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Objective. To increase the effectiveness of neurological evaluation in detecting traumatic intracranial injures in children under 18 years old with clinical criteria of mild traumatic brain injury. Materials and methods. Clinical and clinical-sonographic evaluations of 256 patients aged 0-18 years with clinical criteria of mild traumatic brain injury were performed. Depending of detected clinical and neurological risk factors and the results of the primary clinical and sonographic examination, children were divided into two groups: group I (high or medium risk of traumatic intracranial injury) – 174 (67.9%), group II (low/no risk of traumatic intracranial injury) – 82 (32.1%). Verification of important traumatic and non-traumatic intracranial changes revealed by primary sonographic exam was confirmed by using computerized tomography. Results and conclusion. Identification of traumatic intracranial injures by results of primary clinical examination is most effective when two or more higher or medium risk factors were detected. Application of primary clinical and sonographic examination increases diagnostic efficiency of neurological evaluation to 10.1% and the possibility of detecting traumatic intracranial injures to 57.1%. In 7.0% of cases emergency computed tomography were determined, dynamic observation was performed in 32.1% of cases. Significant non-traumatic brain diseases (cysts, hydrocephalus, congenital malformations) were diagnosed in 3.6% of cases by results primary clinical and sonographic examination.

Demonstrate that transcranial ultrasonography (TUS) scanning is viable and useful as a diagnostic method in experimental hydrocephalus, as well as to compare measurements of cerebral and ventricular width obtained from TUS scans of hydrocephalic rats with post-mortem anatomical specimens, aiming for the development of accurate criteria to establish ventricular enlargement and progression of hydrocephalus subsequently. Thirty-five male Wistar rats were used. Following hydrocephalus induction, they underwent a transcranial ultrasound scan to measure cerebral and ventricular dimensions, in the fourth and 21 post-induction days. By the end of the experiments, measurements obtained from TUS scans were compared with actual values as seen in the post-mortem specimens of each animal. Ventricular dilation could be clearly visualized in hydrocephalic animals. We performed intraclass correlation coefficient and linear regression analyses that have demonstrated a precise correlation between measurements of TUS scans and post-mortem specimens; we have found a similarity of 0,95 for the cerebral diameter and 0,97 for ventricular width. Transcranial ultrasonography is a useful and reliable diagnostic tool for experimental hydrocephalus; also, it can be used to assess the progression of ventriculomegaly in animal models of hydrocephalus.

OBJECTIVES Transcranial ultrasonography (US) is a relatively new neuroimaging modality proposed for early diagnostics of Parkinson disease (PD). The main limitation of transcranial US image-based diagnostics is a high degree of subjectivity caused by low quality of the transcranial images. The article presents a developed image analysis system and evaluates the potential of automated image analysis on transcranial US. METHODS The system consists of algorithms for the segmentation and assessment of informative brain regions (midbrain and substantia nigra) and a decision support subsystem, which is equipped with 64 classification algorithms. Transcranial US images of 191 participants (118 patients with a clinical PD diagnosis and 73 healthy control participants) were analyzed. RESULTS The diagnostic sensitivity and specificity achieved by the proposed system were 85% and 75%, respectively. CONCLUSIONS Digital transcranial US image analysis is challenging, and the application of a such system as the sole instrument for decisions in clinical practice remains inconclusive. However, the proposed system could be used as a supplementary tool for automated assessment of US parameters for decision support in PD diagnostics and to reduce observer variability.

Background. The intracranial changes in children with mild traumatic brain injury in acute period are identified by a combination of clinical-neurological and ultrasonographic evaluations of the condition severity. Aim. The aim of the study was to assess the possibility of performing comprehensive clinical and ultrasonographic evaluations in for determining the severity of the neurological condition of children with mild traumatic brain injury in an acute phase. Materials and Methods. Clinical and ultrasonographic assessment of the severity of the neurological condition was performed on 256 patients with clinical criteria suggesting mild traumatic brain injury. Ultrasonography was used as the main neuroimaging. Results. We found that the diagnostic sensitivity of clinical and ultrasonographic examination for detecting traumatic structural intracranial changes in children with mild traumatic brain injury was 90% (95% confidence interval [CI] 0.71–0.98), diagnostic specificity was 97% (95% CI 0.96–0.98), and diagnostic efficiency was 94.9% (95% CI 0.918–0.971). Conclusions. A comprehensive clinical ultrasonographic approach can be effectively used to assess the severity of the neurological condition of children with mild traumatic brain injury in the acute phase.

