bluuebunny/crossref_metadata_2025 huggingface dataset:
A practical approach to neuroimaging in stroke
Authors: Gerrish Amy C. , Auer Dorothee P. , Evans Amlyn L.
Published: March 2020

This chapter, ‘A practical approach to neuroimaging in stroke’, provides an overview on the different imaging modalities used in stroke medicine, including a brief outline of more advanced research tools. There is a recap of imaging used in acute infarction, the Alberta Stroke Programme Early CT Score (ASPECTS), computed tomography (CT) perfusion, magnetic resonance (MR) perfusion, arterial spin labelling, magnetic resonance spectroscopy; subacute imaging as in haemorrhagic transformation of infarcts, fogging effect, contrast enhancement; direct plaque imaging, and ultrasonography. Finally, it explores the dedicated vascular imaging techniques used for assessing the aetiology of stroke and guiding management. Due to the time-critical nature of treatment in stroke, it is important that imaging is readily accessible. With the multitude of imaging modalities and studies available, it is important that clinicians have sufficient knowledge to be able to select the most appropriate test for the patient, and to be aware of potential limitations and diagnostic pitfalls.
Atrial fibrillation and stroke in the older person
Authors: Mangion David
Published: March 2020

‘Atrial fibrillation and stroke in the older person’ (AF) examines this devastating condition that mainly affects older people. Despite the recent introduction of effective and safer anticoagulants, a significant proportion of older people do not receive appropriate stroke prophylaxis. It describes the incidence, epidemiology, risk factors of AF in older people, mechanisms of stroke in AF, antithrombotic therapy in AF, antithrombotic therapy in older people, risk stratification, screening methods, non-pharmacological and pharmacological treatments, barriers to anticoagulation, the impact of falls, disability, frailty, and cognitive issues on decision-making, and the importance of shared decision-making. Without improvements in stroke prevention, the problem of AF-related stroke will only increase.
Intracerebral haemorrhage in older people
Authors: Law Zhe Kang , Sprigg Nikola
Published: March 2020

Chapter 10 refers to ‘Intracerebral haemorrhage in older people’. The chapter has been written by the investigators of the TICH-2 trial, one of the largest trial of intracerebral haemorrhage in the world. The authors review the aetiology, epidemiology, risk factors and in particular the causes of intracerebral haemorrhage in older people (including hypertensive arteriopathy, cerebral amyloid angiopathy, cerebral small vessel disease, anticoagulant-related bleeds, haemorrhagic transformation of infarcts). Less common causes such as haemorrhagic brain metastasis, cortical vein thrombosis, arteriovenous malformation, cavernomas, dural arteriovenous fistulas, aneurysms, and septic or mycotic aneurysms are also discussed. Evolution of neuroimaging patterns after a bleed, approach to investigations and management are discussed in detail, in addition to important trial evidence.
Cerebral small vessel disease: Potential interventions for prevention and treatment
Authors: Blair Gordon , Appleton Jason P. , Wardlaw Joanna M. , Bath Philip M.
Published: March 2020

Cerebral small vessel disease (SVD) is characterized by lacunar acute ischaemic stroke, imaging findings of recent small subcortical ischaemic stroke which may be symptomatic or silent, white matter hyperintensities, lacunes, microbleeds and visible perivascular spaces, and a substantial proportion of haemorrhagic strokes in older people. It is common, especially in the ageing population and accounts for 25% of all ischaemic strokes and up to 45% of dementias. The pathophysiology of SVD-related stroke is different to that of other stroke subtypes and therefore traditional acute and secondary prevention treatments, such as alteplase, antiplatelets, and lipid-lowering therapy, may not be as effective in most lacunar ischaemic strokes. The chapter reviews the potential targets for management of ischaemic stroke and non-stroke presentations of SVD, current medications and their evidence to date, and future targets, medication, and lifestyle combinations and opportunities for drug repurposing that require further study.
Nutrition, feeding, and dysphagia in the older patient with stroke
Authors: Beavan Jessica , Everton Lisa
Published: March 2020

This chapter, ‘Nutrition, feeding, and dysphagia in the older patient with stroke’, is a detailed review of the nutritional problems in the older person with stroke, the changes that occur in the ageing gastrointestinal system, epidemiology of dysphagia after stroke, its relationship with frailty, and the overall prognosis. The authors look in great detail at the management of undernutrition in stroke, the assessment methods, interventions, oral supplementation, enteral feeding, treatment strategies, special situations (e.g. diabetes), dementia, and others. Dysphagia outcome measures, instrumental assessments, and detailed discussions about interventions are reviewed. The authors describe current accepted management, emerging techniques, medicolegal aspects, and suggest a framework which clinicians will find useful.
Communication disorders post-stroke
Authors: Webster Dee , Knapp Sally
Published: March 2020

