Publicación Oficial de la Sociedad Ecuatoriana de Neurología, de la Liga Ecuatoriana Contra la Epilepsia y de la Sociedad Iberoamericana de Enfermedad Cerebrovascular

Doppler transcraneal

 

Probable Síndrome de Vasoconstricción Cerebral Reversible como Manifestación de Feocromocitoma

Introduction: The pathophysiology of reversible cerebral vasoconstriction syndrome remains incompletely understood. However, failure of cerebral autoregulation, sympathetic overactivity, disruption of the blood–brain barrier, and glymphatic system dysfunction play a central role.

Case report: We present the case of a 35-year-old woman with a history of cerebral vasoconstriction syndrome who developed new episodes of thunderclap headache and intermittent hypertension two years after the initial event. During hospitalization, non-invasive neuroimaging suggested a high probability of recurrent vasoconstriction syndrome. Due to persistent autonomic symptoms, further evaluation revealed a pheochromocytoma.

Conclusion: In patients with recurrent or atypical symptoms of reversible cerebral vasoconstriction syndrome, secondary and potentially treatable causes should always be considered.

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Palabras clave: Autorregulación, Catecolaminas, Cefalea, Doppler transcraneal, Vasoconstricción,

Keywords: Autoregulation, Catecholamines, headache, Transcranial Doppler, Vasoconstriction,

Reactividad Vasomotora Cerebral en un Grupo de Voluntarios Sanos a Más De 2000 Metros de Altura. Estudio con Doppler Transcraneal Cerebral. Vasomotor Reactivity In A Group Of Healthy Volunteers At An Altitude Of More Than 2000 Meters. Transcranial Doppler Study

Introduction. Cerebral vasoreactivity (CVR) is the mechanism that maintains stable cerebral blood flow in response to cerebral metabolic variations or systemic blood pressure. The reference method for studying CVR is transcranial Doppler (TCD) using a vasodilator stimulus. A simple alternative to perform is the apnea test, but its results can be influenced by physiological variables and the height at which the subject is.

The objective of this study was to determine normal CVR values in a group of people residing in Quito.

Material and Methods. 48 people without a history of disease were examined. Flow parameters in the middle cerebral and basilar arteries were recorded. With the results of the apnea test, the percentage increase in flow velocity and the Breath Holding Index were calculated. This data was analyzed by sex and the age group.

Results. The average age was 34.8 years, with a predominance of those under 40 years of age and women (70.8%). Higher Vmf were recorded in women. CVR was significantly higher in the MCA (p 0.000) and lower in women. With age, flow parameters and apnea test results did not demonstrate significant differences.

Conclusions. In the cohort examined, the hemodynamic parameters recorded during the apnea test offer different results than those published in other series. The lower RVC appears to be influenced by altitude and sex.

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Palabras clave: altura, Doppler transcraneal, reactividad vasomotora cerebral, test apnea, ultrasonido,

Keywords: altitude, apnea test, cerebral vasoreactivity, Transcranial Doppler, ultrasound,

Muerte Encefálica: Diagnóstico Apoyado por Doppler Transcraneal. Brain Death: Diagnosis Supported By Transcranial Doppler

Brain death is diagnosed through a clinical examination that requires a period of observation.  We present the case of a patient diagnosed with aneurysmal subarachnoid hemorrhage, in whom after presenting symptomatic vasospasm, brain death was diagnosed with the support of transcranial Doppler sonography.

Conclusion: Transcranial Doppler allows us to demonstrate the cerebral circulatory arrest that accompanies brain death and shortens the observation period.

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Palabras clave: Aneurisma, diagnóstico, Doppler transcraneal, Hemorragia Subaracnoidea, Muerte encefálica,

Keywords: Aneurysm, Brain death, diagnosis, Subarachnoid Hemorrhage, Transcranial Doppler,

Fístula Carótido Cavernosa. Utilidad del ultrasonido Doppler en el diagnóstico. Cavernous carotid fistula. Utility of Doppler ultrasound in diagnosis.

