled both QoL questionnaires (164 men; mean age, 69.7 ± 7.8 years). An independent predictor of worse QoL in all domains was pain. Independent factors decreasing the QoL were lower level of education and blood pressure in the physical health domain, female gender in the psychological domain, and male gender in the social relationships domain. Independent factors decreasing satisfaction with health status were female gender and higher blood pressure. Factors negatively influencing the satisfaction with the QoL were living alone, lower level of education, and higher diastolic blood pressure (WHOQoL-BREF). Factors negatively influencing mobility were age, male gender, living alone, lower level of education, and higher body mass index (EQ-5D-3 L; p < 0.05 in all cases). CONCLUSIONS: Pain, blood pressure, body mass index, education, living alone, gender, and age were associated with the QoL in patients with carotid stenosis. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02360137 . Registered on 26 January 2015.

SONOlysis in prevention of Brain InfaRctions During Internal carotid Endarterectomy (SONOBIRDIE) trial - study protocol for a randomized controlled trial.

BACKGROUND: Carotid endarterectomy (CEA) is a beneficial procedure for selected patients with an internal carotid artery (ICA) stenosis. Surgical risk of CEA varies from between 2 and 15%. The aim of the study is to demonstrate the safety and effectiveness of sonolysis (continual transcranial Doppler monitoring, TCD) using a 2-MHz diagnostic probe with maximal diagnostic energy on the reduction of the incidence of stroke, transient ischemic attack (TIA) and brain infarction detected using magnetic resonance imaging (MRI) by the activation of the endogenous fibrinolytic system during CEA. METHODS/DESIGN: Design: a multicenter, randomized, double-blind, sham-controlled trial. SCOPE: international, multicenter trial for patients with at least 70% symptomatic or asymptomatic ICA stenosis undergoing CEA. INCLUSION CRITERIA: patients with symptomatic or asymptomatic ICA stenosis of at least 70% are candidates for CEA; a sufficient temporal bone window for TCD; aged 40-85 years, functionally independent; provision of signed informed consent. Randomization: consecutive patients will be assigned to the sonolysis or control (sham procedure) group by computer-generated 1:1 randomization. Prestudy calculations showed that a minimum of 704 patients in each group is needed to reach a significant difference with an alpha value of 0.05 (two-tailed) and a beta value of 0.8 assuming that 10% would be lost to follow-up or refuse to participate in the study (estimated 39 endpoints). ENDPOINTS: the primary endpoint is the incidence of stroke or TIA during 30 days after CEA and the incidence of new ischemic lesions on brain MRI performed 24 h after CEA in the sonolysis and control groups. Secondary endpoints are occurrence of death, any stroke, or myocardial infarction within 30 days, changes in cognitive functions 1 year post procedure related to pretreatment scores, and number of new lesions and occurrence of new lesions ≥0.5 mL on post-procedural brain MRI. ANALYSIS: descriptive statistics and linear/logistic multiple regression models will be performed. Clinical relevance will be measured as relative risk reduction, absolute risk reduction and the number needed to treat. DISCUSSION: Reduction of the periprocedural complications of CEA using sonolysis as a widely available and cheap method may significantly increase the safety of CEA and extend the indication criteria for CEA. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02398734 . Registered on 20 March 2015.

Detection of intracranial arterial stenosis using transcranial color-coded duplex sonography, computed tomographic angiography, and digital subtraction angiography.

OBJECTIVES: The aim of this retrospective study was to compare intracranial arterial stenosis in patients with stroke using 3 different methods: transcranial color-coded duplex sonography, computed tomographic (CT) angiography, and digital subtraction angiography in a common clinical practice. METHODS: Sixty-seven patients (47 male and 20 female; age range, 23-79 years; mean age ± SD, 62.0 ± 9.5 years) were enrolled in this study over 40 months. All patients underwent examinations of the intracranial arteries using transcranial color-coded sonography, CT angiography, and digital subtraction angiography. Findings were divided into 4 groups: normal, mild stenosis (<50%), severe stenosis (50%-99%), and occlusion. RESULTS: Because of technical reasons or an insufficient bone window, 465 of 536 arterial segments in 67 patients were evaluated; 12 stenotic and 15 occluded segments were detected using digital subtraction angiography. The sensitivity, specificity, positive predictive value, and negative predictive value of transcranial color-coded sonography and CT angiography in comparison with digital subtraction angiography as a reference standard were 88.9%, 94.8%, 51.1%, and 99.3% and 81.5%, 98.7%, 78.6%, and 98.6%, respectively. The agreement between transcranial color-coded sonography and CT angiography was 93.8% (κ = 0.559); between transcranial color-coded sonography and digital subtraction angiography, it was 93.9% (κ = 0.588); and between CT angiography and digital subtraction angiography, it was 96.6% (κ = 0.697). CONCLUSIONS: Moderate agreement was found between CT angiography, transcranial color-coded sonography, and digital subtraction angiography in the evaluation of intracranial stenosis. Computed tomographic angiography and digital subtraction angiography are sufficient for assessment of the diagnosis.

Distal enlargement of the optic nerve sheath in the hyperacute stage of intracerebral haemorrhage.

