The Eligible Study: Ultrasound Assessment in Acute Ischemic Stroke within 3 Hours

Abstract

Background: Aims of the study: to identify with echo color Doppler ultrasound of the supra-aortic vessels and transcranial color-coded duplex sonography (TCCD) various patterns of vessel occlusion within 3 h from stroke onset, to compare each group defined at the admission with clinical findings and outcome, and to study the recanalization process, independent of therapy. Methods: We enrolled 89 consecutive patients (mean age 68.9 years). Ultrasound evaluation was done within 3 h from stroke onset, and was repeated at 3–6 and 24–36 h, at day 5, and at 3 months. At admission, patients were divided into the following groups: internal carotid artery occlusions and stenoses (<50%, 50–69%, ≧70%, near occlusion), middle cerebral artery stenoses and occlusions, tandem occlusions and T occlusions. Vascular recanalization in each group was evaluated. Subgroups were compared for NIH Stroke Scale (NIHSS) and the outcome measures mortality, Barthel index (BI) and modified Rankin scale (mRS). Favorable outcome was defined as mRS ≤2 and BI ≧90. Results: Each subgroup differed significantly for baseline NIHSS (p < 0.0001), 3-month mortality (p = 0.0235), BI at day 5 (p = 0.0458) and mRS at 3 months (p = 0.0028), even after adjustment for treatment. T and tandem occlusions were the subgroups with the highest NIHSS scores and the poorest outcomes, and the same subgroups had the worst recanalization rates. Conclusions: TCCD in the acute setting of stroke patients allows identification of the presence and site of clots, prediction of outcome and study of the dynamic process of vessel recanalization, in both the acute phase and follow-up.

The use of neurovascular ultrasound versus digital subtraction angiography in acute ischemic stroke

“…The importance of the NVUE in acute IS is related to its capacity to identify the site of the clots, predict patient outcome and evaluate vessel recanalization 6 . The identification of tandem occlusion (ICA + MCA) could help in the decision to an interventional therapy because intravenous reperfusion treatments demonstrated a low recanalization pattern and a poor outcome 16 .…”

“…A more recent technique, transcranial color-coded duplex sonography (TCCS), provides advantages compared to TCD by adding B-mode and color-mode to the spectral Doppler, but few studies have evaluated the NVUE that combines CVD and TCCS during acute IS 5,6,7 . The aim of this study is to compare the use of NVUE (CVD+TCCS) with the gold-standard, digital subtraction angiography (DSA), in diagnosing significant extracranial and intracranial arteriopathy in acute IS patients.…”

Neurosonological Evaluation of the Acute Stroke Patients

“…Atherosclerosis is a relevant cause of transient ischemic attack and stroke, but also non atherosclerotic conditions, like spontaneous cervical artery dissection and arteritis, can be diagnosed and followed-up. In acute stroke patients the involvement of the extracranial carotid axis is the cause of the cerebrovascular event quite in 18%, being the majority of vessel lesions in the intracranial circulation and sometimes both in extracranial and intracranial circulation (Malferrari G et al 2007). For both atherosclerotic and nonatherosclerotic diseases, the ultrasound findings and the diagnostic criteria has been compared to the neuroradiological findings and criteria in the literature, whereas Digital Subtraction Angiography (DSA) is considered the gold standard.…”

“…The main examination plane is the axial transtemporal mesencephalic one ( fig. 7), showing a good visualization of the circle of Willis (Malferrari et al 2007, Wong 2003, Valaikiene et al 2008. A useful information to compare TCCS planes with the corresponding images from neuroradiological techniques, is that the transcranial axial insonation plane is usually different from the axial plane displayed with MR and CT imaging.…”

“…This may have important implications in the decision for thrombolytic therapy…" . The neurosonological examination by TCD and TCCS can help in the early diagnostic workup of patients with acute ischemic stroke (Iannuzzi et al 1995;Lee et al 1996;Razumovsky et al 1999;Alexandrov et al 1999;Garami et al 2003); two studies addressed the reliability of the combined application of ultrasound examination of extracranial and intracranial arteries in acute stroke patients, respectively by TCD and TCCS (Alexandrov et al 1999;Malferrari et al 2007). This strategy allows to identify the vascular occlusive pattern eligible for treatment (accuracy near to 100%) (IMS study investigators 2004) and a fast-track ultrasound examination protocol has been proposed to diagnose the presence and site of vessel lesion bedside (Alexandrov et al 1999;Molina et al 2002;Feldberg et al 2002), achieving a sensitivity, specificity, positive predictive value and negative predictive value near to 100% (Feldberg et al 2002;Grant et al 2003;Burgin et al 2001;El-Mitwalli et al 2002;Christou et al 2001).…”