Cerebral Embolic Activity in a Patient during Acute Crisis of Takayasu's Arteritis

Takayasu's arteritis is a disease that affects large vessels and may cause neurological symptoms either by stenoses/occlusions or embolisms from vessels with an inflammatory process. Transcranial Doppler (TCD) ultrasound can provide useful information for diagnosis and monitoring during the active phase of the disease. Cerebral embolic signals can be detected by TCD and have been considered a risk factor for vascular events. We report a patient in whom TCD ultrasound was used to monitor cerebral embolic signals during the active phase of the disease. This case report suggests that embolic activity in Takayasu's arteritis may represent disease activity, and its monitoring may be useful for evaluating the response to therapy

Magnetic resonance angiography and transcranial Doppler ultrasound findings in patients with a clinical diagnosis of vertebrobasilar insufficiency

OBJECTIVE: To evaluate the findings of magnetic resonance angiography (MRA) and transcranial Doppler ultrasound (TCD) in patients with a clinical diagnosis of vertebrobasilar insufficiency (VBI). METHOD: From our outpatient neurotology clinic, we selected patients (using the criteria proposed by Grad and Baloh) with a clinical diagnosis of VBI. We excluded patients with any definite cause for vestibular symptoms, a noncontrolled metabolic disease or any contraindication to MRA or TCD. The patients in the study group were sex- and age-matched with subjects who did not have vestibular symptoms (control group). Our final group of patients included 24 patients (study, n=12; control, n=12). RESULTS: The MRA results did not demonstrate significant differences in the findings between our study and control groups. TCD demonstrated that the systolic pulse velocity of the right middle cerebral artery, end diastolic velocity of the basilar artery, pulsatility index (PI) of the left middle cerebral artery, PI of the right middle cerebral artery, and PI of the basilar artery were significantly higher in the study group than in the control group, suggesting abnormalities affecting the microcirculation of patients with a clinical diagnosis of VBI compared with controls. CONCLUSION: MRA failed to reveal abnormalities in patients with a clinical diagnosis of VBI compared with controls. The PI of the basilar artery, measured using TCD, demonstrated high sensitivity (91%) and specificity (91%) for detecting clinically diagnosed VBI

Sonografia transcraniana: uma experiência brasileira

Universidade Federal de São Paulo (UNIFESP) Division of General Neurology and Ataxias Department of NeurologyUniversidade de São Paulo Division of Clinical NeurosurgeryUNIFESP, Division of General Neurology and Ataxias Department of NeurologySciEL

Ultrassonografia transcraniana na doença de Parkinson

Transcranial sonography has become a useful tool in the differential diagnosis of parkinsonian syndromes. This is a non-invasive, low cost procedure. The main finding on transcranial sonography in patients with idiopathic Parkinson's disease is an increased echogenicity of the mesencephalic substantia nigra region. This hyperechogenicity is present in more than 90% of cases, and reflects a dysfunction in the dopaminergic nigrostriatal pathway. This study discussed how the hyperechogenicity of the substantia nigra may facilitate the differential diagnosis of parkinsonian syndromes.A ultrassonografia transcraniana tem se tornado ferramenta útil no diagnóstico diferencial das síndromes parkinsonianas. Trata-se de um método não invasivo e de baixo custo. O principal achado da ultrassonografia transcraniana em pacientes com doença de Parkinson idiopática é o aumento da ecogenicidade, ou hiperecogenicidade, na região da substância negra mesencefálica, presente em mais de 90% dos casos, o que reflete disfunção da via dopaminérgica nigroestriatal. O presente trabalho abordou como a hiperecogenicidade da substância negra pode auxiliar no diagnóstico diferencial das síndromes parkinsonianas.Universidade de São Paulo Division of Clinical NeurosurgeryHospital Israelita Albert EinsteinUniversidade Federal de São Paulo (UNIFESP) Department of Neurology and NeurosurgeryHospital Israelita Albert Einstein Instituto do CérebroUNIFESP, Department of Neurology and NeurosurgerySciEL

Decompressive Craniectomy for Traumatic Brain Injury: Postoperative TCD Cerebral Hemodynamic Evaluation

Background: There are no studies describing the cerebral hemodynamic patterns that can occur in traumatic brain injury (TBI) patients following decompressive craniectomy (DC). Such data have potentially clinical importance for guiding the treatment. The objective of this study was to investigate the postoperative cerebral hemodynamic patterns, using transcranial Doppler (TCD) ultrasonography, in patients who underwent DC. The relationship between the cerebral circulatory patterns and the patients' outcome was also analyzed.Methods: Nineteen TBI patients with uncontrolled brain swelling were prospectively studied. Cerebral blood circulation was evaluated by TCD ultrasonography. Patients and their cerebral hemispheres were categorized based on TCD-hemodynamic patterns. The data were correlated with neurological status, midline shift on CT scan, and Glasgow outcome scale scores at 6 months after injury.Results: Different cerebral hemodynamic patterns were observed. One patient (5.3%) presented with cerebral oligoemia, 4 patients (21%) with cerebral hyperemia, and 3 patients (15.8%) with cerebral vasospasm. One patient (5.3%) had hyperemia in one cerebral hemisphere and vasospasm in the other hemisphere. Ten patients (52.6%) had nonspecific circulatory pattern. Abnormal TCD-circulatory patterns were found in 9 patients (47.4%). There was no association between TCD-cerebral hemodynamic findings and outcome.Conclusion: There is a wide heterogeneity of postoperative cerebral hemodynamic findings among TBI patients who underwent DC, including hemodynamic heterogeneity between their cerebral hemispheres. DC was proved to be effective for the treatment of cerebral oligoemia. Our data support the concept of heterogeneous nature of the pathophysiology of the TBI and suggest that DC as the sole treatment modality is insufficient

