Evaluation of right-to-left shunt on contrast-enhanced transcranial Doppler in patent foramen ovale-related cryptogenic stroke: Research based on imaging

BACKGROUND Cardiogenic embolism caused by patent foramen ovale(PFO)is a common etiology of cryptogenic stroke(CS),particularly in young and middle-aged patients.Studies about right-to-left shunt(RLS)detection using contrast-enhanced transcranial Doppler(c-TCD)are numerous.According to the time phase and number of microbubbles detected on c-TCD,RLS can be classified and graded.We hypothesized that the characteristics of an infarction lesion on diffusion-weighted imaging differs when combining the type and grade of RLS on c-TCD in patients with PFO-related CS.AIM To explore the characteristics of infarction lesions on diffusion-weighted imaging when combining the RLS type and grade determined by c-TCD.METHODS We retrospectively evaluated CS patients from August 2015 to December 2019 at a tertiary hospital.In total,111 PFO-related CS patients were divided according to whether RLS was permanent(microbubbles detected both at resting state and after the Valsalva maneuver)or latent(microbubbles detected only after the Valsalva maneuver)on c-TCD.Each group was subdivided into small,mild and large RLS according to the grade of shunt on c-TCD.A normal control group was composed of 33 patients who suffered from simple dizziness.Intragroup and intergroup differences were analyzed in terms of clinical,laboratory and diffusion-weighted imaging lesion characteristics.The correlation between RLS grade evaluated by c-TCD and size of PFO determined by transesophageal echocardiography were also analyzed.RESULTS In 111 patients with PFO-related CS,68 had permanent RLS and 43 had latent RLS.Clinical characteristics and laboratory tests were not significantly different among the permanent RLS,latent RLS and normal control groups.The proportion of patients with multiple territory lesions in the permanent RLS group(50%)was larger than that in the latent RLS group(27.91%;P=0.021).Posterior circulation was more likely to be affected in the latent RLS group than in the permanent RLS group(30.23%vs 8.82%,P=0.004).Permanent-large and latent-large RLS were both more likely to be related to multiple(P_(trend)=0.017 and 0.009,respectively),small(P_(trend)=0.035 and 0.006,respectively)and cortical(P_(trend)=0.031 and 0.033,respectively)lesions.The grade of RLS evaluated by c-TCD was correlated to the size of PFO determined by transesophageal echocardiography(r=0.758,P<0.001).CONCLUSION Distribution of the infarct suggested the possible type of RLS.Multiple,small and cortical infarcts suggest large RLS induced by a large PFO.

Carotid Doppler and transcranial Doppler in diagnosing transient ischemic attack: A healthy control

