ultrasonografia carotidiana in stroke
DESCRIPTION
aportul ultrasonografiei Doppler carotidiana extracraniana la pacientii cu AVC (stroke)-experienta personalaTRANSCRIPT
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ULTRASONOGRAFIA CAROTIDIANA IN STROKE
Alexandru Andritoiu
Sp. Militar de Urgenta
CRAIOVA
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INDICATIILE CDI-CAR
1. Pacienti cu stroke carotidian
2. Evaluarea preoperatorie (indicatie de endarterectomie)
3. Evaluarea eficacitatii endarterectomiei sau permeabilitatii stenturilor carotidiene
4. Suflu vascular cervical
5. Anevrism carotidian
6. Disectia de artera carotida
7. Metoda de screening la pacienti cu risc CV (HTA, BCI, DZ, dislipidemie, fumat)
8. Determinarea progresiei leziunilor parietale
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PARAMETRI EVALUATI PRIN CDI-CAR
Evaluarea anatomica
• Diametrul carotidian
• CIM
• Placa ateromatoasa
• Gradarea stenozei
• Ocluzia carotidiana
• Modificarile de traiect (bucla/ plicatura)
• Disectia de artera carotida
Evaluarea functionala
•Rigiditatea arteriala
•Complinata
•Distensibilitatea
•Elasticitatea (modulul Young)
•Decay index
•Functia endoteliala
•Stresul de forfecare
•Q cerebral
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ULTRASONOGRAFIA DOPPLER COLOR CAROTIDIANA IN STROKE
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Evaluarea bolii ischemice cerebrovasculare prin US
1. Transcraniana:• TCD-spectral• TCD-color2. Extracraniana:• Eco-carotidiana 2D –3D• Eco Doppler spectral, color, power-angio• Eco-panoramica (Sie Scape, SieFlow)• THI (Tissue Harmonic Imaging)• B-flow • Photopic US Imaging• Sono-CT• US angiografica cu AC (Levovist)
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USC EXTRA-CRANIANA
Placile stenozante (localizare, ecostructura)
Gradul stenozei (planimetrie, profil spectral)
CIM (grosime, contur, omogenitate)
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EVALUAREA DOPPLER SPECTRALA
• Directia fluxului
• Distributia velocitatii
• Variatia temporala a velocitatii
• Valocitatea maxima
• Velocitatea medie
PARAMETRII SPECTRALI DE EVALUARE A SEVERITATII STENOZEI CAROTIDIENE
• Vmax sistolica
• Vmax diastolica
• Vmax sistolica ACI/Vmax diastolica ACI
• Index carotidian (Vmax ACVI/ Vmax ACC)
• Largirea spectrala
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Stenoza ACI 70-99%PSV >130 cm/s EDV >100 cm/sIx Car >4.5+/- AO flux inversatAc 95%, Sb81%, Sp98%
Velocitatile normaleACC 59/15 cm/sACI 57/22 cm/sACI dist 65/27 cm/s
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EVALUAREA IMAGINII DOPPLER COLOR POWER-ANGIO
• detectia/absenta fluxului
• directia fluxului
• V medie a fluxului
• turbulenta
• secventa temporala
• Sb mare la fluxurile lente
• independenta de theta
• non aliasing
• identificare acurata a interfetei lumen-intima
• trasare acurata a conturului placii
• informatia asimilata angiografiei
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LOTUL DE STUDIU
• 197 pts. cu AVC ischemic (AIT / stroke)
• US carotidiana (segm. extracranian)
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Stenoza carotidiana
Apreciere planimetrica (%D; %A) Apreciere indirecta (velocimetrie) Prevalenta stenozelor semnificative se asociaza cu virsta si
cu prezenta altor FR
Studiu pe 250 pts cu virsta >60 ani spitalizati ptr infarct cerebral: numai 13% aveau o stenoza carotidiana ipsilaterala >70%.
