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Congenital tracheal stenosis in children is a rare, severe and life-threatening respiratory tract malformation characterized by respiratory failure. We have performed 74 surgical interventions in these patients under extracorporeal membrane oxygenation between 2013 and 2022. In this article, we present surgical treatment of a newborn with congenital tracheal stenosis. For the first time in the world, the patient underwent thoracoscopic resection and reconstruction of the trachea under extracorporeal membrane oxygenation.

The most effective modern treatment for gastrointestinal bleeding following portal hypertension is portosystemic bypass surgery. Hepatic encephalopathy after these procedures is still an urgent problem in modern pediatric surgery, and radical treatment is unknown. To optimize treatment outcomes in children with hepatic encephalopathy, we should choose adequate treatment considering the risk of hepatic encephalopathy in the future. In this review, the authors discuss modern data on hepatic encephalopathy regarding symptoms, advantages and disadvantages of various treatment methods. Risk of hepatic encephalopathy with and without surgical treatment, as well as methods of diagnosis and treatment are particularly analyzed. Total portosystemic bypass surgery, especially portocaval shunt, is followed by higher risk of hepatic encephalopathy compared to selective shunts and physiological mesoportal bypass. The last two approaches are advisable to improve treatment outcomes in children with hepatic encephalopathy.

To date, side-to-side splenorenal shunt (SRS) and its analogues (splenosuprarenal shunts (SSRS)) are mainly used for portal hypertension. These are total portosystemic shunts characterized by total blood shunt from portal vein into inferior vena cava. The latter is fraught with a significant risk of complications such as pulmonary hypertension, decreased portal liver perfusion, liver failure and hepatic encephalopathy. Prevention of these complications is still an urgent problem in modern surgery. However, we proposed a new method of treatment, i.e. reconstruction of SRS and SSRS into selective shunt. This procedure was performed in 37 patients after 2020. We present laparoscopic reconstruction in an 11-year-old girl with portal hypertension and signs of hepatic encephalopathy identified after previous SSRS.

Today, it seems prudent to reconsider how ultrasound technology can be used for providing intraoperative neurophysiologic monitoring that will result in better patient outcomes and decreased length and cost of hospitalization. An extensive and rapidly growing literature suggests that the essential hemodynamic information provided by transcranial Doppler (TCD) ultrasonography neuromonitoring (TCDNM) would provide effective monitoring modality for improving outcomes after different types of vascular, neurosurgical, orthopedic, cardiovascular, and cardiothoracic surgeries and some endovascular interventional or diagnostic procedures, like cardiac catheterization or cerebral angiography. Understanding, avoiding, and preventing peri- or postoperative complications, including neurological deficits following abovementioned surgeries, endovascular intervention, or diagnostic procedures, represents an area of great public and economic benefit for society, especially considering the aging population. The American Society of Neurophysiologic Monitoring and American Society of Neuroimaging Guidelines Committees formed a joint task force and developed updated guidelines to assist in the use of TCDNM in the surgical and intensive care settings. Specifically, these guidelines define (1) the objectives of TCD monitoring; (2) the responsibilities and behaviors of the neurosonographer during monitoring; (3) instrumentation and acquisition parameters; (4) safety considerations; (5) contemporary rationale for TCDNM; (6) TCDNM perspectives; and (7) major recommendations., (© 2022 American Society of Neuroimaging.)

The review is devoted to the current classifications of common bile duct malformations, authors' opinion regarding surgical approach and reconstruction of the bile ducts. The authors describe the modern modifications of bile duct reconstructions and estimate their effectiveness. PubMed database, Google Scholar and National Scientific Electronic Library eLIBRARY.ru databases were used. We analyzed the complications in children depending on various reconstructions, anatomical form, timing of reconstructive surgery and early diagnosis of this pathology.

Objective: To analyze 20-year experience in surgical treatment of cardiac achalasia., Material and Methods: A retrospective analysis included 35 children (20 boys and 15 girls) who underwent surgical treatment of cardiac achalasia at the Filatov Children's Clinical Hospital No. 13 for the period 2001-2020., Results: Heller laparoscopic cardiomyotomy with Douro fundoplication was followed by favorable outcomes in 33 (94.3%) children. We also observed significant decrease of postoperative Eckardt score compared to baseline values., Conclusion: Methods of cardiodilation (balloon dilatation, bougienage) ensure a short-term effect and may be only used in addition to surgical treatment. Heller laparoscopic cardiomyotomy with Douro fundoplication results favorable outcome in more than 92% of patients and can be considered as a standard for the treatment of this disease in children. Oral endoscopic myotomy cannot be considered as an alternative to Heller laparoscopic cardiomyotomy with Douro fundoplication due to high risk of secondary gastroesophageal reflux and its complications. Therefore, additional fundoplication is required that makes treatment of cardiac achalasia more invasive and expensive compared to Heller laparoscopic cardiomyotomy with Douro fundoplication.

