Rosa Santos

Segmentation of the carotid intima-media region in B-mode ultrasound images

This paper proposes a new approach for the segmentation of both near-end and far-end intima-media regions of the common carotid artery in ultrasound images. The method requires minimal user interaction and is able to segment the near-end wall in arteries with large, hypoechogenic and irregular plaques, issues usually not considered previously due to the increased segmentation difficulty. The adventitia is detected by searching for the best fit of a cubic spline to edges having features compatible with the adventitia boundary. The algorithm uses a global smoothness constraint and integrates discriminating features of the adventitia to reduce the attraction by other edges. Afterwards, using the information of the adventitia location, the lumen boundary is detected by combining dynamic programming, smooth intensity thresholding surfaces and geometric snakes. Smooth contours that correctly adapt to the intima are produced, even in the presence of deep concavities. Moreover, unlike balloon-based snakes, the propagation force does not depend on gradients and does not require a predefined direction. An extensive statistical evaluation is computed, using a set of 47 images from 24 different symptomatic patients, including several classes, sizes and shapes of plaques. Bland-Altman plots of the mean intima-media thickness, for manual segmentations of two medical experts, show a high intra-observer and inter-observer agreement, with mean differences close to zero (mean between -0.10mm and 0.18mm) and with the large majority of differences within the limits of agreement (standard deviation between 0.10mm and 0.12mm). Similar plots reveal a good agreement between the automatic and the manual segmentations (mean between -0.07mm and 0.11mm and standard deviation between 0.11mm and 0.12mm).

Clinical improvement in patients with orthostatic intolerance after treatment with bisoprolol and fludrocortisone

Orthostatic intolerance is the development of disabling symptoms upon assuming an upright posture that are relieved partially by resuming the supine position. Postural tachycardia syndrome (POTS) is an orthostatic intolerance syndrome characterized by palpitations because of excessive orthostatic sinus tachycardia, lightheadedness, tremor, and near-syncope. Patients usually undergo extensive medical, cardiac, endocrine, neurologic, and psychiatric evaluation, which usually fails to identify a specific abnormality. The authors investigated the autonomic and hemodynamic profile of patients with POTS and the effectiveness of bisoprolol and fludrocortisone. The authors evaluated 11 female patients with POTS before and after medical treatment with a cardioselective bisoprolol β-blocker or fludrocortisone, or both, and 11 age-matched control patients. Variability of heart rate and systolic blood pressure was assessed by fast Fourier transform, and spontaneous baroreceptor gain was assessed by use of the temporal sequences slope and α index. Modelflow was used to quantify hemodynamics. Symptoms in all patients improved greatly after medication. The autonomic and hemodynamic impairment observed in patients with POTS, particularly after orthostatic stress, is treated effectively with bisoprolol or fludrocortisone or both. These results need further confirmation in a controlled double-blind study. Proper medical treatment improves dramatically the clinical and autonomic-hemodynamic disturbances observed in patients with POTS. The data support the hypothesis that POTS is the result of a hyperadrenergic activation or hypovolemia during orthostasis.

Segmentation of ultrasound images of the carotid using RANSAC and cubic splines

A new algorithm is proposed for the semi-automatic segmentation of the near-end and the far-end adventitia boundary of the common carotid artery in ultrasound images. It uses the random sample consensus method to estimate the most significant cubic splines fitting the edge map of a longitudinal section. The consensus of the geometric model (a spline) is evaluated through a new gain function, which integrates the responses to different discriminating features of the carotid boundary: the proximity of the geometric model to any edge or to valley shaped edges; the consistency between the orientation of the normal to the geometric model and the intensity gradient; and the distance to a rough estimate of the lumen boundary. A set of 50 longitudinal B-mode images of the common carotid and their manual segmentations performed by two medical experts were used to assess the performance of the method. The image set was taken from 25 different subjects, most of them having plaques of different classes (class II to class IV), sizes and shapes. The quantitative evaluation showed promising results, having detection errors similar to the ones observed in manual segmentations for 95% of the far-end boundaries and 73% of the near-end boundaries.

A novel automatic algorithm for the segmentation of the lumen of the carotid artery in ultrasound B-mode images

A novel algorithm is proposed for the segmentation of the lumen and bifurcation boundaries of the carotid artery in B-mode ultrasound images. It uses the image contrast characteristics of the lumen and bifurcation of the carotid artery in relation to other tissues and structures for their identification. The relevant ultrasound data regarding the artery presented in the input image is identified using morphologic operators and processed by an anisotropic diffusion filter for speckle noise removal. The information obtained is then used to define two initial contours, one corresponding to the lumen and the other one regarding the bifurcation boundaries, for the application of the Chan-Vese level set segmentation model. A set of longitudinal ultrasound B-mode grayscale images of the common carotid artery was acquired using a GE Healthcare Vivid-e ultrasound system. The results reveal that the new algorithm is effective and robust, and that its main advantage relies on the automatic identification of the carotid lumen, which overcomes the known limitations of the traditional algorithms.

