Presentation is loading. Please wait.

Presentation is loading. Please wait.

V V asospasmo cerebrovascolare alutazione con TCD Dr. Frank Rasulo

Similar presentations


Presentation on theme: "V V asospasmo cerebrovascolare alutazione con TCD Dr. Frank Rasulo"— Presentation transcript:

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

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

3 Histopathological events in vasospasm
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

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

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

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

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

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

9 CBF CBF Hagen-Poiseuille Law of laminar flow
Therefore by using the Poiseuille relationship, it can be predicted that efforts to increase systemic blood pressure or to decrease blood viscosity will ameliorate cerebralperfusion and reverse ischemia (55). The ∆P is the pressuredifferencebetweenanytwopointsalong a givenlengthof the vessel. Whendescribing the flow ofbloodforanorgan, the pressuredifferenceisgenerallyexpressedas the differencebetween the arterialpressure (PA) and venouspressure (PV)vascularresistance. CBF CBF SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

10 Vasospasmo vs Iperemia
Indice di Lindegaard Vasospasmo Iperemia I.L. Vasospasmo vs Iperemia <3 Iperemia 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
Although the gold standard for the diagnosis of VSP i Angiography, Gold Standard SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

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

13 ANGIOGRAPHY NEUROLOGIC COMPLICATIONS OF CEREBRAL ANGIOGRAPHY
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) Two of the transient and one of the permanent complications were related to thromboembolism, which was evident on the angiogram during the procedure. All three were treated with intraarterial thrombolysis. Of 20 transient complications, six had the typical findings and course of transient global amnesia. Neurologic complications were significantly more common in procedures performed in patients who were 55 years of age or older (25 of 1,361; 1.8%) compared with those performed in patients younger than 55 years of age (14 of 1,538, 0.9%) (P .035) (Table 1). From a logistic regression against age, the estimated odds ratio for neurologic complications was 1.22 per 10 years of age (95% CI: 1.00, 1.52; P .05). Neurologic complications were significantly more common in patients with CVD (20 of 862; 2.3%) compared with those without these risk factors (19 of 2,037; 0.9%) (P .004) (Table 2). When the fluoroscopic times were 10 minutes or longer, there were significantly more neurologic complications (24 of 1,238; 1.9%) compared with those when fluoroscopic times were shorter than 10 minutes (15 of 1,661; 0.9%) (P .004). SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

14 TCD and Vasospasm 250 200 When comparing TCD to angiography we again musn’t forget one of the most important advantages of TCD and that is it reppresents a repeatable, non invasive, risk-free monitoring system. However there are many advantages of using TCD for diagnosis and management of Vasospasm in the ICU, some of the general ones already mentioned previously. MDC in Renal Failure SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

15 TCD and Vasospasm Comparison of TCD with angiography for detection of vasospasm An inverse relationship between vessel diameter and TCD velocities Aaslid et al. FVm > 120 cm/s = mild vasospasm FVm > 200 cm/s = severe vasospasm FVm < 120 cm.sec < 25% narrowing FVm cm.sec % narrowing FVm < 200 cm.sec > 50% narrowing Aaslid et al Sloan et al Vora et al Lindegaard et al Correlation between FVm and angiographic lumen diameter of MCA You can find it in all the text books An inverse relationship between vessel diameter and TCD velocities was first noticed by Aaslid et al.. His group went on to define… SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

16 TCD and Vasospasm Sensitivity & Specificity
When evaluating the efficacy of TCD in detecting angiographic vasospasm…we must take into consideration it’s … SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

17 TCD and Vasospasm “to review the use of TCD for diagnosis”
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: “to review the use of TCD for diagnosis” Now regarding sensitivity and specificity, This systematic review evaluated the clinical utility of TCD as a diagnostic test may be operationally defined as the value of the test result to the clinician caring for the individual patient. (When compared with an appropriate reference standard or in a well designed clinical trial). SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

18 TCD and Vasospasm Vasospasm after Spontaneous SAH INDICATION
SENSITIVITY (%) SPECIFICITY (%) REFERENCE STANDARD Vasospasm after Spontaneous Subarachnoid Hemorrhage Conventional angiography Intracranial ICA 25-30 83-91 MCA 39-94 70-100 ACA 13-71 65-100 VA 44-100 82-88 Sensitivity % Specificity % Bazzocchi et al. Sensitivity 67%, NPV 78 Specificity 99%, PPV 97% Lysakowski. Lysakowski et al. performed a systematic review comparing TCD with cerebral angiography to diagnose vasospasm following SAH and concluded that for the MCA TCD is unlikely to indicate spasm when angiography is negative (high specificity) and may be used to identify patients with spasm (high positive predictive value) BA 77-100 42-79 PCA 48-60 78-87 SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

19 Conventional angiography
TCCD and Vasospasm Courtesy of Andrea Rigamonti Vasospasm after Spontaneous SAH INDICATION SENSITIVITY (%) SPECIFICITY (%) REFERENCE STANDARD Vasospasm after Spontaneous Subarachnoid Hemorrhage 69 83 Conventional angiography Intracranial ICA 100 97 MCA 93 ACA 71 85 Hemorrhagic cerebrovascular disease. Most of the experience with (contrast-enhanced) TCCS in hemorrhagic cerebrovascular disease is in patients with aneurysmal SAH A marked increase in the echodensity of the basal cisterns or ventricular system indicates the presence of blood in the subarachnoid or intraventricular space, respectively.147 TCCS can detect 76 to 91% of nonthrombosed intracranial aneurysms of 6 mm in size ; use of ECA or power Doppler may increase the rate of detection, including aneurysms 5 mm in size.146,147 TCCS may detect VSP in major branches of the circle of Willis following SAH.143,148 Limited data suggest that sensitivity and specificity of TCCS for detection of intracranial ICA and MCA VSP are excellent.148 However, 1476 NEUROLOGY 62 May (1 of 2) 2004 Downloaded from by on June 14, 2008 no data exist to compare the utility of (contrastenhanced) TCCS with conventional TCD in this setting. SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

