Transcranial Doppler ultrasonography of carotid-basilar collateral circulation in subclavian steal.

Klingelhöfer, Jürgen; Conrad, Bastian; Benecke, R.; Frank, Benjamin S.

doi:10.1161/01.str.19.8.1036

Cited by 50 publications

(26 citation statements)

References 22 publications

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“…4 Subsequent examination of both vertebral arteries and the anterior circulation in this patient excluded the diagnosis of subclavian steal and suggested that the intra-aortic balloon pump was responsible for this finding. This was confirmed by TCD examination of two additional patients in whom the pump was used intermittently.…”

Section: Discussionmentioning

confidence: 77%

“…These include increased intracranial pressure, 14 intracranial circulatory arrest, 15 and, in the posterior circulation, the subclavian steal syndrome. 4 Although it is well established that intra-aortic balloon pumping improves cardiac output and decreases myocardial work, its effects on the cerebral circulation have not been systematically examined. The clinical significance of this dramatic alteration in the cerebral blood flow pattern is unknown.…”

mentioning

confidence: 99%

“…Similar blood flow patterns are seen in the subclavian steal syndrome. 4 - 21 In this disease, with blood flow abnormalities restricted predominantly to the posterior circulation, the TCD pattern is usually benign. 21 Long-term monitoring of the cerebral circulation with TCD can identify microemboli within the middle cerebral artery during cardiopulmonary bypass procedures.…”

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confidence: 99%

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Reversed intracranial blood flow in patients with an intra-aortic balloon pump.

Brass

1990

Stroke

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As a preliminary investigation into the cerebral effects of mechanical cardiac assist devices, using transcranial Doppler ultrasonography I examined the basal cerebral arteries in three patients placed on an intra-aortic balloon pump. Unassisted systoles had normal blood velocities and waveforms. When the pump was in use, diastolic blood velocity during balloon inflation increased. As the balloon was deflated and intra-aortic pressure was dramatically lowered, diastolic blood velocity within the intracranial vessels decreased sharply. In two patients there was a reversal of blood flow in the middle cerebral, anterior cerebral, basilar, and vertebral arteries during late diastole. Although the clinical effects of cessation and reversal of blood flow in the cerebral circulation while on an intra-aortic balloon pump remain to be determined, transcranial Doppler ultrasonography appears to be a useful tool for measuring these hemodynamic effects. It may also be helpful in quantifying the effects of such pumps on cerebral blood flow and devising inflation/deflation timing sequences that maximize forward blood flow. (Stroke 1990^1:484-487) W hen medical treatment fails to sustain cardiac output, mechanical assist devices can be used to support left ventricular function. One of the most widely used devices is the intra-aortic balloon pump.1 The most common applications of this device include its use in patients with unstable angina and cardiogenic shock, for preoperative support, and in weaning patients from cardiopulmonary bypass.Intra-aortic balloon pumping decreases myocardial oxygen consumption, increases coronary blood flow, and increases cardiac output in patients with cardiogenic shock. In this procedure, a balloon is placed into the aorta just distal to the left subclavian artery, usually via the femoral artery. The balloon is connected to an external pump via a catheter. The pumping is timed so that the balloon inflates immediately after the aortic valve closes. Balloon inflation decreases diastolic aortic runoff and increases diastolic aortic pressure; these changes increase perfusion of the coronary arteries. The balloon deflates just before systole. Balloon deflation results in systolic unloading and a decrease in the aortic impedance to left ventricular ejection. This combination causes relatively little change in the mean aortic Received May 5, 1989; accepted October 16, 1989. pressure but decreases the left ventricular pressure by approximately 20% and increases cardiac output by up to 40% in patients with cardiogenic shock.

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Section: Discussionmentioning

confidence: 77%

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confidence: 99%

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confidence: 99%

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Reversed intracranial blood flow in patients with an intra-aortic balloon pump.

