The Role of Transcranial Doppler Monitoring in Patients with Multi‐Territory Acute Embolic Strokes: A Review

Abstract

Acute multi‐territory, embolic cerebral infarctions are often associated with serious underlying clinical conditions including the presence of highly “active” emboligenic sources causing that in turn may result in high early recurrence rates. Prompt diagnosis, risk stratification, and treatment are substantial for the prevention of subsequent embolization that would result in further clinical deterioration. Among other clinical investigations, transcranial Doppler (TCD) monitoring is highly efficacious for the detection of microembolic signals (MES) that correspond to microthrombi entering the intracranial circulation. The presence and burden of MES, especially in multiple intracranial arteries, is clearly associated with an increased risk of symptomatic, recurrent embolization, and thus can justify a more aggressive treatment approach (clopidogrel load followed by dual antiplatelet therapy or alternatively therapeutic dose of low‐molecular‐weight heparin). In this narrative review, we discuss the most important causes of multi‐territory embolic ischemic strokes and also underscore the utility of TCD as a noninvasive tool for the diagnosis, risk stratification, and treatment.

Short-Term Outcome and In-Hospital Complications After Acute Cerebral Infarcts in Multiple Arterial Territories

“…72 Another diagnostic tool aiming on the assessment of the effect of secondary prevention and risk of recurrent embolization in patients with endocarditis, is micro-emboli detection. 73 Several studies showed that intravenous thrombolysis for ACI related to endocarditis is associated with higher rates of ICH and worse outcome. 74,75 The treatment is in the first line based on management of the underlying disease in both IE and NBTE.…”

“…Microemboli detection should be used more extensively in patients with MACI in order to avoid a negative progression and to assess the effect and possibly adjust the strategy of secondary prevention of recurrent stroke. 73…”

“…immunoglobulins or plasma exchange alongside with anticoagulation treatment may be indicated. The monitoring of treatment response may be achieved by microemboli detection, especially in patients presenting with MACI 73. Hypereosinophilic syndromeAnother rare etiology of multi-organ thromboembolic event is the hypereosinophilic syndrome.…”

Transcranial Doppler Monitoring of Acute Reperfusion Therapies in Acute Ischemic Stroke Patients with Underlying Large Vessel Occlusions

“…84 Therefore, detection of MES early post-reperfusion may prompt the administration of more potent antithrombotic therapies to reduce risk of stroke recurrence. 85 Absence of recanalization after IVT treatment for LVO-associated AIS increases risk of not only sICH but also of malignant edema development with a subsequent increase of intracranial pressure (ICP). The Systemic thrombolysis in patients with acute ischemic stroke and Internal Carotid ARtery Occlusion study demonstrated that, although IVT increased odds of favorable outcome (adjusted odds ratio: 1.80; 95% CI: 1.03-3.15; p=0.037), it also increased rates of malignant edema (8.3% vs. 3.1%).…”

Injuria encefálica aguda en el posoperatorio de cirugía cardíaca

“…La presencia de placas de ateroma en el arco aórtico cuadriplica la incidencia de stroke, que se caracteriza por lesiones isquémicas múltiples en diferentes territorios vasculares. Independientemente del procedimiento quirúrgico, los pacientes con placas de ateroma mayores de 4 mm tienen una incidencia anual de stroke recurrente del 12% (41) .…”