Detection of Microembolisation with the Use of Transcranial Doppler Sonography

Czech version

Authors: P. Reková; J. Bauer
Authors‘ workplace: Neurologická klinika, Univerzita Karlova v Praze, 1. lékařská fakulta a Všeobecná fakultní nemocnice
Published in: Cesk Slov Neurol N 2009; 72/105(1): 30-37
Category: Review Article

Overview

Cerebrovascular accidents are the second or third most common cause of death in advanced countries. In order to provide effective treatment, including primary and secondary prevention of strokes, a thorough knowledge of their ethiopathogenesis is needed. A frequent cause of a cerebrovascular accident is embolization. One of the advantages of transcranial doppler sonography is the possibility, with long term monitoring, to detect even asymptomatic microemboli in cerebral circulation. The first part of the article gives an overview of the history of microembolization detection using the ultrasound; the second part provides an introduction to the technical background of this investigative method, along with its disadvantages. The sub section on clinical aspects of the detection of microemboli deals with current and future trends of the method and shows its possible clinical application.

Key words:
cerebrovascular accidents – transcranial doppler sonography – embolization – microembolic signal

Sources

1. Kalita Z et al. Akutní cévní mozkové příhody. Diagnostika, patofyziologie, management. Praha: Maxdorf 2006.

2. European Stroke Organisation (ESO) Executive Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25(5): 457–507.

3. Goldemund D, Mikulík R. Neurologické komplikace operací v mimotělním oběhu. Interní Med 2003; 5(3): 22–26.

4. Brucher R, Russell D. Embolus detection with Doppler ultrasonography: background and principles. In: Tegler C, Babikian VL, Gomez CR (eds). Neurosonology. St. Louis: Mosby 1996: 231–234.

5. Austen W, Howry D. Ultrasound as a method to detect bubbles or particulate matter in the arterial line during cardiopulmonary bypass. J Surg Res 1965; 5: 283–284.

6. Spencer MP, Lawrence GH, Thomas GI, Sauvage LR. The use of ultrasonics in the determination of arterial aeroembolism during open-heart surgery. Ann Thorac Surg 1969; 8(6): 489–497.

7. Spencer MP, Thomas GI, Nicholls SC, Sauvage LR. Detection of middle cerebral artery emboli during carotid endarterectomy using transcranial Doppler ultrasonography. Stroke 1990; 21(3): 415–423.

8. Aaslid R, Markwalder TM, Nornes H. Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 1982; 57(6): 769–774.

9. Markus HS, Brown MM. Differenctiation between diferent pathological cerebral embolic materials using transcranial Doppler in an in vitro model. Stroke 1993; 24(1): 1–5.

10. Russel D, Madden KP, Clark WM, Sandset PM, Zivin JA. Detection of arterial emboli using Doppler ultrasound in rabbits. Stroke 1991; 22(2): 253–258.

11. Khaffaf N, Karnik R, Winkler WB, Vaentin A, Slany J. Embolic stroke by compression maneuver during transcranial Doppler sonography. Stroke 1994; 25(5): 1056–1057.

12. Dittrich R, Ritter MA, Droste DW. Microembolus detection by transcranial doppler sonography. Eur J Ultrasound 2002; 16(1–2): 21–30.

13. Škoda O. Transkraniální dopplerovská sonografie. In: Školoudík D, Škoda O, Bar M et al (eds). Neurosonologie. 1st ed. Praha: Galén 2003: 154–155.

14. Consensus Committee of the Ninth International Cerebral Hemodynamic Symposium. Basic identification criteria of Doppler microembolic signals. Stroke 1995; 26(6): 1123.

15. Russel D, Brucher R. Online automatic discrimination between solid and gaseous cerebral microemboli with the first multifrequency transcranial Doppler. Stroke 2002; 33(8): 1975–1980.

16. Markus HS, Punter M. Can transcranial Doppler discriminate between solid and gaseous microemboli? Assessment of a dual-frequency transducer system. Stroke 2005; 36(8): 1731–1734.

17. Skoloudík D, Fadrná T, Bar M, Zapletalová O, Zapletal O, Blatný J et al. Changes in haemocoagulation in healthy volunteers after a 1-hour thrombotripsy using a diagnostic 2–4 MHz transcranial probe. J Tromb Trombolysis 2008; 26(2): 119–124.

