Neurosonology Role for Patients with CVD - asnweb.org Annual Meeting/Handouts/Alex... · American Society of Neuroimaging 42nd Annual Meeting Neurosonology Role for Patients with

American Society of Neuroimaging42nd Annual Meeting


Neurosonology Role for

Patients with CVD

Alexander Razumovsky, PhD, FAHA

42nd Annual Meeting of the American

Society of Neuroimaging


STROKE & TIA

CerebroVascular

Disease

Carotid Duplex TCD

Major Manifestations of Vascular Disease and

Atherothrombotic Events

CEREBRAL

Stroke (795,000)

TIA (500,000)

CARDIAC

MI (2.3 M)

PERIPHERAL

Claudication, limb

ischemia (8-12M)


Stroke Prevention and Neurosonology

• Asymptomatic carotid stenosis (ACS)

• Intracranial arterial stenosis (IAC) and dissection

(anterior and posterior circulations)

• Subclavian steal, Bow Hunter, and Eagle syndromes

• Cerebral vasculitis, reversible vasoconstriction

syndrom

• Sickle Cell disease

• Moya-Moya disease

• Right-to-Left cardiac shunt/Migraines

• TIA


ASYMPTOMATIC CAROTID

STENOSIS (ACS)


ACS and Emboli


TCD and ACS

• Patients with ACS with >2 microemboli per hour hour on TCD

had a >1500% increased risk of 1-year ipsilateral ischemic

stroke compared with patients with ACS without TCD-detected

microemboli (15.6% vs 1.0%, respectively; P<0.0001).

Spence JD et al. Stroke 2005

• With improvements in best medical therapy, there was a marked

reduction in TCD-detected microemboli (12.6% before 2003 vs

3.7% after 2003; P<0.001) and in cardiovascular events (17.6%

before 2003 vs 5.2% after 2003; P<0.001) in 468 patients with

ACS

Spence JD et al. Arch Neurol 2010

• In ACES study patients with one or more TCD emboli had a

>550% higher risk of 1 year ipsilateral stroke compared with

patients without emboli

Markus HS et al. Lancet Neurology, 2010


TCD Detection of Microemboli as a Predictor of Cerebral

Events in Patients with Symptomatic and Asymptomatic

Carotid Disease: A Systematic Review and Meta-Analysis

Best LM et al, Eur J Vasc Endovasc Surg, 2017

• 28 studies reported data regarding both MES status and

neurological outcome. At the median pre-test probability

of 3.0%, the post-test probabilities of a stroke after a

positive and negative TCD were 7.1% and 1.2%,

respectively. In addition, the sensitivities and

specificities of each outcome showed that increasing

the threshold for positivity to 10 MES per hour would

make TCD a more clinically useful tool in peri- and post-

operative patients


Emboli Monitoring

• Useful in TIA

- Especially in cases when symptom is frequent and attributed to

vascular cause without other imaging correlate

- Similar to long-term EEG monitoring, and possibly adjunctive

to EEG monitoring in cases where the dx includes TIA and

seizure

• Goal of monitoring therapy—e.g. in a patient on single

antiplatelet therapy, might dual therapy be needed? The

presence or amount of micro-emboli on one regimen and not the

other might be useful in reaching a risk/benefit decision.

• Suggested for means of evaluating therapy in rare forms of

stroke, such as dissection, to help determine if anticoagulation is

necessary or if antiplatelet therapy is sufficient.


Role of TCD: Emboli Monitoring

1. Quantitative count of emboli

2. Localization of the embolic source (arterial or cardiac) responsible of stroke

3. Identification of high-risk patients for stroke recurrence

4. Evaluate patients for existence of a Patent Foramen Ovale

5. Monitoring of the therapy effectiveness

6. Monitoring of cardiovascular surgery

7. Monitoring different type of invasive procedures

LIMITATIONS

• Challenges of differentiation of embolic material

• Time consuming

• Probe holder design

• Technical limitation: skull thickness


Carotid Duplex (CD) and ACS

• In ACS patients, compared

with no ulcers, the presence

of three or more ulcers (the

sum of both carotids)

predicted the 3-year risk of

stroke or death (18.2% vs.

