Improved Parameterization of the Transcranial Doppler Signal

Patients with symptomatic carotid artery stenosis are at high risk for recurrent stroke. To date, the decision to perform carotid endarterectomy in patients with a recent cerebrovascular event is mainly based on degree of stenosis of the ipsilateral carotid artery. However, additional atherosclerotic plaque characteristics might be better predictors of stroke, allowing for more precise selection of patients for carotid endarterectomy. We investigate the hypothesis that the assessment of carotid plaque characteristics with magnetic resonance imaging, multidetector-row computed tomography angiography, ultrasonography, and transcranial Doppler, either alone or in combination, may improve identification of a subgroup of patients with < 70% carotid artery stenosis with an increased risk of recurrent stroke. The Plaque At RISK (PARISK) study is a prospective multicenter cohort study of patients with recent (<3 months) neurological symptoms due to ischemia in the territory of the carotid artery and < 70% ipsilateral carotid artery stenosis who are not scheduled for carotid endarterectomy or stenting. At baseline, 300 patients will undergo magnetic resonance imaging, multidetector-row computed tomography angiography, and ultrasonography examination of the carotid arteries. In addition, magnetic resonance imaging of the brain, ambulatory transcranial Doppler recording of the middle cerebral artery and blood withdrawal will be performed. After two-years, imaging will be repeated in 150 patients. All patients undergo a follow-up brain magnetic resonance imaging, and there will be regular clinical follow-up until the end of the study. The combined primary end-point contains ipsilateral recurrent ischemic stroke or transient ischemic attack or new ipsilateral ischemic brain lesions on follow-up brain magnetic resonance imaging.

This review provides evidence that the diagnostic accuracy of DUS is high, especially at discriminating between the presence or absence of significant carotid artery stenosis (< 50% or 50% to 99%). This evidence, plus its less invasive nature, supports the early use of DUS for the detection of carotid artery stenosis. The accuracy for 70% to 99% carotid artery stenosis and occlusion is high. Clinicians should exercise caution when using DUS as the single preoperative diagnostic method, and the limitations should be considered. There was little evidence of the accuracy of DUS when compared with CTA or MRA. The results of this review should be interpreted with caution because they are based on studies of low methodological quality, mainly due to the patient selection method. Methodological problems in participant inclusion criteria from the studies discussed above apparently influenced an overestimated estimate of prevalence values. Most of the studies included failed to precisely describe inclusion criteria and previous testing. Future diagnostic accuracy studies should include direct comparisons of the various modalities of diagnostic tests (mainly DUS, CTA, and MRA) for carotid artery stenosis since DSA is no longer considered to be the best method for diagnosing carotid stenosis and less invasive tests are now used as reference standards in clinical practice. Also, for future studies, the participant inclusion criteria require careful attention.

Asymptomatic Carotid Artery Stenosis Screening in Patients with Lower Extremity Atherosclerosis: A Prospective Study

There has been concern regarding the reproducibility of the detection of embolic signals, particularly in patients with carotid artery stenosis in whom the signals are of low intensity. No published studies have examined inter-center agreement in reporting specific embolic signals or the factors responsible for any lack of agreement. We examined reproducibility between two centers in which widely differing proportions of embolic signals have previously been reported in patients with carotid artery stenosis. Recordings from the middle cerebral artery of eight patients with ipsilateral carotid artery stenosis in whom embolic signals had been detected during a previously study were independently examined by three experienced observers in one center and by one experienced observer in another center. We calculated agreement within and between centers by estimating the probability that one observer would identify a specific embolic signal if other observers had identified it (a probability of 1 indicates complete agreement). The influence of different characteristics of the embolic signal on the probability of its detection as an embolic signal was determined. A high level of agreement in the identification of specific embolic signals was found. This was similar between all observers (.90), between the three observers in one center (.89), and between observers in the two different centers (.94). The probability of detection was independently related to the relative intensity of the embolic signal (P<.0001). It was less (although significantly) independently related to the position of the embolic signal in the cardiac cycle (P=.02), with signals in systole being more reliably detected. There was no independent relationship between the probability of detection and either the duration of the embolic signal or the velocity at the maximum intensity increase. The use of threshold intensity as a criterion for embolic signal detection increased interobserver agreement but reduced the sensitivity in detecting signals. The high level of interobserver agreement suggests that the technique is sufficiently reproducible for clinical use.