Today, in our country, as well as throughout the world, there is no single approach to the tactics of managing patients with deformations of the anterior chest wall. These patients constitute a large and heterogeneous group. The team acquired great experience in treating children with pectus excavatum and pectus carinatum, as well as a unique experience in the surgical treatment of pediatric thoracic outlet syndrome and sternum clefts. Now in the world there are a lot of surgical methods used for the correction of congenital deformities of the chest wall, however, the majority of them are extremely traumatic for the patient, and the postoperative scar often presents a minor cosmetic problem than the deformation itself. In addition, almost all methods require the use of expensive technologies, the patient's long hospital stay and the use of potent drugs. As for the children with thoracic outlet syndrome and sternum clefts, these patients are extremely difficult in terms of timely diagnosis and surgical care, due to the fact that pediatric surgeons and pediatricians are very little aware of this pathology. The team of authors developed a number of techniques, based on the collaborative work of surgeons, anesthesiology and resuscitation specialists and pediatric services. They resulted in successful surgical correction of these malformations and gave patients the opportunity to lead a normal life.

Aim: To evaluate complications and long-term results of delayed esophagoesophagostomy in children with esophageal atresia (EA)., Material and Methods: 165 EA children were operated at the Filatov Municipal Children's Hospital #13 for the period 2006-2016. Primary esophageal anastomosis was performed in 136 (82.4%) children with tracheoesophageal fistula. In 5 (3%) neonates with non-fistulous EA esophago- and gastrostomy were made for further coloesophagoplasty. Other 24 (14.5%) children underwent gastrostomy for delayed esophagoesophagostomy. 6 (25%) of them died within 12 days after admission. 18 survivors with gastrostomy subsequently underwent delayed esophagoesophagostomy., Results: Postoperative complications occurred in 16 (88.9%) children. Esophageal anastomosis failure occurred in 4 (22.2%) patients, stenosis of anastomosis in 11 (61.1%) children, gastroesophageal reflux in 14 (77.8%) children. Early postoperative mortality was 16.7% (3 children). In remote period 92.3% of children were not adapted to normal diet and only in 7.7% of patients eating behavior corresponds to the age. 11 children underwent prolonged esophageal bougienage. 9 children underwent re-operation after delayed anastomosis. Esophageal extirpation was made in 4 children., Conclusion: Esophago- and gastrostomy provides 100% survival if primary esophageal anastomosis is impossible. Herewith, in children without esophagostomy mortality rate was 25%. We still can not confirm that delayed esophageal anastomosis is a good alternative for children with esophageal atresia. In view of our results the number of candidates for delayed esophageal anastomosis should be reduced.

Material and Methods: For the period 2013-2016 four patients were treated at the Filatov Children's City Clinical Hospital #13. There were 2 children aged 14 years and 2 children aged 17 years. All patients have been diagnosed via anamnesis, complaints, pulse-wave doppler sonography, contrast-enhanced MDCT and angiography. After comprehensive examination 3 patients underwent laparoscopic decompression of celiac trunk. In all cases celiac trunk compression was predominantly caused by median arcuate ligament of the diaphragm combined with neurofibrotic tissue of celiac plexus., Results: All patients were discharged after laparoscopic decompression of celiac trunk. Intra- and postoperative complications, as well as cases of conversion were absent. Mean time of surgery was 65 minutes. In all cases postoperative period was smooth (4 days on the average). Two patients underwent follow-up examination in long-term postoperative period: pulse-wave doppler sonography, contrast-enhanced MDCT and angiography. In both cases reduced severity, incidence and duration of pain syndrome were observed., Conclusion: Clinical examples show some problems in diagnosis and treatment of compressive stenosis of celiac trunk due to rarity of pathology especially in childhood. Nevertheless, combination of abdominal ischemia and celiac trunk stenosis confirmed by instrumental diagnosis is indication for surgical treatment.

The American Society of Neurophysiologic Monitoring (ASNM) and American Society of Neuroimaging (ASN) Guidelines Committees formed a joint task force and developed guidelines to assist in the use of transcranial Doppler (TCD) monitoring in the surgical and intensive care settings. Specifically, these guidelines: (1) delineate the objectives of TCD monitoring; (2) characterize the responsibilities and behaviors of the sonographer during monitoring; (3) describe methodological and ethical issues uniquely relevant to monitoring. The ASNM and ASN strongly support the positions that (1) acquisition and interpretation of intraoperative TCD ultrasonograms be performed by qualified individuals, (2) service providers define their diagnostic criteria and develop on-going self-validation programs of these performance criteria in their practices. We agree with the guidelines of other professional societies regarding the technical and professional qualifications of individuals responsible for TCD signal acquisition and interpretation (Class III evidence, Type C recommendation). On the basis of current clinical literature and scientific evidence, TCD monitoring is an established monitoring modality for the: (1) assessment of cerebral vasomotor reactivity and autoregulation; (2) documentation of the circle of Willis functional status; (3) identification of cerebral hypo- and hyperperfusion, recanalization and re-occlusion; and (4) detection of cerebral emboli (Class II and III evidence, Type B recommendation)., (Copyright © 2010 by the American Society of Neuroimaging.)