Introduction A number of pre-hospital clinical assessment tools have been developed to triage subjects with acute stroke due to large vessel occlusion (LVO) to a specialised endovascular centre, but their false negative rates remain high leading to inappropriate and costly emergency transfers. Transcranial ultrasonography may represent a valuable pre-hospital tool for selecting patients with LVO who could benefit from rapid transfer to a dedicated centre. Methods Diagnostic accuracy of transcranial ultrasonography in acute stroke was subjected to systematic review. Medline, Embase, PubMed, Scopus, and The Cochrane Library were searched. Published articles reporting diagnostic accuracy of transcranial ultrasonography in comparison to a reference imaging method were selected. Studies reporting estimates of diagnostic accuracy were included in the meta-analysis. Results Twenty-seven published articles were selected for the systematic review. Transcranial Doppler findings, such as absent or diminished blood flow signal in a major cerebral artery and asymmetry index ≥ 21% were shown to be suggestive of LVO. It demonstrated sensitivity ranging from 68 to 100% and specificity of 78–99% for detecting acute steno-occlusive lesions. Area under the receiver operating characteristics curve was 0.91. Transcranial ultrasonography can also detect haemorrhagic foci, however, its application is largely restricted by lesion location. Conclusions Transcranial ultrasonography might potentially be used for the selection of subjects with acute LVO, to help streamline patient care and allow direct transfer to specialised endovascular centres. It can also assist in detecting haemorrhagic lesions in some cases, however, its applicability here is largely restricted. Additional research should optimize the scanning technique. Further work is required to demonstrate whether this diagnostic approach, possibly combined with clinical assessment, could be used at the pre-hospital stage to justify direct transfer to a regional thrombectomy centre in suitable cases.

Objective Several studies have shown an increased prevalence of right-to-left shunt (RLs) in migraine patients, particularly those with aura. However, the prevalence of RLs and its relation to Japanese patients with migraine are unknown. We investigated the prevalence of RLs in Japanese patients with migraine. Methods In total, 112 consecutive patients with migraine were recruited from our headache outpatient clinic. Migraine with aura (MA) and migraine without aura (MWOA) were diagnosed according to the International Classification of Headache Disorders, 3rd edition (beta-version). Contrast transcranial Doppler ultrasound was used to detect RLs, including patent foramen ovale (PFO). Then, the associations between RLs and patients' backgrounds and presence of aura were assessed. Results The overall prevalence of RLs and PFO in migraine patients was 54.5% and 43.8%, respectively. The prevalence of RLs and PFO in the MA group were significantly higher than in the MWOA group (RLs, 62.9% vs. 44.0%, p=0.046; PFO, 54.8% vs. 30.0%, p=0.008). There were no marked differences in the prevalence of large, middle and small shunts between MA and MWOA patients. Compared with the MWOA patients, the MA patients were younger (p=0.013) and had early onset age (p=0.013) and increased prevalence of photophobia (p=0.008). Conclusion RLs were found in over half of the Japanese patients with migraine. Our study suggests a possible link between RLs and MA.

Introduction:Midline shift (MLS) in the brain is a life-threatening emergency, which requires immediate surgical intervention following diagnosis. Currently, CT Brain is accepted as the gold standard in detection of MLS. Unfortunately, the diagnosis may be delayed when the patient is unable to undergo a CT Brain immediately due to several reasons. This has led to a constant endeavor to identify and develop other methods for detection of MLS, among which Transcranial Sonography (TCS) is included.Aim:To validate point-of-care TCS for detection of MLS in neuro-emergency patients in the Emergency Department, and compare it to CT values of MLS.Methods:This double-blinded prospective study was conducted from March 2018 to August 2018 in the Emergency Department of VIMS Hospital, Salem. All patients above the age of 18 who required a CT Brain were included, and a TCS was performed. MLS on TCS was calculated by measuring the distance between the outer table of the skull and the third ventricle on both sides, through the temporal window using a 2.8 MHz Sector Probe. MLS on CT was defined as the difference between ideal midline and septum pellucidum.Results:A total of 87 patients were included in this study. The MLS (mean ± SD) was 0.21cm ± 0.31cm using TCS, and 0.20cm ± 0.34cm using CT. The Pearson’s correlation coefficient between CT and TCS was 0.97 (p < 0.01). The area under the ROC curve for detection of a significant MLS using TLS was 83.7%. Using 0.5cm as a cut-off, the sensitivity, specificity, and positive likelihood ratio were 86.7%, 98.6%, and 61.92, respectively.Discussion:This study concludes that Transcranial Sonography could detect Midline Shift with reasonable accuracy, and can be used as a point-of-care tool in the Emergency Department to facilitate early diagnosis of MLS and intervene accordingly in neuro-emergencies.

