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Publication
Doppler Transcraniano no Contexto do Acidente Vascular Cerebral
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Abstract(s)
Introdução: O Acidente Vascular Cerebral (AVC) é uma emergência médica
caracterizada pela interrupção do fluxo sanguíneo cerebral, resultando em défices
neurológicos súbitos associados a uma causa vascular. O AVC isquémico, predominante
nos casos de AVC, apresenta projeções de prevalência crescentes até 2050. O Doppler
Transcraniano (DTC) surge como uma técnica de neurossonologia não invasiva,
económica e reprodutível, com ampla aplicação diagnóstica, prognóstica e terapêutica.
Objetivos: Analisar o impacto e a aplicação do DTC no diagnóstico, monitorização e
prognóstico do AVC isquémico, visando propor um protocolo clínico para a sua
implementação clínica.
Metodologia: Foi realizada uma pesquisa estruturada na PubMed com os termos
MeSH “Stroke” e “Ultrasonography, Doppler, Transcranial”, complementada pela
revisão de referências bibliográficas. Os critérios de inclusão englobaram estudos
publicados entre 2019-2024, em português, inglês ou espanhol, abordando a aplicação
do DTC em adultos com AVC isquémico, incluindo ensaios clínicos, estudos
observacionais e revisões. Excluíram-se estudos sem acesso integral, fora do intervalo
temporal definido, focados noutras patologias ou em populações pediátricas. A seleção
foi realizada em duas fases, com revisão independente de títulos, resumos e textos
completos. Dados relevantes foram extraídos e organizados numa tabela sistemática. A
qualidade metodológica foi avaliada com a ferramenta ROBINS-I (Risk Of Bias In Nonrandomized Studies of Interventions) por dois revisores independentes.
Resultados: Dos 92 estudos identificados, 27 foram incluídos na análise, abrangendo
3768 participantes. Após a avaliação da qualidade metodológica 8 apresentaram baixo
risco de viés e 13 risco moderado. Os restantes estudos incluem revisões sistemáticas e
de literatura, sem avaliação formal do viés metodológico.
Entre os estudos, onze avaliaram o papel do DTC no estudo etiológico do AVC
criptogénico, destacando a deteção de shunt direito-esquerdo (SDE) associado ao
foramen ovale patente (FOP). O DTC, associado ao ecocardiograma transtorácico (ETT),
aumentou a precisão diagnóstica, reduziu custos e riscos. Quando ultrapassadas
limitações técnicas, com recurso a assistência robótica, obteve-se uma sensibilidade
comparável ao ecocardiograma transesofágico (ETE).
Quatro estudos investigaram o prognóstico, analisando a autorregulação cerebral e
sinais microembólicos, preditores de isquemia recorrente e consequentemente, maior
morbilidade. Seis examinaram o papel do DTC na oclusão de grandes vasos. A integração
do DTC na avaliação clínica pré-hospitalar, através do modelo TUCA (Transcranial
Ultrasound and Clinical Assessment), melhorou significativamente o diagnóstico de AVC isquémico por oclusão de grandes vasos. O DTC demonstrou-se eficaz na decisão
imagiológica, sendo comparável à Angiotomografia.
O DTC revelou-se o método não invasivo mais eficaz para a monitorização de hipertensão
intracraniana. Demonstrou também elevado potencial preditivo na avaliação de
terapêuticas de revascularização, assumindo um papel relevante na
avaliação/monitorização da área de penumbra isquémica.
O potencial para integração com machine learning, permitindo a automatização da
caraterização da morfologia das ondas, aprimorou a sensibilidade diagnóstica,
reforçando o DTC como uma ferramenta indispensável no contexto clínico.
Conclusão: O DTC demonstrou ser uma ferramenta essencial no diagnóstico e gestão
do AVC isquémico, com vantagens significativas em termos de acessibilidade, eficácia e
versatilidade. Os achados deste estudo reforçam o seu papel e potencial como método de
primeira linha em protocolos clínicos, sendo necessário maior investimento e formação
nesta técnica.