BACKGROUND： If changes of hemodynamics in internal or external cranial artery and stenosis of atherosclerosis are found eady, patients with transient ischemic attack （TIA） may be treated at an eady phase so as to prevent and decrease the onset of cerebral infarction. Carotid Doppler can analyze carotid canal wall, hemodynamic properties and stenosis, and changes of plaque morphology; however, transcranial Doppler （TCD） can evaluate vascular stenosis and occlusion and judge collateral circulation in cranium through detecting velocity and direction of blood flow. Can the association of them increase the diagnostic rate of TIA？ OB3ECTIVE： To evaluate the effect of the association of carotid Doppler and TCD on TIA in internal carotid artery. DESIGN： Contrast observational study SETTING： Department of Neuroelectrophysiology, Central People＇s Hospital of Huizhou PARTICIPANTS： A total of 54 patients with TIA in internal carotid artery were selected from the Department of Neurology of Huizhou Central People＇s Hospital from May 2004 to June 2005. There were 35 males and 24 females aged 46-81 years. The clinical situation was asthenia of single limb, hemiplegia, anaesthesia of single upper or lower limb, hemianesthesia, sensory disorder and aphasia. The symptoms lasted for less than 2 hours. All cases were diagnosed with CT, and those who had pathological changes of acute cerebral infarction and history of cardiac disease were excluded. Additionally, 50 healthy subjects who were regarded as control group were selected from the Department of Neurology of Huizhou Central People＇s Hospital. There were 30 males and 20 females aged 45-80 years. All subjects were consent. METHODS： HD15000 color Doppler ultrasound （Philips Company, USA） and Muliti-DopX2 TCD （DWL Company, Germany） were used to detect hemodynamics, stenosis and distribution of atherosclerosis in carotid artery and internal carotid artery. Evaluation of marker： Stenosis was calculated by the ratio between the minimal cavity and vascular sectional area at the maximal site of plaque （mild： stenosis 〈 50%; moderate and severe： stenosis t〉 50%）. With TCD, the following results were regarded as stenosis： blood velocity of average envelope 〉 120 cm/s （diagnostic criteria of vascular stenosis of basilar artery： blood velocity of average envelope 〉 80 cm/s）, increase and segmental property of blood flow, and murmu of turbulent flow and vessel. MAIN OUTCOME MEASURES： Positive rate of atherosclerosis and incidence of stenosis with carotid Doppler and TCD. RESULTS： All 54 TIA patients and 50 healthy subjects were involved in the final analysis. ① Results of carotid Doppler： Atherosclerosis and stenosis were obvious in experimental group. Positive rate of atherosclerosis was 85% （46/54） and incidence of stenosis of carotid artery was 41% （22/54）, which were higher than those in control group [52% （26/54）, 41% （22/54）, x^2 = 13.42, 10.90, P 〈 0.01]. ② Results of TCD： In experimental group, positive rate of atherosclerosis at base of skull was 89% （48/54） and incidence of stenosis of internal cranial artery was 48% （26/54）, which were higher than those in control group [62% （31/50）, 0, x^2 = 10.28, 32.00, P 〈 0.01]. Stenosis of artery was mainly involved in middle cerebral artery, initial segment and crotch of carotid artery. CONCLUSION： The association of carotid Doppler and TCD can increase clinically diagnostic rate of TIA and provide bases for apposition and intensity of TIA lesion.

Comparison of detection results of hypoxic-ischemic encephalopathy at different degrees in infant patients between brain electrical activity mapping, transcranial Doppler sonography and computer tomography examinations

