Document Type : Original Article
Neurosciences Research Center AND Department of Neurology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
Neuroscience Research Center, Qom University of Medical Sciences, Qom, Iran
Background: Atherosclerotic involvement of large and small cerebral arteries leading to infarction is among the most prevalent subtypes of stroke worldwide. The hemodynamic changes due to these arterial pathologies can be studied non-invasively and in real-time by using transcranial Doppler (TCD) techniques. TCD indices of the studied arteries may guide the clinician in differentiating these two underlying arterial pathologies.
Methods: A cross-sectional study of patients with small and large vessel types of cerebral infraction based on the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) stroke classification was undertaken in the inpatient population of neurology service of Razi Hospital, Tabriz, Iran, from October 2018 to October 2019. After clinical diagnosis, all cases underwent TCD studies, brain magnetic resonance imaging (MRI), and brain and cervical four-vessel magnetic resonance angiography (MRA). The results of TCD indices related to major arteries of the circle of Willis were tabulated and compared between large and small vessel subtypes of cerebral infarction.
Results: A statistically significant difference between right middle cerebral artery (MCA) pulsatility index (PI), left MCA PI, right internal carotid artery (ICA) PI, end-diastolic velocity (EDV), left ICA PI, left ICA EDV, left anterior cerebral artery (ACA) PI, and right vertebral artery (VA) PI measures of the two groups was seen (P < 0.05). In comparison to the large vessel group, left ACA, right VA, and bilateral MCAs and ICAs in the small-vessel stroke group demonstrated an elevated PI.
Conclusion: A significant increase of PI occurs in the majority of intracranial arteries of patients with small vessel stroke. This makes PI a valuable marker for differentiating strokes with different underlying pathophysiologies.
- Kim J, Thayabaranathan T, Donnan GA, Howard G, Howard VJ, Rothwell PM, et al. Global Stroke Statistics 2019. Int J Stroke 2020; 15(8): 819-38.
- Sloan MA, Alexandrov AV, Tegeler CH, Spencer MP, Caplan LR, Feldmann E, et al. Assessment: Transcranial Doppler ultrasonography: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2004; 62(9): 1468-81.
- Sarkar S, Ghosh S, Ghosh SK, Collier A. Role of transcranial Doppler ultrasonography in stroke. Postgrad Med J 2007; 83(985): 683-9.
- Kulkarni AA, Sharma VK. Role of transcranial Doppler in cerebrovascular disease. Neurol India 2016; 64(5): 995-1001.
- Tsivgoulis G, Alexandrov AV, Sloan MA. Advances in transcranial Doppler ultrasonography. Curr Neurol Neurosci Rep 2009; 9(1): 46-54.
- Kaczynski J, Home R, Shields K, Walters M, Whiteley W, Wardlaw J, et al. Reproducibility of Transcranial Doppler ultrasound in the middle cerebral artery. Cardiovasc Ultrasound 2018; 16(1): 15.
- D'Andrea A, Conte M, Cavallaro M, Scarafile R, Riegler L, Cocchia R, et al. Transcranial Doppler ultrasonography: From methodology to major clinical applications. World J Cardiol 2016; 8(7): 383-400.
- de RN, Budohoski KP, Smielewski P, Kasprowicz M, Zweifel C, Steiner LA, et al. Transcranial Doppler pulsatility index: what it is and what it isn't. Neurocrit Care 2012; 17(1): 58-66.
- Kidwell CS, el-Saden S, Livshits Z, Martin NA, Glenn TC, Saver JL. Transcranial Doppler pulsatility indices as a measure of diffuse small-vessel disease. J Neuroimaging 2001; 11(3): 229-35.
- Mok V, Ding D, Fu J, Xiong Y, Chu WW, Wang D, et al. Transcranial Doppler ultrasound for screening cerebral small vessel disease: a community study. Stroke 2012; 43(10): 2791-3.
