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Medical and Health Science Journal, MHSJ
ISSN: 1804-1884 (Print) 1805-5014 (Online) Volume 6, 2011, pp. 23-28
DOPPLEROGRAPHIC CHARACTERISTIC OF EXTRA-AND-INTRACRANIAL
HEMODYNAMICS OF THE ACUTE CEREBRAL INFARCTION
The paper studies the characteristics of cerebral hemodynamic in
patients with acute ischemic stroke using ultrasound diagnostics
(dopplerography). It is shown that cerebral atherosclerotic
genesis in patients occurs with the dominated diffuse decrease of
cerebral hemodynamics and increased rigidity and vascular tone
in carotid and extracranial vessels. Significant predominance of
cerebral vessels occlusion, with appearances of average
angiospasm and asymmetric blood flown in intracranial cerebral
vessels, was found among patients with hypertension genesis.
SHERZOD DUSCHANOV
Department of Nervous Diseases
Urgench branch of Tashkent Medical
Academy, Uzbekistan
Keywords:
Extra-and-intracranial hemodynamics, acute stroke, dopplerographic characteristics.
UDC:
616.831-005.4-073.43
Introduction
The problem of the present-day pathogenic therapy of the acute cerebral blood flow
disturbance is the most important in the clinical neurology due to high level of prevalence,
lethality, disability and social adaptation of people affected by the cerebral infarction
(Vereschagin and Piradov, 1999; Yahno and Vilenskiy, 2005). Brain is the main organ
affected by the diseases of different etiology connected with cerebral and vascular
complications (Gusev and Skvortsova, 2001).
Cerebral infarction happens as aftereffect of different pathological processes the main of
which are arteriosclerosis and arterial hypertension (Skvortsova et al., 2006; Pokrovskiy,
1992; Myasnikov, 1965; Barhatov et al., 2006). Prognosis of peculiarities in disease
dynamics and result of the acute cerebral blood flow disturbance can be of decisive
importance in choosing of the first aid and secondary medical treatment (Shnaider and
Vinogradova, 2003; Skvortsova, 2001). Complexity and multiple factors of development
of ischemic infarctions stipulates the necessity of complex study of some aspects of their
pathogenesis (Skvortsova, 2001). Disturbance of hemodynamic is an important issue in
pathogenesis, clinical course and development of complications under the acute cerebral
circulation disturbances (Skvortsova, 2001; Pavlovskaya, 1978). Progressive increase of
numbers of cerebral infarction and its rejuvenation results from the increase of arterial
hypertension and atherosclerosis which are the key factors of pathogenesis of acute
cerebral circulation development. It is quite vividly nowadays that pathological organic
affection of vascular wall goes in line with malfunction of hemodynamic in great vessels of
the brain (Belkin et al., 2006; Gaidar et al., 2008; Yahno and Shtulman, 2003).
Due to the abovementioned, the goal of the current research is studying of peculiarities of
cerebral hemodynamic under the acute ischemic disturbances of the cerebral blood
circulation in case of the atherosclerosis and hypertension.
Data and methods of the research
100 patients with cerebral infarctions of hemisphere localization have been examined,
acute cerebral blood flow disturbance (ACBFD) of atherosclerotic nature appeared as
35% and ACBFD of atherosclerotic and hypertension combination as 65%; 30 patients
were included into the screening group. 41 patients had ischemic stroke in the area of the
right medial cerebral artery and 59 in the area of the left medial cerebral artery. The
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Medical and Health Science Journal / MHSJ / ISSN: 1804-1884 (Print) 1805-5014 (Online)
ischemic infarction patients consisted of 60 men and 40 women, the average age of the
patients was 61.4±3.1. The average age of the screening group was 49±4.8.
All of the patients with the acute cerebral blood flow disturbance received the
homogeneous basic undifferentiated and differentiated treatment of ACBFD.
Undifferentiated therapy included dehydratation by means of the loop diuretics
(furosemide) and/or osmotic diuretics (glycerin), antihypertensive therapy (inhibitors of
angiotensin-converting enzyme, calcium channel inhibitors), cardio-vascular medicine
(electrolytes, cardiac glycoside), spasmolytic medicine (magnesium sulphate),
antihypertensive medicine and antioxidants. Differentiated therapy of ischemic infarctions
was directed into renewal of cerebral circulation (cavinton, pentoxifilin), improvement of
rheological characteristic of blood (heparin, pentocsifilin) and others.