18. Abbott AL, Chambers BR, Stork JL, Levi ChR, Bladin ChF, Donnan GA. Embolic signals and prediction of ipsilateral stroke or transient ischemic attack in asymptomatic carotid stenosis: a multicenter prospective cohort study. Stroke 2005; 36(6): 1128–1133.

19. Major ongoing trials. Stroke 2008; 39(10): e154–e162.

20. Cullinane M, Wainwright R, Brown A, Monaghan M, Markus HS. Asymptomatic embolization in subjects with atrial fibrillation not taking anticoagulants: A prospective study. Stroke 1998; 29(9): 1810–1815.

21. Ringelstein EB, Droste EW, Babikian VL, Evans DH, Grosset DG, Kaps M et al. Consensus on microembolus detection by TCD. Stroke 1998; 29(3): 725–729.

22. Ritter MA, Dittrich R, Thoenissen N, Ringelstein EB, Nabavi DG. Prevalence and prognostic impact of microembolic signals in arterial sources of embolism. A systematic review of the literature. J Neurol 2008; 255(7): 953–961.

23. Mackinnon AD, Aaslid R, Markus HS. Ambulatory transcranial Doppler cerebral embolic signal detection in symptomatic and asymptomatic carotid stenosis. Stroke 2005; 36(8): 1726–1730.

24. Mackinnon AD, Aaslid R, Markus HS. Long term ambulatory monitoring for cerebral emboli using transcranial Doppler ultrasound. Stroke 2004; 35(1): 73–78.

25. Levi CR, O‘Malley HM, Fell G, Roberts AK, Hoare MC, Royle JP et al. Transcranial Doppler detected cerebral microembolism following carotid endarterectomy. High microembolic signal loads predict postoperative cerebral ischaemia. Brain 1997; 120(4): 621–629.

26. Müller M, Behnke S, Walter P, Omlor G, Schimrigk K. Microembolic signals and intraoperative stroke in carotid endarterectomy. Acta Neurol Scand 1998; 97(2): 110–117.

27. Moehring MA, Klepper JR. Pulse Doppler ultrasound detection, characterization and size estimation of emboli in flowing blood. IEEE Trans Biomed Eng 1994; 41(1): 35–44.

28. Brucher R, Russell D. Automatic online embolus detection and artifact rejection with the first multifrequency transcranial Doppler. Stroke 2002; 33(8): 1969–1974.

29. Georgiadis D, Mackay TG, Kelman AW, Grosset DG, Wheatley DJ, Lees KR. Differentiation between gaseous and formed embolic materials in vivo: Application in prosthetic heart valve patients. Stroke 1994; 25(8): 1559–1563.

30. Daffertshofer M, Ries S, Schminke U, Hennerici M. High intensity transient signals in patients with cerebral ischemia. Stroke 1996; 27(10): 1844–1849.

31. Grosset DG, Georgiadis D, Kelman AW, Lees KR. Quantification of ultrasound emboli signals in patients with cardiac and carotid disease. Stroke 1993; 24(12): 1922–1924.

32. Molloy J, Markus HS. Asymptomatic embolization predicts stroke and TIA risk in patients with carotid artery stenosis. Stroke 1999; 30(7): 1440–1443.

33. Censori B, Partziguian T, Castro L, Camerlingo M, Mamoli A. Doppler microembolic signals predict ischemic recurrences in symptomatic carotid stenosis. Acta Neurol Scand 2000; 101(5): 327–331.

34. Valton L, Larrue V, le Traon AP, Massabuau P, Géraud G. Microembolic signals and risk of early recurrence in patients with stroke or transient ischemic attack. Stroke 1998; 29(10): 2125–2128.

35. Markus HS, MacKinnon A. Asymptomatic embolization detected by Doppler ultrasound predicts stroke risk in symptomatic carotid artery stenosis. Stroke 2005; 36(5): 971–975.

36. European Carotid Surgery Trialists‘ Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or with mild (0–20%) carotid stenosis. Lancet 1991; 337(8752): 1235–1243.

37. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Benefical effect of carotid endarterectomy in symptomatic patients with high grade stenosis. N Engl J Med 1991; 325(7): 445–453.

38. Markus HS, Droste DW, Kaps M, Larrue V, Lees KR, Siebler M, Ringelstein EB. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using Doppler embolic signal detection: the clopidogrel and aspirin for reduction of emboli in symptomatic carotid stenosis (CARESS) trial. Circulation 2005; 111(17): 2233–2240.

39. Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl Med 1998; 339(20): 1415–1425.