Interplay of cerebral autoregulation and neurovascular coupling evaluated by functional TCD in different orthostatic conditions

BackgroundAdequate cerebral blood flow (CBF) is mainly governed by neurovascular coupling (NC) which adapts local CBF to underlying cortical activity, and cerebral autoregulation (CA) that tends to maintain constant CBF despite changes in arterial blood pressure (BP). Since it was suggested that resistance vessels play an important role in both mechanisms, we investigated their regulative interplay by performing a functional transcranial Doppler (f-TCD) test under different orthostatic conditions.MethodsFifteen healthy volunteers performed a visual reading test stimulation task after stabilized in sitting, supine and upright position on a tilt table. Simultaneously, BP and heart rate (HR) were recorded by a photoplethysmographic method and CBF velocity was measured with TCD in left posterior cerebral artery, and, as a reference, also in right middle cerebral artery. Evoked flow velocity (FV) responses were evaluated by a control system approach for systolic and diastolic data. Parameters studied were baseline FV with eyes closed, stable FV under stimulation (gain), oscillatory feature (natural frequency) and damping (attenuation) of the control system model, rate time, and also systolic and diastolic BP and HR. ANOVA test was used for comparing the values of variables in different postural settings, inferring statistical significance at a p < 0,05 level.ResultsAlthough there was a significant variation on the different orthostatic conditions in systolic (p = 0,027) and diastolic (p = 0,001) BP and HR (p = 0,0001), there was no significant change in the basal or evoked CBF velocities.ConclusionsAn intact CA compensates the different orthostatic conditions completely thus allowing an independent regulation of NC according to the metabolic needs of cortical stimulation.

Autonomic dysfunction affects cerebral neurovascular coupling

ObjectiveAutonomic failure (AF) affects the peripheral vascular system, but little is known about its influence on cerebrovascular regulation. Patients with familial amyloidotic polyneuropathy (FAP) were studied as a model for AF.MethodsTen mild (FAPm), 10 severe (FAPs) autonomic dysfunction FAP patients, and 15 healthy controls were monitored in supine and sitting positions for arterial blood pressure (ABP) and heart rate (HR) with arterial volume clamping, and for blood flow velocity (BFV) in posterior (PCA) and contralateral middle cerebral arteries (MCA) with transcranial Doppler. Analysis included resting BFV, cerebrovascular resistance parameters (cerebrovascular resistance index, CVRi; resistance area product, RAP; and critical closing pressure, CrCP), and neurovascular coupling through visually evoked BFV responses in PCA (gain, rate time, attenuation, and natural frequency).ResultsIn non-stimulation conditions, in each position, there were no significant differences between the groups, regarding HR, BP, resting BFV, and vascular resistance parameters. Sitting ABP was higher than in supine in the three groups, although only significantly in controls. Mean BFV was lower in sitting in all the groups, lacking statistical significance only in FAPs PCA. CVRi and CrCP increased with sitting in all the groups, while RAP increased in controls but decreased in FAPm and FAPs. In visual stimulation conditions, FAPs comparing to controls had a significant decrease of natural frequency, in supine and sitting, and of rate time and gain in sitting position.InterpretationThese results demonstrate that cerebrovascular regulation is affected in FAP subjects with AF, and that it worsens with orthostasis.

Toward hemodynamic diagnosis of carotid artery stenosis based on ultrasound image data and computational modeling

AbstractThe ability of using non-expensive ultrasound (US) image data together with computer fluid simulation to access various severities of carotid stenosis was inquired in this study. Subject-specific hemodynamic conditions were simulated using a developed finite element solver. Individual structured meshing of the common carotid artery (CCA) bifurcation was built from segmented longitudinal and cross-sectional US images; imposed boundary velocities were based on Doppler US measurements. Simulated hemodynamic parameters such as velocities, wall shear stress (WSS) and derived descriptors were able to predict disturbed flow conditions which play an important role in the development of local atherosclerotic plaques. Hemodynamic features from six individual CCA bifurcations were analyzed. High values of time-averaged WSS (TAWSS) were found at stenosis site. Low values of TAWSS were found at the bulb and at the carotid internal and external branches depending on the particular features of each patient. High oscillating shear index and relative residence time values assigned highly disturbed flows at the same artery surface regions that correlate only moderately with low TAWSS results. Based on clinic US examinations, results provide estimates of flow changes and forces at the carotid artery wall toward the link between hemodynamic behavior and stenosis pathophysiology.