‘Communication disorders after stroke’ examines the common communication disorders which occur post-stroke and their impact on all aspects of daily life for the older person. It describes impairments of language and speech: aphasia, dysarthria, and apraxia of speech, outlining the theoretical models underpinning assessment and treatment, with specific reference to auditory comprehension, reading, the production of spoken language and spelling. The International Classification of Functioning framework which guides the assessment and rehabilitation of communication disorders, and the methods used to assess breakdown of communication are detailed. The role of the speech and language therapist is explored. The impact of spontaneous recovery and the internal and external factors which impact on suitability for therapy are described. The role of collaborative goal setting is outlined and intervention approaches targeted at the level of the impairment and at increasing communicative activity and social and life participation are explored. The impact of digital literacy, health-related quality of life, and the challenges of the care home setting on the older population are also examined.
Occupational therapy in older people with stroke
Authors: Padamsey Rowena , Drummond Avril
Published: March 2020

‘Occupational therapy in older people with stroke’ examines how occupational therapists (OTs) increase people’s independence, quality of life, and satisfaction in all aspects of daily life. A fundamental philosophy of OT is to treat everyone as an individual, taking into account their personal roles, beliefs, attitudes, function, and environment. Consequently, the approaches to rehabilitation described in this chapter may be applied to both older and younger adults. A case study has been used for illustration. Key aspects of functioning affected by stroke are explored, focusing in particular on cognition and perception. The OT will work with the patient and their family to identify areas of function which are particularly important to them, and will aim to enable people to complete these activities as independently as possible. This chapter gives an insight into key fundamental therapeutic interventions with the older person following a stroke.
Ethical and moral dilemmas including do not attempt resuscitation orders, advanced care planning, and end-of-life care
Authors: Harwood Rowan H.
Published: March 2020

‘Ethical and moral dilemmas including do not attempt resuscitation orders, advanced care planning, and end-of-life care’ examines the difficulties of decision-making in stroke medicine, the definitions of ‘ethics’, laws’, ‘profession’, and ‘culture’; ethical systems (consequentialism, rights and duties, virtues, communication and relationships; practical ethics), principlism (autonomy, beneficence, non-maleficence, and justice), communication, and relationship-based ethics; consent, mental capacity, best interests, quantified decision-making, cardiopulmonary resuscitation, difficulties in feeding decisions, end-of-life care; proxy and substitute decision-making, advance care planning, and shared decision-making. Stroke care raises situations where the best course of action is not clear. Ethical theory helps to understand these dilemmas, but applying them in practice needs knowledge (about stroke and about people), time, skills in communication, teamwork, and managing situations, compassion and sensitivity, and broad-mindedness. This only comes from experience, professionalism, and the support of teams and colleagues. Practitioners must be adept at thinking about benefits, burdens, autonomy, mental capacity, developing communication skills, and building trusting relationships, should respect fundamental rights, and show virtues of honesty, compassion, and courage.
Urinary incontinence after stroke
Authors: Hillarious Amy , Munshi Sunil K. , Harwood Rowan H.
Published: March 2020

‘Urinary incontinence after stroke’ explores the problem of urinary incontinence. It describes the different types of urinary incontinence with a focus on the types of incontinence prevalent after a stroke; the impact of this symptom complex on the psychological state of the patient, mortality, dependency, and institutionalization; the age related changes in the urinary tract; the epidemiology of post-stroke urinary incontinence, risk factors predisposing to it, assessment methods (including bedside assessments), management with identification of transient causes of incontinence, behavioural strategies, pharmacological therapy, treatment of comorbid conditions, and management in special situations. Urge incontinence, stress incontinence, incomplete emptying, functional incontinence, overflow incontinence, and lower urinary tract symptoms, are all discussed in the context of the pathophysiology and management of these conditions.
Fatigue and the older stroke patient
Authors: Kneebone Ian I. , Chan Daniel Kam Yin
Published: March 2020