Estimation of intracranial pressure by ultrasound of the optic nerve sheath in an animal model of intracranial hypertension

Antecedentes: La ecografía del diámetro de la vaina del nervio óptico (ONSD) se ha utilizado como alternativa no invasiva y rentable a la monitorización invasiva de la presión intracraneal (PIC). Sin embargo, aún se desconoce el comportamiento temporal del ONSD en la hipertensión intracraneal (HIC) y su alivio mediante infusión salina o cirugía. El objetivo de este estudio fue correlacionar la presión intracraneal (PIC) y la ultrasonografía de la vaina del nervio óptico (ONS) en un modelo animal experimental de HIC y determinar el intervalo necesario para que la ONSD vuelva a los niveles basales. Métodos: Se realizó un estudio experimental en 30 cerdos. La ONSD se evaluó mediante ecografía a diferentes PIC generadas por inflado intracraneal con balón, infusión salina y desinflado con balón, y se midió utilizando un catéter intraventricular. Resultados: Todas las variables obtenidas por ultrasonografía ONS como ONSD izquierdo, derecho y promedio (AON) fueron estadísticamente significativas para estimar el valor de la PIC. La ONSD cambió inmediatamente después del inflado del balón y volvió a los valores basales tras un retraso medio de 30 min después del desinflado del balón (p = 0,016). No se observó significación estadística en los valores de PIC y ONSD con la infusión de solución salina hipertónica. En este modelo porcino, la PIC y la ONSD mostraron una correlación lineal y la PIC pudo estimarse mediante la fórmula: -80,5 + 238,2 × AON. Conclusiones: En el presente estudio, la ecografía para medir la ONSD mostró una correlación lineal con la PIC, aunque se observó un breve retraso en volver a los niveles basales en el caso de alivio súbito de la HIC.Background: Ultrasound of the optic nerve sheath diameter (ONSD) has been used as a non-invasive and cost-effective bedside alternative to invasive intracranial pressure (ICP) monitoring. However, ONSD time-lapse behavior in intracranial hypertension (ICH) and its relief by means of either saline infusion or surgery are still unknown. The objective of this study was to correlate intracranial pressure (ICP) and ultrasonography of the optic nerve sheath (ONS) in an experimental animal model of ICH and determine the interval needed for ONSD to return to baseline levels. Methods: An experimental study was conducted on 30 pigs. ONSD was evaluated by ultrasound at different ICPs generated by intracranial balloon inflation, saline infusion, and balloon deflation, and measured using an intraventricular catheter. Results: All variables obtained by ONS ultrasonography such as left, right, and average ONSD (AON) were statistically significant to estimate the ICP value. ONSD changed immediately after balloon inflation and returned to baseline after an average delay of 30 min after balloon deflation (p = 0.016). No statistical significance was observed in the ICP and ONSD values with hypertonic saline infusion. In this swine model, ICP and ONSD showed linear correlation and ICP could be estimated using the formula: −80.5 + 238.2 × AON. Conclusion: In the present study, ultrasound to measure ONSD showed a linear correlation with ICP, although a short delay in returning to baseline levels was observed in the case of sudden ICH relief

Prediction of Early TBI Mortality Using a Machine Learning Approach in a LMIC Population.

Background: In a time when the incidence of severe traumatic brain injury (TBI) is increasing in low- to middle-income countries (LMICs), it is important to understand the behavior of predictive variables in an LMIC's population. There are few previous attempts to generate prediction models for TBI outcomes from local data in LMICs. Our study aim is to design and compare a series of predictive models for mortality on a new cohort in TBI patients in Brazil using Machine Learning. Methods: A prospective registry was set in São Paulo, Brazil, enrolling all patients with a diagnosis of TBI that require admission to the intensive care unit. We evaluated the following predictors: gender, age, pupil reactivity at admission, Glasgow Coma Scale (GCS), presence of hypoxia and hypotension, computed tomography findings, trauma severity score, and laboratory results. Results: Overall mortality at 14 days was 22.8%. Models had a high prediction performance, with the best prediction for overall mortality achieved through Naive Bayes (area under the curve = 0.906). The most significant predictors were the GCS at admission and prehospital GCS, age, and pupil reaction. When predicting the length of stay at the intensive care unit, the Conditional Inference Tree model had the best performance (root mean square error = 1.011), with the most important variable across all models being the GCS at scene. Conclusions: Models for early mortality and hospital length of stay using Machine Learning can achieve high performance when based on registry data even in LMICs. These models have the potential to inform treatment decisions and counsel family members. Level of evidence: This observational study provides a level IV evidence on prognosis after TBI