J Neurocrit Care.  2020 Jun;13(1):32-40. 10.18700/jnc.200002.

Robotically assisted transcranial Doppler with artificial intelligence for assessment of cerebral vasospasm after subarachnoid hemorrhage

• Esmaeeli S
• Hrdlicka CM
• Bastos AB
• Wang J
• Gomez-Paz S
• Hanafy KA
• Lioutas VA
• Ogilvy CS
• Thomas AJ
• Shaefi S
• Fehnel CR
• Nozari A

• KMID: 2503383
• DOI: http://doi.org/10.18700/jnc.200002

Abstract

Background
Transcranial Doppler (TCD) ultrasound is an essential tool for the detection of cerebral vasospasm after subarachnoid hemorrhage (SAH) but is limited by the availability of skilled operators. We examined the clinical feasibility and concordance of a robotically assisted TCD system with artificial intelligence with routine handheld TCD after SAH.
Methods
We evaluated TCD velocities in the anterior cerebral artery (ACA) and middle cerebral artery (MCA) of two patients with high-grade SAH and angiographic evidence of vasospasm. A single channel TCD device with a handheld diagnostic probe as well as a robotically assisted TCD device was used, the relationship of the two tests was evaluated using the bootstrap method of resampling for the concordance correlation coefficient (CCC) paired with a Pearson’s correlation analysis, followed by a Bland-Altman plot.
Results
Patient 1 developed angiographic and TCD evidence of vasospasm in the proximal right MCA, but except for periods of disorientation remained neurologically intact. Angiographic, TCD and clinical evidence of ACA spasm occurred 6 days after ictus in patient 2. Robotically measured mean flow velocities were comparable to manual TCDs in the MCAs (CCC=0.83; 95% confidence interval [CI], 0.42 to 0.96; P=0.001) but not in the ACAs (CCC=0.26; 95% CI, –0.01 to 0.71; P=0.26).
Conclusion
Robotically assisted TCD system with artificial intelligence provides an alternative to manual TCD for assessment of MCA velocities in patients with SAH, expanding the availability of TCD to settings in which specialized clinicians are not available. Further studies for validation of this technology are warranted.

Keyword

Vasospasm, intracranial; Subarachnoid hemorrhage; Middle cerebral artery; Ultrasonography, Doppler, transcranial; Anterior cerebral artery; Artificial intelligence

Figure

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  Fig. 1. Computer tomography imaging of (A) patient 1 and (B) 2 showing diffuse thick subarachnoid hemorrhage with intraventricular blood.

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  Fig. 2. Angiographic findings in patient 2, (A) initially demonstrating normal calibers in all cerebral vessels and (B) significant vasospasm in bilateral anterior cerebral arteries 6 days after ictus.

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  Fig. 3. (A) Robotic and (B) manual transcranial Doppler waveform of the right middle cerebral artery (MCA) of patient 1 on postictus day 10 demonstrating elevated right MCA mean flow velocity, consistent with vasospasm in both techniques.

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  Fig. 4. (A) Moderate agreement between transcranial Doppler (TCD) findings using robotic technique and TCD findings using manual technique for the middle cerebral artery (concordance correlation coefficient=0.83; 95% confidence interval [CI], 0.42 to 0.96). (B) Poor agreement between TCD findings using robotic technique and TCD findings using manual technique for the anterior cerebral artery (concordance correlation coefficient=0.26; 95% CI, –0.01 to 0.71).

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  Fig. 5. Bland-Altman plot shows no proportional bias, indicating agreement between the two methods for the (A) middle cerebral artery and (B) anterior cerebral artery.

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  Fig. 6. The robotically assisted transcranial Doppler system used in this study (Neural Analytics Lucid Robotic System. Credit: Neural Analytics).

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