Autonomic dysfunction affects dynamic cerebral autoregulation during Valsalva maneuver: comparison between healthy and autonomic dysfunction subjects

The role of autonomic nervous system (ANS) in adapting cerebral blood flow (CBF) to arterial blood pressure (ABP) fluctuations [cerebral autoregulation (CA)] is still controversial. We aimed to study the repercussion of autonomic failure (AF) on dynamic CA during the Valsalva maneuver (VM). Eight AF subjects with familial amyloidotic polineuropahty (FAP) were compared with eight healthy controls. ABP and CBF velocity (CBFV) were measured continuously with Finapres and transcranial Doppler, respectively. Cerebrovascular response was evaluated by cerebrovascular resistance index (CVRi), critical closing pressure (CrCP), and resistance-area product (RAP) changes. Dynamic CA was derived from continuous estimates of autoregulatory index (ARI) [ARI(t)]. During phase II of VM, FAP subjects showed a more pronounced decrease in normalized CBFV (78 ± 19 and 111 ± 16%; P = 0.002), ABP (78 ± 19 and 124 ± 12%; P = 0.0003), and RAP (67 ± 17 and 89 ± 17%; P = 0.019) compared with controls. CrCP and CVRi increased similarly in both groups during strain. ARI(t) showed a biphasic variation in controls with initial increase followed by a decrease during phase II but in FAP this response was blunted (5.4 ± 3.0 and 2.0 ± 2.9; P = 0.033). Our data suggest that dynamic cerebral autoregulatory response is a time-varying phenomena during VM and that it is disturbed by autonomic dysfunction. This study also emphasizes the fact that RAP + CrCP model allowed additional insights into understanding of cerebral hemodynamics, showing a higher vasodilatory response expressed by RAP in AF and an equal CrCP response in both groups during the increased intracranial and intrathoracic pressure, while classical CVRi paradoxically suggests a cerebral vasoconstriction.

Deep brain stimulation does not change neurovascular coupling in non-motor visual cortex: An autonomic and visual evoked blood flow velocity response study

BACKGROUND AND PURPOSE In Parkinsons disease (PD) subthalamic nucleus deep brain stimulation (STN-DBS) improves motor function. Also an effect on the neurovascular coupling in motor cortex was reported due to a parallel activation of a subthalamic vasodilator area (SVA). To address this issue further we analysed neurovascular coupling in a non-motor area. METHODS Twenty PD patients selected for bilateral STN-DBS were investigated with functional transcranial Doppler (f-TCD) before and after surgery. Hemodynamic responses to visual stimulation were registered in left posterior cerebral artery (PCA) and analysed with a control-system approach (parameters gain, rate time, attenuation and natural frequency). To exclude autonomic effects of STN-DBS, we also addressed spectrum analysis of heart rate and of systolic arterial blood pressure variability, and baroreceptor gain. Findings in the PD group were compared with healthy age-matched controls. RESULTS PD patients showed no neurovascular coupling changes in PCA territory, compared to controls, and STN-DBS changed neither blood flow regulatory parameters nor autonomic function. CONCLUSIONS Improvement of vasoregulation in some motor cortical areas after STN-DBS might be related to an improved neuronal functional rather than indicating an effect on the neurovascular coupling or autonomic function.

Functional Transcranial Doppler: Presymptomatic Changes in Fabry Disease

Background and Aim: Cerebrovascular disease may progress asymptomatically in the early stages of Fabry disease (FD). Our aim was to test whether functional transcranial Doppler (fTCD) could provide useful data in the evaluation of these presymptomatic FD patients. Methods: A cohort of 12 adult FD patients from families with the classical phenotype of the disease was evaluated with fTCD in the posterior cerebral artery. Results: Compared to healthy controls, resting blood velocities were significantly lower in the FD cohort (p = 0.032 for systolic, p = 0.021 for diastolic). FTCD suggested a disturbed neurovascular coupling in the visual cortex of FD patients, with lower gain (p = 0.007) and rate time (p = 0.019). Men had a significantly higher attenuation (p = 0.013) and lower natural frequency (p = 0.046) than the heterozygous women. Conclusion: These data are the first to suggest that patients with FD may develop cortical vascular dysfunction in the territory of the posterior circulation, early in the natural history of the disease. If the present findings are confirmed in larger, prospective studies, fTCD will be useful for assessing stroke risk in as yet asymptomatic FD patients, improving preventive therapeutic management.