D.H. Evans

Analysis of cerebral blood flow autoregulation in neonates

The dynamic response of cerebral autoregulation to spontaneous changes in arterial blood pressure (ABP) is described by the relationship between cerebral blood flow velocity (CBFV) and resistance-area product (RAP). CBFV was measured with Doppler ultrasound in the middle cerebral artery and ABP with an intra-arterial catheter in 66 neonates. Spontaneous changes in mean ABP were automatically detected and the maximum derivative was used to synchronize the coherent averaging of corresponding CBFV and RAP transients. These were classified into two groups corresponding to intact (group A) or impaired (group B) autoregulation. The cross correlation between RAP and CBFV indicates a significant relationship with a time delay of 5 s for group A. The frequency response of RAP was estimated by the cross spectra with CBFV. Groups A and B present a similar amplitude spectra but the phase spectra of group A lags that of group B. The impulse responses of the two groups are also markedly different and were used to simulate the velocity response to a 5% step change in ABP. Impulse responses were also obtained for four different levels of pCO/sub 2/ showing that hypercapnia leads to an impulse response similar to-that of group B (impaired autoregulation). This method can be used to extend the usual dichotomic classification adopted in clinical studies of autoregulation.

Quadrature-to-directional format conversion of Doppler signals using digital methods

Four possible quadrature-to-directional format conversion methods using digital techniques are described. These are the phasing-filter technique, the extended Weaver receiver technique, the Hilbert transform in the frequency domain, and the complex FFT. All methods are implemented to give separated time domain outputs as well as frequency domain outputs. The theoretical descriptions are verified by practical implementations. Each of the methods has been implemented in real-time using a commercially available digital signal processing board.

Processing Doppler ultrasound signals from blood-borne emboli

Abstract Analysing Doppler ultrasound signals from blood-borne emboli has been hindered by two basic problems. Firstly, the ratio of the signal levels from blood and emboli is greater than the dynamic range of conventional Doppler instruments used to detect such emboli. This causes amplitude overload, which must be eliminated before accurate analysis of embolic data can be performed. Secondly, the temporal resolution of fast Fourier transforms (FFT) usually used to analyse Doppler signals, is insufficient to quantify accurately such short duration signals. This paper describes methods to overcome these two problems. The Doppler signal is recorded from close to the front-end of the velocimeter, and a Wigner distribution analyser is used to provide Doppler spectra with both high temporal and frequency resolution. The resulting sonographic display allows quantitative measurement of embolic events to be made.

Cerebrovascular Response to Dynamic Changes in pCO2

Fifty-six subjects with carotid artery disease were assessed by measuring the cerebral blood flow velocity (CBFV) change in response to inhalation of 5% CO2 in air whilst continuously monitoring the blood pressure (BP). Coherent averaging of the data characterised differences in CBFV, BP, resistance area product and critical closing pressure during changes in end-tidal CO2 (ETCO2). The results primarily demonstrate that the augmentation of ETCO2 increases the CBFV and BP, causing a pressure autoregulatory response, and allows the processes of pressure autoregulation and cerebral vascular reserve to be differentiated.

Implementation of directional Doppler techniques using a digital signal processor

Three methods of deriving directional signals from phase quadrature Doppler signals, using digital techniques, are described. These are the phasing-filter technique, the Weaver receiver technique and the complex FFT. The basic theory behind the three methods is presented, together with the results of digital simulations. Each of the methods has been implemented in real time using a commercially available digital signal-processing board, and their relative processing times are compared. All the methods work well, and the decision to implement one or other in a specific application is likely to rest on secondary factors, such as the need to tape-record the time domain output.

Compensatory fuzzy neural networks-based intelligent detection of abnormal neonatal cerebral Doppler ultrasound waveforms

Compensatory fuzzy neural networks (CFNN) without normalization, which can be trained with a backpropagation learning algorithm, are proposed as a pattern recognition technique for the intelligent detection of Doppler ultrasound waveforms of abnormal neonatal cerebral hemodynamics. Doppler ultrasound signals were recorded from the anterior cerebral arteries of 40 normal full-term babies and 14 mature babies with intracranial pathology. The features of normal and abnormal groups as inputs to the pattern recognition algorithms were extracted from the maximum-velocity waveforms by using principal component analysis. The proposed technique is compared with the CFNN with normalization and other pattern recognition techniques applied to Doppler ultrasound signals from various arteries. The results show that the proposed method is superior to the other techniques, and can be a powerful way to analyze Doppler ultrasound signals from various arteries.

