Trodimenzionalni ultrazvuk u procjeni moždanog krvožilja

Three-dimensional ultrasound has started developing in the fifth decade of the last century using numerous imaging innovations. For the exploration of extracranial circulation, three-dimensional ultrasound is used primarily on carotid arteries that are easy to access due to their anatomical position. In the evaluation of intracranial circulation, three-dimensionality can be achieved only partially due to the size of the bony window that prevents probe movement in all 360°. Three-dimensional ultrasound allows greater spatial resolution than conventional two-dimensional ultrasound. In comparison with magnetic resonance, three-dimensional ultrasound reaches transaxial resolution of 5 mm, longitudinal resolution of up to 10 mm and rotational resolution of up to 40º. Other advantages are noninvasiveness, volumetric tissue analysis instead of planimetric analysis, relatively low cost with high reproduction accuracy, high sensitivity and specificity (r=0.982). The principal shortcomings of three-dimensional ultrasound are the impossibility to distinctly differentiate between periarterial and intra-arterial tissue that will cause problems with tissue segmentation, cost of the ultrasound device that is somewhat more expensive, and the need for a skilled operator. Movement artifacts are most responsible for all artifacts but are easy to diminish with the use of the mechanical arm and ECG synchronization. Three-dimensional ultrasound is best used as a complimentary method of examination along with conventional ultrasound that enables mandatory hemodynamic evaluation. Recently, along with three-dimensional ultrasound, four-dimensional ultrasound is being developed that will allow real time tissue movement analysis and thus atherosclerotic plaque instability assessment.Trodimenzionalni ultrazvuk se razvija od sredine pedesetih godina prošloga stoljeća uporabom raznih inovacija u slikovnom prikazu. U ispitivanju ekstrakranijske cirkulacije rabi se prvenstveno trodimenzionalni ultrazvuk karotidnih arterija koje su lako dostupne pregledu zbog obilježja njihovog smještaja. U procjeni intrakranijske cirkulacije trodimenzionalnost je moguće samo djelomice postići, jer zbog veličine koštanoga prozora opseg pokreta sondom u svih 360° nije moguće napraviti. Trodimenzionalni ultrazvuk dopušta veću prostornu rezoluciju od konvencionalnog, dvodimenzionalnog ultrazvuka. U usporedbi s magnetnom rezonancijom trodimenzionalni ultrazvuk omogućuje transaksijalnu rezoluciju od 5 mm, longitudinalnu rezoluciju do 10 mm i rotacijsku rezoluciju do 40º. Ostale prednosti su neinvazivnost, volumetrijska analiza tkiva umjesto planimetrijske, relativno niska cijena uz veliku točnost reprodukcije, te visoka osjetljivost i specifičnost (r=0,982). Glavni nedostaci trodimenzionalnog ultrazvuka su nemogućnost jasnog razlikovanja periarterijskog i intraarterijskog tkiva, što uzrokuje probleme u segmentaciji tkiva, trošak nabave ultrazvučnog uređaja koji je nešto veći od troška nabave konvencionalnog uređaja, a uz to je potreban i vrsni operater. Pomaci tkiva također uzrokuju brojne artefakte, no uporabom mehaničke ruke i EKG sinhronizacije moguće je umanjiti navedene poteškoće. Trodimenzionalni ultrazvuk najbolje je rabiti kao dopunsku metodu pregleda uz konvencionalni ultrazvuk koji dopušta nužnu hemodinamsku procjenu. Uz trodimenzionalni ultrazvuk razvija se i četverodimenzionalni ultrazvuk koji omogućava prikaz pomaka tkiva u stvarnom vremenu, čime su dostupne informacije o nestabilnosti aterosklerotskog plaka

Aging and carotid remodeling

As we age, remodeling takes place in our body, and while some changes can be attributed to the mere aging process, others can be attributed to an early pathological process of subclinical changes typical in atherosclerosis. Aging is an imminent part of life and is a risk factor for atherosclerosis and cerebro- vascular disorders in both sexes. Once established, cerebrovascular diseases are strong contributors in worldwide morbidity and mortality scales, and stroke is the worldwide leading cause of mortality and disability in adults. Cerebrovascular disorders in Croatia are the second leading cause of mortality and the first in adult disability. In this article, we attempt to present all the changes of aging in the com- mon carotid artery thus distinguishing them from a pathological processes