Brass

1990

Stroke

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“…However, with additional extracranial vascular disease the haemodynamic consequences of subclavian steal are more significant, and the likelihood and severity of vascular events in the carotid territory may exceed that in the vertebrobasilar territory [13, 14]. In man, there is transcranial Doppler evidence of perturbation in circle of Willis flow patterns in subclavian stenosis at rest and during functional tests of the collaterally supplied arm, with improvements after decompression [15, 16]. We believe that in our case the combination of an ipsilateral ICA occlusion and subclavian stenosis with steal exceeded the compensatory mechanisms of the circle of Willis predisposing to ischaemia in the ipsilateral carotid territory, itself already haemodynamically compromised secondary to the ICA occlusion.…”

Section: Discussionmentioning

confidence: 99%

Symptomatic Haemodynamically Significant Carotid Occlusion Treated by Posterior Circulation Revascularization

White

Barnes²,

Markus³

1998

Cerebrovasc Dis

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Haemodynamic cerebral ischaemic symptoms secondary to occlusive atheromatous disease of the internal carotid artery may resolve with revascularization. We describe a case of symptomatic internal carotid artery occlusion and ipsilateral subclavian stenosis with duplex and angiographically demonstrated vertebrobasilar steal and a patent ipsilateral posterior communicating artery with flow towards the steal. The patient suffered frequent ipsilateral middle cerebral artery territory transient ischaemic attacks and one minor stroke. Transcranial Doppler demonstrated markedly impaired ipsilateral carbon dioxide reactivity (13.8%, lower-limit normal range >32.6%). Percutaneous angioplasty to the subclavian artery stenosis resulted in resolution of symptoms and an improvement in reactivity to near the lower limit of the normal range (33.5%). This case demonstrates that normalization of vertebral artery steal by subclavian artery revascularization may benefit anterior circulation haemodynamic symptoms in the presence of a functioning posterior communicating artery. The measurement of middle cerebral artery reactivity using transcranial Doppler can identify such cases of haemodynamic impairment and monitor the effect of therapy.

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“…In the most common form of a vertebro-vertebral collateral circulation, the obstruction is bypassed by retrograde blood flow from the ipsilateral VA into the subclavian artery distal to the occlusion, and the reversed flow is fed by the contralateral vertebral artery. If the capacity of the contralateral vertebral artery is also reduced by stenosis or if this artery is occluded, other collateral circulation can arise from external carotid branches (occipital artery) that anastomose with muscular branches of the VA, and anastomoses with the thyrocervical and costocervical trunks may develop [45,46]. …”

Section: Reversed Va Flowmentioning

confidence: 99%

Usefulness of Transcranial Doppler Ultrasound in Evaluating Cervical-Cranial Collateral Circulations

et al. 2013

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Transcranial Doppler (TCD) ultrasound is a noninvasive, safe and cost-effective bedside test for evaluating cerebrovascular circulation in real time. It has been rapidly evolving from a simple noninvasive diagnostic tool to an imaging model with a broad spectrum of clinical applications. TCD can show the spectral flow waveforms, blood flow direction, velocities and intensity in the intracerebral vessels, adding physiologic information to other imaging models. TCD can also detect collateral channels through the anterior communicating artery, posterior communicating arteries, reversed ophthalmic artery, leptomeningeal collaterals, reversed basilar artery and reversed vertebral artery caused by hemodynamically significant carotid or intracranial stenosis. This article gives a brief overview of its use in evaluation of collateral circulation in carotid and intracranial steno-occlusive disease.

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Transcranial Doppler ultrasonography of carotid-basilar collateral circulation in subclavian steal.

Cited by 50 publications

References 22 publications

Reversed intracranial blood flow in patients with an intra-aortic balloon pump.

Reversed intracranial blood flow in patients with an intra-aortic balloon pump.

Symptomatic Haemodynamically Significant Carotid Occlusion Treated by Posterior Circulation Revascularization

Usefulness of Transcranial Doppler Ultrasound in Evaluating Cervical-Cranial Collateral Circulations

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