BACKGROUND： It has been proved that brain electrical activity mapping （BEAM） and transcranial Doppler （TCD） detection can reflect the function of brain cell and its diseased degree of infant patients with moderate to severe hypoxic-ischemic encephalopathy （HIE）. OBJECTIVE： To observe the abnormal results of HIE at different degrees detected with BEAM and TCD in infant patients, and compare the detection results at the same time point between BEAM, TCD and computer tomography （CT） examinations. DESIGN ： Contrast observation SETTING： Departments of Neuro-electrophysiology and Pediatrics, Second Affiliated Hospital of Qiqihar Medical College. PARTICIPANTS： Totally 416 infant patients with HIE who received treatment in the Department of Newborn Infants, Second Affiliated Hospital of Qiqihar Medical College during January 2001 and December 2005. The infant patients, 278 male and 138 female, were at embryonic 37 to 42 weeks and weighing 2.0 to 4.1 kg, and they were diagnosed with CT and met the diagnostic criteria of HIE of newborn infants compiled by Department of Neonatology, Pediatric Academy, Chinese Medical Association. According to diagnostic criteria, 130 patients were mild abnormal, 196 moderate abnormal and 90 severe abnormal. The relatives of all the infant patients were informed of the experiment. METHOOS： BEAM and TCD examinations were performed in the involved 416 infant patients with HIE at different degrees with DYD2000 16-channel BEAM instrument and EME-2000 ultrasonograph before preliminary diagnosis treatment （within 1 month after birth） and 1,3,6,12 and 24 months after birth, and detected results were compared between BEAM, TCD and CT examinations. MAIN OUTCOME MEASURES： Comparison of detection results of HIE at different time points in infant patients between BEAM. TCD and CT examinations. RESULTS： All the 416 infant patients with HIE participated in the result analysis. （1） Comparison of the detected results in infant patients with mild HIE at different time points after birth between BEAM, TCD and CT examinations： BEAM examination showed that the recovery was delayed, and the abnormal rate of BEAM examination was significantly higher than that of CT examination 1 and 3 months after birth [55.4%（72/130）vs. 17.0% （22/130 ）,x^2=41.66 ;29.2% （ 38/130 ） vs. 6.2% （ 8/130 ）, x^2=23.77, P 〈 0.01 ], exceptional patients had mild abnormality and reached the normal level in about 6 months. TCD examination showed that the disease condition significantly improved and infant patients with HIE basically recovered 1 or 2 months after birth, while CT examination showed that infant patients recovered 3 or 4 months after birth. （2） Comparison of detection results of infant patients with moderate HIE at different time points between BEAM, TCD and CT examinations： The abnormal rate of BEAM examination was significantly higher than that of CT examination 1,3,6 and 12 months after birth [90.8% （178/196）,78.6% （154/196）,x^2=4.32,P 〈 0.05;64.3% （126/196）,43.9% （86/196） ,x^2=16.44 ;44.9% （88/196） ,22.4% （44/196）,x^2=22.11 ;21.4% （42/196）, 10.2% （20/196）,x^2=9.27, P 〈 0.01]. BEAM examination showed that there was still one patient who did not completely recovered in the 24^th month due to the relatives of infant patients did not combine the treatment,. TCD examination showed that the abnormal rate was 23.1%（30/196）in the 1^st month after birth, and all the patients recovered to the normal in the 3^rd month after birth, while CT examination showed that mild abnormality still existed in the 24^th month after birth （1.0% ,2/196）. （3） Comparison of detection results of infant patients with severe HIE at different time points between BEAM, TCD and CT examinations： The abnormal rate of BEAM examination was significantly higher than that of CT examination in the 1^st, 3^rd, 6^th and 12^th months after birth[86.7% （78/90）,44.4% （40/90）,x^2=35.53;62.2% （56/90）,31.1% （28/90）,x^2=17.51 ;37.8% （34/90）,6.7% （6/90）, x^2=27.14, P 〈 0.01]. BEAM examination showed that mild abnormality still existed in 4 infant patients in the 24^th month after birth. TCD examination showed that the abnormal rate was 11.1% （10/90） in the 3^rd month after birth, and all the infant patients recovered in the 6^th month after birth. CT examination showed that the abnormal rate was 6.7%（6/90） in the 12^th month after birth, and all of infant patients recovered to the normal in the 24^th month after birth.CONCLUSION ： BEAM is the direct index to detect brain function of infant patients with HIE, and positive reaction is still very sensitive in the tracking detection of convalescent period. The positive rate of morphological reaction in CT examination is superior to that in TCD examination, and the positive rate is very high in the acute period of HIE in examination.

