Evaluation of intracranial collateral circulation in patients with chronic middle cerebral artery occlusion with transcranial color Doppler ultrasonography
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Objectives To investigate the value of intracranial collateral circulation in patients with chronic middle cerebral artery (MCA) occlusion with transcranial color Doppler ultrasonography (TCD) and to establish the indicators of hemodynamic parameter and assess their accuracy.Methods A total of 140 consecutive patients with unilateral MCA occlusion diagnosed by digital subtraction angiography (DSA) in the Departments of Neurology and Neurosurgery, Xuan Wu Hospital, Capital Medical University, Beijing, China were included from September 2008 to February 2010.According to the leptomeningeal branch compensation showed on DSA, the patients were divided into no compensation (n =21) , simple anterior cerebral artery (ACA) compensation (n = 43) , simple posterior cerebral artery (PCA) compensation (n =28) , and ACA + PCA compensation (n =48) groups.TCD was used to detect the peak systolic velocity (PSV) of bilateral MCA, anterior cerebral artery (ACA) , and posterior cerebral artery (PCA).The ratios of ACA peak velocity on the ipsilateral side (d) and MCA peak velocity on the contralateral side (n) (dPSV_(ACA)/nPSV_(MCA)) , the ratios of ACA peak velocity on the ipsilateral side and ACA peak velocity on the contralateral side (dPSV_(ACA)/nPSV_(ACA)), as well as the ratios of PCA peak velocity on the ipsilateral side and PCA peak velocity on the contralateral side (dPSV_(PCA)/nPSV_(PCA)) were calculated.Taking ACA and PCA leptomeningeal branches open or not showed on DSA as a reference standard, the ROC curve was used to establish the optimal boundary values of hemodynamic parameters for evaluating ACA and PCA in participation of compensation, and the sensitivity, specificity, and accuracy were assessed.Results ①The dPSV_(ACA)/nPSV_(MCA) in the simple ACA compensation and ACA + PCA compensation groups were 1.341 ± 0.348 and 1.337 ±0.403 respectively, which were significantly higher than 0.883 ±0.256 in the no ACA compensation group.The dPSV_(ACA)/nPSV_(ACA) in the simple ACA compensation and ACA + PCA compensation groups were 1.660 ±0.753 and 1.670 ±0.404 respectively, which were significantly higher than 0.978 ±0.259 in the no ACA compensation group.The dPSV_(PCA)/nPSV_(PCA) in the simple PCA compensation and ACA + PCA compensation groups were 1.758 ±0.560 and 1.735 ±0.486 respectively, which were significantly higher than 1.210 ±0.336 in the no PCA compensation group.② The dPSV_(ACA)/nPSV_(MCA) ≥1.20 and dPSV_(ACA)/nPSV_(ACA) ≥1.25 were used as the optimal cutoff values of ACA compensation, and their accuracy were 65.7% and 78.5% respectively.The dPSV_(PCA)/nPSV_(PCA) 3= 1.45 were used as the optimal cutoff values of PCA compensation, and its accuracy was 75.0%.Conclusions TCD can be used as an examination method for evaluating ACA and PCA leptomeningeal branch compensation ability in patients with MCA occlusion. Establishment of TCD hemodynamic parameters has important clinical value for accurately assessing the status and prognosis of collateral circulation in patients with MCA occlusion.Keywords:
Anterior cerebral artery
Posterior cerebral artery
Digital subtraction angiography
Posterior communicating artery
Collateral circulation
Transcranial Doppler
Anterior communicating artery
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ABSTRACT BACKGROUND AND PURPOSE Increased cerebral blood flow velocity of basilar artery (BA) is common but often neglected. By using digital subtraction angiography (DSA) to detect intracranial large artery stenosis, we performed transcranial Doppler (TCD) to evaluate cerebral hemodynamic changes of stroke patients. METHODS Acute stroke patients with TCD‐detected raised peak systolic velocity (PSV) in BA (≥100 cm/second) were recruited. RESULTS Among 91 recruited patients, BA stenosis (>50%) was confirmed by using DSA in 29 patients (32%), among which 20 patients (70.0%) had coexistent internal carotid artery (ICA) and vertebral artery (VA) stenoses. Among patients without BA stenosis ( n = 62, 68%), severe stenosis or occlusion of ICA was evaluated in 22 patients (22/62, 35.4%) and severe stenosis or occlusion of VA was detected in 22 patients (22/62, 35.4%). Among the values of PSV (120, 140, 160, and 180 cm/second) and the stenotic‐to‐prestenotic ratio (SPR) (1.5, 2.0, 2.5, and 3.0), 160 cm/second was found to show the highest predictive value (area under the receiver operator characteristic curve: .75, 95% CI: .65‐.86), with a sensitivity of .70 and a specificity of .81. CONCLUSIONS Apart from an intrinsic BA stenosis, high‐grade steno‐occlusion of ICA or VA may contribute a lot to induce an elevated flow velocity in BA. A higher value of cutoff point may increase the accuracy of diagnosing BA stenosis.