Indications for the clinical use of transcranial Doppler (TCD) continue to expand while scanning protocols and quality of reporting vary between institutions. Based on literature analysis and extensive personal experience, an international expert panel started the development of guidelines for TCD performance, interpretation, and competence. The first part describes complete diagnostic spectral TCD examination for patients with cerebrovascular diseases. Cranial temporal bone windows are used for the detection of the middle cerebral arteries (MCA), anterior cerebral arteries (ACA), posterior cerebral arteries (PCA), C1 segment of the internal carotid arteries (ICA), and collateralization of flow via the anterior (AComA) and posterior (PComA) communicating arteries; orbital windows-for the ophthalmic artery (OA) and ICA siphon; the foraminal window-for the terminal vertebral (VA) and basilar (BA) arteries. Although there is a significant individual variability of the circle of Willis with and without disease, the complete diagnostic TCD examination should include bilateral assessment of the M2 (arbitrarily located at 30-40 mm depth), M1 (40-65 mm) MCA [with M1 MCA mid-point at 50 mm (range 45-55 mm), average length 16 mm (range 5-24 mm), A1 ACA (60-75 mm), C1 ICA (60-70 mm), P1-P2 PCA (average depth 63 mm (range 55-75 mm), AComA (70-80 mm), PComA (58-65 mm), OA (40-50 mm), ICA siphons (55-65 mm), terminal VA (40-75 mm), proximal (75-80), mid (80-90 mm), and distal (90-110 mm) BA]. The distal ICA on the neck (40-60 mm) can be located via submandibular windows to calculate the VMCA/VICA index, or the Lindegaard ratio for vasospasm grading after subarachnoid hemorrhage. Performance goals of diagnostic TCD are to detect and optimize arterial segment-specific spectral waveforms, determine flow direction, measure cerebral blood flow velocities and flow pulsatility in the above-mentioned arteries. These practice standards will assist laboratory accreditation processes by providing a standard scanning protocol with transducer positioning and orientation, depth selection and vessel identification for ultrasound devices equipped with spectral Doppler and power motion Doppler.

Cardiac surgery (CS) with cardiopulmonary bypass (CPB) is currently the most common surgery in the United States. Understanding, avoiding, and preventing postoperative complications, including neurologic deficits following CS, represents a great public and economic benefit for society, especially considering our aging population. There is a critical need to identify new strategies that will prevent harmful events during and after CS. At present, experience with neurophysiologic techniques includes the ability to measure cerebral blood flow velocity/emboli and regional cerebral venous oxygen saturation by transcranial Doppler ultrasound, and by near-infrared spectroscopy, respectively. Continuous monitoring of these variables along with systemic hemodynamics will provide a better understanding of mechanisms of brain and other organ injury during CPB. Neuroprotective interventions based on multimodality neurologic monitoring would ideally eliminate postoperative complications and improve patient outcomes.

Background and Purpose: Patients with a combination of atrial septal aneurysm (ASA) and patent foramen ovale (PFO) have a substantially higher rate of recurrent ischemic events as compared to PFO alone. One possible explanation is a greater degree of right-to-left shunting with the combination., Methods: Retrospective study using contrast transcranial Doppler ultrasonography (c-TCD) to study the degree of shunting in 46 patients with PFO with either transient ischemic attack or cryptogenic ischemic stroke. Eight patients with PFO+ASA identified on transesophageal echocardiogram were compared to 38 patients with PFO but without ASA., Results: The number of embolic counts was no different with or without an ASA. Valsalva maneuver increased number of emboli, especially in patients with large PFOs., Conclusions: Patients with ASA in addition to PFO do not appear to have an increased risk of right-to-left shunting as measured by c-TCD as compared to PFO alone.

Background and Purpose: There is an unmet need to classify cerebrovascular conditions physiologically and to assess cerebrovascular system performance. The authors hypothesized that by simultaneously considering the dynamic parameters of flow velocity, acceleration, and pulsatility index (PI) (impedance) in individual Doppler spectrum waveforms, they could develop an objective method to elucidate the pathophysiology of vascular conditions and classify cerebrovascular disorders. This method, dynamic vascular analysis (DVA), is described., Methods: First, a theoretical model was developed to determine how any vascular segment and the ensemble of intracranial vascular segments could be defined according to its dynamic physiological characteristics. Next, the DVA method was applied to 847 anonymous serial complete clinical transcranial Doppler (TCD) studies of patients without regard for their diagnosis to ascertain actual reference ranges and the normality of the distribution curves for each dimension of the 3-parameter nomogram. The authors applied DVA to 2 clinical cases to see if they could track the changes in vascular performance of 2 known progressive diseases., Results: The theoretical analysis identified 295,245 possible vascular states for the ensemble of vascular segments in the cerebral circulation. When applied to clinical TCD data, DVA revealed continuous, normally distributed data for the velocity, PI, and logarithm of the acceleration., Conclusions: DVA is proposed as a method for monitoring the physiological state of each cerebral artery segment individually and in ensemble. DVA evaluates the relationship among acceleration (force or pressure), velocity, and PI and provides an objective means to evaluate intracranial vascular segments using the paradigm of the well-described pressure-perfusion autoregulation relationship. DVA may be used to study cerebrovascular pathophysiology and to classify, evaluate, and monitor cerebrovascular disorders or systemic disorders with cerebrovascular effects.