Evaluation of Early Acute Cerebral Infarction with Transcranial Doppler

Objective:For patients with early acute cerebral infarction(ACI),transcranial Doppler ultrasound was used in the clinical examination,and its application effect was observed and analyzed.Methods:This study was carried out between October 2018 and October 2019.50 patients with ACI included as the research object was evaluated by transcranial Doppler and CT examination,and the application of the two examination methods was compared.Results:The results of transcranial Doppler examination showed that the abnormal rate of blood flow velocity and the ratio of both sides(VACA)in patients with early ACI was higher than that of CT examination.Conclusion:With the impact on the location and area of vascular occlusion in patients,VACA can effectively reflect the status and effectiveness of the collateral circulation function of the patient’s pia vessels during cerebral infarction.

Nitrogen monoxide vector of ultrasonic atomizing inhalation improves vertebro-basilar artery insufficiency Hemodynamic changes are detected by transcranial Doppler test

BACKGROUND： Latest researches at home and abroad indicate that glycerol trinitrate plays its function because it can metabolize into nitrogen monoxide （NO） in vivo. OBJECTIVE： To study the therapeutic effects of NO vector of ultrasonic atomizing inhalation on vertebro-basilar artery insufficiency （VBI） through transcranial Doppler （TCD） detection and serum NO content and indirect effect of TCD on cerebral blood flow changes. DESIGN： Randomized grouping and controlled clinical study. SETTING： Department of Neurology, the Fourth People＇s Hospital of Jinan. PARTICIPANTS： A total of 130 patients who were diagnosed as VBI were selected from Department of Neurology, the Fourth People＇s Hospital of Jinan from December 2001 to December 2005. The involved inpatients were checked by CT and MRI, and met the VBI diagnostic standard enacted by the Fourth National Academic Meeting of Cerebrovascular Disease in 1995. All patients and their relatives provided the confumed consent. They were randomly divided into low-dose treatment group （n =60）, high-lose treatment group （n =30） and control group （n =40）. METHODS： Patients in the low-dose and high-dose treatment groups were given ultrasonic atomizing inhalation of 3 mg and 5 mg glycerol trinitrate, respectively, for 20 minutes, once a day. In addition, ligustrazine and energy mixture were used once a day for three days in a course. Cases in the control group were only given ligustrazine and energy mixture. All selected cases accepted TCD, blood NO content was checked at the time of beginning, after the first time and after a period of treatment. According to the TCD test, VBI patients were divided into two groups （high-low flow velocity）. The vertebral artery （VA） and basal artery （BA） of left or right sides were detected by 2 Hz detector via occipital window. MAIN OUTCOME MEASURES： ①Blood flow velocity of systolic phase, blood flow velocity of diastole phase and vascular resistance in left and right VA and BA detected by using TCD before treatment, after treatment for one course; ②content of serum NO indirectly measured by using nitric acid disoxidation technique. RESULTS： All 130 VBI patients were involved in the final analysis. ①Changes of hemodynamic indexes： Systolic phase of VA and diastole phase of BA were higher in low-dose treatment group than that in the control group after first treatment, and there was significant difference （P 〈 0.05）; meanwhile, systolic phase and diastole phase of VA and systolic phase of BA were also higher in treatment group than that in the control group after one course （P 〈 0.05）. However, both systolic phase and diastole phase of VA and BA were lower in high-dose treatment group than that in the control group after first treatment and one course, and there was significant difference （P 〈 0.05）. ②Content of serum NO： After first treatment, there was no significant difference between low-dose treatment group and high-dose treatment group （P 〉 0.05）; but both groups were higher than control group, and there was significant difference （P 〈 0.05, 0.01）. CONCLUSION： NO vector of ultrasonic atomizing inhalation can improve VBI so as to improve cerebral blood-supply state.

Clinical utilization of microembolus detection by transcranial Doppler sonography in intracranial stenosis-occlusive disease

Objective To discuss the clinical ultiliazation and significance of microembolus detection by transcranial Doppler （TCD） sonography in intracranial stenosis-occlusive disease. Data sources All related articles in this review were mainly searched from PubMed published in English from 1996 to 2012 using the terms of microembolic signal, transcranial Doppler, intracranial stenosis, stroke. Study selection Original articles and reviews were selected if they were related to the clinical utilization of microembolus detection in intracranial stenosis-occlusive disease. Results Intracranial stenosis is a significant cause of cerebral emboli, and microembolus detection by TCD sonography were widely used in exploring the mechanisms of ischemic stroke with intracranial stenosis （including the middle cerebral artery stenosis and the vertebral-basilar stenosis）, evaluating the prognosis of acute stroke, evaluating the therapeutic effects, and predicting the recurrent events of stroke. Conclusion Microembolus detection by TCD sonography plays an important role in the cerebral ischemic stroke patients with intracranial stenosis.

Compromised cerebrovascular modulation in chronic anxiety:evidence from cerebral blood flow velocity measured by transcranial Doppler sonography

Objective Cerebral autoregulation （CA） is the mechanism by which constant cerebral blood flow is maintained despite changes in cerebral perfusion pressure. CA can be evaluated by dynamic monitoring of cerebral blood flow velocity （CBFV） with transcranial Doppler sonography （TCD）. The present study aimed to explore CA in chronic anxiety. Methods Subjects with Hamilton anxiety scale scores 〉14 were enrolled and the dynamic changes of CBFV in response to an orthostatic challenge were investigated using TCD. Results In both the anxious and the healthy subjects, the mean CBFV was significantly lower in the upright position than when supine. However, the CBFV changes from supine to upright differed between the anxious and the healthy groups. Anxious subjects showed more pronounced decreases in CBFV with abrupt standing. Conclusion Our results indicate that cerebrovascular modulation is compromised in chronic anxiety; anxious subjects have some insufficiency in maintaining cerebral perfusion after postural change. Given the fact that anxiety and impaired CA are associated with cardiovascular disease, early ascertainment of compromised cerebrovascular modulation using TCD might suggest interventional therapies in the anxious population, and improve the primary prevention of cardiovascular disease.

