Trans-cranial Doppler predicts early neurologic deterioration in anterior circulation ischemic stroke after successful endovascular treatment

Abstract

Background Early neurologic deterioration (END) may occur in patients with anterior circulation ischemic stroke (ACIS) after receiving endovascular treatment (EVT). Hemodynamic insufficiency, re-occlusion, and post-re-canalization hyper-perfusion are likely to play a critical role in END. We hypothesized that hemodynamic changes can predict END in patients with ACIS post-successful EVT using trans-cranial Doppler (TCD). Methods We utilized a prospectively maintained database of ACIS patients treated with EVT between September 2016 and June 2018 in the Xuanwu Hospital, Capital Medical University. TCD parameters including peak systolic velocity (PSV), bilateral mean flow velocity (MFV), and pulse index (PI) were determined via the middle cerebral arteries within 72 h post-EVT. A logistic regression model was applied to detect independent predictors for END. Results Totally, 112 EVT patients were included in this study and 80/112 patients experienced successful re-canalization with <50% residual stenosis, while 17/80 (21.3%) patients suffered END, for which vasogenic cerebral edema (11/17) was considered as a leading role and followed by symptomatic intra-cranial hemorrhage (4/17) and ischemia progression (2/17). For the 80 patients, the PSV (median: 127 cm/s vs. 116 cm/s, P = 0.039), the ratio of ipsilateral-MFV/contra-lateral-MFV (iMFV/cMFV) (median: 1.29 vs. 1.02, P = 0.036) and iMFV/mean blood pressure (MBP) (median: 0.97 vs. 0.79, P = 0.008) in END patients were higher than those of non-END. Using the receiver-operating characteristic curve to obtain cut-off values for PSV, PI, iMFV/cMFV, and iMFV/MBP for END, we found that PI ≥0.85 (odds ratio: 11.03, 95% confidence interval: 1.92–63.46, P = 0.007) and iMFV/MBP ≥0.84 (odds ratio: 9.20, 95% confidence interval: 2.07–40.84, P = 0.004) were independent predictors of END in a multivariate logistic regression model, with a sensitivity of 82.4% and 76.5% and a specificity of 42.9% and 66.7%, respectively, and had the positive predictive values of 29.0% and 38.2%, and negative predictive values of 90.0% and 91.3%, with an area under the receiver-operating characteristic curve of 0.57 and 0.71, respectively. Conclusion TCD examination of EVT patients may be used as a real-time tool to detect END predictors, such as the higher PI and iMFV/MBP, allowing for better post-thrombectomy management in ACIS patients.

A Prospective Study to Investigate Controlling Blood Pressure Under Transcranial Doppler After Endovascular Treatment in Patients With Occlusion of Anterior Circulation

“…First, a previous ROC analysis has suggested that PSV ≥ 118 cm/s was an independent risk factor for early neurological deterioration, with a sensitivity of 88.1% and a specificity of 52.4%, respectively. Moreover, the risk of sICH and vasogenic cerebral edema also increased significantly when PSV ≥ 118 cm/s ( 14 ). Second, iMFV/cMFV ≥ 1.25 was chosen because Kneihsl et al found that the risk of postinterventional ICH (OR 3.6, 95% CI 1.1 to 13.2) and mRS 3–6 at 90 days (OR 3.2, CI 1.1–9.7) increased significantly when MFV on the lesion side was higher than 125% that on the opposite side ( 9 ).…”

“…Mean flow velocity (MFV) was calculated automatically using the following equation: MFV = (PSV – EDV) / 3 + EDV. PSV was selected as the primary target in this study because previous research showed that the risk of early neurological deterioration significantly increased when PSV ≤74 cm/s or ≥118 cm/s among patients after anterior circulation EVT ( 14 ). A continuous monitoring of MCA cerebral blood flow velocity was conducted, and an automatic reminder was set up when PSV ≥ 118 cm/s, MFV on the lesion side was higher than 125% that on the opposite side, and PSV ≤ 74 cm/s ( 14 ).…”

“…In the TBM group, patients received BP-lowering treatment when the cerebral blood flow was accelerated (PSV ≥ 118 cm/s or MFV on the lesion side was higher than 125% that on the opposite side), and patients received BP-raising treatment when the cerebral blood flow was decelerated (PSV ≤ 74 cm/s) ( 14 ). All patients in the TBM group received BP intervention when TCD parameters became abnormal regardless of the BP level.…”

ASNM and ASN joint guidelines for transcranial Doppler ultrasonic monitoring: An update

“…Finally, TCDNM can identify the sudden appearance of echogenic material (ie, emboli) 51,52,54–57 . In certain clinical situations, each of these pieces of information, unobtainable by other means, may be literally lifesaving 58–60 …”

Potential Therapies for Cerebral Edema After Ischemic Stroke: A Mini Review

“…Ischemic stroke accounts for 69.6–70.8% of all strokes (Wang W. et al, 2017 ). The mortality rate of patients with acute ischemic stroke is as high as 2.3–3.2% within 1 month after onset (Huang et al, 2010 ; Wang D. et al, 2017 ; Li et al, 2019 ; He et al, 2020 ). The formation of cerebral edema is a major cause of death in stroke patients (Simard et al, 2007 ; Walcott et al, 2014 ; Rungta et al, 2015 ).…”