Intraventricular hemorrhage (IVH) occurred in a 32-year-old man following the use of both ephedrine and pseudoephedrine. Cerebral angiography and transcranial Doppler studies showed changes suggestive of vasculitis. We describe the management and investigations of a unique case of IVH. This patient was treated with ventriculostomy and intraventricular urokinase (UK). A favorable outcome was obtained with independent function at 10 weeks post hemorrhage. The use of intraventricular thrombolysis for drug-induced IVH has not previously been reported, although it has been shown to be a safe and potentially beneficial intervention.

Background and Purpose: During head-up tilt (HUT), patients with chronic fatigue syndrome (CFS) have higher rates of neurally mediated hypotension (NMH) and postural tachycardia syndrome (POTS) than healthy controls. The authors studied whether patients with CFS were also more likely to have abnormal cerebral blood flow velocity (CBFV) compared with controls in response to orthostatic stress., Methods: Transcranial Doppler monitoring of middle cerebral artery (MCA) CBFV was performed during 3-stage HUT prospectively in 26 patients with CFS and 23 healthy controls. At the same time, continuous monitoring of arterial blood pressure (BP), heart rate (HR), endtidal CO2 (ET-CO2) were performed. Results are reported as mean +/- SD., Results: NMH developed in 21 patients with CFS and in 14 controls (P = .22). POTS was present in 9 CFS patients and 7 controls (P = .76). Supine HR was higher in CFS patients, but all other hemodynamics and CBFV measures were similar at baseline. The median time to hypotension did not differ, but the median time to onset of orthostatic symptoms was shorter in those with CFS (P < .001). The CBFV did not differ between groups in the supine posture, at 1 or 5 minutes after upright tilt, at 5 or 1 minute before the end of the test, or at termination of the test. Mean CBFV fell at termination of tilt testing in those with CFS and controls. ET-CO2 was lower at termination of the test in those with CFS versus controls (P = .002)., Conclusions: The results of this study are not consistent with the hypothesis that patients with CFS have a distinctive pattern of MCA CBFV changes in response to orthostatic stress.

Background and Purpose: During the evaluation of acute ischemic stroke with diffusion- and perfusion-weighted magnetic resonance imaging (DWI and PWI, respectively), the presence of salvageable brain tissue is suggested by the occurrence of a perfusion-diffusion "mismatch." DWI and PWI, however, are not universally available and have inherent inconveniences, which justify a search for practical diagnostic alternatives. The purpose of this study is to investigate whether there are transcranial Doppler (TCD) markers of mismatch., Methods: Retrospective analysis of 22 patients with acute ischemic stroke affecting the middle cerebral artery (MCA) territory, who had a TCD performed within 24 hours of magnetic resonance imaging (MRI) with DWI and PWI., Results: MRI and TCD were performed on average 10.8 +/- 9.2 hours apart. Time from symptom onset to MRI and TCD completion were 1.6 +/- 1.6 and 2 +/- 1.9 days, respectively. MCA and intracranial internal carotid artery (ICA) cerebral blood flow velocity (CBFV) asymmetry, together with a large ICA-to-MCA gradient, were associated with the presence of mismatch. The combined use of 2 TCD parameters (MCA CBFV asymmetry of > or = 30% and ICA-to-MCA gradient > or = 20 cm/sec) had a sensitivity of 75%, specificity of 80%, positive predictive value of 82%, and negative predictive value of 73% at detecting mismatch cases., Conclusions: Diffusion-perfusion mismatch appears to be associated with interhemispheric asymmetry between MCA and ICA CBFVs, and a large CBFV gradient between the ICA and MCA on the affected side. Prospective studies are required to verify these observations and to determine whether TCD can be used to follow patients with mismatch.

Introduction: Intracerebral hemorrhage (ICH) associated with pregnancy commonly occurs in the postpartum period in the setting of preeclampsia/eclampsia. We describe the clinical course of two patients with ICH due to postpartum cerebral vasculopathy in the absence of toxemia., Methods: We reviewed two cases with ICH and postpartum vasculopathy in our hospital (1996-2001) and compared them with seven similar case reports from the literature., Results: Mean age of all patients is 28.7+/-5.6 years (mean+/-S.D.). Toxemia of pregnancy was absent in all cases. ICHs were cortical in eight and putaminal in one patient. Erythrocyte sedimentation rate was elevated in two. Two cases rehemorrhaged during the same admission. No cerebral infarctions were reported. All patients had diffuse vasculopathy on conventional catheter angiography, with no clinical manifestations or laboratory data supportive of extracerebral or systemic vasculitis. Eight patients were treated with corticosteroids, two with additional cytotoxic agents and one with nimodipine alone. Improvement on follow-up cerebral angiography (catheter or MRA) and transcranial Doppler ultrasonography (TCD) was noted in eight cases. One did not have follow-up cerebral imaging but had an excellent clinical outcome. All cases had good to excellent functional recovery., Conclusions: Postpartum ICH in the absence of toxemia may be associated with isolated cerebral vasculopathy. The clinical course and functional outcome is good to excellent. This entity appears to be distinct from cerebral vasculitis, which is usually associated with poor outcome.

