Pulsed Doppler Assessment of Innominate Artery Obstructive Diseases

Transcription

1 54 Puled oppler Aement of nnomnate Artery Obtructve eae Wolfgang Rautenberg, M, and Mchael Hennerc, M n 4 patent wth evere teno or occluon of the nnomnate artery a new hgh-energy, low-frequency (2 MHz) puled oppler ultraound method wa ued to nvetgate blood flow velocty pattern of both ntrathoracc and ntracranal cerebral artere. rect acquton and evaluaton of the nnomnate artery at t orgn near the aortc arch enabled eparaton of t from adjacent artere and relable dfferentaton of teno from occluon. Trancranal recordng from the baal cerebral artere howed abnormal oppler gnal n 2 patent (86%). Among thee abnormalte, obervaton of a latent teal phenomenon wa cloely related to the prevalence of cerebrovacular event. Th latent teal phenomenon wa characterzed by a tranent reducton of orthograde blood flow n the plateral anteror, mddle, and poteror cerebral artere or n the balar artery durng potchemc hyperema of the upper extremte. The predctve value of the latent teal phenomenon for the management and follow-up of aymptomatc patent wth evere nnomnate artery obtructon dcued. (Stroke 988;9:54-52) ownloaded from by on September 28, 28 A lthough nnomnate artery (A) obtructve L\ deae rare, t ha been hown to be J_ \. aocated wth conderable alteraton of the extracranal crculaton and wth occaonal cerebrovacular event. 2-3 However, radologc etmaton of the degree of thee ntrathoracc leon and of the ntracranal hemodynamc nduced wthn the collateral pathway often dffcult. Furthermore, parameter predctve of the development of cerebral gn and ymptom have not been etablhed n thoe patent who reman neurologcally aymptomatc for a long tme. 4-5 Th artcle provde evdence of the valdty of a new hgh-energy, low-frequency puled-wave (PW) oppler ultraound method for the aement of obtructon of the ntrathoracc brachocephalc trunk and the evaluaton of functonal hemodynamc ntablte wthn the baal cerebral artere at ret and durng provocatve tet. The latter may be ueful n defnng the rk aocated wth A obtructve leon for an ndvdual patent and may help gude decon regardng medcal or urgcal treatment. Subject and Method Between October 985 and October 987 the dagno of a evere obtructon (>8% lumen narrow- From the epartment of Neurology, Unverty of eldorf, Federal Republc of Germany. Supported by eutche Forchunggemenchaft Grant SFB 2/2. Addre for correpondence: Profeor Mchael Hennerc, Neurologche Unvertatklnk, MoorentraBe 5, -4 eldorf, Federal Republc of Germany. Receved July 23, 987; accepted July 6, 988. ng) of the A wa made by nonnvave oppler ultraound n 2 patent. Fourteen (eght men and x women) underwent ubequent angography and form the ba of our tudy; ntra-arteral angography wa avalable n 3 patent and ntravenou dgtal ubtracton angography (V SA) of good qualty n one. The mean age of the 4 patent wa 54.7 (range 36-74) year. All patent underwent neurologc examnaton and computed tomography. Seven patent were neurologcally aymptomatc (Stage ), two reported amauro fugax attack of the rght eye (Stage ), and fve reported tranent chemc attack orgnatng from the brantem (Stage ). Ten of the 4 patent underwent recontructve vacular urgery; from a tranthoracc approach the A wa ether oblterated (n one) or lgated (n nne), and a bypa wa nerted between the aorta and the dtal A. Nonnvave vacular examnaton conted of both contnuou-wave (W) oppler ultraound (ebmetre ultraonque elalande, 4 MHz) and duplex ytem tude (Sonotron, Koln, FRG; MHz for B-mode, 5 MHz for oppler mode) of the extracranal carotd artere, vertebral artere (VA), and ubclavan artere. etal of thee procedure have been reported. 6-8 haractertc fndng upportng the dagno of evere obtructon wthn the A were abnormal oppler gnal n all artere dtal to the leon (the rght common, nternal, and external carotd, the vertebral, and the ubclavan artere). The degree and dtrbuton of pontaneou blood flow velocty alteraton vared ndvdually a dd reactvty to potchemc hyperema

