ASSESSMENT TRANSCRANIAL DOPPLER ULTRASONOGRAPHY

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Slide 1 : ASSESSMENT: TRANSCRANIAL DOPPLER ULTRASONOGRAPHY Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Neurology 2004;62(9):1468
Slide 2 : Copyright 2004 American Academy of Neurology 2 Authors Michael A. Sloan, MD, MS; Andrei V. Alexandrov, MD, RVT; Charles H. Tegeler, MD; Merrill P. Spencer, MD; Louis R. Caplan, MD; Edward Feldmann, MD; Lawrence R. Wechsler, MD; David W. Newell, MD; Camilo R. Gomez, MD; Viken L. Babikian, MD; David Lefkowitz, MD; Robert S. Goldman, MD; Carmel Armon, MD; Chung Y. Hsu, MD, PhD; and Douglas S. Goodin, MD
Slide 3 : Copyright 2004 American Academy of Neurology 3 Objective of the guideline To review the use of transcranial Doppler ultrasonography (TCD) and transcranial color-coded sonography (TCCS) for diagnosis.
Slide 4 : Copyright 2004 American Academy of Neurology 4 Methods of evidence review Panel reviewed summary statements and other articles, based upon selection of relevant publications cited in these new articles and additional MEDLINE search through June, 2003 using the AAN rating system, Articles reviewed and cited contain a mixture of diagnostic, therapeutic or prognostic information used as the reference standard in individual studies. Sensitivity and specificity reflect the ability of a diagnostic test to detect disease. Reviewed for TCD and TCCS.
Slide 5 : Copyright 2004 American Academy of Neurology 5 Methods of evidence review Sensitivity and specificity were operationally defined as excellent (>/= 90%), good (80-89%), fair (60-79%) and poor (<60%). The clinical utility of a diagnostic test was operationally defined as the value of the test result to the clinician caring for the individual patient. Panel summarized the clinical utility of TCD/TCCS and focus on the clinical indications for which conclusions can be drawn.
Slide 6 : Copyright 2004 American Academy of Neurology 6 AAN’s Class of evidence for determining the yield of established diagnostic and screening tests
Slide 7 : Copyright 2004 American Academy of Neurology 7 AAN’s Class of evidence for determining the yield of established diagnostic and screening tests
Slide 8 : Copyright 2004 American Academy of Neurology 8 AAN’s Recommendation levels
Slide 9 : Copyright 2004 American Academy of Neurology 9 AAN’s Recommendation levels
Slide 10 : Copyright 2004 American Academy of Neurology 10 Introduction TCD is a non-invasive ultrasonic technique measuring local blood flow velocity and direction in the proximal portions of large intracranial arteries. TCD’s principal use is in the evaluation and management of patients with cerebrovascular disease.