Introduction: Stroke is a medical emergency characterized by the interruption of cerebral blood flow, resulting in sudden neurological deficits associated with a vascular cause. Ischemic stroke, the predominant cause of stroke, is projected to increase in prevalence by 2050. Transcranial Doppler (TCD) has emerged as a non-invasive, inexpensive and reproducible neurosonology technique with broad diagnostic, prognostic and therapeutic applications. Objectives: To analyze the impact and application of TCD in the diagnosis, monitoring and prognosis of ischemic stroke, with the aim of proposing a clinical protocol for its clinical implementation. Methodology: A structured PubMed search was carried out using the MeSH terms “Stroke” and “Ultrasonography, Doppler, Transcranial”, complemented by a review of bibliographic references. The inclusion criteria included studies published between 2019-2024, in Portuguese, English or Spanish, addressing the application of TCD in adults with ischemic stroke, including clinical trials, observational studies and reviews. Studies without full access, outside the defined time range, focused on other pathologies or pediatric populations were excluded. The selection was carried out in two phases, with independent review of titles, abstracts and full texts. Relevant data was extracted and organized in a systematic table. Methodological quality was assessed using the ROBINSI tool (Risk Of Bias In Non-randomized Studies of Interventions) by two independent reviewers. Results: Of the 92 studies identified, 27 were included in the analysis, covering 3768 participants. After assessing methodological quality, 8 presented a low risk of bias and 13 a moderate risk. The remaining studies included systematic and literature reviews, with no formal assessment of methodological bias. Among the studies, eleven evaluated the role of TCD in the etiological study of cryptogenic stroke, highlighting the detection of right-left shunt (RLS) associated with patent foramen ovale (PFO). TCD, combined with transthoracic echocardiography (TTE), has increased diagnostic accuracy, reduced costs and risks. When technical limitations were overcome, using robotic assistance, sensitivity comparable to transesophageal echocardiography (TEE) was achieved. Four studies investigated prognosis, analyzing cerebral autoregulation and microembolic signs, predictors of recurrent ischemia and consequently greater morbidity. Six examined the role of TCD in large vessel occlusion. Integrating TCD into the pre-hospital clinical assessment, using the TUCA (Transcranial Ultrasound and Clinical Assessment) model, significantly improved the diagnosis of ischemic stroke due to large vessel occlusion. TCD proved to be an effective imaging method, comparable to CT angiography. TCD has proved to be the most effective non-invasive method for monitoring intracranial hypertension. It has also shown high predictive potential in the evaluation of revascularization therapies, playing an important role in the evaluation/monitoring of the ischemic penumbra area. The potential for integration with machine learning, allowing automation of wave morphology characterization, has improved diagnostic sensitivity, reinforcing the TCD as an indispensable tool in the clinical context. Conclusion: TCD has proven to be an essential tool in the diagnosis and management of ischemic stroke, with significant advantages in terms of accessibility, efficacy and versatility. The findings of this study reinforce its role and potential as a first-line method in clinical protocols, requiring greater investment and training in this technique.
Introduction: Stroke is a medical emergency characterized by the interruption of cerebral blood flow, resulting in sudden neurological deficits associated with a vascular cause. Ischemic stroke, the predominant cause of stroke, is projected to increase in prevalence by 2050. Transcranial Doppler (TCD) has emerged as a non-invasive, inexpensive and reproducible neurosonology technique with broad diagnostic, prognostic and therapeutic applications. Objectives: To analyze the impact and application of TCD in the diagnosis, monitoring and prognosis of ischemic stroke, with the aim of proposing a clinical protocol for its clinical implementation. Methodology: A structured PubMed search was carried out using the MeSH terms “Stroke” and “Ultrasonography, Doppler, Transcranial”, complemented by a review of bibliographic references. The inclusion criteria included studies published between 2019-2024, in Portuguese, English or Spanish, addressing the application of TCD in adults with ischemic stroke, including clinical trials, observational studies and reviews. Studies without full access, outside the defined time range, focused on other pathologies or pediatric populations were excluded. The selection was carried out in two phases, with independent review of titles, abstracts and full texts. Relevant data was extracted and organized in a systematic table. Methodological quality was assessed using the ROBINSI tool (Risk Of Bias In Non-randomized Studies of Interventions) by two independent reviewers. Results: Of the 92 studies identified, 27 were included in the analysis, covering 3768 participants. After assessing methodological quality, 8 presented a low risk of bias and 13 a moderate risk. The remaining studies included systematic and literature reviews, with no formal assessment of methodological bias. Among the studies, eleven evaluated the role of TCD in the etiological study of cryptogenic stroke, highlighting the detection of right-left shunt (RLS) associated with patent foramen ovale (PFO). TCD, combined with transthoracic echocardiography (TTE), has increased diagnostic accuracy, reduced costs and risks. When technical limitations were overcome, using robotic assistance, sensitivity comparable to transesophageal echocardiography (TEE) was achieved. Four studies investigated prognosis, analyzing cerebral autoregulation and microembolic signs, predictors of recurrent ischemia and consequently greater morbidity. Six examined the role of TCD in large vessel occlusion. Integrating TCD into the pre-hospital clinical assessment, using the TUCA (Transcranial Ultrasound and Clinical Assessment) model, significantly improved the diagnosis of ischemic stroke due to large vessel occlusion. TCD proved to be an effective imaging method, comparable to CT angiography. TCD has proved to be the most effective non-invasive method for monitoring intracranial hypertension. It has also shown high predictive potential in the evaluation of revascularization therapies, playing an important role in the evaluation/monitoring of the ischemic penumbra area. The potential for integration with machine learning, allowing automation of wave morphology characterization, has improved diagnostic sensitivity, reinforcing the TCD as an indispensable tool in the clinical context. Conclusion: TCD has proven to be an essential tool in the diagnosis and management of ischemic stroke, with significant advantages in terms of accessibility, efficacy and versatility. The findings of this study reinforce its role and potential as a first-line method in clinical protocols, requiring greater investment and training in this technique.
Description
Keywords
Avc Avc Isquémico Doppler Trasncraniano Neurologia Neurossonologia