Objective: To evaluate the reliability of transcranial Doppler ultrasound in detecting symptomatic vasospasm in patients after aneurysmal subarachnoid hemorrhage and monitoring response after hypertensive and endovascular treatments., Design: Retrospective chart review., Setting: Neurosciences critical care unit in a tertiary-care university hospital., Patients: All patients admitted to a neurosciences critical care unit with the diagnosis of subarachnoid hemorrhage between January 1990 and June 1997., Interventions: None, Measurements and Main Results: We reviewed transcranial Doppler ultrasound data of 199 patients; 55 had symptomatic vasospasm. Clinical symptoms and corresponding vascular distributions were identified, as was angiographic vasospasm (n = 35). The sensitivity and specificity of transcranial Doppler ultrasound for anterior circulation vessels were calculated by using a mean cerebral blood flow velocity criterion of >120 cm/sec. Clinical diagnosis of symptomatic vasospasm was used as the standard to determine sensitivity and specificity of transcranial Doppler ultrasound and cerebral angiography. The sensitivity of transcranial Doppler ultrasound for anterior circulation in patients with symptomatic vasospasm was 73% with a specificity of 80%. The sensitivity of cerebral angiography was 80%. For individual vessels, the sensitivity and specificity of transcranial Doppler ultrasound were middle cerebral artery, 64% and 78%; anterior cerebral artery, 45% and 84%; and internal carotid artery, 80% and 77%, respectively. The mean times for symptomatic and transcranial Doppler ultrasound signs of vasospasm presentation were 6.4 +/- 2 and 6.1 +/- 3 days, respectively. In patients without symptomatic vasospasm, the mean time for mean cerebral blood flow velocities >120 cm/sec was 7.0 +/- 3 days (p <.05). Symptomatic vasospasm also was associated with thickness of clot on head computed tomography scan and rapidly increasing mean cerebral blood flow velocities. Transcranial Doppler ultrasound signs of vasospasm improved after endovascular treatment in 30 patients., Conclusions: The reliability of transcranial Doppler ultrasound was better at detecting high mean cerebral blood flow velocities in patients with symptomatic vasospasm related to middle cerebral and internal carotid artery distributions than for anterior cerebral artery distribution. Transcranial Doppler ultrasound was as sensitive as cerebral angiography at detecting symptomatic vasospasm. High mean cerebral blood flow velocities can be apparent before the presence of symptomatic vasospasm. Daily transcranial Doppler ultrasound monitoring could provide early identification of patients with aneurysmal subarachnoid hemorrhage who are at high risk for symptomatic vasospasm and may be helpful at following success of endovascular treatment.

Background and Purpose: Current transcranial Doppler criteria for vasospasm after aneurysmal subarachnoid hemorrhage are not age specific. We analyzed the effect of age on cerebral blood flow velocity changes after subarachnoid hemorrhage and constructed an age-adjusted predictive model of cerebral blood flow velocity in subarachnoid hemorrhage patients., Methods: We identified patients with aneurysmal subarachnoid hemorrhage admitted between 1991 and 1999 with a prospective transcranial Doppler database. Eighty-one patients, with complete medical records and transcranial Doppler examinations of the vessels of interest, were included. Patients were subdivided into 2 groups by age: younger, <68 years of age (n=47) and older, >/=68 years of age (n=34). Maximum mean flow velocity and incidence of symptomatic vasospasm were reported. Linear and nonlinear regression analyses were performed., Results: Middle cerebral artery and internal carotid artery mean flow velocity were lower in older patients (median 76 versus 114 cm/s and 76 versus 126 cm/s, respectively; P<0.003). Incidence of symptomatic vasospasm was lower in older patients (44% versus 66%; P=0.05). Older patients developed symptomatic vasospasm at lower middle cerebral artery (median 57 versus 103 cm/s; P=0.04) and internal carotid artery (median 54 versus 81 cm/s, P=0.02) mean flow velocity. Relationship between middle cerebral artery and internal carotid artery mean flow velocity and age was quadratic (ANOVA, P<0.0001)., Conclusions: Older patients have a lower incidence of symptomatic vasospasm, and such vasospasm develops at lower cerebral blood flow velocity than younger patients. A quadratic relationship was found between age and cerebral blood flow velocity. This model could be used to create an age-adjusted nomogram that might improve diagnostic capabilities of transcranial Doppler.