The water column flow velocity of 36 river sections in the river reach between Hankou (Wuhan) and Wuxue of the middle-lower Changjiang River. Their cross sectional distribution patterns in relation to the river channel morphologies were examined by using ship-mounted ADCP (Acoustic Doppler Current Profiler) instrument. The results indicate four (I-VI) types of river channel morphology associated flow patterns: I—laterally deepening riverbed topographic pattern; II—symmetrical to asymmetrical riverbed topographic pattern; III—relative flat riverbed topographic pattern, and IV—sandbar supported riverbed topographic pattern. All these correspond to the different patterns of flow velocity distribution. The maximum flow velocity is usually related to the deeper water depth, but irregular water column distribution of flow current velocity results often from the vortices’ current associated with river knots. Deeper river water depth is usually identified in the river reach located slightly downstream to the river knot, where faster flow velocity occurs. Downward change in flow velocity fits semi-log law, showing an exponential decreasing flow current with the maximum flow velocity near the water surface. However, in the river reach near the river knots, the water column distribution of flow current velocity does not fit the semi-log law, showing the irregular flow current pattern. This study, in context of river catchment management, highlights the controls of riverbed morphology to the flow current structure, which will shed light on the post study of Three Gorges damming in 2009.

Objective To explore the related factors of subependymal hemorrhage (SEH) and cerebral hemodynamic changes. Methods From October 2012 to October 2017, 200 cases of children with subependymal hemorrhage diagnosed by ultrasound in our department of pediatrics were selected as the observation group , and a total of 150 children who were admitted to the Department of Pediatrics in the same period due to craniocerebral diseases and other serious diseases were selected as control group. The independent risk factors of the children in the observation group were analyzed, and the difference of the maximum systolic blood flow velocity (SV), the diastolic maximum flow velocity (DV), the systolic and diastolic velocity ratio (S/D), the resistance index (RI), and the pulsatile index (PI) were compared between the two groups. Results Neonatal asphyxia, preterm birth, acidosis, neonatal respiratory distress syndrome (NRDS), patent ductus arteriosus and coagulation dysfunction were independent risk factors for subependymal hemorrhage. The bleeding side SV and DV of the observation group were higher than those of the control group, with statistically significant difference (P 0.05). Conclusions Children with ependymal hemorrhage can observe the hemodynamic indexes of anterior cerebral artery (ACA) dynamically by craniocerebral ultrasound, and judge the therapeutic effect by evaluating the systolic and diastolic blood flow velocity, so as to prevent the further aggravation of subependymal hemorrhage Key words: Infant, premature; Subependymal hemorrhage; Hemodynamics; Ultrasonography, doppler, transcranial

The strength of salt bridges resulting from the interaction of cations and anions is modulated by their environment. However, polarization of the solvent molecules by the charged moieties makes the accurate description of cation-anion interactions in an aqueous solution by means of a pairwise additive potential energy function and classical combination rules particularly challenging. In this contribution, aiming at improving the representation of solvent-exposed salt-bridge interactions with an all-atom non-polarizable force field, we put forth here a parametrization strategy. First, the interaction of a cation and an anion is characterized by hybrid quantum mechanical/molecular mechanics (QM/MM) potential of mean force (PMF) calculations, whereby constantly exchanging solvent molecules around the ions are treated at the quantum mechanical level. The Lennard-Jones (LJ) parameters describing the salt-bridge ion pairs are then optimized to match the reference QM/MM PMFs through the so-called nonbonded FIX, or NBFIX, feature of the CHARMM force field. We apply the new set of parameters, coined CHARMM36m-SBFIX, to the calculation of association constants for the ammonium-acetate and guanidinium-acetate complexes, the osmotic pressures for glycine zwitterions, guanidinium, and acetate ions, and to the simulation of both folded and intrinsically disordered proteins. Our findings indicate that CHARMM36m-SBFIX improves the description of solvent-exposed salt-bridge interactions, both structurally and thermodynamically. However, application of this force field to the standard binding free-energy calculation of a protein-ligand complex featuring solvent-excluded salt-bridge interactions leads to a poor reproduction of the experimental value, suggesting that the parameters optimized in an aqueous solution cannot be readily transferred to describe solvent-excluded salt-bridge interactions. Put together, owing to their sensitivity to the environment, modeling salt-bridge interactions by means of a single, universal set of LJ parameters remains a daunting theoretical challenge.