Introduction. Carotid cavernous fistulas are infrequent vascular malformations that generate a pathological arteriovenous shunt, which compromises ocular function. The definitive diagnosis is established by cerebral arteriography. However, its invasive nature limits its use in follow-up. The aim of this work is to illustrate the value of the study with transcranial doppler ultrasound for the diagnosis of cavernous carotid fistulas and to describe the flow parameters that could be modified. Patients. A retrospective review of the clinical histories of the patients treated with a diagnosis of cavernous carotid fistula was carried out in the stroke unit of the Hermanos Ameijeiras Hospital in Havana, between January 2005 and May 2014. Demographic and disease variables were collected, as well as the results of imaging and ultrasound studies. Results. We describe the clinical and imaging characteristics of three patients in whom carotid cavernous fistula was confirmed. In the two patients with direct communications, an increase of the mean flow velocity in the ophthalmic vein, arterialized, with decrease in pulsatility were registered; in addition to an increase in the diastolic peak velocity in the internal carotid artery ipsilateral to the fistula. In the patient with the indirect fistula the changes were less marked. Conclusion. The ultrasound study was useful in the diagnosis of carotid cavernous fistulas, showing differences in the flow parameters that can be used to classify the fistulas.

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Palabras clave: Doppler transcraneal, Fistula arteriovenosa dural, Fistula carótido cavernosa, Ictus, ultrasonido,

Keywords: Cavernous carotid fistula, dural arteriovenous fistula, Ictus, Transcranial Doppler, ultrasound,

Índice de Pulsatilidad Cerebral en Adultos Mayores con Infarto Lacunar Silente (Proyecto Atahualpa). Cerebral Pulsatility Index In Older Adults With Silent Lacunar Strokes (The Atahualpa Project).

Background: Diagnosis of silent lacunar infarcts is complicated in remote rural areas where MRI is not available. Hospital series have suggested an association between the pulsatility index of intracranial arteries –as assessed by transcranial Doppler –and some neuroimaging signatures of cerebral small vessel disease. We aimed to assess the reliability of cerebral pulsatility indices to identify candidates for MRI screening in population-based studies assessing prevalence of silent lacunar infarctions.

Methods: A random sample of stroke-free Atahualpa residents aged ≥60 years investigated with MRI underwent transcranial Doppler for calculating the pulsatility index (PI) of the middle cerebral artery (MCA). For each person, mean PI was obtained by averaging both MCAs. Using conditional logistic regression for matched pairs data, we evaluated whether the pulsatility index of both MCAs correlate with silent lacunar infarcts.

Results: Silent lacunar infarcts were noticed in 28 (12%) of 234 scanned persons. Six of them were excluded due to poor insonation through transtemporal windows. The remaining 22 participants were considered case-patients and were matched 1:1 with individuals free of infarcts (controls). Moderate-to-severe white matter hyperintensities were noticed in 12 (55%) case-patients and 7 (32%) controls (p=0.228). The mean MCA PI value in the 44 participants was 1.15 ± 0.21, with no difference found across case-patients and controls, after adjustment for white matter hyperintensities (β coefficient: 3.361, 95% C.I.: -0.693 to 7.417, p=0.104).

Conclusions: Cerebral PI should not be used to identify candidates for MRI screening in population-based studies assessing the burden of silent lacunar infarcts.

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Palabras clave: Doppler transcraneal, índice de pulsatilidad, infarto lacunar,

Keywords: Lacunar infarction, pulsatility index, Transcranial Doppler,

Foramen Oval Permeable, un Diagnóstico Posible en Manos del Neurólogo. Descripción de Caso. Patent Foramen Ovale, A Possible Diagnosis From The Neurologist. Case Report.

Introduction: A high prevalence of atrial septal defects is reported in patients with cryptogenic ischemic stroke, also related to an increase of the risk of recurrence. Objective: To report case of a young patient with a history of diabetes mellitus and ischemic stroke without arterial changes proven. A transcraneal Doppler study with a bubble test helped to diagnose a patent foramen ovale. Conclusion: As part of the initial evaluation of this patient, a TCD study has helped to clarify the stroke etiology. The demonstration of a patent foramen ovale has implications fo r the secondary prevention of stroke.