Cerebral blood flow velocity during neonatal seizures

AIM To determine if cerebral blood flow velocity increases during all types of neonatal seizure, and whether the effect is due solely to an increase in blood pressure, transmitted to the cerebral circulation when autoregulation is impaired. METHODS Seizures were diagnosed in 11 high risk neonates using cotside 16 channel video–EEG polygraphy. EEG, cerebral blood flow velocity (CBFV) using transcranial Doppler ultrasound, and arterial blood pressure (ABP) measurements were made. At least two 5–10 minute epochs of simultaneous measurements were performed on each infant. These epochs were then reviewed to eliminate artefacts, and one minute data periods containing a clear seizure onset were created. Each period contained 20 seconds before the seizure. Data periods without seizures from the same infants were also analysed and compared with seizure periods. RESULTS Four infants had purely electrographic seizures—without clinical manifestations. Six infants had electroclinical seizures. One infant displayed both seizure types. A random effects linear regression analysis was used to determine the effect of seizures on CBFV and ABP. A significant increase was found in mean CBFV in those periods containing seizures. The mean percentage change in velocity for all infants was 15.6%. Three infants showed a significant increase in mean ABP after seizures but the overall increase in ABP for all infants was not significant. CONCLUSION Electroclinical and electrographic neonatal seizures produce an increase in CBFV. In some infants the increase is not associated with an increase in blood pressure. These preliminary results suggest that electrographic seizures are associated with disturbed cerebral metabolism. Treatment of neonatal seizures until electrographic seizure activity is abolished may improve outcome for these infants.

A parametric approach to measuring cerebral blood flow autoregulation from spontaneous variations in blood pressure

AbstractAutoregulation maintains cerebral blood flow (CBF) almost constant in the face of changes in arterial blood pressure (ABP). Tests for impairment of this process using only spontaneous fluctuations in ABP, without provoking large variations, are of great clinical interest, and a range of different approaches have previously been applied. Extending earlier work based on linear filters, we propose a simple parametric method using a first order finite impulse response filter. We evaluate the method on ABP and CBF velocity [(CBFV), from trancranial Doppler ultrasound] signals collected in 60 patients with stenosis or occlusion of the carotid arteries. Data were collected during the inspiration of ambient air, a 5% CO2/air mixture, and finally the return to ambient air. Equivalent data were collected in 15 normal subjects. The filters estimated from the data segments with constant inspiratory pCO2 showed the expected high-pass characteristic, which was reduced during hypercapnia and also in patients. Highly significant correlation between the filter parameters and cerebrovascular reactivity (percent increase in CBFV per unit change in end-tidal pCO2) gives further evidence that the filters reflect autoregulation. The method allows simple parametrization of the dynamic autoregulatory responses in CBFV, and the analysis of short (1 min) data segments.

The relationship between cerebral blood flow velocity fluctuations and sleep state in normal newborns.

ABSTRACT: Cerebral blood flow velocity was recorded for an average of 23 4-min epochs during natural sleep in 11 normal full-term newborn babies. Intracranial pressure, core temperature, and respiration were simultaneously and non-invasively monitored. Sleep state was classified using information from EEG, pattern of respiration, and eye and body movements by a trained observer. From a total of 238 epochs, 66 were considered to occur in quiet sleep, 101 in active sleep, and in 77 the baby was awake, in a transitional state or moving excessively. Slow cyclical variations in cerebral blood flow velocity were observed with a frequency of between 2 and 6 cycles/min, and these were of significantly greater amplitude during quiet sleep (24%) compared to active sleep (16%; p < 0.0001, Mann Whitney U test). There was no difference in median cerebral blood flow velocity (7.5 cm/s). The cyclical variation observed in normal babies were similar to those described in preterm babies and adults, at a similar frequency to B waves in intracranial pressure. They may represent vasomotor waves in the small autoregulatory arteries of the brain. Reduction in sensitivity of the receptors initiating the waves may occur in active sleep or there may be competition from other oscillatory mechanisms.

Estimating normal and pathological dynamic responses in cerebral blood flow velocity to step changes in end-tidal pCO2

The regulation of cerebral blood flow (CBF) following changes in arterial blood pressure (ABP) and end-tidal pCO2 (EtCO2) are of clinical interest in assessing cerebrovascular reserve capacity. Linear finite-impulse-response modelling is applied to ABP, EtCO2 and CBF velocity (CBFV, from transcranial Doppler measurements), which allows the CBFV response to ideal step changes in EtCO2 to be estimated from clinical data showing more sluggish, and additional random variations. The confounding effects of ABP changes provoked by hypercapnia on the CBFV are also corrected for. Data from 56 patients suffering from stenosis of the carotid arteries (with normal or diminished cerebrovascular reactivity to EtCO2 changes—CVRCO2 were analysed. The results show the expected significant differences (p<0.05) between EtCO2 steps up and down, the significant contribution from ABP variation, and also differences in the dynamic responses of patients with reduced CVRCO2 (p<0.01 after 10 s). For the latter the CBFV response appears exhausted after about 15s, whereas for normals CBFV continues to increase. While dispersion of individual step responses remains large, the method gives encouraging results for the non-invasive study of compromised haemodynamics in different patient groups.