Condition of patients’ severity was evaluated based on two clinical scales - NIH Stroke
Scale (Goldstein et al., 1989) and Scandinavian one (Scandinavian Stroke Study Group,
1985). Research doesn’t cover cases of high severity, in accordance with NIHSS clinical
scales (not more than 29 scores) and Scandinavian scale (not less than 11 scores).
All patients underwent ultrasonic and dopplerography of brachycephalic trunk
examination (UDBT) of common carotid artery (CCA), internal carotid artery (ICA) and
supratrochlear artery, including transcranial dopplerography examination (as well as study
of hemodynamic of medium cerebral artery (MCA), anterior cerebral artery (ACA) and
posterior cerebral artery (PCA) by using “LOGIDOP-4” device (made by
“Kransbuchler”, Germany) equipped with 2.4 and 8 MHz sensor identifying linear and
average blood circulation velocity, and Purselo (RI) and Gosling (PI) indexes. Evaluation
of extracranial sectors of carotid artery was carried out by means of functional test carotid compression test.
Research results
The main neurological occurrence of ischemic hemisphere infarction have been
characterized by the prevailed focal signs: central paralysis of the VIIth and XIIth nerves,
mono- and hemiparesis or hemiplegia, occurrence of pathological reflexes, reflexes of oral
automatism in combination with sensitivity disorders in form of surface or total monoand hemianesthesia. Affection of dominating hemisphere was accompanied by disorder of
higher cortical functions. The average clinical score under the registration of patients with
cerebral infarctions appeared as 20.4±1.7 based on NIHSS scale and 27.8±2.3 as per the
Scandinavian one, what is in both cases the moderated severe level of the disease.
Studying of the age and sexual structure of the disease demonstrates that acute cerebral
blood flow disturbance (ACBFD) of atherosclerotic nature affects more the old men, and
ACBFD of the hypertensive nature affects the young men and women.
Ultrasonic examination of carotid extracranial arteries showed stenotic lesion prevailing
within the internal carotid artery (ICA), atherosclerotic changing of the curve, vasomotor
spasm symptoms and decline in vessels’ reactivity. Signs of the internal carotid artery
stenosis included: increase of the blood flow velocity in bifurcation area; presence of
turbulent blood flow; decline in blood flow velocity in common and/or internal carotid
artery by 30% and more in comparison with contralateral arteries; decrease of diastolic
component of the blood flow velocity in the common carotid artery (CCA) in
comparison with contralateral part; 40% decrease in blood flow velocity in supratrochlear
artery and more in comparison with contralateral part; appearance of the retrograde
blood flow in supratrochlear artery under the compression of 1-2 with homolateral
common carotid artery; blood flow velocity decrease in supratrochlear artery under the
compression of homolateral and/or superficial temporal artery; no decrease of blood flow
velocity in supratrochlear artery under the carrying out of superciliary test of
hemodynamics; no change of blood flow velocity in supratrochlear artery under the
compression of homolateral superficial temporal or facial artery under the blood flow
© 2011 Prague Development Center
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Medical and Health Science Journal / MHSJ / ISSN: 1804-1884 (Print) 1805-5014 (Online)
increase reaction in contralateral artery during the compression of these arteries at the
similar side; changing of spectral characteristic of blood flow in carotid artery.
Ultrasonic and Dopplerography examination of carotid braheocephalous vessels
demonstrated diversified Ultrasonic and Dopplerographic results and was specific for each
of the examined groups of the patients (Table 1).