Slide 11 : Copyright 2004 American Academy of Neurology 11 Introduction Advantages of TCD: non-invasive can be performed at the bedside easily repeated or used for continuous monitoring is generally less expensive than other techniques contrast agents are not used avoiding allergic reactions and decreasing risk to the patient
Slide 12 : Copyright 2004 American Academy of Neurology 12 Introduction Limitation of TCD: examination of cerebral blood flow velocities in certain segments of large intracranial vessels detects indirect effects (abnormal waveform characteristics) suggesting of proximal hemodynamic or distal obstructive lesions more valuable in specific conditions
Slide 13 : Conventional or Non-imaging TCD
Slide 14 : Copyright 2004 American Academy of Neurology 14 Summary of findingsSickle Cell Disease
Slide 15 : Copyright 2004 American Academy of Neurology 15 Summary of findingsRight to Left Cardiac Shunts
Slide 16 : Copyright 2004 American Academy of Neurology 16 Summary of findingsIntracranial Steno-Occlusive Disease
Slide 17 : Copyright 2004 American Academy of Neurology 17 Summary of findingsIntracranial Steno-Occlusive Disease (Continued )
Slide 18 : Copyright 2004 American Academy of Neurology 18 Summary of findingsAcute cerebral infarction
Slide 19 : Copyright 2004 American Academy of Neurology 19 Summary of findingsExtracranial ICA Stenosis
Slide 20 : Copyright 2004 American Academy of Neurology 20 Summary of findingsVasomotor Reactivity (VMR) Testing
Slide 21 : Copyright 2004 American Academy of Neurology 21 Summary of findingsVasomotor Reactivity (VMR) Testing(continued)
Slide 22 : Copyright 2004 American Academy of Neurology 22 Summary of findingsDetection of Cerebral Microemboli
Slide 23 : Perioperative and Periprocedural Monitoring
Slide 24 : Copyright 2004 American Academy of Neurology 24 Summary of findingsCarotid Endarterectomy (CEA)
Slide 25 : Copyright 2004 American Academy of Neurology 25 Summary of findingsCoronary Artery Bypass Graft (CABG) Surgery
Slide 26 : Copyright 2004 American Academy of Neurology 26 Summary of findingsCerebral Thrombolysis
Slide 27 : Copyright 2004 American Academy of Neurology 27 Summary of findingsCerebral Thrombolysis (continued)
Slide 28 : Monitoring in the Neurology/ Neurosurgery Intensive Care Unit
Slide 29 : Copyright 2004 American Academy of Neurology 29 Summary of findingsSubarachnoid Hemorrhage (SAH):
Slide 30 : Copyright 2004 American Academy of Neurology 30 Summary of findingsSubarachnoid Hemorrhage (SAH) (continued)
Slide 31 : Copyright 2004 American Academy of Neurology 31 Summary of findingsTraumatic SAH (tSAH)
Slide 32 : Copyright 2004 American Academy of Neurology 32 Summary of findingsIncreased Intracranial Pressure (ICP) and Cerebral Circulatory Arrest
Slide 33 : Transcranial Color-Coded Sonography (TCCS) or Imaging TCD
Slide 34 : Copyright 2004 American Academy of Neurology 34 Transcranial Color-Coded Sonography (TCCS)
Slide 35 : Copyright 2004 American Academy of Neurology 35 Summary of findingsIschemic Cerebrovascular Disease
Slide 36 : Copyright 2004 American Academy of Neurology 36 Summary of findingsIschemic Cerebrovascular Disease(Continued)
Slide 37 : Copyright 2004 American Academy of Neurology 37 Summary of findingsIschemic Cerebrovascular Disease(Continued)
Slide 38 : Copyright 2004 American Academy of Neurology 38 Summary of findingsIschemic Cerebrovascular Disease(Continued)
Slide 39 : Copyright 2004 American Academy of Neurology 39 Summary of findingsHemorrhagic Cerebrovascular Disease
Slide 40 : Copyright 2004 American Academy of Neurology 40 Summary of findingsVasospasm after Spontaneous Subarachnoid Hemorrhage
Slide 41 : Copyright 2004 American Academy of Neurology 41 Summary of findingsIntracerebral Hemorrhage
Slide 42 : Copyright 2004 American Academy of Neurology 42 Summary of TCD recommendations Settings in which TCD is able to provide information and in which its clinical utility is established Screening of children aged 2-16 years with sickle cell disease for assessing stroke risk (Type A, Class I), although the optimal frequency of testing is unknown (Type U). Detection and monitoring of angiographic vasospasm after spontaneous subarachnoid hemorrhage (Type A, Class I-II). More data are needed to show if its use affects clinical outcomes (Type U).