Extracranial and transcranial colour-coded duplex sonography (TCCD) are used routinely in clinical practice to assess physiologic and pathologic arterial blood flow to the brain. Such investigations are straightforward, safe, and cost effective, and can be repeated frequently for patient follow-up. In addition, the portability of extracranial colour-coded duplex sonography and TCCD provides the option of bedside investigations, particularly useful for evaluation of the critically ill patient. However, duplex ultrasound can be hampered by insufficient acoustic penetration, an unfavourable insonation angle, or by conditions of low or no flow. Echocontrast agents capable of surviving pulmonary and capillary transit have been developed, and such agents increase the Doppler signal and, therefore, the success rate of neurosonographic investigations. Approximately 20% of TCCD studies involve poor insonation conditions and, therefore, the use of echocontrast agents is of particular interest for this application. Levovist® and SonoVue® are the two agents currently approved for use in neurosonography. Such agents have a relatively long-lasting effect (up to 7 min), and can be administered as a single injection or, alternatively, a fractionated injection protocol can be used, depending on the quality of the window.

Avaliaram-se 55 cães com distúrbios neurológicos e verificou-se a ocorrência de afecções neurológicas de origem central, detectadas pela ultra-sonografia transcraniana (USTC). Vinte e nove (52,9%) animais apresentaram diagnóstico compatível com hidrocefalia, e destes, 16 (55,1%) eram fêmeas e 15 (51,7%) tinham menos de dois anos. Quinze (27,3%) cães apresentaram lesões focais, quatro (7,2%), alterações difusas e quatro (7,2%) apresentavam imagens sugestivas de lissencefalia; em três (5,4%) não foram detectadas alterações pela USTC. A hidrocefalia foi o distúrbio neurológico de origem central mais freqüente e a USTC é uma alternativa viável para auxiliar na rotina clínica veterinária como ferramenta diagnóstica na detecção de alterações morfológicas e estruturais do cérebro no cão. In this work, 55 dogs with neurologycal disorder were examined and central neurological affections were detected by transcranial ultrasonography (TCUS). They were classifyed in hydrocephaly, lissencephaly, focal and difuse parenchimal disorders, and none changes. From the examinated dogs, 52.9% presented diagnosis compatible with hydrocephaly, being 55.1% female and 51.7% younger than 2 year-old. Fifteen dogs (27.3%) presented focal lesions, 7.2% diffuse lesions, 7.2% images that suggested lissencephaly, and in 5.4% no changes were detected by TCUS. It was concluded that hydrocephaly was the most frequent central neurologycal disorder and TCUS is a valuable alternative to be used in clinical routine as a tool of diagnostic to detect morphological and structural cerebral disorders in dogs.

Post-admission hematoma expansion in patients with intracerebral hemorrhage (ICH) comprises a simultaneous major clinical problem and a possible target for medical intervention. In any case, the ability to predict and observe hematoma expansion is of great clinical importance. We review radiological concepts in predicting and observing post-admission hematoma expansion. Hematoma expansion can be observed within the first 24 h after symptom onset, but predominantly occurs in the early hours. Thus capturing markers of on-going bleeding on imaging techniques could predict hematoma expansion. The spot sign observed on computed tomography angiography is believed to represent on-going bleeding and is to date the most well investigated and reliable radiological predictor of hematoma expansion as well as functional outcome and mortality. On non-contrast CT, the presence of foci of hypoattenuation within the hematoma along with the hematoma-size is reported to be predictive of hematoma expansion and outcome. Because patients tend to arrive earlier to the hospital, a larger fraction of acute ICH-patients must be expected to undergo hematoma expansion. This renders observation and radiological follow-up investigations increasingly relevant. Transcranial duplex sonography has in recent years proven to be able to estimate hematoma volume with good precision and could be a valuable tool in bedside serial observation of acute ICH-patients. Future studies will elucidate, if better prediction and observation of post-admission hematoma expansion can help select patients, who will benefit from hemostatic treatment.