AIMS: Optic nerve sheath diameter (ONSD) enlargement is detectable in patients with increased intracranial pressure. The aim was to detect an enlargement of the ONSD using optic nerve sonography in patients with acute intracerebral haemorrhage (ICH) within 6 h of the onset of symptoms. METHODS: Thirty-one acute ICH patients, 15 age-matched acute ischaemic stroke patients and 16 age-matched healthy volunteers were enrolled consecutively in this prospective bi-centre observational study. All acute stroke patients underwent brain CT, optic nerve sonography and transcranial colour-coded duplex sonography (TCCS) at admission within 6 h of stroke onset. The ONSD both 3.0 and 12.0 mm behind the globe using optic nerve sonography were recorded and statistically evaluated, as were age, sex, haemorrhage volume and midline shift measured by CT, and blood flow velocities in both middle cerebral arteries using TCCS. RESULTS: In acute ICH patients, a significant enlargement of ONSD was detected (p < 0.0083). The best cut-off point to predict ICH volume >2.5 cm³ was the relative ONSD enlargement of > 0.66 mm (> 21 %), with 90.3% accuracy and kappa coefficient 0.760 (95% CI 0.509 to 1.000). CONCLUSIONS: Sonographically measured enlargement of the ONSD may already be detectable in the hyperacute stage of increased intracranial pressure.

Changes in hemocoagulation in acute stroke patients after one-hour sono-thrombolysis using a diagnostic probe.

The aim was to monitor the changes in hemocoagulation parameters in acute ischemic stroke (AIS) patients after sono-thrombolysis of the occluded middle cerebral artery using a duplex transcranial probe with 2.0-MHz frequency in Doppler mode. Sixteen AIS patients indicated for intravenous thrombolysis (IVT) (8 males; mean age 68.3 +/- 7.1 y) and 16 AIS patients contraindicated for IVT (11 males; mean age 67.9 +/- 7.9 y) were randomized for sono-thrombolysis (8 + 8 patients) or standard treatment (control group) (8 + 8 patients). The significant decrease of plasminogen activator inhibitor-1, plasminogen and alpha-2-antiplasmin activity by a mean of 60, 32 and 24%, respectively, and the increase of tissue plasminogen activator by a mean of 56% was found after sono-thrombolysis when compared with control group (p < 0.0125); these changes were more evident in patients treated with a combination of sono-thrombolysis and IVT (79, 38, 50 and 82%, respectively) than in patients treated by sono-thrombolysis alone (34, 13, 17 and 30%, respectively).

Changes in haemocoagulation in healthy volunteers after a 1-hour thrombotripsy using a diagnostic 2-4 MHz transcranial probe.

INTRODUCTION: The aim was to monitor the changes in haemocoagulation parameters in healthy volunteers after a thrombotripsy with 1-hour transcranial Doppler monitoring using a 2-4 MHz probe. MATERIALS AND METHODS: About 10 healthy volunteers underwent a 1-hour thrombotripsy of the middle cerebral artery (MCA), thrombotripsy of the radial artery and a standard 20-min neurosonologic examination (NSE) in 2-week intervals. Platelet count, aPTT, prothrombin time, fibrinogen, D-dimers, tPA, FDP, alpha-2-antiplasmin (AP), plasminogen, PAI-1 antigen, time of euglobulin clot lysis (ECL), homocysteine, and lipoprotein (a) were examined before, at the end and 24 h after a thrombotripsy. All adverse events were monitored. RESULTS: After a thrombotripsy of the MCA, PAI-1 antigen, tPA antigen, fibrinogen and AP activity were significantly decreased by a mean of 32, 23, 7, and 4% respectively (P < 0.05 in all cases). After a thrombotripsy of the RA, there was a significant decrease in tPA antigen alone by an average of 14% (P < 0.05). Standard NSE did not affect any of the measured factors. CONCLUSIONS: Thrombotripsy with 1-hour TCD monitoring using a 2-4 MHz diagnostic probe may affect the fibrinolytic system in humans.

Reproducibility of sonographic measurement of the substantia nigra.

The aim of this study was to evaluate inter-reader, intra-investigator and inter-investigator reproducibility and correlations in the assessment of substantia nigra (SN) echogenicity and area measurement by a physician-sonographer (PS), a sonographic laboratory assistant (SLA) and a physician without sonographic experience (PN). A total of 22 patients with extrapyramidal symptoms were examined using transcranial sonography (TCS). SN images were encoded and evaluated by the three readers. A second TCS examination was performed after 7+/-2 d. A second investigator performed TCS examination 1 mo later. Spearman rank correlation and Pearson's correlation coefficient were used when assessing the agreement between readers. All three readers identified the same 15 patients with SN echogenicity III or more. Inter-reader SN echogenicity and area measurement correlations were r=0.55 to 0.82 and r=0.31 to 0.74 between PS and SLA and r=0.55 to 0.77 and 0.49 to 0.62 between PS and PN, respectively (p<0.05 in all cases). Intra-reader echogenicity and area measurement correlations (r=0.85 to 0.96 and r=0.51 to 0.69) were statistically significant only for PS (p<0.001). All intra- and inter-investigator correlations of SN area measurement (r=0.69 to 0.88 and r=0.5 to 0.61) and SN echogenicity (r=0.64 to 0.92 and r=0.51 to 0.69) were statistically significant (p<0.05). Semiquantitative evaluation of SN echogenicity and area using TCS is highly dependent on the experience of the sonographer. Only an experienced sonographer was able to produce very reproducible results with statistically significant correlations; SLA and PN intra-reader correlations were poor.