Slide 43 : Copyright 2004 American Academy of Neurology 43 Summary of TCD recommendations Settings in which TCD is able to provide information, but in which its clinical utility remains to be determined Cerebral Thrombolysis: TCD is probably useful for monitoring thrombolysis of acute MCA occlusions (Type B, Class II-III). More data are needed to assess the frequency of monitoring for clot dissolution and enhanced recanalization and to influence therapy (Type U). Cerebral Microembolism Detection: TCD monitoring is probably useful for the detection of cerebral microembolic signals in a variety of cardiovascular/ cerebrovascular disorders/procedures (Type B, Class II-IV). Data do not support the use of this TCD technique for diagnosis or monitoring response to antithrombotic therapy in ischemic cerebrovascular disease (Type U).
Slide 44 : Copyright 2004 American Academy of Neurology 44 Summary of TCD recommendations Settings in which TCD is able to provide information, but in which its clinical utility remains to be determined Carotid Endarterectomy: TCD monitoring is probably useful to detect hemodynamic and embolic events that may result in perioperative stroke during and after CEA in settings where monitoring is felt to be necessary (Type B, Class II-III). Coronary Artery Bypass Graft (CABG) Surgery: TCD monitoring is probably useful (Type B, Class II-III) during CABG for detection of cerebral microemboli. TCD is possibly useful to document changes in flow velocities and CO2 reactivity during CABG surgery (Type C, Class III). Data are insufficient regarding the clinical impact of this information (Type U).
Slide 45 : Copyright 2004 American Academy of Neurology 45 Summary of TCD recommendations Settings in which TCD is able to provide information, but in which its clinical utility remains to be determined Vasomotor Reactivity Testing: TCD is probably useful (Type B, Class II-III) for the detection of impaired cerebral hemodynamics in patients with severe (>70%) asymptomatic extracranial ICA stenosis, symptomatic or asymptomatic extracranial ICA occlusion and cerebral small artery disease. Whether these techniques should be used to influence therapy and improve patient outcomes remains to be determined (Type U). Vasospasm after traumatic subarachnoid hemorrhage: TCD is probably useful for the detection of VSP following traumatic SAH (Type B, Class III), but data are needed to show its accuracy and clinical impact in this setting (Type U).
Slide 46 : Copyright 2004 American Academy of Neurology 46 Summary of TCD recommendations Settings in which TCD is able to provide information, but in which its clinical utility remains to be determined Transcranial Color-Coded Sonography: TCCS is possibly useful (Type C, Class III) for the evaluation and monitoring of space-occupying ischemic MCA infarctions. More data are needed to show if it has value vs. CT and MRI scanning and if its use affects clinical outcomes (Type U).
Slide 47 : Copyright 2004 American Academy of Neurology 47 Summary of TCD recommendations Settings in which TCD is able to provide information, but in which other diagnostic tests are typically preferable Right-to-left cardiac shunts: While TCD is useful for detection of right-to-left cardiac and extracardiac shunts (Type A, Class II), TEE is superior, as it can provide direct information regarding the anatomic site and nature of the shunt. Extracranial ICA Stenosis: TCD is possibly useful for the evaluation of severe extracranial ICA stenosis or occlusion (Type C, Class II-III) but, in general, carotid duplex or MRA are the diagnostic tests of choice. Contrast-Enhanced Transcranial Color-Coded Sonography: (CE)-TCCS may provide information in patients with ischemic cerebrovascular disease and aneurysmal SAH (Type B, Class II-IV). Its clinical utility vs. CT scanning, conventional angiography or non-imaging TCD, is unclear (Type U).
Slide 48 : Copyright 2004 American Academy of Neurology 48 Recommendations for future research Ischemic Cerebrovascular Disease Sickle Cell Disease: The optimal frequency for screening children between the ages of 2 and 16 years needs to be determined. Data are needed to assess the value of TCD in the evaluation of adults with sickle cell disease and its impact, if any, on selection of treatment and prognosis.