2 Rautenberg and Hennerc nnomnate Artery Obtructon 55 m ff HYf -> c ownloaded from by on September 28, 28 OMPRSSON RATV HYPRMA 8G 38 U o ) \- * f FGUR. Varou alteraton of blood flow n balar artere demontrated by puled-wave oppler ultraound n patent wth proxmal obtructon of nnomnate (A-, F) or ubclavan () artere. A: normal; B: delayed ytolc peak;, : ntermedate tage; : complete reveral of blood flow; F: typcal example of "latent teal" phenomenon: ntermedate pattern wth orthograde flow drecton () change nto partal flow reveral () durng hyperema of upper lmb, that, true teal for a few cardac beat. Permanent retrograde perfuon wthn balar artery () wa not oberved n patent wth obtructon of nnomnate artery. ubequent to compreon of the brachal artere.-7 The major dadvantage of both method the frequent nablty to nvetgate the A drectly becaue of the lmted reoluton of deep movng tructure ung oppler probe operatng at an emon frequency of > 4 MHz. 9 Reoluton could»oj UJ > FGUR 2. Angogram (A) and puled-wave oppler fat Fourer tranformed ultraound pectrum (B, ) of patent wth evere teno of nnomnate artery (A). rect examnaton of A from upraclavcular foa at depth of 55 mm reveal typcal parameter of evere teno: ncreaed peak ytolc (25 cm/ec) and mean (74 cm/ec) velocte and fluctuaton at baelne ndcatng evere turbulence. : After urgery, normal oppler gnal ndcate retoraton of blood flow. be better and more regularly acheved by the addtonal ue of a low-frequency (2 MHz) PW oppler ytem (T-2-64, M, Uberlngen, FRG). Recordng from the upra-aortc branche can be made relably at depth between 35 and mm by amng the probe from the rght upraclavcular foa or the upraternal regon to the aortc arch. ue to the contant, mall (-3 ) angle of nonaton, we expre the oppler hft n velocty (centmeter per econd) rather than frequency (klohertz) a commonly done for trancranal (T) recordng.' '-' 3

3 56 Stroke Vol 9, No 2, ecember 988 TABL. lncal and Vacular Fndng n 4 Patent Wth Steno or Occluon of nnomnate Artery Pt/age/ex /64/M 2/5/F 3/66/F 4/6/M 5/36/F 6/74/F 7/44/F 8/57/F 9/49/M /58/M /4/M 2/54/M 3/56/M 4/56/M lncal tage A A B R carotd and vertebral ytem A A VA Neck artere S; R VS S;RVS S; R VS S; R VS S; R VS S* S; R VS + L Sten S; R VS, L O S; R, L VS S; R, L VS S; R, L VS S; R, L VS S;R, LVS S; R, L VS + L O ntracranal artere wth latent teal R MA, R AA R MA, R AA RPA R MA, R AA R MA, R AA, R PA, L MA, L AA, Artere wth abnormal pectrum pattern R MA, R AA RPA R MA, R PA Pt, patent number; age n year; M, male; F, female;, tranent chemc attack;, aymptomatc; A, nnomnate artery; O, occluon; S, teno; A, common carotd artery; A, nternal carotd artery; A, external carotd artery; VA, vertebral artery;, alternatng blood flow;, complete reveral of blood flow;, ytolc deceleraton; B, delayed ytolc peak; S, carotd teal on rght; R, rght; L, left; VS, vertebral teal; Sten, carotd teno; O, carotd occluon; MA, mddle cerebral artery; AA, anteror cerebral artery; PA, poteror cerebral artery;, balar artery. A by puled-wave oppler ultraound and angography; R carotd and vertebral ytem hemodynamc a demontrated n Fgure ; neck artere by duplex and contnuou-wave oppler ultraound. *plateral VA hypoplaa wthout teal phenomenon. ownloaded from by on September 28, 28 Th low-frequency PW oppler ytem wa alo ued for T recordng of cerebral artere wthn the crcle of Wll. "- 3 nterpretaton of the fat Fourer tranformed oppler gnal condered four man parameter (ytolc peak, datolc peak, averaged mean blood flow velocte, and the calculated pulatlty ndexe [P]), normal value of whch have been elaborated for varou age group. 23 For our purpoe the mddle cerebral artery (MA), the anteror cerebral artery MA BFOR SURGRY (AA), and the poteror cerebral artery (PA) were nonated from ether de through a trantemporal approach. The ntracranal egment of the VA and the balar artery () were examned through the foramen magnum at depth rangng from 5 to 2 mm. 3-5 The oppler data were analyzed and the arteral egment were dentfed a for the anteror cerebral crculaton, wth partcular attenton to the topographc anatomy revealed by the angogram. /) o e o AFTR SURGRY V AA - v> o SS FGUR 3. Puled-wave opplerfat Fourer tranformed ultraound pectra of rght mddle cerebral artery (MA) and anteror cerebral artery (AA) n patent wth occluon of nnomnate artery before and after urgery. Note change of velocty pattern and ncreae of peak ytolc velocty after urgery. Furthermore, blood flow drecton n rght AA returned to normal after urgery.

