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Dr. Frank Rasulo U.O. Neurorianimazione Università di Brescia alutazione con TCD LA NEUROSONOLOGIA NELLAMBITO DELLE NEUROSCIENZE: Primo Corso teorico pratico.

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Presentation on theme: "Dr. Frank Rasulo U.O. Neurorianimazione Università di Brescia alutazione con TCD LA NEUROSONOLOGIA NELLAMBITO DELLE NEUROSCIENZE: Primo Corso teorico pratico."— Presentation transcript:

1 Dr. Frank Rasulo U.O. Neurorianimazione Università di Brescia alutazione con TCD LA NEUROSONOLOGIA NELLAMBITO DELLE NEUROSCIENZE: Primo Corso teorico pratico BRESCIA 12-13 NOVEMBRE 2010 U.O. Neurorianimazione Spedali Civili di Brescia asospasmo cerebrovascolare

2 VASOSPASM VASOSPASM INTRACRANIAL INTRACRANIAL HYPERTENSION HYPERTENSION CEREBRAL CEREBRAL CIRCULATORY ARREST CIRCULATORY ARREST AUTOREGULATION AUTOREGULATION STENOSIS STENOSIS SUBARACHNOID HEMORRHAGE HEAD TRAUMA STROKE BRAIN DEATH TCD in the ICU SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

3 Day Vessel layer Pathological change 1–8 Adventitia Increase in inflammatory cells (plasma cells, lymphocytes, mast cells, and connective tissue) Media Muscle necrosis and corrugation of elastica Intima Thickening with endothelial swelling and vacuolisation, opening of interendothelial tight unctions 9–60 Intima Proliferation of smooth muscle leads progressive intimal thickening Histopathological events in vasospasm

4 SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

5 SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

6 Definition of vasospasm FV CBF SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

7 Definition of hyperemia CBF FV SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

8 SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

9 Hagen-Poiseuille Law of laminar flow CBF SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

10 Indice di Lindegaard Vasospasmo IperemiaI.L. Vasospasmo vs Iperemia <3Iperemia 3-6 Vasospasmo moderato (25-50%) >6 Vasospasmo grave (>50%) SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

11 VASOSPASM & ANGIOGRAPHY SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

12 ANGIOGRAPHY SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

13 39 (1.3%) neurologic complications in 2,899 procedures; 20 (0.7%) transient 5 (0.2%) reversible 14 (0.5%) permanent (strokes) NEUROLOGIC COMPLICATIONS OF CEREBRAL ANGIOGRAPHY A retrospective study of complication rate and patient risk factors AM Leffers, A Wagner. Acta Radiologica 41 (2000) 204-210 ANGIOGRAPHY SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

14 0 250 200 TCD and Vasospasm SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

15 An inverse relationship between vessel diameter and TCD velocities Aaslid et al. 120 cm/s FVm > 120 cm/s = mild vasospasm 200 cm/s FVm > 200 cm/s = severe vasospasm Comparison of TCD with angiography for detection of vasospasm - < 25% FVm < 120 cm.sec - < 25% narrowing 25-50% FVm 120-200 cm.sec - 25-50% narrowing > 50% FVm 50% narrowing Aaslid et al Sloan et al Vora et al Lindegaard et al Correlation between FVm and angiographic lumen diameter of MCA TCD and Vasospasm SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

16 TCD and Vasospasm Sensitivity & Specificity SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

17 TCD and Vasospasm Assessment: Transcranial Doppler ultrasonography Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology M. A. Sloan, et al: NEUROLOGY 2004;62:1468-1481 to review the use of TCD for diagnosis SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

18 INDICATIONSENSITIVITY (%) SPECIFICITY (%)REFERENCE STANDARD Vasospasm after Spontaneous Subarachnoid Hemorrhage Conventional angiography Intracranial ICA25-3083-91 MCA 3994 39-94 70100 70-100 ACA13-7165-100 VA44-10082-88 Vasospasm after Spontaneous SAH BA77-10042-79 PCA48-6078-87 TCD and Vasospasm SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

19 INDICATIONSENSITIVITY (%) SPECIFICITY (%)REFERENCE STANDARD Vasospasm after Spontaneous Subarachnoid Hemorrhage 6983Conventional angiography Intracranial ICA10097 MCA10093 ACA7185 Vasospasm after Spontaneous SAH TCCD and Vasospasm Courtesy of Andrea Rigamonti SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

20 Predicting Outcome after Traumatic Brain Injury: Development and International Validation of Prognostic Scores Based on Admission Characteristics Ewout W. Steyerberg et al., PLoS Medicine August 2008 | Volume 5 | Issue 8 | e165 Head injury patients with worse prognosis SAH have a worse prognosis than patients without SAH or Vasospasm. TCD and post-traumatic SAH SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

21 TCD and p ost-traumatic SAH 63% 15% 63% tSAH 15% VSP INDICATIONSENSITIVITY (%)SPECIFICITY (%)REFERENCE STANDARD Vasospasm after Traumatic Subarachnoid Hemorrhage Conventional angiography Data on sensitivity, specificity and predictive value of TCD for VSP after tSAH are needed. CT evidence of SAH following closed head injury occurs in up to 63% of patients Lee JH Martin NA focal DID ? SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

22 Vasospasm-related DIDs were the major cause of bad outcome. 20–30% DIDs occured in 20–30% of SAH pts. within 3–14 days after bleed. TCD & Delayed Ischemic Deficits (DID) Ability of TCD to predict onset of DIDs following SAH Kassell NF et al. 8 of 21 patients with SAH developed DID. Good correlation between TCD and DID. Sekhar et al. SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

23 TCD monitoring and Clinical Decision Making After Subarachnoid Hemorrhage MJ. McGirt et al. J Stroke Cerbrovasc Disease. March 2003 TCD-defined vasospasm preceded the neurological 64%earlier intervention deficit in 64%, therefore earlier intervention might reduce the incidence of vasospasm-related stroke. TCD and Vasospasm 36% What about the other 36% ? SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

24 ILLUSTRATIVE CASE SAH - rupture of a left MCA aneurysm. Day 0 - Fully conscious, with no neurological deficits, after. However, primary THRT impairment was observed on the side of surgery. Xenon-CT also demonstrated regional impairment of autoregulation. Day 4 - Developed delayed weakness of the right upper limb as the left MCA FV increased. The symptom improved with time THRT predicted the occurrence of DID SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

25 Regions of cerebral ischemia are not always associated with territories of maximal vasospasm. TCD and Vasospasm Positron Emission Tomographic Cerebral Perfusion Disturbances And Transcranial Doppler Findings Among Patients With Neurological Deterioration After Subarachnoid Hemorrhage Pawan S. Minhas et al. Neurosurgery 52: 1017-1024, 2003 SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

26 SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

27 SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

28 SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

29 SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

30 The accuracy of TCD to detect vasospasm in patients with aneurysmal subarachnoid hemorrhage L.Mascia et al. Intensive Care Medicine 2003 MFv threshold > 160 cm/s TCD Delayed Ischemic Deficits (DID) SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

31 TCD and Vasospasm Rapid rise in Fvm in a few days High Lindegaard ratio SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE


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