1.7%)

Madani A et al, Neurology,

2014

• The ACS and Risk of Stroke

(ACSRS) study, showed

clearly that progression in

the severity of ACS was a

predictor of future stroke

Kakkos SK et al, J Vasc

Surgery, 2014

• A recent meta-analysis

(7557 patients; mean follow-

up: 37.2 months) showed a

correlation between plaque

echolucency and the risk of

future ipsilateral stroke

Gupta A et al, Stroke, 2015


Neurosonology Role: Carotid

Artery Disease

• Detects impaired cerebral

perfusion and presence or

absence of altered collateral

circulation

• TCD may further assist by

mapping collateral circulation

and evaluating the impairment

of vasomotor reactivity

– Severely exhausted reactivity

is an independent

predictor of stroke/TIA

• CD provides invaluable

information on plaque

echogenicity, degree of

stenosis, ulceration, risk of

thrombosis, rupture and

collateral circulation

• TCD embolus detection is

currently the best validated

method for the identification

of high-risk patients with ACS

• Provides follow-up after

medical/surgical/endovascular

treatment

• Neurosonology examinations

are indispensable bedside tools

assisting in the diagnosis, risk

stratification, peri-interventional

monitoring, and follow-up of

patients with ACS


INTRACRANIAL ARTERIAL

STENOSIS (IAS)


Imaging for IAS

• “Gold Standard” – cerebral angiography

• CTA is quite good – superior to MRA

• Sensitivity of CTA vs. MRA – 98% vs. 70%

• Positive predictive value of CTA vs MRA – 93% vs. 65%

• TCD, MRA, CTA maybe be not as good as

angiography… but CTA & MRA also known to

overestimate IAS


• Rotterdam population based

study (1997-1999)

• Participants were 61 years

or older and free from

previous stroke (n= 2002)

• Average follow up 5.1 years

• End-points: first-ever stroke,

death

• Total 2022 patients were

evaluated with TCD and

MCA CBFV was measured

• Pathology of the large

intracranial arteries was

associated with the risk of

stroke independent of

pathology elsewhere in the

arterial tree suggests that the

large intracranial arteries

indeed deserve to be

regarded as an independent

place of origin of ischemic

stroke, and not just a place

where emboli get stuck

Neurosonology and Intracranial

Arterial Stenosis

MCA CBFV and Risk of Stroke. Bos et al., 2007


Peak Systolic Velocity Measurements with TCD Ultrasound

Is a Predictor of Incident Stroke among the General

Population in China

Wang HB et al, 2016

• Study was conducted to determine the prediction value of peak systolic

velocities as measured by TCD on subsequent stroke risk in a prospective

cohort of the general population from Beijing, China

• METHODS: In 2002, a prospective cohort study was conducted among

1392 individuals. The cohort was scheduled for follow up with regard to

incident stroke in 2005, 2007, and 2012

• RESULTS: Participants identified by TCD criteria as having intracranial

stenosis had a 3.6-fold greater risk of incident stroke than those without

TCD evidence of intracranial stenosis. The association remained significant

in multivariate analysis after adjusting for other risk factors or confounders

Older age, cigarette smoking, hypertension, and diabetes mellitus remained

statistically significant as risk factors after controlling for other factors.

• CONCLUSIONS: The study confirmed the screening value of TCD among

the general population in urban China. Increasing the availability of TCD

screening may help identify subjects as higher risk for stroke


Criteria for abnormal TCD diagnosis

of IAS

• An MCA, ICA and ACA stenosis were considered if

CBFV > 80 cm/s

• ICA siphon stenosis if CBFV > 65 cm/s

• BA and VA stenosis if CBFV > 60 cm/s


Additional criteria for abnormal TCD

diagnosis of IAS

• Criteria for M1, A1, C1

• Criteria for VB system

CBFV (cms/sec) STENOSIS

80-99 Mild

100-139 Moderate

> 140 Severe

CBFV (cms/sec) STENOSIS

60-80 Mild

81-100 Moderate

> 100 Severe


Additional criteria for abnormal TCD

diagnosis of IAS

• Significant stenosis will be associated with delayed

systolic upstroke distal to the lesion.

• At the site of stenosis CBFV will be elevated. Distal to

the stenosis it will be reduced.

• Proximal to stenosis, PI will often be elevated (>1).

Distal to stenosis PI will be reduced.


Sentient study

INCIDENCE OF THE IAS

• In order to identify potential patient population who might

benefit from intracranial screening, we examined the

results of TCD testing in high-risk Caucasian patients

undergoing cardiac surgery


Sentient study

Patients Characteristics

• 290 patients

• Age, median 72 years

• Gender - male 110 (38%), - female 180 (62%)

• Race - Caucasian 274 (94%)- African-American 15(5%)- Asian 1 (<1%)


Sentient study

Results

• IAS of the large artery was detected in 175 patients (60.3%)

• Mild stenosis: 158 patients (54.4%)

• Moderate stenosis: 16 (5.5%)

• Severe stenosis: 1 (<1%)

• 84 patients (29%) had multiple lesions


Sentient study

INCIDENCE OF THE IAS

• The data indicates an unrecognized frequency of IAS in

a Caucasian high-risk patient population

• Statement above is probably true for other races


A High Prevalence of Intracranial Stenosis in Patients with

Coronary Artery Disease and the Diagnostic Value of

Transcranial Duplex Sonography

Valaikiene J et al, JSCD, 2019

• Estimate the prevalence of intracranial arterial stenosis (IAS) using

noninvasive transcranial color-coded duplex sonography (TCCS) in

neurologically asymptomatic patients with coronary artery disease (CAD)

• METHODS: 389 patients with angiographically-confirmed, severe CAD were

included prospectively. All of them were examined using extracranial and

TCCS.