Digital subtraction angiography
Transcranial Doppler
Stroke
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Leptomeningeal collateral volume flow has not been previously quantified. Quantitative magnetic resonance angiography (QMRA) can determine flow in the large vessels of the intracranial circulation.We reviewed consecutive QMRA studies performed between December 1, 2004 and August 30, 2005, for cases showing asymmetrically higher flow in a posterior cerebral artery (PCA) just distal to the origin of the posterior communicating artery ipsilateral to a hemodynamic middle cerebral artery (MCA) or internal carotid artery lesion. The mean, range, and standard deviation (SD) of the flow rate in the PCAs, MCAs, and PCA ipsilateral-contralateral difference were calculated. Ipsilateral and contralateral PCA flow rates were compared using the Student's t-test.Sixteen studies met selection criteria. Mean age was 52 years (range 21-79) and 9 were female. MCA flow was below QMRA detection limits in 6 studies. Mean measurable ipsilateral MCA flow reduction was 84 mL/min (range 9-147, SD 51.4). Mean ipsilateral PCA flow was 118 mL/min (range 72-206, SD 38.5) and mean contralateral PCA flow was 68 mL/min (range 35-144, SD 30.5, P < .001); mean difference was 50 mL/min (range 10-93, SD 24.3).Leptomeningeal collateral flow can be assessed with QMRA and may be substantial.
Magnetic resonance angiography
Collateral circulation
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Transcranial Doppler
Magnetic resonance angiography
Lumen (anatomy)
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Objective To investigate the combination of color Doppler flow imaging （CDFI） and transcranial Doppler （TCD） in the assessment of the hemodynamic changes of vertebral artery occlusion disease and their clinical value. Methods A total of 101 patients with vertebral artery occlusion detected by the combination of CDFI and TCD and confirmed by DSA were enrolled from January 2005 to January 2009. Taking the result of digital subtraction angiography （DSA） as a golden standard, The differences between the different types of the side of vertebral artery occlusion and contralateral vertebral artery on the extra- and intracranial segments were compared and analyzed in peak systolic velocity （PSV）, end diastolic velocity （EDV）, resistive indices （RI）, pulsatility index （PI）, spectrum morphology, and hemodynamics. Results No blood flow signals were detected by CDFI and TCD in patients of complete occlusion of the vertebral artery; the weak blood flow signals were detected by CDFI in patients of the occlusion in the intracranial segment of the vertebral artery. The blood flow signals after the establishment of collateral circulation in patients of the segmental occlusion were detected in the extracranial segment or intracranial segment of the vertebral artery. The PSV on the occluded sides of the extracranial segments were decreased more significantly than that on the unoccluded sides （27.39 ± 12.44 cm/s vs. 62.61 ± 13.22 cm/s, P = 0. 000）; RI was significantly higher than the unoccluded sides （0.99 ± 0.21 vs. 0.62 ± 0.07, P = 0. 000）. When a vertebral artery had the segmental occlusion and the collateral circulation was established, the PSV, EDV, and PI of the intracranial segment of the vertebral artery on the occluded sides were decreased more significantly than those on the unoccluded sides, PSV were 37.81 ± 12.28 crn/s and 73.17 ±30.99 crn/s, respectively （P =0.000）, EDV were 17.58 ± 7.10 crn/s and 29.31 ± 12.94 cm/s, respectively （P = 0. 000）, PI were 0.84 ± 0.22 and 1.01 ±0.18, respectively （P =0. 000）. The compared DSA showed that the sites of vertebral artery occlusion were different. There was significant difference in the Doppler flow velocity spectrum between the CDFI and TCD. Conclusions PSV, EDV, RI, and PI are the hemodynamic parameters of accurately assessing vertebral artery occlusion, and the combination of CDFI and TCD has significant value for the hemodynamic changes of different types of vertebral artery occlusion and the clinical comprehensive assessment.