20 TCD and post-traumatic SAH
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 SAH have a worse prognosis than patients without SAH or Vasospasm. Traumatic brain injury (TBI) is a leading cause of death and disability. A reliable prediction of outcome on admission is of great clinical relevance. We aimed to develop prognostic models with readily available traditional and novel predictors. Methods and Findings Prospectively collected individual patient data were analyzed from 11 studies. We considered predictors available at admission in logistic regression models to predict mortality and unfavorable outcome according to the Glasgow Outcome Scale at 6 mo after injury. Prognostic models were developed in 8,509 patients with severe or moderate TBI, with cross-validation by omission of each of the 11 studies in turn. External validation was on 6,681 patients from the recent Medical Research Council Corticosteroid Randomisation after Significant Head Injury (MRC CRASH) trial. We found that the strongest predictors of outcome were age, motor score, pupillary reactivity, and CT characteristics, including the presence of traumatic subarachnoid hemorrhage. A prognostic model that combined age, motor score, and pupillary reactivity had an area under the receiver operating characteristic curve (AUC) between 0.66 and 0.84 at crossvalidation. This performance could be improved (AUC increased by approximately 0.05) by considering CT characteristics, secondary insults (hypotension and hypoxia), and laboratory parameters (glucose and hemoglobin). External validation confirmed that the discriminative ability of the model was adequate (AUC 0.80). Outcomes were systematically worse than predicted, but less so in 1,588 patients who were from high-income countries in the CRASH trial. Conclusions Prognostic models using baseline characteristics provide adequate discrimination between patients with good and poor 6 mo outcomes after TBI, especially if CT and laboratory findings are considered in addition to traditional predictors. The model predictions may support clinical practice and research, including the design and analysis of randomized controlled trials. The Editors’ Summary of this article follows the references. PLoS Medicine SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

21 TCD and post-traumatic SAH
CT evidence of SAH following closed head injury occurs in up to 63% of patients Lee JH Martin NA 63% tSAH 15% VSP focal DID ? INDICATION SENSITIVITY (%) 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. SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

22 TCD & Delayed Ischemic Deficits (DID)
Ability of TCD to predict onset of DID’s following SAH DID’s occured in 20–30% of SAH pts. within 3–14 days after bleed. Vasospasm-related DIDs were the major cause of bad outcome. Kassell NF et al. 8 of 21 patients with SAH developed DID. Good correlation between TCD and DID. Sekhar et al. The International Cooperative Study on the Timing of Aneurysm Surgery Kassell NF et al., J Neurosurg 1990;73:18–36. SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

23 TCD and Vasospasm 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 deficit in 64%, therefore earlier intervention might reduce the incidence of vasospasm-related stroke.” What about the other 36% ? SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

24 The symptom improved with time THRT predicted the occurrence of DID
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 TCD and Vasospasm Regions of cerebral ischemia
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: , 2003 Regions of cerebral ischemia are not always associated with territories of maximal vasospasm. TCD shows you VSP of the larger vessels and not what’s going on peripheraly, which is also the cas for angiography where only 50% of angiographic VSP is clinically relevant. SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

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

27 Primary THRT impairment in pts of good neurological status was related to failure of the periferal cerebrovascular responce, indicatind impaired cerebral autoregulation. The regions of the brain with focal failure of autoregulation are potentially more vulnerable to cerebral ischemia after cerebral artery vasospasm. SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

28 Cerebral Autoregulation occurs at the level of the arterioles more distal to arteries affected by VSP as determined by TCD. This may explain why despite the large number of pts with angiographic or TCD evidence of severe vasospasm, only a small number actually develope DIDs and may also explain the results of the paper by Minhas. SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

29 Impaiment of autoregulation and vasospasm is anatomically distinct
With an Intact microvascular autoregulation responce, CBF can be maintained even with severe narrowing of the large-caliber vessels. Impaiment of autoregulation and vasospasm is anatomically distinct SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE

30 TCD Delayed Ischemic Deficits (DID)
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 MCA FVm threshold of 160 cm·sec–1 discriminated between patients with, and without, clinical vasospasm with a sensitivity and specificity equal to The results of this study support the daily use of the TCD by trained operators, to provide early identification of SAH patients at high risk of delayed cerebral ischemia. The reference standard used in this study was reppresented by the percentage vessel caliber reduction measured from the comparison of two consecutive angiograms. Analysis of thge ROC curve. Questo studio: Diagnostic test study; Prospective blind comparison of TCD and angiography (gold standard), the Receiver Operator Characteristics (ROC) analysis for the definition of the TCD threshold was used 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 I beleve that to help us with this grey zone we should evaluate autoregulation and use multimodality monitoring. SSVD Neurorianimazione ,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI VASOSPASMO CEREBRALE


Download ppt "V V asospasmo cerebrovascolare alutazione con TCD Dr. Frank Rasulo"

Similar presentations


Ads by Google