• RESULTS: Out of 389 patients (age 66.7 ± 9.2, 39-88), 237 (61%) were

diagnosed wiith 3 vessels disease and 152 patients (39%) with left stem

disease with/without 3 vessels damage. Transcranial sonography revealed at

least 1 IAS in 63.6% of echo positive patients (220/346). IS was found in 127

(61.4%) patients with 3 vessels disease, 20 patients (58.8%) with isolated left

stem disease, and 73 patients (69.5%) with 3 vessels and left stem disease

(P = .305). CONCLUSIONS: It was found that two thirds of patients with

advanced CAD have a silent IAS.


Neurosonology Role: Subclavian

Steal

• Detects abnormal changes in Doppler spectrum

waveform (systolic deceleration, alternating flow,

retrograde flow) in the VA, and/or VA’s, and/or BA

• Indicates low pressure in the BA

• Raises option of subclavian bypass surgery


Neurosonology and Subclavian Steal

Progressive levels of subclavian

stenosis


80-90% stenosis of the brachiocephalic

trunk

Right carotid siphon Right MCA

Right VA


Neurosonology Role: Intracranial

Arterial Stenosis

• Detects stenosis of intracranial vessels

• Provides longitudinal follow up and monitor effects of

treatment (medical, endovascular)

• TCD accurately, noninvasively and inexpensively

evaluate intracranial circulation without adverse side

effects or discomfort for patient

• TCD screening may help identify subjects as higher

risk for stroke

• Pre-cardiovascular surgery TCD examinations may

help identify subjects as higher risk for stroke


SICKLE-CELL DISEASE


Sickle Cell Disease

• Sickle cell can be

present in many

nationalities:

- African Americans,

- Africans,

- Arabs,

- Greeks,

- Italians,

- Latin Americans, and

those from India


• Children with SCD who had been found to be at high risk for stroke on the basis of elevated CBFV greater or equal 200 cm/sec

• Two abnormal comparable TCD’s are needed to identify patients at higher risk of stroke (CBFV greater than 200 cm/sec on two separate occasions

• If CBFV is equal or greater than 170 cm/sec –conditional

• TCD screening is a management standard for children with SCD in the USA

• The multicenter Stroke

Prevention (STOP) Trial in

SCD was terminated

prematurely in September

1997 because the children

randomized to receive

prophylactic chronic

transfusions had

substantially fewer strokes

than did the untreated

controls

• The STOP trial was a major

step forward in the

treatment of patients with

sickle cell disease and

only one successful stroke

protection trial

STOP Trial

Adams RJ et al, N Engl J Med. 1998


CEREBRAL VASCULITIS AND

REVERSIBLE VASOCONSTRICTIONSYNDROME


TCD As a Non-Invasive Tool for Diagnosis and

Monitoring of Vasculitis and RCVS

• Cerebral vasculitis leads to

relevant CBFV changes and

that the TCD technique may

assist in diagnosis and follow-

up of these patients

Razumovsky A et al, 2001

• TCD as a non-invasive

neuroimaging modality has a

potential for the initial diagnosis

and subsequent monitoring of

patients with suspected RCVS

Levin JH et al, 2013

Alpaidze M, Beridze M, 2014

• SPECT and MRI abnormalities,

as well as TCD anomalies

suggest the presence of

microangiopathy in

asymptomatic vasculitis

Gonzales-Suarez I et al, 2016


PFO DIAGNOSIS: CONTRAST TCD

OR CONTRAST TTE/TEE?


PFO Diagnosis

What first: c-TCD vs. c-TTE or c-TEE?


Recent Systematic Reviews

Accuracy of TCD for the diagnosis of intracardiac RLS

• A total of 27 studies with

1,968 patients (mean age

47.8±5.7 years; 51% male)

fulfilled the inclusion criteria.

The weighted mean

sensitivity and specificity for

TCD were 97% and 93%,

respectively

Mojadidi et al, JACC

Cardiovascular Imaging,

2014

• Systematic literature search

identified 35 prospective

observational studies

including 3,067 patients.