Transcranial Doppler for detection of changes in ophthalmic artery blood flow

The ophthalmic artery （OA） is a main branch of the internal carotid artery （ICA）. Severe internal carotidartery stenosis or occlusion may not only affect the blood supply to the brain, but may also cause OA insufficiency, leading to ocular ischemia. Therefore, research on the hemodynamic changes in the OA in patients with ICA stenosis or occlusion has increasingly attracted more ophthalmologists＇ attention.1 Transcranial Doppler （TCD） is simple and noninvasive, has been widely used in the inspection of cerebrovascular disease,

Is medical management useful in Moyamoya disease?

Moyamoya disease(MMD),characterized by progressive internal carotid artery stenosis and collateral vessel formation,prompts cerebral perfusion complications and is stratified into idiopathic and Moyamoya syndrome subtypes.A multifa-ceted approach toward MMD management addresses cerebral infarctions through revascularization surgery and adjunctive medical therapy,while also navigating risks such as intracranial hemorrhage and cerebral infarction resulting from arte-rial stenosis and fragile collateral vessels.Addressing antithrombotic management reveals a potential role for treatments like antiplatelet agents and anticoagulants,despite the ambiguous contribution of thrombosis to MMD-related infarctions and the critical balance between preventing ischemic events and averting hemo-rrhagic complications.Transcranial doppler has proven useful in thromboembolic detection,despite persisting challenges concerning the efficacy and safety of an-tithrombotic treatments.Furthermore,antihypertensive interventions aim to ma-nage blood pressure meticulously,especially during intracerebral hemorrhage,with recommendations and protocols varying based on the patient’s hypertension status.Additionally,lipid-lowering therapeutic strategies,particularly employing statins,are appraised for their possible beneficial role in MMD management,even as comprehensive data from disease-specific clinical trials remains elusive.Com-prehensive guidelines and protocols to navigate the multifaceted therapeutic ave-nues for MMD,while maintaining a delicate balance between efficacy and safety,warrant further meticulous research and development.This protocol manuscript seeks to elucidate the various aspects and challenges imbued in managing and navigating through the complex landscape of MMD treatment.

Future of neurocritical care:Integrating neurophysics,multimodal monitoring,and machine learning

Multimodal monitoring(MMM)in the intensive care unit(ICU)has become increasingly sophisticated with the integration of neurophysical principles.However,the challenge remains to select and interpret the most appropriate combination of neuromonitoring modalities to optimize patient outcomes.This manuscript reviewed current neuromonitoring tools,focusing on intracranial pressure,cerebral electrical activity,metabolism,and invasive and noninvasive autoregulation moni-toring.In addition,the integration of advanced machine learning and data science tools within the ICU were discussed.Invasive monitoring includes analysis of intracranial pressure waveforms,jugular venous oximetry,monitoring of brain tissue oxygenation,thermal diffusion flowmetry,electrocorticography,depth electroencephalography,and cerebral microdialysis.Noninvasive measures include transcranial Doppler,tympanic membrane displacement,near-infrared spectroscopy,optic nerve sheath diameter,positron emission tomography,and systemic hemodynamic monitoring including heart rate variability analysis.The neurophysical basis and clinical relevance of each method within the ICU setting were examined.Machine learning algorithms have shown promise by helping to analyze and interpret data in real time from continuous MMM tools,helping clinicians make more accurate and timely decisions.These algorithms can integrate diverse data streams to generate predictive models for patient outcomes and optimize treatment strategies.MMM,grounded in neurophysics,offers a more nuanced understanding of cerebral physiology and disease in the ICU.Although each modality has its strengths and limitations,its integrated use,especially in combination with machine learning algorithms,can offer invaluable information for individualized patient care.