4 Rautenberg and Hennerc nnomnate Artery Obtructon 57 MA LFT MA RGHT FGUR 4. Angle ndex. To expre abnormalty of blood flow profle een wthn ntracranal artere n patent wth nnomnate artery deae, angle from end-datolc velocty to peak ytole wa meaured on oppler pectra of rght and left mddle cerebral artery (MA). Angle on rght vared from 48 to 88 (mean 72.7 ), on left from 75 to 88 (mean 85.7 ). Angle ndex A n. Bh/Atef, wa.85. ownloaded from by on September 28, 28 xamnaton were regularly performed n a upne poton and ncluded arm exerce tet known to provoke blood phonng from the cerebral to the brachal artere durng potchemc hyperema n patent wth evere obtructon of the A. A known from extracranal and T oppler tude of the VA and n patent wth ubclavan teal phenomena 75 (Fgure ), ntermedate tage of blood flow reveral can be dfferentated from normal and completely revered blood flow. Thee ntermedate tage are frt, an alternatng flow wth early ytolc and late datolc forward flow but late ytolc flow reveral armward; and econd, a ytolc deceleraton armward. Whether thee exerce tet have mlar effect on the ntracranal crculaton n patent wth A obtructve leon ha not been tuded to date. Reult xtracranal rculaton W oppler and duplex ytem tude howed ndrect gn of olated obtructve deae wthn the A (.e., two-veel deae nvolvng both the carotd and the vertebral crculaton) n x patent (Table ). Addtonal nvolvement of the left nternal carotd artery (n two) and a ubclavan teal phenomenon on the left (n fve) (three-veel deae), or both (n one) (four-veel deae), were found n the remanng eght patent. Sx patent howed blateral ubclavan teal phenomena. No defnte dfferentaton of teno from occluon of the A could be obtaned wth W oppler and duplex ytem ultraound. Fgure 2 how the typcally dtorted PW oppler pectrum of a evere teno of the A and a normal pectrum after urgcal retoraton of blood flow. Smlar reult ndcatng evere teno of the A were found n nne patent wth peak flow velocte rangng between 55 and 334 cm/ec at 4-75 mm depth. n contrat, n age- and ex-matched normal control peak flow velocte ranged from 32 to 86 (mean±s 54.6±6.9) cm/ec. n the fve patent wth an occluded A no gnal or only low flow velocte could be obtaned wthn the adjacent dtal egment of the rght common carotd artere for peak ytolc blood flow velocte (range 28-42, mean±s 34.7±7. cm/ec) and mean blood flow velocte (range -8, mean±s 3.3±4.2 cm/ec). Angography performed n all 4 patent confrmed the oppler dagno. Normalzaton of blood flow velocty after urgery wa oberved n all urgcal patent. ntracranal rculaton oppler pectrum pattern. Sgnal from the baal cerebral artere (MA, AA, and PA) were obtaned from all 4 patent. The wa med n one patent becaue of the deep locaton of the vertebral juncton, > mm from the probe, and a poor gnal-to-noe rato. n the 3 remanng patent oppler gnal of the were of reaonable qualty and allowed dfferentaton of the varou form of blood flow alteraton. The angographc locaton of the proxmal correponded to the depth of the ample volume; the mean depth wa 95.2 mm. The major fndng were abnormal oppler pectrum pattern of the baal cerebral artere, whch were oberved n the and/or n the rght AA, MA, and PA n 2 patent at ret (Fgure 3, Table ). Thee abnormal pattern were characterzed by a TABL 2. oppler Ultraound Spectrum Parameter of Mddle erebral Artery n 2 Normal ontrol and n 4 Patent Wth Obtructon of nnomnate Artery Peak velocty (cm/ec) Mean velocty (cm/ec) Pulatlty ndex Group ontrol Patent n 2 4 Left 9.± ±34. Rght 9.O± ±6.* Left 57.7±.,5 59.6±23.,7 Rght 57.7±.5 54.±.7 Left.9± Rght.9±.8.65±.8t ata are mean±s. *tp<.5, p<., repectvely, by t tet.