TABLE 1. DOPPLEROGRAPHIC PERFORMANCES OF EXTRACRANIAL
HEMODYNAMIC OF THE EXAMINED PATIENTS
The examined groups
Screening group
(n=30)
Atherosclerotic stroke
(n=35)
Combination of
atherosclerosis and
hypertension (n=65)
Artery
CCA
ICA
SA (supratrochlear artery)
CCA
ICA
SA
CCA
ICA
SA
GS. cm/sec
88.3±10.5
78.4±12.6
54.5±7.8
65.6±4.2*
51.8±3.98*
30.8±4.8*
60.4±5.4*
45.6±5.7*
27.6±4.1**
Parameters
PI
1.42 ±0.35
0.93±0.52
0.87±0.19
2.49±0.40*
2.14±0.30*
1.62±0.32*
2.53±0.43*
2.18±0.27*
1.69±0.35*
RI
0.65±0.17
0.62±0.23
0.64±0.15
1.25±0.22*
1.26±0.22*
1.05±0.19
1.28±0.25*
1.30±0.25*
1.17±0.21*
Note: reliability of performances in regards to the norm was noted: *- (Р<0.05); **- (Р<0.01);
Atherosclerotic ACBFD have been accompanied by the diffuse atherosclerotic changing
of CCA and ICA dopplerographic curve with the considerable reduce of linear blood flow
velocity level, increase of rigidity of vessel wall. In this group of patients the stenotic
changes of vessels walls in most cases happened both in CCA and ICA. Stenosis reached
critical rate in 28.6% of the cases. 71.42 % of patients with atherosclerotic ACBFD had
low reactivity of the vessels during the compression test. Decrease of linear blood flow
velocity by more than 30% was found in 23 of 35 cases, CCA, ICA and supratrochlear
artery were affected at most of the patients. 8.57% of the patients had retrograde blood
flow, and 34.28% had antegrade blood flow changed into the retrograde one in response
to the compression test. It was noted that quite often in this group (40.0% of the patients)
higher stenosis of extracranial carotid trunks was more at the opposite side from the
affected hemisphere. This group of the examined patients had a statistically significant
increase of Purselo (more than by 40%) and Gosling (more that by 70%) coefficients,
what evidenced the increase of resistance in regards to the blood flow and increase of the
periphery resistance and brachycephalic trunk rigidity.
Under the combination of atherosclerosis and hypertension at the acute cerebral blood
flow disturbance, the ultrasonic and Doppler examination demonstrated the early stenotic
changes which were often located within the internal carotid artery, prevailing from one of
the sides and accompanying with a moderate two-sided vasomotor spasm. This group
more often included hemodynamic stenosis leading to the occlusion of extracranial carotid
brachiocephalic trunk. Reactivity of vessels in this group of patients was in most cases
lowered. Retrograded blood flow in supratrochlear artery was recorded in 20% of the
studied cases, and in 60% of the studied cases the antegrade blood flow after the
compressive test changed in the retrograded direction with the significant hemodynamic
decrease of blood flow velocity in supratrochlear artery and moderate increase of the
vascular tone.
Here is the clinical observation.
Patient named B., 60 years old. Diagnosis: Cerebral vascular disease. The acute
disturbance of cerebral blood flow of ischemic nature, in medium cerebral artery of the
right hemisphere with left-sided hemisyndrome developed as a result of atherosclerosis of
cerebral vessels and hypertension.
Patient was hospitalized to the department of intensive neurology. He complained of a
weakness and numbness in left extremities, headache and giddiness.
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Medical and Health Science Journal / MHSJ / ISSN: 1804-1884 (Print) 1805-5014 (Online)
Impartial observations: systolic noise over the carotid arteries from both sides was
auscultated.
Results of dopplerographic examination: Retrograded blood flow in supratrochlear artery
was recorded; it was disappearing under the compression of homolateral CCA. Under the
compression of homolateral surface of temporal artery blood flow partially reduces. Linear
blood flow velocity in the left ICA is significantly intensified up to 250 cm/sec, it was
impossible to check condition in ICA on the right. Periphery type of curve was recorded
in the common carotid arteries. Blood flow is aggravated in vertebral arteries from both
sides and the main artery, what evidences the compensation of blood circulation by means
of carotid arteries and system of vertebral arteries. The velocity of blood flow in the right
MCA is increased by 34cm/sec and in the left СМА by 40 cm/sec. Blood flow in the
anterior cerebral artery from both sides was not subject to location detection. An intensive
blood flow is recorded in posterior cerebral artery and it becomes more intensive under
the compression of homolateral MCA.
Based on the above mentioned conclusion was made as follows: signs of occlusion of the
right ICA; hemodynamically important stenosis of the left ICA. Diagnosis was confirmed
after the angiography. Source of the collateral blood flow: it was originated from the
vertebral basilar system and extra and intracranial anastomosis through the eye artery.