‘Fatigue and the older stroke patient’ explores with the help of a case vignette and a conceptual model, the complex field of fatigue after stroke. It looks at the definition of fatigue, assessment of fatigue in older stroke patients, mechanisms of fatigue, medical management, and psychological treatment of post-stroke fatigue. While fatigue is common after stroke, research into its management is in its infancy. With respect to the older person there is in particular a deficiency in research not only into fatigue management but also its nature and origins in this age group. Older people often have multiple medical comorbidities that can also cause fatigue and these need to be addressed appropriately. Nonetheless, clinically both psychological and medical management offer treatments that at the individual level may be worthwhile. Further rigorous empirical research particularly considering older people after stroke might assist in refining understanding and treatment of fatigue in this population.
Visual disorders in stroke
Authors: Plunkett Deborah , Dhar-Munshi Sushma
Published: March 2020

‘Visual disorders in stroke’ explores the mechanisms of the disorders, clinical features, prevalence and mechanisms of central visual processing, the functional neurological architecture of vision, the visual pathway, the nature of visual disorders after stroke( central visual loss, eye movement disorders, peripheral visual disorders, visual perceptual disorders), prognosis of post-stroke visual disorders, implications for driving, impact on quality of life and psychological issues, and a description of various support strategies. A comparison of hemianopia with visual neglect and drug-induced visual problems is also discussed. The main focus in stroke rehabilitation is often motor impairment. A significant proportion of stroke patients have unrecognized visual problems resulting in little or no advice or treatment.
Discharge from hospital and early supported discharge
Authors: Gaynor Catherine
Published: March 2020

‘Discharge from hospital and early supported discharge’ provides some useful guidance and outlines the issues that we encounter in facilitating effective discharge from hospital following a stroke. Hospital discharge is an important milestone in a stroke patient’s journey. It marks the end of the acute hospital episode, and the start of a new life living with and adjusting to their stroke and its sequelae. It can be a stressful time for patients and their carers, but careful and thorough discharge planning can help to ease the transition from hospital to home. The chapter explores the timing of discharge, models of care after discharge, early supported discharge, the evidence from SSNAP (Sentinel Stroke National Audit Programme) in the United Kingdom, the initiative of CLAHRC (Collaborative for Leadership in Applied Health Research and Care), guidance from the National Institute for Health and Care Excellence (NICE), institutionalization, role of capacity, role of IMCA (independent mental capacity advocate), communication with primary care, and follow-up after discharge from hospital.
Secondary prevention and revascularization in the older person
Authors: Minhas Jatinder S. , Mistri Amit K. , Robinson Thompson G.
Published: March 2020

‘Secondary prevention and revascularization in the older person’ examines the proven and contentious issues of secondary prevention strategies following stroke or transient ischaemic attack; however, the majority of large randomized clinical trials supporting individual interventions are in a younger population than real-life, older, stroke survivors. Various strategies for secondary prevention, lifestyle approaches, research trials of antithrombotic therapy and blood pressure reduction, lipid modification, atrial fibrillation, glycaemia, surgical interventions, and intracerebral haemorrhage are dealt with in detail. The older population has greater disability and dependency from stroke and other comorbidities, and the benefits and risks of secondary prevention therapy may therefore differ from their younger counterparts. While there is a need for further research on secondary prevention strategies in older populations, the current management involves incorporation of evidence-based approaches into a pragmatic individualized approach, with careful consideration of risks and benefits.
Hypertension in older people
Authors: Sunman Wayne
Published: March 2020

‘Hypertension in older people’ highlights the issues concerning ageism in the diagnosis and management of hypertension, the prevalence, future predictions, and its historical aspects. Stroke is a disease of old age. The average age of stroke patients passing through our stroke unit is 76 years, in common with other units in the United Kingdom. Trials examining only those patients under 80 years old are examining a skewed population, in which around 40% of patients have been excluded. The author examines several trials of blood pressure lowering in older people, age related changes in blood pressure, the importance of systolic versus diastolic hypertension, targets of blood pressure control, impact of frailty, dementia, and cognitive impairment, orthostatic hypotension, and diabetes. Post-stroke blood pressure management is discussed in greater detail along with a review of the important trials in this group of patients.
Post-stroke cognitive impairment
Authors: Ankolekar Sandeep , Simoni Michela
Published: March 2020