Slide 49 : Copyright 2004 American Academy of Neurology 49 Recommendations for future research Intracranial Steno-Occlusive Disease: More data are needed to define the ability of TCD to detect >/= 50% stenosis of major basal intracranial arteries vs. MRA and CTA. Once MRA and CTA are validated, the determination of the relative value of each technique for specific vascular lesions which may influence patient management. The ability of TCD to predict outcome in vertebrobasilar distribution stroke, if any, requires study. The value of TCD in the prediction of hemorrhagic transformation of ischemic infarction needs confirmation in well designed studies of patients who do and do not receive anticoagulation or thrombolysis.
Slide 50 : Copyright 2004 American Academy of Neurology 50 Recommendations for future research Extracranial ICA Stenosis: The clinical utility of TCD’s ability to detect impaired cerebral hemodynamics distal to high grade extracranial ICA stenosis or occlusion and assist with stroke risk assessment needs confirmation and evaluation in randomized clinical trials. In patients with symptomatic ICA occlusion, it would be useful to directly compare TCD/vasomotor reactivity testing with PET to see if TCD would be valuable to select and serially monitor patients for extracranial to intracranial bypass surgery. In patients with asymptomatic high grade ICA stenosis, it would be useful to learn if TCD assessment of vasomotor reactivity or microembolic signal detection can improve selection of patients for CEA or angioplasty.
Slide 51 : Copyright 2004 American Academy of Neurology 51 Recommendations for future research Perioperative and Periprocedural Monitoring Cerebral Microembolization: The ability of TCD to better distinguish between the various types of microembolic signals needs to be enhanced. Clinical utility in specific disease states should be defined. Carotid Endarterectomy: The incremental value of TCD monitoring compared with other intraoperative monitoring procedures (EEG, evoked potentials, stump pressures, cerebral blood flow) needs further study.
Slide 52 : Copyright 2004 American Academy of Neurology 52 Recommendations for future research Perioperative and Periprocedural Monitoring Coronary Artery Bypass Graft (CABG) Surgery: More data are needed to show if TCD predicts the occurrence of stroke or neurocognitive impairment following CABG or be useful as a biomarker or surrogate endpoint for clinical trials of neuroprotective agents or new surgical techniques. Cerebral Thrombolysis: The value of TCD in monitoring thrombolytic therapy (intravenous and intra-arterial) and other recanalizing techniques needs to be shown in clinical trials. Data from such studies might help in determining the need for further interventions and predicting the outcome of treated and non-treated patients. In addition, studies should be done to determine if thrombolysis can be enhanced with specific frequency(ies) of transcranial ultrasound.
Slide 53 : Copyright 2004 American Academy of Neurology 53 Recommendations for future research Monitoring in the Neurology / Neurosurgery Intensive Care Unit Spontaneous Subarachnoid Hemorrhage: More data are needed on the sensitivity and specificity of TCD in the detection of angiographic VSP in different age groups, since diagnostic criteria (like normative data) may vary with age. It remains to be shown how use of TCD affects clinical outcomes. The ability of specific TCD measurements to predict long term outcome from SAH requires study. Traumatic Subarachnoid Hemorrhage: Data on the sensitivity and specificity of TCD for detection of angiographic VSP in this setting are needed. More data are needed to show the clinical utility and predictive power of TCD in this setting.
Slide 54 : Copyright 2004 American Academy of Neurology 54 Recommendations for future research Monitoring in the Neurology/Neurosurgery Intensive Care Unit Contrast-Enhanced Transcranial Color-Coded Sonography: The incremental value of (CE)-TCCS in diverse settings of ischemic and hemorrhagic cerebrovascular disease, in comparison to TCD, CT, CTA, MRI, MRA and conventional angiography, needs to be confirmed. Whether (CE)-TCCS can assist stroke and NeuroICU clinicians in the monitoring of reperfusion techniques or selection of patients with severe MCA territory infarction for clinical trials of aggressive, putative beneficial or life-saving therapies remains to be determined.
Slide 55 : Copyright 2004 American Academy of Neurology 55 To view the entire guideline and additional AAN guidelines visit: www.aan.com/professionals/practice/index.cfm Neurology 2004;62(9):1468

 


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