SELECTION OF ACUPOINTS BY DOPPLER SOUND SPECTROGRAM FOR TREATMENT OF INSUFFICIENT BLOOD SUPPLY OF CEREBRAL BASILAR ARTERY

Acupuncture moxibustion has been recognized to be effective for treatment of cerebral ischemia, but there are still some problems such as undefined criteria for evaluating the effectiveness and unchecked selection of acupoints. In the late 1980s, cerebrovascular examination was revolutionized in China

Ankle-brachial index and brachial-ankle pulse wave velocity are risk factors for ischemic stroke in patients with type 2 diabetes

The incidence of ischemic stroke in patients with diabetes is increasing. While brachial-ankle pulse wave velocity （BaPWV） and ankle-bra- chial index （ABI） are known to be associated with ischemic cardiovascular and cerebrovascular diseases, whether these measures predict the risk of ischemic cerebrovascular disease in diabetic patients remains unclear. 117 patients with type 2 diabetes were enrolled in this study. According to the results of head magnetic resonance imaging, the patients were divided into a diabetes-only group （n = 55） and a diabetes and ischemic stroke group （n = 62）. We then performed ABI and BaPWV examinations for all patients. Compared with the diabe- tes-only group, we found decreased ABI and increased BaPWV in the diabetes and ischemic stroke group. Multivariate logistic regression analyses revealed that BaPWV and ABI were risk factors for ischemic stroke in patients with type 2 diabetes. Our findings indicate that decreased ABI and increased BaPWV are objective indicators of increased risk of ischemic stroke in patients with type 2 diabetes.

Neuroimaging diagnosis for cerebral infarction An 8-year bibliometric analysis

OBJECTIVE： To identify global research trends in neuroimaging diagnosis for cerebral infarction using a bibliometric analysis of the Web of Science. DATA RETRIEVAL： We performed a bibliometric analysis of data retrieval for neuroimaging diagnosis for cerebral infarction containing the key words ＂CT, magnetic resonance imaging, MRI, transcranial Doppler, transvaginal color Doppler, digital subtraction angiography, and cerebral infarction＂ using the Web of Science. SELECTION CRITERIA： Inclusion criteria were： （a） peer-reviewed articles on neuroimaging diagnosis for cerebral infarction which were published and indexed in the Web of Science; （b） original research articles and reviews; and （c） publication between 2004-2011. Exclusion criteria were： （a） articles that required manual searching or telephone access; and （b） corrected papers or book chapters. MAIN OUTCOME MEASURES： （1）Annual publication output; （2） distribution according to country; （3） distribution according to institution; （4） top cited publications; （5） distribution according to journals; and （6） comparison of study results on neuroimaging diagnosis for cerebral infarction. RESULTS： Imaging has become the predominant method used in diagnosing cerebral infarction. The most frequently used clinical imaging methods were digital subtraction angiography, CT, MRI, and transcranial color Doppler examination. Digital subtraction angiography is used as the gold standard. However, it is a costly and time-consuming invasive diagnosis that requires some radiation exposure, and is poorly accepted by patients. As such, it is mostly adopted in interventional therapy in the clinic. CT is now accepted as a rapid, simple, and reliable non-invasive method for use in diagnosis of cerebrovascular disease and preoperative appraisal. Ultrasonic Doppler can be used to reflect the hardness of the vascular wall and the nature of the plaque more clearly than CT and MRI. CONCLUSION： At present, there is no unified standard of classification of cerebral infarction imaging. Detection of clinical super-acute cerebral infarction remains controversial due to its changes on imaging, lack of specificity, and its similarity to a space-occupying lesion. Neuroimaging diagnosis for cerebral infarction remains a highly active area of research and development.

Effects of cilostazol on the progression and regression of symptomatic intracranial artery stenosis:it reduces the risk of ischemic stroke