Key words:
vertebral artery; arterial occlusive diseases; blood flow velocity; ultrasonography, Doppler, color; ultrasonography, Doppler transcranial; hemodynamics
Digital subtraction angiography
Transcranial Doppler
Collateral circulation
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Circle of Willis
Posterior cerebral artery
Anterior cerebral artery
Posterior communicating artery
Neuroradiology
Anterior communicating artery
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Transcranial Doppler sonography (TCD) is commonly used for the diagnosis of middle cerebral artery (MCA) stenosis. However, TCD indices to predict distal MCA (M2) stenosis have not yet been established. We compared TCD and magnetic resonance angiography (MRA) to validate a new index for the diagnosis of M2 stenosis.Consecutive patients who underwent TCD and MRA were included. Based on MRA, M2 stenosis was defined as >50% narrowing beyond the bifurcation area. TCD index of the M2/M1 ratio was defined as the ratio between the mean flow velocity (MFV) obtained at a depth of 30-44 mm (M2) and a depth of 45-65 mm (M1). Sensitivity and specificity of the M2/M1 ratio were calculated from the receiver operating characteristic curve. The diagnostic yield of elevated MFV (>80 cm/s) and asymmetry index of >30% for M2 stenosis were also investigated.Among the consecutive patients, 105 with M2 stenosis were compared with 123 without MCA stenosis. The M2/M1 ratio was significantly higher in the M2 stenosis group (1.10 versus 0.86, p < 0.001). Sensitivity and specificity for M2 stenosis were most satisfying when the M2/M1 ratio of 0.97 was adopted as the cutoff value. Diagnostic yield of the M2/M1 ratio was better than MFV or asymmetry index.The M2/M1 ratio may be a highly specific parameter for assessing M2 stenosis with TCD.
Transcranial Doppler
Magnetic resonance angiography
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To investigate the optimal values of flow velocity on transcranial Doppler (TCD) in grading the severity of middle cerebral artery (MCA) stenosis in comparison with magnetic resonance angiography (MRA).Both TCD and MRA examinations were performed on 148 asymptomatic patients. The peak flow velocities of each MCA were recorded. Severity of MCA stenosis on MRA was classified as normal-mild (< 50% lumen diameter reduction), moderate (50%-75%), and severe-void (> 75% and void of flow signal).Among 296 MCAs evaluated, normal-mild stenosis was found in 75 (25%), moderate stenosis in 112 (38%), and severe stenosis in 109 (37%). The mean of systolic velocity (Vs) of MCA differed significantly among these three groups: mean Vs = 121.83 +/- 22.52 cm/s in the normal-mild group; 155.96 +/- 21.62 cm/s for the moderate group; and 199.39 +/- 43.86 cm/s for the severe group (P < .001). The optimal cutoff velocity for detection of MCA (> 50%) stenosis was found at Vs > 140 cm/s on TCD (area under the ROC curve is 0.87, P < 0.001). The best cutoff points for grading severity of on TCD were 140 cm/s and 180 cm/s.TCD enables grading of the severity of MCA stenosis according to the flow velocity. This method provides a noninvasive and reliable method for grading MCA stenosis and allows longitudinal monitoring of the relationship between clinical outcome and hemodynamic change.
Transcranial Doppler
Magnetic resonance angiography
Grading (engineering)
Cut-off
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Citations (54)
Objective
To study the clinical significance of transcranial Doppler (TCD) and/or transcranial color-coded sonography (TCCS) in the evaluation of collateral circulation in patients with unilateral chronic middle cerebral artery occlusion (CMCAO).
Methods
From August 2015 to April 2018, 54 consecutive patients diagnosed as unilateral CMCAO by TCD and/or TCCS and confirmed by digital subtraction angiography (DSA) from the First Affiliated Hospital of Soochow University were enrolled retrospectively. The leptomeningeal anastomoses (LMA) grades on DSA were recorded. TCD and/or TCCS were used to measure and record the mean velocity (MV) of bilateral anterior cerebral artery (ACA) and posterior cerebral artery (PCA), and the ratios of ipsilateral MV to the contralateral were calculated (MViACA/MVcACA, MViPCA/MVcPCA). Spearman rank correlation analysis was used to analyze the correlation between ACA, PCA blood flow parameters and LMA grades on DSA. All patients were divided into three groups according to clinical symptoms: asymtom group (n=8) and transient ischemic attack (TIA) group (n=19)and cerebral infarction (CI) group (n=27). The differences in ACA and PCA blood flow parameters and relative CT perfusion parameters were compared between the three groups.
Results
MViACA and MViACA/MVcACA were significantly positively correlated (r=0.568, P=0.000; r=0.757, P=0.000); MViPCA and MViPCA/MVcPCA were positively correlated with LMA grades on DSA (r=0.383, P=0.004; r=0.624, P=0.000). MViACA, MViPCA and MViACA/MVcACA, MViPCA/MVcPCA in asymtom group and TIA group were higher than those in CI group, and the differences were statistically significant (P<0.05). Relative cerebral blood flow (rCBF) and relative cerebral blood volume (rCBV) in asymtom group and TIA group were higher than those in CI group, and the differences were statistically significant (P<0.05), the relative mean transit time (rMTT) and relative peak time (rTTP) were lower in asymtom and TIA group than in CI group, and the differences were statistically significant (P<0.05).