Background and Purpose: Evidence suggests that adenosine (ADN) is a potent vasodilator of cerebral vessels. However, the feasibility of manipulating human cerebral vascular resistance with ADN has not been assessed by means of TCD. The purpose of this study was to quantitatively estimate the change in middle cerebral artery cerebral blood flow velocity (CBFV) in response to intravenous ADN infusion in humans., Methods: Eleven patients with subacute cerebrovascular events (ischemic stroke, transient ischemic attack, or hemorrhage) undergoing adenosine-thallium stress testing were studied before, during, and after ADN infusion to evaluate the effect of ADN on cerebral blood flow velocity. Continuous blood pressure (BP), heart rate (HR), respiration rate (RR), end-tidal CO2 (ET-CO2), and transcranial Doppler ultrasonography monitoring of CBFV and pulsatility index (PI) in both middle cerebral arteries were performed., Results: The mean CBFVs were 65.4 +/- 19.2 cm/s before, 55.4 +/- 18.1 cm/s during, and 64.1 +/- 22.5 cm/s after ADN infusion, which represents a statistically significant decrease during ADN test compared with both baseline (P = .007) and posttest levels (P = .017). The PI was increased during the test (0.91 +/- 0.2) when compared with baseline (0.71 +/- 0.1) (P = .007). During ADN injection, mean HR increased (P = .004) and mean ET-CO2 levels decreased significantly (P = .003). Mean BP and RR did not change significantly., Conclusions: The authors hypothesize that any direct vasodilatory effect of ADN on the distal cerebral peripheral vasculature may be negated by an effect of ADN on depth of respiration resulting in hypocapnia and secondary distal vasoconstriction.

The authors report a patient with postpartum intracerebral hemorrhage associated with cerebral vasculitis. Cerebral circulation was assessed with transcranial Doppler (TCD) ultrasonography, magnetic resonance angiography, and conventional cerebral angiography. Initial TCD studies demonstrated bilateral patchy increased cerebral blood flow velocity (CBFV) in the anterior circulation with complete normalization during remission. This case report provides evidence that cerebral vasculitis leads to relevant CBFV changes and that the TCD technique may assist in diagnosis and follow-up of these patients.

The objective of this study was to examine cerebral hemodynamics changes during hypothermic circulatory arrest (HCA) with and without retrograde cerebral perfusion (RCP). Thirteen colony-bred hound dogs were placed on cardiopulmonary bypass (CPB) and cooled to 18 degrees C. Five dogs underwent 2 hours of HCA without RCP and 8 with RCP. The animals were then rewarmed on CPB until normothermic and weaned. Cerebral blood flow velocity (CBFV) and Gosling Pulsatility Index (PI) in the middle cerebral artery (MCA) were studied using trans-cranial Doppler ultrasound (TCD). At baseline and during pre- and postarrest CPB, there was anterograde direction of blood flow in the MCA. During HCA with RCP, there was retrograde direction of blood flow in the MCA. There was no difference in CBFV between pre-, during, and postarrest CPB in the group with RCP; however, there was significantly increased CBFV during postarrest CPB in the group without RCP compared to the dogs with RCP. Later, at 3 hours after postarrest CPB, there was decreased CBFV in all animals accompanied by increased PI (2.4 +/- 0.4 and 2.2 +/- 0.6 for animals with RCP and without RCP, respectively) and abnormal TCD waveform changes including decreased diastolic compartment and sharp systolic peak. During hypothermic circulatory arrest, RCP provides CBFV in the MCA comparable to MCA CBFV during CPB. HCA dogs without RCP showed immediate hyperemia on reperfusion. The decreased CBFV and increased PI at 1 hour after postarrest CPB could be an indicator of progressive ischemic injury due to the increased intracranial pressure despite the implementation of RCP.

Objective: The impact of early transcranial Doppler ultrasonography (TCD) upon stroke subtype diagnosis is unknown and may affect therapeutic strategies. In this study, the diagnostic usefulness of TCD in stroke subtype diagnosis according to the criteria of the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) study was investigated in patients with acute cerebral ischemia., Methods: TCD examination within 24 h of symptom onset was performed in 50 consecutive patients with acute cerebral ischemia. Of these 54% were female. Sixty percent of patients were black, 36% white, and 4% Asian. Initial TOAST stroke subtype diagnosis (ITSSD) was based upon clinical presentation and initial brain imaging studies. Modified TOAST stroke subtype diagnosis was determined subsequently after additional review of the TCD examination. Final TOAST stroke subtype diagnosis was determined at hospital discharge, incorporating all diagnostic studies. Using final TOAST stroke subtype diagnosis as the 'gold standard' ITSSD and modified TOAST stroke subtype diagnosis were compared in order to determine additional benefit from the information obtained by TCD. Data were collected retrospectively by a single investigator., Results: ITSSD classified 23 of 50 (46%) patients correctly. After TCD, 30 of 50 (60%) patients were classified correctly, for an absolute benefit of 14% and a relative benefit of 30% (p = 0.018). Most benefit from TCD was observed in the TOAST stroke subtype category large-artery atherosclerosis, in particular in patients with intracranial vascular disease. In this category, ITSSD had a sensitivity of 27% which increased to 64% after TCD (p = 0.002)., Conclusion: TCD within 24 h of symptom onset improves the accuracy of early stroke subtype diagnosis in patients with acute cerebral ischemia due to large-artery atherosclerosis. This may have clinical implications for early therapeutic interventions., (Copyright 2001 S. Karger AG, Basel.)