PurposeMetal-based additive manufacturing is a relatively new technology used to fabricate metal objects within an entirely digital workflow. However, only a small number of different metals are proven for this process. This is partly due to the need to find a new set of parameters which can be used to successfully build an object for every new alloy investigated. There are dozens of variables which contribute to a successful set of parameters and process parameter optimisation is currently a manual process which relies on human judgement.Design/methodology/approachHere, the authors demonstrate the application of machine learning as an alternative method to determine this set of process parameters, the subject of this test is the processing of pure copper in a laser powder bed fusion printer. Data in the form of optical images were collected over the course of traditional parameter optimisation. These images were segmented and fed into a convolutional autoencoder and then clustered to find the clusters which best represented a high-quality result. The clusters were manually scored according to their quality and the results applied to the original set of parameters.FindingsIt was found that the machine-learned clustering and subsequent scoring reflected many of the observations which were found in the traditional parameter optimisation process.Originality/valueThis exercise, as well as demonstrating the effectiveness of the ML approach, indicates an opportunity to fully automate the approach to process optimisation by applying labels to the data, hence, an approach that could also potentially be suited for on-the-fly process optimisation.Graphical abstract

OBJECTIVESBetter methods of identifying patients with asymptomatic carotid artery stenosis who are at high risk of stroke are required. It has been suggested that proton magnetic resonance spectroscopy (MRS) may...

To estimate the prevalence and outcome of symptomatic internal carotid artery lesions in young adults. Multicentre hospital based observational study with five year follow up. Seven neurological departments in northern and central Italy. 240 patients (115 men) aged 15-44 with a recent transient ischaemic attack or stroke in the carotid territory. (a) Prevalence of symptomatic internal carotid artery stenosis or occlusion detected by continuous wave Doppler ultrasonography at entry; (b) incidence rates of cerebral, cardiac, and non-vascular death; non-fatal stroke; and non-fatal myocardial infarction. Carotid stenoses of 50-99% and occlusions were found in 38 patients (15.8%). Both conditions were significantly more frequent in patients aged over 35 and in those with hypertension, diabetes mellitus, and stroke at entry. The standardised mortality ratio at five years was 10.5 (95% confidence interval 5.0 to 19.3). Survival of patients with stenoses of 0-49% and occlusions was significantly better than that of patients with stenoses of 50-99%. Carotid stenosis of 50-99% was an independent predictor of death (hazard ratio 7.9; 95% confidence interval 2.2 to 29) and non-fatal stroke (hazard ratio 7.4; 1.5 to 37.4). The prevalence of carotid stenosis or occlusion in young adults after a cerebrovascular event is low. Though patients with high grade symptomatic carotid stenosis are at risk of non-fetal and fetal events, patients with internal artery occlusion apparently have a benign prognosis.

Advanced digital image segmentation framework implemented by using service oriented architecture is presented. The intelligence is not incorporated just in a segmentation method, which is controlled by 11 parameters, but mostly in a routine for easier parameters’ values determination. Three different approaches are implemented: 1) manual parameter value selection, 2) interactive step-by-step parameter value selection based on visual image content, and 3) fast and intelligent parameter value determination based on machine learning. Intelligence of second and third approach is introduced by end-users in the repeated interaction with our prototype in attempts to correctly segment out the structures from image. Fast and intelligent parameter determination predicts a new set of parameters’ values for current image being processed based on knowledge models constructed from previous successful (positive samples) and unsuccessful (negative samples) parameter selections. Such approach pointed out to be very efficient and fast, especially if we have many positive and negative samples in the learning set.