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Palabras clave: Doppler transcraneal, Foramen Oval permeable, Ictus criptogénico,

Keywords: Cryptogenic Stroke, Patent Foramen Ovale, Transcraneal Doppler,

Búsqueda de Substitutos Para Estudios de Neuroimagen con Propósitos de Investigación: Experiencia del Proyecto Atahualpa. The Search Of Surrogates For Neuroimaging Studies For Research Purposes: The Atahualpa Project Experience

Diagnosis of many non-communicable neurological diseases require the use of MRI, which is not readily available in remote rural populations. Efforts should be directed to find portable screening diagnostic tools that may help identify candidates for MRI screening. In the Atahualpa Project, all participants aged ≥60 years have been invited for the practice of MRI, and about 80% of them have underwent the procedure. Therefore, we have the unique opportunity to test the accuracy of non-invasive exams to be used as surrogates to MRI for identifying candidates for the practice of this exam. To date, we have assessed the value of the ankle-brachial index (ABI), the reliability of the neutrophil-to-lymphocyte ratio (NLR), the accuracy of hypertensive retinopathy, and the value of transcranial Doppler (TCD) to detect individuals with cerebral small vessel disease. Individuals with an abnormal ABI have 4 times de odds of having a silent lacunar infarct than those with a normal ABI. A high NLR has a poor sensitivity but is highly specific for detecting persons with at least one imaging signature of small vessel disease. Individuals with hypertensive retinopathy Grades 2-3 are almost four times more likely to have moderate-to-severe white matter hyperintensities than those with no- or only Grade 1 retinopathy. Finally, the correlation between the pulsatility indexes of major cerebral arteries with imaging markers of small vessel disease, as assessed by TCD, was poor. We are still in the search of some non-expensive and readily available biomarker that allow the identification of apparently healthy persons at risk of suffering a catastrophic cerebrovascular event.

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Palabras clave: Atahualpa, Doppler transcraneal, Ecuador, epidemiología, estudio poblacional, índice tobillo-brazo, relación neutrófilos-linfocitos, Retinopatía,

Keywords: ankle-brachial index, Atahualpa, Ecuador, epidemiology, neutrophil-to-lymphocyte ratio, population-based study, Retinopathy, Transcranial Doppler,

Síndrome de Guillain Barré imitando Muerte Encefálica.

Guillain Barré Syndrome is a neurological disease frequently admitted to the Intensive Care Unit, especially if there is associated hemodynamic or ventilatory compromise. Brain death is the irreversible cessation of all functions of Central Nervous System, and rarely, Guillain Barré Syndrome can mimick it, with subsequent recovery in the next few days or weeks. We report a case admitted to the Intensive Care Unit, with this type of evolution.

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Palabras clave: Doppler transcraneal, Guillain Barré, Muerte encefálica, polineuropatía,

Keywords: Brain death, Guillain Barre, polyneuropathy, Transcraneal Doppler,

Utilidad del doppler transcraneal en la evaluación del stroke criptogénico.

Cryptogenic stroke accounts for 40% of patients with ischemic stroke and it is considered that in which after conducting a thorough investigation, a cause cannot be determined. For several years there has been a close association between cryptogenic stroke and paradoxical embolism through right-to-left shunt, which occurred specially in patients with patent foramen ovale (PFO), whose prevalence is significantly higher in patients with cryptogenic stroke than in patients with stroke of a definite cause. The study of this type of cardiac abnormalities has been strengthened today with the advent of new technologies including transesophageal echocardiography (TEE) which remains the gold standard in the diagnosis of PFO, however, there are increasing reports of the usefulness of transcraneal doppler in the evaluation of these patients in a way that makes its recommendation comparable to TEE. This review is intended to expand the knowledge available on this specific procedure according to the current existing evidence.

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Palabras clave: Doppler transcraneal, Ecocardiograma Transesofágico, Foramen Ovale Permeable, Stroke Criptogénico,

Keywords: Cryptogenic Stroke, Patent Foramen Ovale, Transcraneal Doppler, Transesophageal Echocardiography,

Síndrome de Moyamoya en un niño con Drepanocitosis.

Sickle cell disease is one of the main causes of ischemic stroke in the childhood, generally related with stenosis of the arteries of the anterior carotid circulation. We present the results of the studies carried out in a patient with sickle cell with no history of stroke, in treatment with hidroxyurea. Transcraneal Doppler and Magnetic Resonance Imaging demonstrated the existence of stenosis in medial cerebral arteries and a Moyamoya pattern in the cerebral circulation with hemodynamic ischemic lesions.

 

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Palabras clave: Doppler transcraneal, Drepanocitosis, enfermedad cerebrovascular, Hematología, Ictus, Moyamoya,

Keywords: Cerebrovascular disease, Hematology, Moyamoya, Sickle cell disease, stroke, Transcraneal Doppler,
 
 
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