Trans-cranial Doppler Predicts Early Neurologic Deterioration in Anterior Circulation Ischemic Stroke After Successful Endovascular Treatment
Endovascular treatment (EVT) has emerged as a highly effective intervention for patients with acute ischemic stroke caused by proximal occlusion of a large vessel in the anterior circulation. Despite the success of EVT in achieving recanalization, a significant proportion of patients experience early neurologic deterioration (END) within 72 hours post-treatment. This phenomenon, which includes conditions such as ischemia progression (IS), symptomatic intracranial hemorrhage (sICH), and vasogenic cerebral edema (VCE), is associated with worse patient outcomes and higher mortality rates. Understanding the predictors and mechanisms of END is crucial for improving post-thrombectomy management and patient prognosis.
The study conducted at Xuanwu Hospital, Capital Medical University, Beijing, China, aimed to explore the role of trans-cranial Doppler (TCD) in predicting END following successful EVT. TCD, a non-invasive imaging technique, was used to assess hemodynamic changes in the middle cerebral arteries (MCA) within 72 hours post-EVT. The study hypothesized that specific TCD parameters could serve as real-time tools to detect END predictors, thereby enabling better post-thrombectomy management.
Patient Selection and Methodology
The study prospectively included patients with large vessel occlusion (LVO) in the anterior circulation who received EVT between September 2016 and June 2018. All patients underwent computed tomography (CT) and/or CT perfusion (CTP) or magnetic resonance imaging (MRI) to confirm the diagnosis. Exclusion criteria included the unavailability of bilateral temporal TCD windows, severe systemic diseases such as heart failure, and acute respiratory distress syndrome.
Clinical data, including gender, age, medical history, vessels of occlusion, and National Institute of Health Stroke Scale (NIHSS) scores, were extracted from medical records. EVT procedures included mechanical thrombectomy using stent retrievers or clot aspiration systems, stent implantation, balloon dilation, or intravenous thrombolysis combined with mechanical thrombectomy (bridging thrombolysis). Post-interventional recanalization status was assessed using the Thrombolysis in Cerebral Infarction (TICI) grading scale.
TCD sonography was performed using a German DWL model DB-1395 portable bedside TCD-Box probe with a 2-MHz pulse. Parameters such as peak systolic velocity (PSV), end-diastolic velocity (EDV), mean flow velocity (MFV) of ipsilateral and contralateral MCA, ipsilateral pulse index (iPI), and the ratio of ipsilateral MFV to contralateral MFV (iMFV/cMFV) were measured. The study also calculated the iMFV/mean blood pressure (MBP) index to assess cerebral perfusion.
Results and Findings
Out of 112 EVT patients, 80 achieved successful recanalization with less than 50% residual stenosis. Among these, 17 patients (21.3%) experienced END, with VCE being the most common subtype (11 patients), followed by sICH (4 patients) and IS (2 patients). The majority of END cases (11 out of 17) occurred within 24 hours post-EVT.
TCD parameters revealed significant differences between END and non-END patients. The median PSV (127 cm/s vs. 116 cm/s), iMFV/cMFV ratio (1.29 vs. 1.02), and iMFV/MBP ratio (0.97 vs. 0.79) were higher in the END group. Receiver-operating characteristic (ROC) curve analysis identified iPI ≥0.85 and iMFV/MBP ≥0.84 as independent predictors of END. These parameters demonstrated sensitivity and specificity values of 82.4% and 42.9% for iPI, and 76.5% and 66.7% for iMFV/MBP, respectively.
In a subgroup analysis focusing on ENDVCE and ENDsICH, the study found that iPSV ≥118 cm/s and iMFV ≥66 cm/s were significant predictors. The iMFV/MBP ratio ≥0.85 emerged as an independent risk factor for ENDVCE and ENDsICH, with a sensitivity of 80.0% and specificity of 67.7%.
Discussion and Implications
The study’s findings underscore the potential of TCD as a valuable tool for predicting END in patients with anterior circulation ischemic stroke following successful EVT. The identified TCD parameters, particularly iPI and iMFV/MBP, provide insights into the hemodynamic changes associated with END, including increased intracranial pressure and cerebral hyperperfusion.
Cerebral hyperperfusion syndrome, characterized by excessive blood flow relative to metabolic demands, is a critical factor in the development of END. The study’s results align with previous research indicating that higher PSV and MFV values in the ipsilateral MCA are associated with an increased risk of intracranial hemorrhage and reperfusion injury. The iMFV/MBP ratio, which accounts for changes in blood pressure, offers a more accurate assessment of cerebral perfusion and its impact on END.
The study also highlights the importance of early detection and intervention in managing END. By identifying patients at risk of END through TCD monitoring, clinicians can implement targeted therapies to mitigate adverse outcomes. For instance, controlling blood pressure and managing cerebral edema can help reduce the risk of VCE and sICH.
Limitations and Future Directions
While the study provides valuable insights, it is not without limitations. The reliance on a single-center cohort may limit the generalizability of the findings. Additionally, TCD is operator-dependent, and the lack of trained personnel could delay evaluations. Future research should focus on multicenter studies to validate the results and explore additional TCD parameters, such as microembolic signals (MES), to enhance the predictive accuracy of END.
Conclusion
The study demonstrates that TCD examination is a practical and effective method for predicting early neurologic deterioration in patients with anterior circulation ischemic stroke following successful endovascular treatment. By identifying key hemodynamic parameters, TCD enables clinicians to assess the risk of END and implement timely interventions to improve patient outcomes. The findings underscore the importance of integrating TCD into post-thrombectomy management protocols to enhance the quality of care for stroke patients.
doi.org/10.1097/CM9.0000000000000881
Was this helpful?
0 / 0