Beta indeks žilne krutosti pomoću trodimenzijskog ultrazvuka

Beta stiffness index is the most common marker for assessment of subclinical atherosclerosis. The aim of the study was to explore the new technique of three-dimensional ultrasound for carotid stiffness evaluation. This pilot investigation was conducted in ten healthy volunteers. Measurements were performed in common carotid artery (CCA) on an Aloka 5500-SSD Prosound ultrasound platform in B and M modes. Data were collected freehandedly over 10 seconds and post processing analysis was performed using TomTec Imaging software. Beta indexes were mathematically computed and statistically evaluated by use of nonparametric statistics for two related samples. There were nine women and one man aged 39.3±9.23 years. There was one borderline hypertensive subject and four subjects were active smokers. The mean body mass index was 23.85±5.83 kg/m2, and mean intima-media thickness on CCA bilaterally 0.42±0.063 mm. Statistically, comparison between conventional and three-dimensional ultrasound corroborated consistency in the left CCA (p>0.05). This investigation proved that three-dimensional ultrasound could be used as a complementary method for evaluation of subclinical carotid atherosclerosis, with a greater sensitivity in the left CCA.Beta indeks krutosti jedan je od najčešće upotrebljavanih za opisivanje pretkliničke ateroskleroze. Cilj ovoga istraživanja bio je utvrditi je li moguće upotrijebiti novu metodu trodimenzijskog ultrazvuka karotidnih arterija za ispitivanje žilne krutosti. Ovo probno istraživanje provedeno je u 10 zdravih dobrovoljaca na ultrazvučnom uređaju Aloka 5500-SSD Prosound uporabom B i M prikaza na zajedničkoj karotidnoj arteriji (ACC). Za trodimenzijsku analizu rabila se je metoda "slobodne ruke" tijekom 10 sekunda uz pomoć programske potpore TomTec Imaging. Beta indeksi žilne krutosti izračunati su matematičkim putem, za analizu se je rabila neparametrijska statistika s dva povezana uzorka. U ispitivanje je bilo uključeno 9 žena i 1 muškarac prosječene dobi 9, ±9,2 godine. Jedan ispitanik je imao granično povišene vrijednosti krvnoga tlaka, a 4 ispitanika su bili aktivni pušači. Srednji indeks tjelesne težine bio je 2 ,85±5,8 kg/m2, a srednja vrijednost intimalnog dijela stjenke ACC obostrano 0,42±0,06 mm. Statističkom usporedbom vrijednosti beta indeksa krutosti dobiveni su podudarajući rezultati u lijevoj ACC (p>0,05). Istraživanje je potvrdilo da se trodimenzijski ultrazvuk može rabiti kao komplementarna metoda za ispitivanje pretkliničke karotidne ateroskleroze s većom osjetljivosti na lijevoj ACC

Trodimenzionalni ultrazvuk vertebrobazilarnog sustava

Background: Transcranial color-coded sonography (TCCS) and power Doppler imaging (PDI) are used for the evaluation of the vertebrobasilar (VB) system. Due to the unfavorable angle of the vertebral arteries’ (VA) junction and angle of insonation, all three vessels can rarely be visualized at the same time. Three-dimensional ultrasound (3D US) enables volumetric reconstruction of the VB junction. Methods: 2D TCCS and PD as well as 3D US were applied in 25 patients in order to visualize the intracranial part of the VB system. Results: In TCCS mode it was not possible to obtain all three vessels at the same time, in PD mode it was possible in 6/25 patients, and in 3D PD method in 19/25 patients. In 6 patients the VB angle could not be visualized (2 VAs were occluded – confirmed by angiography, in 4 cases there was a suboptimal suboccipital window), and volumetric reconstruction was applied. Conclusion: 3D US enabled better visualization of the VB junction due to the possibility of volumetric reconstructions.Uvod: Transkranijska bojom kodirana sonografija (TCCS) i osnaženi dopler (PD) se upotrebljavaju za procjenu vertebrobazilarnog (VB) sustava. Zbog nepovoljnog kuta spoja vertebralnih arterija (VA) i kuta insonacije, rijetko se mogu prikazati sve tri žile istovremeno. Trodimenzionalni ultrazvuk (3D UZ) omogućava volumetrijsku rekonstrukciju VB spoja. Metode: Primijenili smo 2D TCCS, PD i 3D UZ u 25 bolesnika kako bismo prikazali intrakranijski dio VB sustava. Rezultati: Primjenom TCCS nije bilo moguće prikazati sve tri krvne žile istovremeno, primjenom PD to je bilo moguće u 6 od 25 bolesnika, a primjenom 3D PD u 19 od 25 bolesnika. U 6 bolesnika VB kut se nije mogao prikazati (2 VA su bile okludirane što je potvrđeno angiografijom, u 4 slučaja bio je suboptimalni okcipitalni prozor), pa je primijenjena volumetrijska rekonstrukcija. Zaključak: 3D UZ omogućuje bolji prikaz VB spoja zbog mogućnosti volumetrijske rekonstrukcije