FIGURE 1. PATIENT B. RETROGRADE TYPE OF BLOOD FLOW
IN THE RIGHT SUPRATROCHLEAR ARTERY
FIGURE 2. PATIENT B. PERIPHERAL TYPE OF CURVE
IN THE COMMON CAROTID ARTERIES
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Medical and Health Science Journal / MHSJ / ISSN: 1804-1884 (Print) 1805-5014 (Online)
FIGURE 3. PATIENT B. STENOSIS OF THE LEFT
INTERNAL CAROTID ARTERY
Studying of the intracranial hemodynamics demonstrated that in case of atherosclerotic
cerebral hemisphere stroke the dominating indicators include reduction of perfusion of
the medium cerebral artery accompanied with rigidity growth of the vessel wall, and
increase of the linear blood flow velocity in homolateral anterior cerebral artery, what is
the sign of stenosis of segments of medium cerebral artery (sometimes with the similar
increase of linear blood flow velocity in posterior cerebral artery). A significant factor
(p<0.05) in this group of patients was also reduction of perfusion in carotid arteries of the
opposite cerebral hemisphere. Presence of symmetrical and asymmetrical arterial flow and
symptoms of labored perfusion against the background of peripheral vasoconstriction and
arteriolosclerosis was recorded as 17.14% of atherosclerotic ACBFD (Table 2).
TABLE 2. DOPPLEROGRAPHIC PERFORMANCES OF EXTRACRANIAL
HEMODYNAMIC OF THE EXAMINED PATIENTS
The examined groups
Screening group
(n=30)
Atherosclerotic stroke
(n=35)
Combination of
atherosclerosis and
hypertension (n=65)
Artery
MCA
ACA
PCA
MCA
ACA
PCA
MCA
ACA
PCA
GS. cm/sec
85.5±8.4
70.6±7.3
60.4±7.8
60.6±6.5**
50.4±6.9*
30.8±7.5**
54.1±8.2**
138±14.5***
100±11.5**
Parameters
PI
0.82±0.11
0.80±0.13
0.78±0.12
2.08±0.22***
1.67±0.16***
1.45±0.18**
2.25±0.24***
1.75±0.16***
2.00±0.15***
RI
0.52±0.12
0.53±0.15
0.55±0.18
0.97±0.20
0.88±0.16
0.83±0.21
1.08±0.25*
0.95±0.22
0.90±0.19
Note: reliability of performances to the norm was noted: *- (Р<0.05); **- (Р<0.01); ***- (Р<0.001)
When cerebral stroke is accompanied with atherosclerosis and hypertension according to
the statistic records such signs as asymmetry of blood flow with hypoperfusion in the
affected area are prevailing (p<0.05). In 45.71% cases there were local changing of blood
flow with turbulence signs, moderate increase of linear blood flow velocity at ACA
(anterior cerebral artery) considerably increasing under the compression of contralateral
CCA (common carotid artery), and considerable increase of linear blood flow velocity at
PCA (posterior cerebral artery) under the compression of homolateral CCA with lowering
of MCA (medium cerebral artery) after the compressive test. In 7.69% of cases there was
recorded absence of blood flow at MCA or presence of residual blood flow. 26.15%
patients suffering from the acute blood flow disturbance accompanied with
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Medical and Health Science Journal / MHSJ / ISSN: 1804-1884 (Print) 1805-5014 (Online)
atherosclerosis and hypertension had moderate increase of the linear blood flow velocity
with the increase of the peripheral resistance and vascular tone index.
Conclusion
The results of the undertaken researches demonstrated considerable difference in
hemodynamic performances of extracranial vessels of the carotid area in case of the acute
cerebral blood flow disturbance of different etiology. Thus, in case of the atherosclerotic
lesion the diffusive decrease of blood flow velocity in the carotid brachiocephalic trunks
dominates under their stenotic lesion of the diffusive two-sided nature and increase of
rigidity and tone of vessels. The diffusive decrease of blood flow velocity against the
growth of rigidity of the vessel wall prevails in intracranial vessels. When atherosclerosis
was accompanied with hypertension, the acute blood flow disturbance was in line with the
early development of stenotic changes with the statistically significant prevailing of the
occlusive lesion and signs of the moderate vasomotor spasm. Intracranial perfusion was
characterized by the asymmetry of blood flow with hypoperfusion in the affected area.
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