40. Alamowitch S, Eliasziw M, Algra A, Meldrum H, Barnett HJ. Risk, causes, and prevention of ischaemic stroke in elderly patients with symptomatic internal-carotid artery stenosis. Lancet 2001; 357(9263): 1154–1160.

41. Alamowitch S, Eliasziw M, Barnett HJ. The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease. Stroke 2005; 36(1): 27–31.

42. Siebler M., Nachtmann A, Sitzer M, Rose G, Kleinschmidt A, Rademacher J et al. Cerebral microembolism and the risk of ischemia in asymptomatic high grade internal carotid artery ischemia. Stroke 1995; 26(11): 2184–2186.

43. Fujimoto A, Yasaka M, Otsubo R, Oe H, Nagatsuka K, Minematsu K. Aortic arch atherosclerotic lesions and the recurrence of ischemic stroke. Stroke 2004; 35(6): 1426–1429.

44. Eicke BM, Barth V, Kukowski B, Werner G, Paulus W. Cardiac microembolism: prevalence and clinical outcome. J Neurol Sci 1996; 136(1–2): 143–147.

45. Kumral E. Balkir K. Uzuner N, Evyapan D, Nalbantgil S. Microembolic signal detection in patients with symptomatic and asymptomatic lone atrial fibrillation. Cerebrovasc Dis 2001; 12(3): 192–196.

46. Knappertz VA, Tegeler CH, Furberg CD, Wesley DJ, Stewart KP, Kitzman DW. Carotid Doppler high intensity transient signals in dilated cardiomyopathy. Am Heart J 2000; 140(2): E1–E4.

47. Braekken SK, Russell D, Brucher R, Svennevig J. Incidence and frequency of cerebral embolic signals in patients with a similar bileaflet mechanical heart valve. Stroke 1995; 26(7): 1225–1230.

48. Deklunder G, Roussel M, Lecroart JL, Prat A, Gautier C. Microemboli in cerebral circulation and alteration of cognitive abilities in patients with mechanical prosthetic heart valves. Stroke 1998; 29(9): 1821–1826.

49. Cantelmo NL, Babikian VL, Samaraweera RN, Gordon JK, Pochay VE, Winter MR. Cerebral microembolism and ischemic changes associated with carotid endarterectomy. J Vasc Surg 1998; 27(6): 1024–1031.

50. Stork JL, Levi CR, Chambers BR, Abbott AL, Donnan GA. Possible determinants of early microembolism after carotid endarterectomy. Stroke 2002; 33(8): 2082–2085.

51. Stygall J, Kong R, Walker JM, Hardman SM, Harrison MJ, Newman SP. Cerebral microembolism detected by transcranial Doppler during cardiac procedures. Stroke 2000; 31(10): 2508–2510.

52. Dittrich R, Ringelstein EB. Occurence and clinical impact of microembolic signals during or after cardiochirurgical procedures. Stroke 2008; 39(2): 503–511.

53. Leclercq F, Kassnarsallah S, Cesari JB, Blard JM, Macia JC, Messner-Pellenc P et al. Transcranial Doppler detection of cerebral microemboli during left heart cathetrization. Cerebrovasc Dis 2001; 12(1): 59–65.

54. Bladin CF, Bingham L, Grigg L, Yapanis AG, Gerraty R, Davis SM. Transcranial Doppler detection of microemboli during percutaneous transluminal coronary angioplasty. Stroke 1998; 29(11): 2367–2370.

55. Junghans U, Siebler M. Cerebral microembolism is blocked by tirofiban, a selective nonopeptide platelet glycoprotein IIb/IIIa receptor antagonist. Circulation 2003; 107(21): 2717–2721.

56. Lennard N, Smith J, Dumville J, Abbott R, Evans DH, London NJ et al. Prevention of postoperative trombotic stroke after endarterectomy: the role of transcranial Doppler ultrasound. J Vasc Surg. 1997; 26(4): 579–584.

57. Payne DA, Jones CI, Hayes PD, Thompson MM, London NJ, Bell PR et al. Beneficial effects of clopidogrel combined with aspirin in reducing cerebral emboli in patients undergoing carotid endarterectomy. Circulation 2004; 109(12): 1476–1481.

58. Molloy J, Martin JF, Baskerville PA, Fraser SCA, Markus HS. S-nitrosoglutathione reduces the rate of embolization in humans. Circulation 1998; 98(14): 1372–1375.