• The pooled sensitivity and

specificity for TCD was

96.1% and 92.4%, whereas

the respective measures for

TTE were 45.1% and 99.6%

• The overall diagnostic yield

of TCD appears to outweigh

that of TTE

Katsanos AH et al, Ann

Neurology, 2016


TCD to Detect Right to Left Communication:

Evaluation Versus TEE in Real Life

Maillet A et al, Angiology, 2018

• C-TCD was compared with c-TEE and c-TTE.

transthoracic echocardiography (TTE) for the detection of

the PFO

• Of the negative patients after c-TCD, none was positive

for c-TEE and 1 was positive for c-TTE with no evidence

of PFO

• C-TCD was sensitive to detect PFO, even in patients with

negative c-TTE or c-TTE. A negative c-TEE did not

exclude PFO demonstrated by TCD


Bubble-TCD


Neurosonology Role: PFO

• TCD and TEE have similar sensitivity and specificity in shunt

detection

• C-TCD is a low cost, high feasibility and reliable test with

excellent diagnostic accuracies, making it a proficient test for

detecting RLS

• TCD is also a noninvasive exam - easy to perform and

repeat, if necessary. TEE should be limited to the patients

scheduled for transcatheter PFO closure, patients with high-

risk PFO with recurrent stroke, and patients with ASA or

large shunt detected on TCD


TCD AND RISK EVALUATION

FOR NEURO- AND ORTHOPEDIC

SURGERIES


• Venous air-embolism occur in 23-45% of patients

undergoing neurosurgical procedures

• Prospective study, 92 pts, c-TCD, c-TEE (ref.

standard) and c-TTE

• A PFO was detected in 24 pts (26%) using c-TEE, c-

TCD correctly identified 22 pts (24%), c-TTE only 10

pts (11%)

TCD as a screening technique for detection

of PFO before surgery in the sitting position

Stendel R. et al, 2000


Patent foramen ovale and neurosurgery in

sitting position: a systematic review

Fathi AR et al, Br J Anaesth, 2009

• The databases Medline, Embase, and Cochrane Controlled Trial

Register were systematically searched from inception to November

2007 for keywords in both topics separately

• In total, 4806 patients were considered for neurosurgery in sitting

position

• The overall rate of venous air embolism during neurosurgery in sitting

position was 39% for posterior fossa surgery and 12% for cervical

surgery

• The rate of clinical and TEE detected paradoxical air embolism was

reported between 0% and 14%. The overall success rate for PFO

closure using new and the most common closure devices was reported

99%, whereas the average risk of major complications is <1%

• On the basis of this systematic review, the authors recommend

screening for PFO and considering closure in cases in which the sitting

position is the preferred neurosurgical approach


TCD PFO testing and monitoring during operations

on long-bone fractures

(frequent injury for military personnel)

• It is well known that during these types of surgeries the

Fat Embolism Syndrome (FES) is a frequent

complication. The incidence of FES after single long-

bone fractures is estimated to be 0.5% to 10%

• Paper from Forteza et al. (Circulation, 2011;123, 1947-

52) showed that in patients with long bone fractures, the

presence of a PFO was associated with larger and more

frequent microemboli signals to the brain detected by

TCD (PPV 86%, NPV 97%)


NEUROSONOLOGY AND CVD:

SUMMARY


What Neurosonology (TCD & CD) service

could achieve for patients with CVD

• Immediate bed-side results in out-patient settings or in hospital settings (ER, OR, Recovery Room, ICU, hospital ward or out-patient clinic)

• Provides accurate CBFV information for determination of disease severity (extra- or intracranial)

• Detects even minimal cerebral hemodynamic changes

• Detects emboli

• Ideal tool for following disease progression, therapeutic, radiological, surgical or endovascular revascularization, stages of recovery and long-term therapeutic effects


Neurosonology and CVD (cont.)

• CD provides invaluable information on plaque echogenicity,

degree of stenosis, ulceration, risk of thrombosis, rupture and

collateral circulation

• TCD is the only non-invasive examination that provides a

reliable evaluation of intracranial blood flow patterns and

potential changes in ICP in real-time, adding physiological

information to the anatomical information obtained from other

neuroimaging modalities

• Extended applications of TCD in emboli monitoring, right-to-left

shunt detection and vasomotor reactivity provide important

information about the pathophysiology of cerebrovascular

ischemia


Neurosonology and CVD

• Carotid Duplex and TCD has an established

clinical value in the diagnostic workup of

CVD, TIA and stroke patients and must be an

essential component of a comprehensive

stroke center or any out-patient vascular

neurology offices


Questions?

[email protected]

[email protected]

mailto:[email protected]

mailto:[email protected]

Documents

Neurosonology Role for Patients with CVD - asnweb.org Annual Meeting/Handouts/Alex... · American Society of Neuroimaging 42nd Annual Meeting Neurosonology Role for Patients with