Transcranial Doppler sonography has recently been used to describe cerebral hemodynamics during the Valsalva maneuver in normal human subjects. Since some changes in flow velocity during the Valsalva maneuver seem to reflect the brain's autoregulatory response to a decrease in cerebral perfusion pressure during the strain, we hypothesized that this method could identify vascular territories with impaired autoregulatory capacity. Eight patients with unilateral (n=7) or bilateral (n=1) severe obstruction of the internal carotid artery and impaired vascular responses to the CO2 reactivity test and to dynamic autoregulation testing were studied. We compared changes in flow velocities and blood pressures during defined phases of the Valsalva maneuver in the patients with the results in a group of 17 normal volunteers. We defined two indices to evaluate autoregulatory capacity based on the response to the Valsalva maneuver. During the Valsalva maneuver, changes in flow velocity in the middle cerebral arteries ipsilateral to the lesions showed characteristic abnormalities compared with the normal pattern. Autoregulatory indices of these vessels as defined by the Valsalva maneuver were significantly different from those with normal vascular reactivity to CO2 (P<.0001). There were good correlations between an index based on the changes in flow velocity and blood pressure in phase II and the results of the CO2 test (r=.78; P<.0001) or those of dynamic autoregulatory testing (r=.6; P<.0001). Vascular territories with severely impaired vasomotor reactivity due to carotid obstruction can be identified by transcranial Doppler sonography by their pattern of flow velocity changes if their autoregulatory capacity is challenged during the Valsalva maneuver.

Intracranial artery calcification (IAC) has been demonstrated to be correlated with ischemic stroke, cognitive decline, and other vascular events by accumulating evidences from both Western and Asian populations. The proposed study aimed to investigate its potential mechanisms by evaluating the blood flow velocity and pulsatility index (PI) of cerebral arteries. Consecutive ischemic stroke patients admitted to the Prince of Wales Hospital were recruited after excluding those with atrial fibrillation or poor temporal window. Quantitative measurements of IAC severity were assessed on brain CT scans. Transcranial Doppler (TCD) ultrasonography was performed to evaluate the blood flow velocity of the middle cerebral artery (MCA) and vertebral-basilar artery (VBA). In total, 318 patients were analyzed. Spearman's correlation analysis demonstrated both high MCA systolic flow velocity and high MCA PI were correlated with IAC Agatston score, p < 0.001 individually. Similar correlation was also found between IAC Agatston score and high VBA velocity/high VBA PI, p ≤ 0.001 individually. Multiple logistic regression analysis showed IAC Agatston score was an independent risk factor for high MCA velocity (OR 1.533; 95% CI 1.235-1.903), high VBA velocity (OR 1.964; 95% CI 1.381-2.794), and high VBA PI (OR 1.200; 95% CI 1.016-1.418), respectively. Heavier IAC might cause generalized artery flow velocity changes and increased pulsatility index, which may indicate high resistance within cerebrovasculature.

Nearly 25%-30% of ischemic strokes are due to atherosclerosis of the carotid bifurcation. Cerebrovascular reactivity (CVR) is an indicator for testing hemodynamic status of cerebral circulation. The purpose of the presentation was to determine the effects of CEA (endarterectomy) on cerebral hemodynamics with cerebral hemodynamic change tracking, by measuring the average flow velocities (MFV) in the ipsilateral and contralateral middle cerebral artery (MCA) severe carotid stenosis and pulsatility index (PI) by the help of the Transcranian Doppler (TCD) and the study of CVR (cerebrovascular reactivity) by performing BHT (Breath-holding test) both before and at 7 days and at 2 and 4 months post intervention, as well as cerebral hemodynamic parameters determining through Cerebral Perfusion CT and correlation with risk factors and prior stroke event. Using ultrasound methods ECD (Extracranial Doppler) and TCD (Transcranial Doppler) and imaging (Perfusion Cerebral CT, angioCT cervical region, angiocoronarography) allowed: increased detection of patients at risk of stroke and myocardial infarction, stroke diagnosis of ischemic sites, the calculation of hemodynamic parameters of cerebral circulation at patients with coronary stenosis and carotid stenosis, occlusion with stroke up, TIAs or stroke risk and heart attack.

Cardiovascular Risk Factors in Central Retinal Artery Occlusion: Results of a Prospective and Standardized Medical Examination