European Society of Neurosonology and Cerebral Hemodynamics (ESNCH)
European Society of Neurosonology and Cerebral Hemodynamics (ESNCH)
 
Stand / Druckdatum: 25.09.2017

Guidelines

 

 
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Standard examination and report of the extracranial cerebrovascular system

G.-Michael von Reutern/Bad Nauheim, Germany

 
 
 
 
 
 
 
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Further literature:

Grading Carotid Stenosis Using Ultrasonic Methods.
Gerhard-Michael von Reutern; Michael-Wolfgang Goertler; Natan M. Bornstein; Massimo Del Sette; David H. Evans; Andreas Hetzel; Manfred Kaps; Fabienne Perren; Alexander Razumovky; Toshiyuki Shiogai; Ekaterina Titianova; Pavel Traubner; Narayanaswamy Venketasubramanian; Lawrence K.S. Wong; Masahiro Yasaka; on behalf of the Neurosonology Research Group of the World Federation of Neurology.
Stroke. 2012;43:916-921

Abstract—The controversy as to whether Doppler ultrasonic methods should play a role in clinical decision-making in the prevention of stroke is attributable to reported disagreement between angiographic and ultrasonic results and the lack of internationally accepted ultrasound criteria for describing the degree of stenosis. Foremost among the explanations for both is the broad scatter of peak systolic velocities in the stenosis, the criterion that has so far received most attention. Grading based on a set of main and additional criteria can overcome diagnostic errors. Morphological measurements (B-mode images and color flow imaging) are the main criteria for low and moderate degrees of stenosis. Increased velocities in the stenosis indicate narrowing, but the appearance of collateral flow and decreased poststenotic flow velocity prove a high degree stenosis (±70%), additionally allowing the estimation of the hemodynamic effect in the category of high-degree stenosis. Additional criteria refer to the effect of a stenosis on prestenotic flow (common carotid artery), the extent of poststenotic flow disturbances, and derived velocity criteria (diastolic peak velocity and the carotid ratio). This multiparametric approach is intended to increase the reliability and the standard of reporting of ultrasonic results for arteriosclerotic disease of the carotid artery.
 
 

Discussion - Standard examination and report of the extracranial cerebrovascular system

We look forward to your comments and suggestions.

3 comments write comment
 

comment from Galina Baltgaile at 11.09.2014, 12:49

Dear Professor von Reutern, I would be thankful to know your arguments about some subjects of your lecture: 1. Why the examination of V1segment (if the insonation is possible) and V3 segment of VA as well as ophthalmic artery (as a collateral) are excluded from the "non neurologic view" of US examination? Is the pathology of VA in V2 segment more informative for non neurologist? This point of "neurologic" and "non neurologic view " I can not understand clearly since examiners are producing reports for neurologists mostly.
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comment from G. M. von Reutern at 11.09.2014, 12:56

Dear Galina, 1. There is a misunderstanding. In my experience cardiologists and internists examine the vertebral Aa. only at V2. This results in most cases in a report like “flow in both vertebral arteries in physiologic direction” They always miss a proximal occlusion or severe stenosis with collateral filling. The only diagnosis they are able to make is steal. Therefore an examination exclusively at V2 is a “no go” for neurologist. I think you agree. My presentation and language was polemical concerning this point and the basic message is, this field is a purely neurologic one!!! Why I vote for V3? This the point where the effect of collateral flow through cervical arteries is best evaluated as well as the reduced pulsatility in cases of a proximal stenosis. I always start here and sometime this results in an early warning: There may be a proximal obstruction. This will increase my awareness for the V 0 segment.
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comment from Galina Baltgaile at 11.09.2014, 13:03

2.Why the proximal part of ICA (where the stenotic lesions are located most often) and the color flow (B- flow could be in black-white) image of CCA (elongation, plaques...) are excluded from the minimum requirements for documentation? Why the latest is excluded from advanced requirements?
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comment from G. M. von Reutern at 11.09.2014, 13:27

2. We have to differentiate between documentation and examination. Most of our time during examination is spent for documentation. We would be able to make a quick screen in few minutes without documentation and will probably not miss any relevant pathologic findings. In fact personally I take at least 20 min in a normal case including documentation. Documentation is a legal requirement and for so called quality assurance. A minimum requirement takes in account this limitation and is not sufficient for a full diagnosis. In addition requirements change from normal to pathologic findings being more demanding in the latter. In a practice outside hospital it may be difficult to document comprehensively all of the 95 % normal tests for economic reasons. Therefore “minimal requirement”. This was the message of my slide: ”Purposes of documentation” I agree that we can ask for colour and B-Mode at the bifurcation. (I prefer B-Mode in a normal situation) But I think we do need only a spectral display in the more distal ICA in case of minimal requirements.
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comment from Galina Baltgaile at 11.09.2014, 13:08

3.What is your opinion of the possibility to include dissection of VA in V1-V2- V3 segments ( compression of VA in V2?) in a "case specific" part of documentation And finally, I completely agree that the schematic drawing of arteries with marked pathology provides rapid useful information for all doctors. We already use the schematic drawing of all extracranial arteries similar to those in your first slides. Thank you With kindest regards
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comment from G. M. von Reutern at 11.09.2014, 13:33

3. Dissection is indeed of major interest for neurologist. In case of a documentation in V1 it can be seen, in V2 it may be overlooked if somebody is attentive and experienced. Your proposal is helpful, we may add this diagnosis in the slide :” advanced requirements , case specific, as well as the diagnosis of steal effect.
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