Migrena, karotidna krutost i genetski polimorfizam

Recently migraine has been associated with increased arterial stiffness, procoagulant state, increased incidence of cerebral white matter lesions (WML) and stroke. Our aim was to compare the characteristics of migraineurs to headache free controls regarding their functional carotid ultrasound parameters. Sixty patients (45 women) with migraine (mean age 40.42±10.61 years) were compared with 45 controls (30 women) with no prior history of repeating headache (men age 38.94±5.46 years) using E-tracking software on Alpha 10 ultrasound platform. Student’s t-test was used on statistical analysis with alpha <0.05. All tested carotid vascular parameters were worse in patients with migraine including increased intima-media thickness, greater carotid diameter and carotid diameter change, as well as several arterial stiffness indices. Additionally, patients with migraine had greater incidence of homozygous mutations for procoagulant genes (MTHFR (C677T), PAI-1 and ACE I/D) than expected. Computed tomography and magnetic resonance imaging of the brain showed WML in 11 patients, four of them migraine with aura patients. Since we established increased carotid stiffness and higher frequency of procoagulant gene mutations in migraineurs, we propose prospective ultrasound monitoring in such patients, especially those with detected WML, in order to timely commence more active and specific preventive stroke management strategies.Nedavno se pojam migrene povezao s povećanom arterijskom krutosti, prokoagulantnim stanjem, povećanim brojem zamijećenih otšećenja bijele moždane tvari te moždanim udarom. Naš cilj je bio usporediti funkcijske karakteristike mjerenja u zajedničkoj karotidnoj arteriji kod bolesnika s migrenom i u kontrolnoj skupini osoba bez učestalih glavobolja. U ispitivanje je bilo uključeno šezdeset ispitanika (45 žena) s migrenom (srednje dobi 40,42±10,61 godina) te 45 ispitanika u kontrolnoj skupini (30 žena) koji u anamnezi nisu imali učestale glavobolje (srednje dobi 38,94±5,46 godina). Mjerenja su provedena putem korisničke potpore E-tracking na ultrazvučnom aparatu Alpha 10. Studentov t-test se koristio za statističku analizu te je alfa bila određena na <0,05. Sve ispitivane vrijednosti bile su lošije kod bolesnika s migrenom uključujući zadebljanu tuniku intime i medije, veći karotidni promjer i promjenu karotidnog promjera, kao i nekoliko indeksa arterijske krutosti. Uz to, bolesnici s migrenom imali su veću učestalost homozigotnih mutacija za prokoagulantne gene (MTHFR (C677T), PAI-1 and ACE I/D) nego što je očekivano. Kompjutorizirana tomografija i magnetska rezonancija mozga zabilježile su oštećenje bijele moždane tvari kod 11 bolesnika, od kojih je 4 imalo migrenu s aurom. Kako smo zabilježili da postoji povećana arterijska krutost te veća učestalost mutacija prokoagulantnih gena kod bolesnika s migrenom, predlažemo da se takve osobe ultrazvučno prate, a osobito one kod kojih već postoji oštećenje bijele moždane tvari, kako bi se na vrijeme mogle poduzeti aktivne specifične mjere prevencije nastanka moždanih krvožilnih bolesti

Beta krutost - utvrđivanje dobnih standarda

Beta stiffness index is one of the most commonly used measures of depicting mechanical arterial properties and development of preclinical atherosclerosis. Main influences on its value hold age and blood pressure levels. The goal of this study was to determine age standards of beta stiffness index on common carotid artery in our population using a formula modified by Kawasaki. The study was conducted in 150 healthy volunteers aged 25-75 on an Aloka 5500-SSD Prosound ultrasound platform using Band M modes. The data obtained were analyzed by appropriate statistical methods. Study results confirmed linear relationship of beta index and age. Calculation of beta index is applicable for assessment and monitoring of vascular physiology changes because it is simple for use, prompt in analysis and suitable for bed-side evaluation.Beta indeks krutosti (engl. beta stiffness index) je jedna od klinički najčešće upotrebljavanih mjera za opisivanje mehaničkih svojstava arterija i pojave pretkliničke ateroskleroze. Glavni utjecaj na njegovu vrijednost imaju životna dob i vrijednost krvnoga tlaka. Cilj ovoga rada bio je utvrditi dobne standarde beta indeksa krutosti na zajedničkoj karotidnoj arteriji u našoj populaciji prema formuli koju je modificirao Kawasaki. Ovo istraživanje provedeno je na 150 zdravih dobrovoljaca u dobi od 25 do 75 godina na ultrazvučnom aparatu Aloka 5500-SSD Prosound uporabom B i M prikaza. Na prikupljenim podacima izvršila se prikladna statistička obrada. Rezultati su pokazali da beta indeks raste linearno u ovisnosti s dobi. Računanje beta indeksa primjenjivo je za procjenu i praćenje nastanka rane promjene vaskularne fiziologije, jer je jednostavno, brzo i primjenjivo uz krevet bolesnika