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Metoda NASCET – evaluarea stenozei ACI
% sten = (1 – N/D) x 100
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REZULTATE
STENOZA CAROTIDIANA >60% (N=197)
12%
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Clasificarea stenozelor carotidiene
NASCET• Usoara 0-29%• Medie 60-69%• Severa 70-99%
Gradarea ATS carotidieneGrad 0 fara placi, fara stenoza, CIM normal
Grad I CIM in std. Granulatie/fragmentatie sau placa unica, nodulara
Grad II sten <25,sau placi nultiple nodulare
Grad III sten 25-49%,sau mai multe placi medii
Grad IV sten 50-74%, placa voluminosa sau mai multe placi medii dispune simetric
Grad V sten 75-99 %
Grad VI ocluzie
A placi fibroase C placi calcare B placi fibrocalcare D combinate
Andritoiu A, 2000
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CIMT
CIMT – factor de risc ptr. stroke alaturi de FR consacrati; CIMT ingrosat se asociaza semnificativ cu prezenta placilor
ATS; Studiul ARIC, Rotterdam; Cardiovascular Health Study relatia stroke –CIMT de tip non-linear numai valorile extreme ale CIMT s-au corelat cu prezenta
simptomelor cerebrovasculare; CIMT >1.17 mm la M si CIMT > 0.85 mm la F – riscul de AVC
simptomatic este de >2 ori.
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REZULTATE
Lot 197 pts. CIM =0.81+/-0.29 mm
ANALIZA SUBLOT 104 PTS. CIM>0.8 mm a asociat prezenta placilor la 45% pts. CIM > izolat (fara placi) la 15.5% pts. Placi existente fara CIM > la 12.5% pts. Perete carotidian normal (fara placi, CIM <0.8 mm) la
27% pts.
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ECOSTRUCTURA PLACII
Caracterizarea tisulara a materialului ecogen din placa ATS
3D , 4D , backscattering
STADIALIZAREA PLACILOR STADIALIZAREA PLACILOR Std 1. anecogene Std.2 predominant hipoecogene Std.3 predominant hiperecogene Std 4 ecogene Std.5 hiperecogene cu con de umbra
Gray-Weale et al. J Cardiovasc Surg 1988
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Placa moale (hipoecogena / anecogena)
asociere puternica intre AIT si prezenta placilor hipoecogene (Odds ratio 3.00;p=0.005) (Ianuzzi A 1995)
localizare predilecta la niv. bifurcatiei ACC si orig. ACI virsta mai tinara frecv la diabetici predispusa la ulceratie
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Placile calcare
hiperecogene insotite de umbra acustica mai frecvente la B si virstnici pe intreg axul carotidian extern incluse in grosime mediei rar ating dimensiuni mari si produc stenoze severe
excentrice
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Deficit motor – lez. carotidiene
66%
34%
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CDI -CAR ofera informatii aditionale privind substratul aterosclerotic al bolii ischemice cerebrovasculare;
Leziunile severe se coreleaza mai bine cu prezenta si severitatea stroke
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= +
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DEBITUL CEREBRAL
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Q cer = Q ACI dr + Q ACI stg + Q AV dr + Q AV stg
Q = TAV x A
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Felodiopina (Plendil)Astra-Zeneca
• vasodilatator (Ca-blocant)
• antihipertensiv
• folosit in serv. neurologie (inclusiv in AVC hipertensiv)
Efecte adverse:
• cefalee vasculara
• ameteli
• rush al fetei
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Evolutia Q cer
0
50100
150200
250300
350400
450500
bazal 2 spt 4 spt
Q cerQ car Q vert
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% Q car vs % Q vert
67
33
86
14
73
27
0
10
20
30
40
50
60
70
80
90
bazal 2 spt 4 spt
% Q car
% vert
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ACM
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
bazal 2 spt 4 spt
PI
RI
Indicii de impedanta arteriala scad usor sub efectul felodipinei
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