- Mok VC, Ma RC, Chu WW. Transcranial Doppler ultrasonography for detection of cerebral white matter changes in a high-risk population. Hong Kong Med J 2017; 23 Suppl 2(3): 16-8.
- Thibeault CM, Dorn AY, Thorpe SG, Canac N, Jalaleddini K, Wilk SJ, et al. A case study on the utility of Transcranial Doppler ultrasound in acute stroke evaluation. J Vasc Ultrasound 2019; 44(1): 25-7.
- Thorpe SG, Thibeault CM, Canac N, Wilk SJ, Devlin T, Hamilton RB. Decision criteria for large vessel occlusion using Transcranial Doppler waveform morphology. Front Neurol 2018; 9: 847.
- Wardlaw JM, Smith EE, Biessels GJ, Cordonnier C, Fazekas F, Frayne R, et al. Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration. Lancet Neurol 2013; 12(8): 822-38.
- van Laar PJ, van der Grond J, Mali WP, Hendrikse J. Magnetic resonance evaluation of the cerebral circulation in obstructive arterial disease. Cerebrovasc Dis 2006; 21(5-6): 297-306.
- Brisset M, Boutouyrie P, Pico F, Zhu Y, Zureik M, Schilling S, et al. Large-vessel correlates of cerebral small-vessel disease. Neurology 2013; 80(7): 662-9.
- Adams HP, Bendixen BH, Kappelle LJ,
Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24(1): 35-41.
- Chung JW, Park SH, Kim N, Kim WJ, Park JH, Ko Y, et al. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification and vascular territory of ischemic stroke lesions diagnosed by diffusion-weighted imaging. J Am Heart Assoc 2014; 3(4): e001119.
- Kim Y, Lee H, An SA, Yim B, Kim J, Kim OJ, et al. The effect of pulsatility index on infarct volume in acute lacunar stroke. Yonsei Med J 2016; 57(4): 950-5.
- Ghorbani A, Ahmadi MJ, Shemshaki H. The value of transcranial Doppler derived pulsatility index for diagnosing cerebral small-vessel disease. Adv Biomed Res 2015; 4: 54.
- Spencer MP. Hemodynamics of arterial stenosis. In: Spencer MP, editor. Ultrasonic diagnosis of cerebrovascular disease: Doppler techniques and pulse echo imaging. Dordrecht, Netherlands: Springer Netherlands; 1987. p. 117-46.
- Topcuoglu MA. Transcranial Doppler ultrasound in neurovascular diseases: diagnostic and therapeutic aspects. J Neurochem 2012; 123(Suppl 2): 39-51.
- Bathala L, Mehndiratta MM, Sharma VK. Transcranial doppler: Technique and common findings (Part 1). Ann Indian Acad Neurol 2013; 16(2): 174-9.
- Purkayastha S, Sorond F. Transcranial Doppler ultrasound: Technique and application. Semin Neurol 2012; 32(4): 411-20.
- Alexandrov AV, Sloan MA, Tegeler CH, Newell DN, Lumsden A, Garami Z, et al. Practice standards for transcranial Doppler (TCD) ultrasound. Part II. Clinical indications and expected outcomes. J Neuroimaging 2012; 22(3): 215-24.
- Maurits NM, Loots GE, Veldman AE. The influence of vessel wall elasticity and peripheral resistance on the carotid artery flow wave form: A CFD model compared to in vivo ultrasound measurements. J Biomech 2007; 40(2): 427-36.
- Grant EG, Benson CB, Moneta GL, Alexandrov AV, Baker JD, Bluth EI, et al. Carotid artery stenosis: Gray-scale and Doppler US diagnosis--Society of Radiologists in Ultrasound Consensus Conference. Radiology 2003; 229(2): 340-6.
- Alexandrov AV, Tsivgoulis G, Rubiera M, Vadikolias K, Stamboulis E, Molina CA, et al. End-diastolic velocity increase predicts recanalization and neurological improvement in patients with ischemic stroke with proximal arterial occlusions receiving reperfusion therapies. Stroke 2010; 41(5): 948-52.