Objective: To develop a scheme for early identification of individuals at risk for symptomatic vasospasm after subarachnoid hemorrhage (SAH)., Design: Analysis of prospectively collected data from the placebo-treated group in a multicenter clinical trial., Settings: Fifty-four neurosurgical centers in North America., Measurements and Main Results: We identified independent predictors of symptomatic vasospasm using stepwise logistic regression analysis from demographic, clinical, laboratory, and neuroimaging characteristics of the participants. We developed a scoring system (symptomatic vasospasm risk index) based on a combination of these predictors. Out of 283 patients in the analysis (all treated with oral nimodipine), 93 (33%) developed symptomatic vasospasm within 14 days after SAH. There were four independent predictors of symptomatic vasospasm: thickness of subarachnoid clot on computed tomographic scan (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.8-10.0); early rise in middle cerebral artery mean flow velocity (MCA-MFV), defined as a value > or =110 cm/sec recorded on or before post-SAH day 5 (OR, 1.9; 95% CI, 1.1-3.3), Glasgow Coma Scale score <14 (OR, 1.8; 95% CI, 1.1-3.1); and rupture of anterior cerebral or internal carotid artery aneurysm (OR, 1.9; 95% CI, 1.0-3.4). The probability of identifying patients who would develop symptomatic vasospasm (percentage of area under receiver operating characteristics curve +/- SEM) was higher with symptomatic vasospasm risk index (68%+/-8%) compared with thickness of clot (62%+/-8%; p = .08) or MCA-MFV (45%+/-7%, p < .05) criteria alone., Conclusions: Patients at high risk for symptomatic vasospasm can be identified early in the course of SAH using a risk index. A risk index based on a combination of variables may represent a predictive paradigm superior to conventionally used criteria based on clot thickness or MCA-MFV criteria.

Background: S-100B is a protein mainly found in astroglial cells and only detected to a low level in blood. Serum levels of S-100B increase in patients with acute brain injuries. The aim of this study was to establish feasibility of a new Optical ImmunoAssay ([OIA], Bio-Star, Inc, Boulder, CO) test for determination of S-100B in blood., Methods: We have developed a new, rapid, and sensitive OIA test to identify elevated levels of S-100B in whole blood. The OIA test for S-100B combines monoclonal antibodies specific for the B-subunit of S-100 with OIA thin film technology. Each sample was tested for S-100B by the OIA method and a commercially available immunoluminometric assay. Blood samples were drawn serially from 9 patients undergoing coronary artery bypass graft surgery and during the early postoperative period., Results: The OIA test determination of S-100B protein correlated with immunoluminometric assay data (r = 0.8) with a detection limit of 0.25 ng/mL., Conclusions: The sensitivity and feasibility of this rapid assay may be suitable for rapid evaluation of S-100B in urgent care settings (surgery, intensive care units, or emergency room).

Objectives: The aim of this study was to determine accuracy of transcranial Doppler ultrasound (TCD) and compare efficacy of three non-invasive tests [TCD, magnetic resonance angiography (MRA), and magnetic resonance imaging (MRI)] in patients with acute cerebral ischemia., Material and Methods: This prospective study involved 30 patients. MRI, MRA, and TCD were performed within 24 h after onset of ictus. The 2nd MRI was repeated at 48-72 h and was used as the standard for the evaluation of sensitivity and specificity of MRA, TCD, and initial MRI., Results: TCD showed a sensitivity of 96% and a specificity of 33% for recognizing abnormal cerebral blood flow velocities. MRA showed a sensitivity of 46% and a specificity of 75% for assessing intracranial vascular anatomy, while initial MRI revealed a sensitivity of 84% and a specificity of 100% for evaluation of ischemic parenchymal changes., Conclusion: Our results revealed that TCD is an accurate indicator of blood flow status and correlated well with MRI, MRA abnormalities in acute stroke.

We evaluated 86 patients for possible normal pressure hydrocephalus (NPH) by: 1) CSF pressure (Pcsf) monitoring and analysis for percent of time with A or B-waves, and 2) controlled CSF drainage for 3 days via a lumbar subarachnoid catheter. Clinical outcome after CSF drainage and shunt surgery was assessed as change of clinical exam, with grades of none, minor, moderate, or marked change. For outcome analysis in 47 patients after shunt surgery, NPH was defined as moderate or marked clinical improvement. We assessed the diagnostic discrimination of percent-of-time thresholds of A and B-waves for 38 patients. At 10%, sensitivity for NPH is 91%, specificity is 13%, positive predictive value (PPV) is 62%, and the false positive rate is 38%. At the 25% threshold, sensitivity is 78%, specificity is 40%, PPV is 67%, false positive rate is 33%, and the false negative rate is 22%. For CSF drainage (threshold of minor improvement or better), the sensitivity is 97%, specificity is 60%, PPV is 84%, negative predictive value (NPV) is 90%, and the false negative rate is 3%. We conclude: 1) clinical response to controlled CSF drainage accurately predicts the outcome after shunt surgery in patients suspected of having NPH, and 2) A or B-waves poorly predict which patients will respond to shunt surgery. Three days of CSF drainage seems to encompass critical thresholds of CSF volume removal or duration of Pcsf reduction necessary for neuronal function to begin returning and symptoms to begin resolving in patients with NPH.