5 58 Stroke Vol 9, No 2, ecember 988 u > h U J -5O 5 PTH 8 J -o) LU t ownloaded from by on September 28, Angogram and trancranal (T) oppler ultraound recordng ofpatent wth occluon of nnomnate and left ubclavan artere. T oppler how ntermedate tage of blood flow reveral n balar artery even at ret; whle orthograde flow drecton (upper rght) preerved, ytolc deceleraton occur durng early ytole. urng hort compreon of left common carotd artery (bar) no blood flow occur, demontratng blood uppled from left common carotd artery to balar artery. Th collateral pathway wa confrmed by angography. Lower rght: urng potchemc hyperema of both arm (bar, multaneou compreon of both arm) another type of ntermedate blood flow wth alternatng flow around baelne durng each cardac cycle wa noted (ee Fgure ). FGUR damped gnal pectrum durng early ytole, aocated wth a oftly whperng audo gnal, whch wa due manly to a delayed peak bloodflowvelocty. The angle of ncreae of the oppler pectrum (A) n early ytole wa lower on the rght than on the left. Th angle ndex (Angh,/Akft, normally ) wa calculated a ndcated n Fgure 4. On the rght de, angle vared from 48 to 88 (mean±s 72.7±3 ), but they vared from 75 to 88 on the left de (mean±s 85.7±3.7 ). The angle ndex wa.85. epte thee dfference, blood flow velocte wthn the MA and PA were wthn normal lmt n all patent; although peak and mean blood flow velocte n the rght MA were lower than n the left MA, they were tll wthn the normal range compared wth control3 (Table 2). Spontaneouly, durng long examnaton (>4 mnute), abnormal oppler pattern tended to become le pronounced over tme, whch reflect the lablty of the cerebral crculaton to ytemc regulatve mechanm uch a orthotatc cardovacular and cerebral autoregulatve control n low-flow terrtore. Pathway ofcollateralzaton. The anteror communcatng artery wa the predomnant collateral pathway n eght patent. ro-flow from the left to the rght hemphere ndcated by retrograde flow wthn the rght AA and no blood flow or change of flow drecton durng hort compreon of the left common carotd artery wa noted n x patent. Two patent wth evere teno of the A and occluon of the left nternal carotd artery, however, provded collateral blood flow to the left MA from the rght de va retrograde blood flow wthn the left AA. Among the remanng x patent, one howed collateral blood flow from the poteror crculaton to the rght hemphere, ndcated by ncreaed flow velocty n the and n the proxmal part of the PA (P egment and the poteror communcatng artery). n the other fve patent, blood upply through the rght nternal carotd artery wa uffcent to mantan orthogradeflowdrecton nto the plateral MA and AA. Thee collateral pathway revealed by T oppler were confrmed by ubequent ntracranal angogram n 3 of the 4 patent; n one patent wth

6 Rautenberg and Hennerc nnomnate Artery Obtructon 59 u o ownloaded from by on September 28, 28 FGUR 6. Varou type of oppler blood flow alteraton n dfferent baal cerebral artere n patent wth evere obtructon of nnomnate artery durng brachal hyperema. A: mddle cerebral artery; B: anteror cerebral artery; : poteror cerebral artery; : balar artery. Bar ndcate compreon of rght arm. evere generalzed atheroclero (occluon of both ubclavan and femoral artere), electve ntraarteral angography wa not poble and V SA, although of good qualty, faled to how detal of the ntracranal collateral pathway. Reactvty to potchemc hyperema. T oppler tude demontrated a tranent decreae of peak blood flow velocte or partal reveral of flow n the baal cerebral artere durng potchemc hyperema of the upper extremte ubequent to a compreon maneuver n patent, termed the "latent teal" phenomenon. Th phenomenon repreent