Multipla skleroza ili Fabryjeva bolest - za i protiv

Fabry disease is a rare X-linked inherited lysosomal storage disease affecting multiple organ systems, presenting in the central nervous system (CNS) as white matter lesions with underlying cerebral vasculopathy and autoinflammatory changes of the choroid plexus and leptomeninges. We present a young female patient (age 36 years) admitted to our department due to visual loss on the left eye. Magnetic resonance imaging (MRI) showed demyelinating lesions in the frontal and parietal lobe, periventricularly, in mesencephalon and right cerebellar hemisphere, and left optic neuritis; MR angiography was normal. Her medical history revealed renal dysfunction, hypothyroidism, and miscarriage in the 6th month of pregnancy due to eclampsia and Fabry disease in the family (mother). Cerebrospinal fluid analysis showed mild pleocytosis, normal blood brain barrier function and oligoclonal bands type 3. Visual evoked potentials showed prechiasmal dysfunction of the left optic nerve. Genetical testing for Fabry disease was positive (two heterozygous mutations), with decreased alpha galactosidase activity values and increased Lyso GB3 values. The patient received corticosteroid therapy (methylprednisolone) 1 g for 5 days, which led to regression of visual disturbances on the left eye. After this acute treatment, there was a question of definitive diagnosis and further treatment of the underlying cause. Considering renal dysfunction, miscarriage, arterial hypertension, positive genetic and biochemical testing for Fabry disease, as well as MRI findings showing lesions in posterior circulation, we concluded that the patient probably had Fabry disease with autoinflammatory changes in the CNS and should be treated with enzyme replacement therapy. Still, there was a question of optic neuritis on the left eye and positive oligoclonal bands favoring the diagnosis of multiple sclerosis. Therefore, further clinical and neuroradiological follow up was needed to distinguish multiple sclerosis and Fabry disease in this patient.Fabryjeva bolest je rijetka X vezana lizosomska bolest nakupljanja koja zahvaća više organskih sustava u organizmu, a u središnjem živčanom sustavu (SŽS) se prezentira kao lezije bijele tvari koje su posljedica vaskulopatije i autoimunih procesa na razini koroidnog pleksusa. U radu se prikazuje slučaj mlade žene (36 godina) koja je primljena na našu Kliniku zbog poremećaja vida na lijevom oku. Nalaz magnetske rezonance (MR) mozga je pokazao demijelinizacijske lezije u frontalnom i parijetalnom režnju, periventrikularno, u mezencefalonu, desnoj hemisferi malog mozga te optički neuritis lijevo. Nalaz MR angiografije mozga je bio uredan. U osobnoj anamnezi se doznaje da se bolesnica liječila zbog bubrežne insuficijencije, hipotireoze te da je u 6. mjesecu trudnoće imala spontani pobačaj uslijed eklampsije. U obiteljskoj anamnezi se doznaje da majka boluje od Fabryjeve bolesti. U analizi cerebrospinalnog likvora nađe se blaga pleocitoza, uredna funkcija krvnomoždane barijere te sinteza IgG unutar SŽS-a, oligoklonske vrpce tip 3. Vidni evocirani potencijali pokazali su disfunkciju prekjazmalno lijevo. Genetsko testiranje na Fabryjevu bolest pokazalo je pozitivan nalaz, 2 heterozigotne mutacije, smanjenu aktivnost alfa galaktosidaze te povišene vrijednosti Lyso GB3. Bolesnica je primila pulsnu kortikosteroidnu terapiju (metilprednisolon 1 g) kroz 5 dana, što je dovelo do regresije smetnji vida na lijevom oku. Nakon akutnog liječenja simptoma postavlja se pitanje konačne dijagnoze i dugoročnog liječenja. Uzimajući u obzir prisutnost bubrežne insuficijencije, eklampsiju u trudnoći uz spontani pobačaj, pozitivne rezultate genetskog testiranja i biokemijskih analiza za Fabryjevu bolest te nalaza MR mozga koji opisuje promjene dominantno u području stražnje cirkulacije zaključili smo da se u bolesnice najvjerojatnije radi o Fabryjevoj bolesti uz autoimune promjene u SŽS-u i da je bolesnicu potrebno liječiti enzimskom nadomjesnom terapijom. S obzirom na smetnje vida i nalaze pozitivnih oligoklonskih vrpci koji mogu govoriti i u prilog multiple skleroze potrebno je dalje pratiti bolesnicu klinički i neuroradiološki kako bi se postavila konačna dijagnoza