We investigated the cause of poor outcome in patients with normal pressure hydrocephalus (NPH) who did not respond as expected after shunt surgery. Two methods were used to evaluate shunts: radionuclide shunt patency study, or continuous ICP monitoring. 33/52 shunted patients (64%) from 1989 to 1995 had poor outcome, and 28/52 (54%) were investigated. Of those investigated, 9/28 (32%) were never better, and 19/28 (68%) were initially better then worse. Of 9 patients who were never better, ineffective shunt function was seen in 7; 5 had shunt revision (2 declined), and 1 improved. Of 19 patients who were initially better then worse, 15 had ineffective shunts; 15 underwent shunt revision, and 13 improved. Poor clinical outcome occurred in two-thirds of all patients after shunt surgery for NPH, but a potentially treatable cause (i.e. obstruction of the shunt or a shunt system that was patent but did not adequately correct the CSF circulatory disorder) was found in nearly 80% (22/28) of those investigated. The predominant cause of ineffective shunt function was obstruction of the peritoneal catheter. Clinical recovery occurred in 70% (14/20) of patients who had shunt revision surgery. We conclude that ineffective shunt function is a frequent cause of poor outcome after shunt surgery to treat NPH that should be sought and treated. These results have implications for longitudinal studies of the diagnosis and treatment of NPH. The effect of unrecognized shunt ineffectiveness on prior studies is unknown. Future studies should be designed to confirm that shunts are functioning before the diagnosis of NPH is considered incorrect.

To identify features on magnetic resonance imaging (MRI) scans that are associated with unstable intracranial pressure (ICP) and outcome after CSF shunting in patients with NPH, we reviewed MRI scans of 17 patients who had continuous ICP monitoring performed prior to ventriculo-peritoneal shunt insertion. We evaluated the association between periventricular/deep white matter lesion burden, focal impingement of the corpus callosum, aqueductal CSF flow void, and B-waves with outcome after shunting. The change in neurological function between pre- and post CSF shunting evaluation was scored according to a standard scale (range -3 or +3). Patients were divided into those with clinical improvement (score > 0) or without improvement (score < or = 0) after shunt surgery. Focal impingement of the corpus callosum was more frequent in patients who improved after CSF shunting compared to those without improvement (8 of 13 vs 0 of 4, p = 0.05). Patients with focal impingement of corpus callosum had more B-wave time than those without impingement (60.5% vs 24.7%, p = 0.02). Focal impingement of corpus callosum on MRI may be associated with unstable intracranial pressure in patients with NPH and may be useful in identifying patients who will benefit from CSF shunting.

Vessel identification during a transcranial Doppler (TCD) ultrasound examination is usually based on well-established inferential criteria without confirmation by imaging. Part of a routine study involves taking measurements from the M1 segment of the middle cerebral artery (MCA) and the A1 segment of the anterior cerebral artery (ACA) at the points of maximum mean linear blood flow velocity (LBFV). The authors tested the hypothesis that insonation is from the midpoints of the M1 and A1 segments during clinical TCD examinations. Conventional hand-held TCD examinations were performed on five volunteers. The points of maximum mean LBFV of the M1 and A1 segments of the MCA and ACA were located. Measurements were also taken from the midpoints of the M1 and A1 segments using a magnetic resonance (MR) imaging-guided stereotactic TCD technique. Values for depths of insonation and maximum mean LBFV obtained with the two techniques were compared. There was no significant difference between the two techniques for the measured values of depth of insonation of either the individual vessels (p > 0.11) or the aggregate (p = 0.46). There was a significant difference between the aggregate maximum mean LBFV measurements (p = 0.0022). The hand-held technique systematically produced higher maximum mean LBFV than the MR-guided stereotactic technique. The authors conclude that when using traditional criteria for TCD examination of the ACA and MCA, the points of insonation approximate the middle of the A1 and M1 segments.

The absolute value of intracranial pressure (ICP) should be considered in conjunction with evaluation of a patient's clinical condition. In addition, other aspects of cranial vault mechanics may be important in multiple disease states. Among the important physiological measures of cranial vault sufficiency are hydrodynamic interaction between brain tissue, blood and cerebrospinal fluid (CSF)--volume-pressure relation, CSF dynamics--CSF outflow resistance, CSF production rate, sagittal sinus pressure, and appearance of ICP waves. Clinical and experimental studies brought together in this review provide an insight into the dynamics of ICP and the cranial vault.

67 patients with benign intracranial hypertension (BIH) and 44 with normal pressure hydrocephalus (NPH) were examined by employment of infusion tests. Brain swelling (decrease of ventricular size with normal or increased brain tissue density) was a characteristic feature of BIH. It may result from venous outflow disturbances leading to vascular engorgement. But later, the process appears to be independent from the increase of the dural sinus pressure. This was normal in patients with BIH and NPH. Despite absorption disturbances there was a strong positive correlation in NPH between cerebrospinal fluid- and dural sinus pressure, while in BIH such a correlation was absent. The data confirm a pathogenesis of brain swelling in BIH as an obstacle to venous outflow at the level of the bridging veins and venous lacunae, however, not at the level of the dural sinuses.