the ntal tage n a pectrum of blood flow abnormalte (Fgure, B and ), leadng from normal orthograde flow (Fgure A) to complete blood flow reveral (Fgure ) va ntermedate tage uch a ytolc deceleraton and alternatngflowdrecton (Fgure, and ). Wherea blood flow velocty pattern wthn the baal TABL 3. Reacton to Potchemc Hyperema n Baal erebral Artere of Symptomatc and Aymptomatc Patent Wth Obtructon of nnomnate Artery Reacton ntracranal latent teal No teal N 3 Symptomatc patent (n = 7) No. % 7 Aymptomatc patent («= 7) No. % cerebral artere reman unchanged durng provocatve tet n normal upra-aortc arteral condton, the occurrence of latent teal at ret and a marked decreae of peak flow velocte wth ether preervaton of the flow drecton or wth a partal true flow reveral (Fgure F and 5) wa noted even tme n the MA, fve tme n the AA, two tme n the PA, and fve tme n the (Table, Fgure 6). Apart from unlateral or blateral compreon tet of the brachal artere, uch phenomena could be provoked by orthota after a perod of ret n the upne poton n a few patent. n fve patent, more than one veel wa nvolved. The reducton of peak blood flow velocty vared between 4% and 22% n the MA (mean 8.9%), between 5% and 5% n the AA (mean 26.8%), between 7% and 22% n the PA (mean 9.9%), and wa hghet n the (between 3% and 66%, mean 44.%). Such phenomena were not oberved n the baal cerebral artere of the normal control. Nether pontaneouly nor durng provocatve tet wa a permanent retrograde perfuon wthn the MA, PA, or oberved (Fgure ). Notably, none of x patent wth a blateral ubclavan teal phenomenon howed retrograde flow drecton wthn the although the wa defntely dentfed at depth of between 8 and 2 mm and wa confrmed by the correpondng ango-

7 ownloaded from by on September 28, Stroke Vol 9, No 2, ecember 988 gram. Th lack of retrograde blood flow wa due to the uual collateral pathway that provded blood from the left external carotd to the left dtal VA and draned nto the n an orthograde drecton. A hown n Table 3, the preence of thee blood flow alteraton n the baal cerebral artere wa cloely correlated wth the prevalence of clncal ymptom. Blood flow alteraton were een n all ymptomatc patent wth obtructon of the A. cuon n the preventon of troke, nteret ha focued on atheroclero of the carotd bfurcaton. Obtructve leon of that te are thought to be frequently aocated wth cerebrovacular event and can be detected by mean of everal nonnvave technque. n contrat, obtructon of the A occur conderably le frequently, and ther prece evaluaton ha been retrcted by everal techncal problem for both radologc and ultraound method. The major dadvantage of the latter ha been the nablty to drectly record vald data from the aortc arch and t major ntrathoracc branche although the complex hemodynamc alteraton n the carotd and vertebral ytem have long been recognzed. 6 The applcaton of combned W and low-frequency PW oppler analy now avalable conderably mprove the aement of ntrathoracc obtructve leon and the complex hemodynamc change nduced n dtal arteral egment ncludng the ntracranal crculaton. Th partcularly promng nce many patent wth A obtructon (even of 4 n our ere) are neurologcally aymptomatc. The nformaton provded by uch tude may be ued n propectve tral on the natural htory and troke rk aocated wth evere proxmal upra-aortc leon. Snce obtructon of the A often lead to a relevant reducton of the cerebral blood upply and markedly change collateral pathway, the progno of thee patent may be dfferent from thoe wth aymptomatc carotd 47-9 or VA deae. 5-2 Our data from 4 patent ugget that the extracranal hemodynamc tuaton alone doe not correpond wth an ndvdual patent' cerebrovacular