Autism spectrum disorders (ASDs) are now recognized as urgent public health concerns with dramatically increased frequencies seen across Western countries for more than 2 decades (Baio, 2014). ASDs significantly impact on the quality of life for both patients and their families (Siniscalco et al., 2013). It has been estimated that the total lifetime societal cost of caring for one individual with ASDs is about $3.2 million US dollars (Siniscalco, 2013). The diagnosis of ASDs is based on the evaluation of social communication skills and behavior; currently there is no specific biomarker rendering a diagnosis potentially subjective. Recent changes with the DSM-5 diagnostic criteria illustrate the challenges clinicians face due to the lack of quantifiable diagnostic markers. The search for biomarkers is a priority in autism research and care (Siniscalco et al., 2012). The authors Bradstreet et al. (2014) used a novel imaging approach to detect abnormalities in the central nervous system of autistic subjects. The authors used a transcranial ultrasonography (TUS) imaging technique, that allowed the detection of abnormalities in extra-axial fluid production and cortical structures. Alternative brain imaging technologies such as MRI are generally expensive and invasive, especially for children with ASDs who need sedation to undergo such investigation. TUS resolution is potentially capable of observing structures as small as 0.1 mm and can detect a cortical abnormality up to a depth of several cm in order of magnitude. Using this approach the authors were able to identify a cortical dysplasia and increased extra-axial fluid presence in brains of autistic patients. These brain abnormalities correlated with autism severity. In addition, this study raised the possibility that the detected cortical abnormalities may be associated with impaired neurotransmissions which could underlie some of the cognitive abnormalities seen in ASDs. This very interesting technique is simple, reproducible, safe, and effective. It is non-invasive and presents the advantage of being inexpensive. It further has the potentials to enable real-time analysis of sub-arachnoidal and cortical brain regions. Functional imaging studies conducted in autism have shown consistently abnormalities of hypo-perfusion in the temporal lobe areas which may correlate with the degree of impairment. Unfortunately most ASD subjects do not have access to such analysis, due to limited access and cost. Clinicians are in need of fast, non-invasive, accurate and safe means to evaluate any potential structural brain abnormality, especially if such abnormalities correlate with mental and neurological dysfunctions. 2D TUS might offer such fast analysis of the upper brain anatomy. Whether this can assist with regard to diagnosis remains to be shown with larger scale investigations and comparison with age matched individuals suffering from other developmental abnormalities.

A widely under-recognized brain-death confirming transcranial ultrasonography pattern resembling the red-blue beacon signal was demonstrated. Familiarity to this distinct and characteristic ultrasonic pattern seems to be important in the perspective of point-of-care neurological ultrasound use and knobology.

Transcranial ultrasonography is an established and reliable method for the evaluation of the arteries of the circle of Willis, even at the patient’s bedside. Examination of cerebral veins and sinuse

Background: Transesophageal echocardiography (TEE) and transcranial Doppler sonography (TCD) can identify right-to-left-shunts that predispose to paradoxical embolism. In a large cohort we compared the results of both techniques. Methods: 222 patients were investigated by both techniques using the contrast agent Echovist®-300 and performing each test once without and once with the Valsalva maneuver (VM). Results: TEE-proven right-to-left-shunts were detected by TCD with a high sensitivity of 94%. In addition, TCD revealed shunts not noted during TEE in about 20% of all patients studied. These shunts are in general smaller than those concordantly identified; however, 9% of the patients without a TEE-proven shunt presented with a shunt that allows a considerable amount of contrast medium to pass. There were 12% more microbubbles detected in the right middle cerebral artery than in the left middle cerebral artery during the TCD test performed with VM, but not during the TCD test performed without VM. Conclusions: Contrast-enhanced TEE and TCD are complementary methods in the assessment of stroke and stroke-prone patients. The side difference of microbubbles may indicate a selective streaming of cardiac emboli during VM.

Objective: Ultrasonographic characterization of intracranial pathologies with respect to acute bacterial meningitis and its sequale. Materials and methods: A prospective study of 70 cases, below 12 months of age within a period of two years, was undertaken to characterize sonographic abnormalities in acute bacterial meningitis and its sequale. Results: Echogenic sulci, ventriculomegaly and ventriculitis were the findings observed on ultrasonography in cases with acute bacterial meningitis and its sequale. Conclusion: Infantile transcranial ultrasonography is an useful diagnostic tool for rapid, safe and fairly accurate evaluation of intracranial pathologies in relation to acute bacterial meningitis and its sequale.

Background There may be a link between right-to-left shunt (RLs) and brain white matter lesions (WMLs) in patients with migraine. In this study, we assessed the relationship between WMLs and RLs in Japanese migraine patients. Methods A total of 107 consecutive patients with migraine with (MA) and without aura (MWOA) were included in this study. Contrast transcranial Doppler ultrasound was used to detect RLs. WMLs were graded using brain magnetic resonance imaging based on well-established criteria. Findings The prevalence of RLs was significantly increased in the WMLs positive group (n = 24) compared with the WMLs negative group (n = 83) (75.0% vs. 47.0%, p = 0.015). In prevalence of WMLs between MA and MWOA patients, there were no statistical differences (p = 0.410). Logistic regression analysis adjusted by age and disease duration of migraine identified an RLs-positive status as the sole determinant for the presence of WMLs (OR = 6.15; 95% CI 1.82–20.8; p = 0.003) Conclusion Our study suggests a possible link between RLs and WMLs in Japanese patients with migraine.