OBJeCTIve：To assess the efifcacy and safety of cilostazol on the progression and regression of symptomatic intracranial artery stenosis. DATA ReTRIvAL： We searched the main databases for eligible trials including Medline （from 1966 to June 2014）, Embase （from 1980 to June 2014）, Cochrane Library （Issue 6, 2014）, Chinese National Knowledge Infrastructure （from 1995 to June 2014）, Current Controlled Trials （http：//controlled-trials.com）, Clinical Trials.gov （http：//clinicaltrials.gov）, and Chinese Clinical Trial Registry （http：//www.chictr.org）. All studies regarding prevention and treatment of symptomatic intracranial arterial stenosis by cilostazol were collected. The Mesh or text keywords were the En-glish words： “cilostazol, phosphodiesterase 3 inhibitor, atherosclerosis, and ischemic stroke.” No restrictions were put on publications or publication language. SeLeCTION CRITeRIA：Grade A or B randomized controlled trials were selected according to the quality of evaluation criteria from the Cochrane Collaboration, in which cilostazol and aspi-rin were used to evaluate the effects of cilostazol in the treatment of patients with symptomatic intracranial artery stenosis. The quality of study methodology was evaluated based on criteria de-scribed in Cochrane Reviewer’s Handbook 5.0.1. RevMan 5.2 software was used for data analysis. MAIN OUTCOMe MeASUReS： Clinical efifcacy and safety of cilostazol in stopping progression and promoting regression of symptomatic intracranial artery stenosis were measured by magnet-ic resonance angiography and transcranial Doppler. ReSULTS：Two randomized controlled trials with a total of 203 patients were included in this study. The results showed that while cilostazol was associated with a significantly reduced progression of intracranial artery stenosis （OR = 0.21, 95%CI： 0.09–0.47,P 〈 0.01）, it had no beneifcial effect on symptom regression （OR = 1.42, 95%CI： 0.80–2.51,P = 0.24）. During the follow-up period, although some adverse effects developed, including headache, gastrointestinal disturbance, and dizziness, incidences of bleeding were lower than in aspirin-treated patients. CONCLUSION：Cilostazol may prevent the progression of symptomatic intracranial artery ste-nosis, which could reduce the incidence of ischemic stroke.

Cognitive Functional Impairment and Hemodynamic Changes in Patients with Symptomatic Leukoaraiosis

Objective: The pathogenesis of leukoaraiosis is still unclear. Many studies have determined that changes in the hemodynamics associated with leukoaraiosis, impaired cerebrovascular reserve, and intracranial hypoperfusion can lead to various clinical manifestations such as motor or cognitive impairment. The purpose of this study was to investigate the relationship between cognitive functional changes and imaging characteristics in patients with symptomatic leukoaraiosis, and to observe the corresponding changes in hemodynamics. Methods: A total of 203 Han patients (aged 43 - 93 years) with symptomatic leukoaraiosis were included in this study. Head magnetic resonance imaging was semi-quantified according to the Fazekas grading standard. Then, each patient was evaluated in terms of cognitive (Montreal scale) and executive function (trail-making test A [TMTA] and TMTB). Specifically, the TMTA asks patients to connect points on a piece of paper numbered from 1 to 25 in order and the TMTB asks patients to arrange numbers and letters in alternating order. In the current work, revised versions of these tests used are to include numbers in square and circular shapes where the shapes needed to be arranged in alternating order. The time required to complete the TMTA and TMTB was recorded. The changes in the blood flow velocity of the middle cerebral artery were also observed using routine Transcranial Doppler ultrasound and the breath-holding test. The dynamic curves of blood flow velocity during the breath-holding test were examined. Results: The cognitive and executive functions of patients with leukoaraiosis are related to the classification of image-based disease characteristics. In this sense, the more serious the leukoaraiosis is, the larger the impairment of cognitive and executive function is. According to the breath-holding test, the peak pattern of the blood flow velocity in the middle cerebral artery was significantly different between the various grades of leukoaraiosis. The peak type of Fazekas grade 0 and I was in the same direction, while the peak type of Fazekas grade II and III was significantly opposed (both p Conclusions: The impairment of cognitive and executive functions in patients with leukoaraiosis correlates with the severity of image-based disease manifestations, which are generally depicted as intracranial hypoperfusion.

Impact of Adding Midazolam to Bupivacaine 0.5% in Regional Spinal Anesthesia on Maternal Middle Cerebral Artery Velocimetry in Parturients with Severe Preeclampsia

Severe preeclampsia is a challenging issue facing both intensivist and anesthetic team carrying both maternal and fetal morbidity and mortality. Termination of pregnancy after blood pressure control is the golden key in management. Cerebral complications due to diffuse cerebral vasospasm are most common and serious. Intrathecal midazolam with its gamma amino butyric action may antidote glutamate mediated sympathetic surge and decreasing cerebral vasospasm. Temporal view transcranial Doppler imaging maternal middle cerebral artery is used to examine blood flow indices namely pulsatility index and resistive index. One hundred ladies with severe preeclampsia scheduled for urgent caesarian section were recruited in 2 groups, both received 10 mg bupivacaine 0.5%, Midazolam group received 1 mg midazolam and the other group received 0.2 ml sterile saline 0.9% NaCl. All vascular indices were significantly better in midazolam group, less ICU stay.