event. Smlarly, ntracranal tude howed that each patent had reaonably good ntracranal collateralzaton ndcated by normal peak and mean blood flow velocte and by uffcent collateral cro-flow va the anteror or poteror baal cerebral pathway or even from the rght to the left hemphere n patent wth evere teno of the A and addtonal left-ded carotd artery deae. However, the obervaton of tranent alteraton of blood flow velocty wthn the baal cerebral artere elcted only durng potchemc hyperema of the upper extremte wa cloely correlated wth the ncdence or development of clncal ymptom n thee patent. Furthermore, the event reported could contently be correlated wth the artere that revealed uch a latent teal phenomenon (amauro fugax attack of the rght eye, rght hempherc and brantem event). Pathogenetcally, th mght be explaned ether by a hgher rk of chema from ntermttent ytemc hypotenon or hypocapna n a borderlne hemodynamc ytem or a the reult of mcroembol n low-flow vacular terrtore. Reference. Hennerc M, Aulch A, Sandmann W, Lerut J: Stenoen und Verchlue de Trundu brachocephalcu. tch Med Wochenchr 98 ;6: Ha WK, Feld WS, North RR, Krcheff, hae N, Bauer RB: Jont tudy of extracranal arteral occluon.. Arterography, technque, te and complcaton. JAMA 968;23: Patel A, Toole JF: Subclavan teal yndromereveral of cephalc blood flow. Medcne 965;44: Hennerc M, Hlbomer H-B, Hefter H, Lammert, Rautenberg W: Natural htory of aymptomatc extracranal arteral deae. Bran 987;: Hennerc M, Aulch A, Sandmann W, Freund H-J: ncdence of aymptomatc extracranal arteral deae. Stroke 98;2: Trockel U, Hennerc M, Aulch A, Sandmann W: The uperorty of combned contnuou wave oppler examnaton over perorbtal oppler for the detecton of extracranal carotd deae. J Neurol Neurourg Pychatry 984;47: Reutern von GM, Pourcelot L: ardac cycle dependent alternatng flow n vertebral artere wth ubclavan artery tenoe. Stroke 978;9: Fell G, Phllp J, hko PM, Harley J, Thele BL, Strandne : Ultraonc duplex cannng for deae of the carotd artery. rculaton 98 ;64: Ackertaff RGA, Hoeneveld H, Slowkowk JM, Moll FL, ckelboom B, Ludwg JW: Ultraonc duplex cannng n atheroclerotc deae of the nnomnate, ubclavan, and vertebral artere. A comparatve tudy wth angography. Ultraound Med Bol 984;: Touboul P-J, Bouer M-G, LaPlane, atagne P: uplex cannng of normal vertebral artere. Stroke 986;7: Aald R, Markwalder T-K, Norne H: Non-nvave trancranal oppler ultraound recordng of flow velocty n baal cerebral artere. J Neurourg 982;57: Arnold JB, von Reutern G-M: Trancranal oppler onography. xamnaton technque and normal reference value. Ultraound Med Bol 986;2: Hennerc M, Rautenberg W, Stzer G, Schwartz A: Trancranal oppler ultraound for the aement of ntracranal arteral flow velocty.. xamnaton technque and normal value. Surg Neurol 987;27: Hennerc M, Rautenberg W, Schwartz A: Trancranal oppler ultraound for the aement of ntracranal arteral flow velocty.. valuaton of ntracranal arteral deae. Surg Neurol 987;27: Hennerc M, Klemm, Rautenberg W: The ubclavan teal phenomenon. A common vacular dorder wth rare neurologc defct. Neurology!988;38: Mozerky J, Barne RW, Sumner S, Strandne : Hemodynamc of nnomnate artery occluon. Ann Surg 973;78: hamber BR, Norr JW: Outcome n patent wth aymptomatc neck brut. N nglj Med 986;35: Roederer GO, Langlo Y, Jager KA, Prmozch JF, Beach KW, Phllp J, Strandne : The natural htory of carotd arteral deae n aymptomatc patent wth cervcal brut. Stroke 984;5: Bogoulavky J, epland PA, Regl F: Aymptomatc tght teno of the nternal carotd artery: Long-term progno. Neurology 986;36: Bornten NM, Norr JW: Subclavan teal: A harmle hemodynamc phenomenon? Lancet 986;2:33-35 KY WORS arteral occluve deae ultraonc