Conclusion
The hemodynamic parameters of ACA and PCA on TCD and/or TCCS have significant correlation with the LMA grades on DSA and have good consistency with the CTP results, which play an important role in guiding patients with unilateral CMCAO to select individualized treatment strategies.
Key words:
Ultrasonography, Doppler, transcranial; Infarction, middle cerebral artery; Collateral circulation
Digital subtraction angiography
Anterior cerebral artery
Transcranial Doppler
Collateral circulation
Posterior cerebral artery
Posterior communicating artery
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OBJECTIVETranscranial color-coded duplex sonography (TCCS) is a reliable tool that is used to assess vasospasm in the M1 segment of the middle cerebral artery (MCA) after subarachnoid hemorrhage (SAH). A distinct increase in blood flow velocity (BFV) is the principal criterion for vasospasm. The MCA/internal carotid artery (ICA) index (Lindegaard Index) is also widely used to distinguish between vasospasm and cerebral hyperperfusion. However, extracranial ultrasonography assessment of the neck vessels might be difficult in an intensive care unit. Therefore, the authors evaluated whether the relationship of intracranial arterial to venous BFV might indicate vasospasm with similar or even better accuracy.METHODSPatients who presented between 2008 and 2015 with aneurysmal SAH were prospectively enrolled in the study. Digital subtraction angiography (DSA) and TCCS were performed within 24 hours of each other to assess vasospasm 8-10 days after SAH. The following different TCCS parameters were analyzed to assess vasospasm in the MCA and were compared with the gold-standard DSA parameters: 1) mean time-averaged maximum BFV (Vmean) of the MCA, 2) peak systolic velocity (PSV) of the MCA, 3) the Lindegaard Index using Vmean as well as PSV, and 4) a new arteriovenous index (AVI) between the MCA and the basal vein of Rosenthal using Vmean and PSV. The best cutoff values for these parameters to distinguish vasospasm from normal perfusion or hyperperfusion were calculated using receiver operating characteristic curve analysis. Sensitivity, specificity, positive predictive value, and negative predictive value as well as the overall accuracy for each cutoff value were analyzed.RESULTSA total of 102 patients (mean age 52 ± 12 years) were evaluated. Bilateral MCA assessment by TCCS was successful in all patients. In 6 cases (3%), the BFV of the basal vein of Rosenthal could not be analyzed. The AVI could not be calculated in 50 of 204 cases (25%) because the insonation quality was very low in one of the ICAs. An AVI > 10 for Vmean and an AVI > 12 for systolic velocity provided the highest accuracies of 87% and 86%, respectively. Regarding the Lindegaard Index, the accuracy was highest using a threshold of > 3 for the mean BFV (84%) as well as systolic BFV (80%). BFVs in the MCA of ≥ 120 cm/sec (Vmean) and ≥ 200 cm/sec (PSV) predicted vasospasm with accuracies of 84% and 83%, respectively. A combined analysis of the MCA BFV and the AVI led to a slight increase in specificity (Vmean, 94%; PSV, 93%) and positive predictive value (Vmean, 88%; PSV 86%) without further improvement in accuracy (Vmean, 88%; PSV, 84%).CONCLUSIONSThe intracranial AVI is a reliable parameter that can be used to assess vasospasm after SAH. Its reliability for differentiating vasospasm and hyperperfusion is slightly higher than that for the established Lindegaard Index, and this method has the additional advantage of a remarkably lower failure rate.
Digital subtraction angiography
Cerebral Vasospasm
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Using a high-frame-rate technique, intravenous digital subtraction angiography (IVOSA) of the intracranial circulation was performed in patients with transient ischemic attacks and asymptomatic bruits. Twenty patients with normal carotid arteries or mild stenosis of no hemodynamic significance were selected as a control group to evaluate the effect of carotid stenosis on the difference between hemispheres in the peak arrival time (Δ TMAX) of the contrast bolus. Data were obtained for the anterior (ACA), middle (MCA), and posterior (PCA) cerebral artery distributions. Raw data of the time-density curve in a region of interest were analyzed by polynomial curve-fitting techniques to obtain the peak arrival time (TMAX). The Δ TMAXs for normal middle, anterior, and posterior distributions were 0.140 ± 0.119 sec, 0.152 ± 0.146 sec, and 0.189 ± 0.187 sec, respectively. Eleven patients with tight carotid stenosis or occlusion whose Δ TMAX fell outside the normal range as established from the 20 control patients were analyzed with regard to ischemic symptoms. The Δ TMAXs of the MCA, ACA distributions in the asymptomatic patients with tight carotid stenosis or occlusion were 0.653 ± 0.379 sec and 0.118 ± 0.159 sec, respectively; p p
Digital subtraction angiography
Bolus (digestion)
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