Clinical features of bilateral multiple pulmonary arteriovenous fistulas with paroxysmal aphasia as the first symptom:a case report

Objective:to describe the clinical features of bilateral multiple pulmonary arteriovenous fistulas(PAF)with paroxysmal aphasia as the first symptom.Methods:we collected the clinical history and examination data of a patient with paroxysmal aphasia.In order to trace the etiology,we performed chest computed tomography(CT)and pulmonary CT angiography(CIA).Results:the patient had paroxysmal aphasia with dizziness,brain magnetic resonance imaging(MRI)showed cerebral infarction,the transcranial Doppler(TCD)foaming test was positive,transesophageal ultrasound showed no patent foramen ovale,and chest CT and CIA showed bilateral multiple PAF.Conclusion:bilateral multiple PAF are rare in clinic.When patients have paroxysmal neurological symptoms,the possibility of PAF leading to embolism should be considered.

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

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 postsuccessful 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 receiveroperating 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.

Diagnosis of brain death： confirmatory tests after clinical test

Background The brain death confirmation tests occupy a different position in each country＇s diagnostic criteria （or guideline）; the choices of tests are also different.China brain death criteria include clinical judgment and confirmation tests.This study aimed to confirm the preferred confirmatory test and complementary confirmatory tests.Methods We did a clinical brain death determination on deep coma patients,and then divided them into brain death group and non-brain death group.According to the Chinese standards for determining brain death,both the groups accepted confirmatory tests including electroencephalograph （EEG）,somatosensory evoked potentials （SEP）,and transcranial Doppler （TCD）.The sensitivity,specificity,false positive rate,and false negative rate were calculated to evaluate the accuracy of the confirmatory tests.Results Among the 131 cases of patients,103 patients met the clinical criteria of brain death.Respiratory arrest provocation test was performed on 44 cases and 32 cases （73％） successfully completed and confirmed that they have no spontaneous breathing.Of the three confirmation tests,EEG had the highest completion rate （98％） and good sensitivity （83％） and specificity （97％）; TCD had followed completion rate （54％） and not good sensitivity （73％） and specificity （75％）; SEP had the lowest completion rate （49％）,good sensitivity （100％）,and not good specificity （78％）.After the combination of SEP or TCD with EEG,the specificity can increase to 100％.Conclusions The completion rate of respiratory arrest provocation test remains a problem in the clinical diagnosis of brain death.If the test cannot be completed,whether to increase a confirmatory test is debatable.SEP had an ideal sensitivity,and the specificity will reach 100％ after combining with TCD or EEG.When a confirmed test was uncertain,we suggest increasing another confirmatory test.

Prediction of Cerebral Hyperperfusion Syndrome with Velocity Blood Pressure Index

Background：Cerebral hyperperfusion syndrome is an important complication of carotid endarterectomy （CEA）.An 〉 100% increase in middle cerebral artery velocity （MCAV） after CEA is used to predict the cerebral hyperperfusion syndrome （CHS） development,but the accuracy is limited.The increase in blood pressure （BP） after surgery is a risk factor of CHS,but no study uses it to predict CHS.This study was to create a more precise parameter for prediction of CHS by combined the increase of MCAV and BP after CEA.Methods：Systolic MCAV measured by transcranial Doppler and systematic BP were recorded preoperatively;30 min postoperatively.The new parameter velocity BP index （VBI） was calculated from the postoperative increase ratios of MCAV and BE The prediction powers of VBI and the increase ratio of MCAV （velocity ratio [VR]） were compared for predicting CHS occurrence.Results：Totally,6/185 cases suffered CHS.The best-fit cut-off point of 2.0 for VBI was identified,which had 83.3% sensitivity,98.3% specificity,62.5% positive predictive value and 99.4% negative predictive value for CHS development.This result is significantly better than VR （33.3%,97.2%,28.6% and 97.8%）.The area under the curve （AUC） of receiver operating characteristic：AUCvBI =0.981,95% confidence interval [CI] 0.949-0.995;AUCvR =0.935,95% CI 0.890-0.966,P =0.02.Conclusions：The new parameter VBI can more accurately predict patients at risk of CHS after CEA.This observation needs to be validated by larger studies.