Towards clinical assessment of cerebral blood flow regulation using ultrasonography : model applicability in clinical studies

For preservation of its vital functions, the brain is largely dependent of a sufficient delivery of oxygen and nutrients. Blood flow to the brain is essentially regulated by 2 control mechanisms i.e. neurovascular coupling and cerebral autoregulation. Cerebral autoregulation aims for constant adequate blood supply by compensating for blood pressure variations by dilatation or narrowing of the cerebral microvasculature. Neurovascular coupling adjusts blood supply to the local metabolic need. Cerebral perfusion and blood flow regulation are compromised in several pathological conditions. Clinical examination of cerebral blood flow and its regulation may therefore provide helpful diagnostic, predictive and therapeutic information. The work in this thesis was aimed at putting a step forward towards development of reliable and clinically usable parameters for cerebral blood flow regulation assessment using ultrasonography. Regarding early diagnostics, screening and monitoring of cerebral blood flow and its regulation, ultrasonography has major advantages over other imaging tools because of its noninvasiveness, cost-effectiveness, easy usability and its good time resolution. It allows examination of blood flow velocities at multiple locations throughout the extra- and intracranial circulation and evaluation of both control mechanisms by transfer function analysis. For evaluation of cerebral autoregulation, transcranial Doppler blood flow velocities in the large middle cerebral arteries have been recorded simultaneously with plethysmographic (finger) blood pressure. Gain and phase of the pressure-flow transfer function have been determined to obtain quantitative measures for cerebral autoregulation. Neurovascular coupling has been assessed by presenting a visual block stimulus to a subject and simultaneous measurement of the blood flow velocity in the artery exclusively supplying the visual cortex. The obtained visually-evoked blood flow response (VEFR) has been considered as the step response of a linear second order control system model providing patient-specific parameters such as gain and damping as quantitative measures for neurovascular coupling . In chapter 2, a clinical study has been described in which extra- and intracranial blood flow velocities (BFVs), measured at multiple sites in the circulation, have been compared between Alzheimer patients (AD), patients with mild cognitive impairment (MCI) and healthy aging controls (HC). BFVs of AD were significantly lowered at proximal sites but preserved at distal sites for the internal carotid artery and middle and posterior cerebral arteries as compared to those of MCI or HC. This specific pattern can presumably be ascribed to reduced distal diameters resulting from AD pathology. MCI BFV were similar to HC BFV in the extracranial and intracranial posterior circulation, whereas they were intermediate between AD and HC in the intracranial anterior circulation. This suggests that intracranial anterior vessels are most suitable for early detection of pathological alterations resulting from AD. The study findings further indicate that extensive ultrasonographic screening of intra- and extracranial arteries is useful for monitoring BFV decline in the MCI stage. Future follow-up of MCI patients may reveal the predictive value of location-specific BFV for conversion to AD. In the same study cohort, dynamic cerebral autoregulation has been studied as discussed in chapter 3. Cerebral autoregulatory gain and phase values were similar for AD, MCI and HC which implies that the cerebral autoregulatory mechanism is preserved in AD. However, the cerebrovascular resistance index i.e. the ratio between absolute time-averaged blood pressure and flow velocity, was significantly higher in AD as compared to MCI and HC indicating that vessel stiffness is increased in AD. Indeed, it appeared to be a potential biomarker for AD development of MCI. The cerebrovascular resistance increase in AD was furthermore confirmed by windkessel model findings of a significantly elevated peripheral resistance in AD. Arterial resistance and peripheral compliance were equal for all groups. From chapter 4, the focus was shifted to assessment of local blood flow regulation. Visuallyevoked blood flow responses (VEFRs) of formerly (pre-)eclamptic patients and healthy controls have been examined to evaluate neurovascular coupling first in a relative young study population. The aim of the study was to investigate whether possible local (pre)eclampsia-induced endothelial damage was reversible or not. The measured VEFRs have been fitted with the step response of a 2nd order control system model. Although inter-group differences in model parameters were not found, a trend was observed that critical damping (z>1) occurred more frequently in former patients than in controls. Critical damping reflects an atypical VEFR, which is either uncompensated (sluggish, z>1; Tv <20) or compensated by a rise in rate time (intermediate, z>1; Tv > 20). Since these abnormal VEFRs were mainly found in former patients (but not exclusively), these response types were hypothesized to result from pathological disturbances. A revised VEFR analysis procedure to account for reliability and blood pressure dynamics has been proposed in chapter 5. This revised procedure consists of the introduction of a reliability measure for model parameters and of a model extension to consider possible blood pressure contribution to the measured VEFR. The effects of these adjustments on study outcomes have been evaluated by applying both the standard VEFR analysis procedure (applied in chapter 4) and the revised procedure to the AD study cohort. Reliability consideration resulted in about 40% VEFR exclusion, mainly due to the models’ inability to fit critically damped responses. Reliability consideration reduced parameter variability substantially. Regarding the influence of blood pressure variation, a significantly increased damping was found in AD for the standard but not for the revised model. This reversed the study conclusion from altered to normal neurovascular coupling in AD. Considering their influence on obtained parameters, both aspects i.e. reliability and blood pressure variation should be included in VEFR-analysis. Regarding clinical study outcomes, neurovascular coupling seems to be unaffected in AD since the finding of an increased damping may be ascribed to ignorance of blood pressure contribution to VEFR. Study conclusions of earlier chapters (4 and 5) emphasize the need for a model incorporating physiological features. In chapter 6, preliminary results have been reported of the application of a newly developed lumped parameter model of the visual cortex vasculature to the 3 different VEFR types. In the new model, regulatory processes i.e. neurogenic, metabolic, myogenic and shear stress mechanisms, act on smooth muscle tone which inherently leads to adjustment of microcirculatory resistance and compliance. This allows the study of effects of pathological changes on the VEFR. It may be concluded that the model provides an improved link between VEFR and physiology. Preliminary results show that the physiology-based model can describe VEFR type representatives reasonably well obtaining physiologically plausible parameter values. Thus, from a clinical perspective it may be concluded that (Duplex) ultrasonography has great potential as a standard screening tool for MCI patients. It seems worthwhile to examine all future MCI patients on extra- and intracranial blood flow velocity and to determine their cerebrovascular resistance index by simultaneous blood pressure recording. Follow-up of MCI patients will reveal the predictive value of these parameters for future AD development. Furthermore, from a methodological perspective, it can be concluded that the current standard of control system analysis to assess local cerebral blood flow regulation has limitations regarding parameter reliability and VEFR interpretation. Both reliability and interpretation may be improved by optimization and control of data acquisition quality and by use of physiology-based models. Physiological mechanisms influencing VEFR establishment should be incorporated in such a model to possibly explain part of its variance. Efforts should be directed to development and validation of physiology-based models aimed at reliable description of VEFRs by physiologically meaningful parameters.