‘Post-stroke cognitive impairment’ explores in great depth the burden of post-stroke cognitive impairment, its pathological substrates and clinical characteristics, the causes of these impairments, post-stroke dementia, and the risk factors implicated. The chapter examines common definitions (vascular cognitive impairment, vascular dementia, post-stroke cognitive impairment), the DSM-5 criteria (Diagnostic and Statistical Manual of Mental Disorders-5), ICD-10 criteria (International Classification of Diseases), NINDS-AIREN criteria (National Institute of Neurological Disorders and Stroke and the Association Internationale pour la Recherche et l’Enseignement en Neurosciences) for vascular dementia, and vascular mild cognitive impairment. The VASCOG (vascular cognitive disorder) criteria are also described. A pragmatic approach to investigations and various assessment scales, a description of important clinical trials, and the management of these disorders are also included.
Stroke care in the community and long-term care facilities
Authors: Gordon Adam L. , Logan Phillipa A.
Published: March 2020

‘Stroke care in the community and long-term care facilities’ explores the ‘good common-sense’ approach to care in these situations. The technical aspects of stroke rehabilitation and maintenance of function in the community are discussed as well as the influence of many jurisdiction- and healthcare system-specific issues. Working to patient-centred treatment goals in non-clinical settings requires adaptability and improvisational skills and the ability to accommodate often imperfect management plans. Ethical dilemmas, the limitations of real-world settings, challenges of multidisciplinary teams, negotiating boundaries of rehabilitation, and models of care are explored. All of these require stroke-specific training and experiential learning to establish the community-specific competencies required to deliver high-quality specialist care. Simplicity is in the eye of the beholder and is often only witnessed when care is delivered by highly specialized teams who understand the very demanding nuances of providing care within such settings.
Research trials in the older stroke patient
Authors: Krishnan Kailash , Sprigg Nikola
Published: March 2020

‘Research trials in the older stroke patient’ examines the challenges of research in older people, the phenomenon of ageism, the impact of frailty, trials of acute treatments like intravenous thrombolysis and endovascular therapy, acute lowering of blood pressure, and decompressive hemicraniectomy. Trials looking at secondary prevention, including cardioembolism, role of the newer oral anticoagulants (DOACs), carotid endarterectomy, lipid lowering, antihypertensive therapy, are examined. The broader issue of difficulties in recruiting older people to stroke trials and the potential solutions are discussed. Until recently most participants in clinical trials of stroke have been relatively young with little or no comorbidity. With a group growing more than any other, it becomes a priority to understand the challenges in recruiting and retaining older patients into clinical trials. Barriers to recruitment relate to both researchers and participants; solutions include good communication, logistical support, and innovative study design and sampling. Further research will hopefully narrow the gap to those seen in real-world clinical practice.
End-of-life care in stroke
Authors: O’Kane Declan
Published: March 2020

‘End-of-life care in stroke’ examines the specific challenges in stroke, the challenges and difficulties of decision-making, identifiers of poor outcome, defining what is ‘good stroke death’, effective communication, role of resuscitation, clinically assisted hydration and nutrition, prepalliative care plans, personalized end-of-life care for the dying patient, symptom control, and issues concerning grieving and caring for the staff members.

Over 80% of stroke deaths happen in those over 75. In most cases of life-threatening stroke, mental capacity is lost. Advanced care planning is rarely done and issues around decision-making are often challenging for those close to the patient. Families need an active communication process from day one with a realistic discussion of options. Where a poor outcome is feared, this needs communicating with reassurance and decisions made that would reflect the wishes and best interests of the person.
Common Doppler artefacts and pitfalls
Authors: Huang Stephen
Published: March 2020

Artefacts are spurious signals that do not represent true signals or physical structures. It is important to differentiate artefacts from genuine signals in ultrasound studies as this may help avoid misinterpretations and measurement errors. The nature of many Doppler ultrasound artefacts is similar to 2D echocardiography artefacts, including inappropriate gain settings, mirror artefacts, and reverberation artefacts. However, as Doppler ultrasound is used to detect blood flow and myocardial velocity, it is susceptible to insonation (Doppler) angle error, aliasing, and other velocity-related artefacts. These will be presented in this chapter as two main types of artefacts: one that is related to spectral Doppler, and the other related to colour-flow Doppler ultrasound.
Haemodynamics for echocardiography
Authors: Huang Stephen
Published: March 2020

Haemodynamics is the study of the physics of blood flows through the cardiovascular system, and is mainly concerned with the physical factors that controls the blood flow. Experienced clinicians and echocardiographers can deduce the haemodynamic status of a patient from examining the shapes, velocities, timings, and durations of the Doppler spectrum without performing any sophisticated measurements. If accurate measurements are needed, the operators need recourse to advanced concepts in fluid dynamics. For example, the simplified Bernoulli equation and continuity equation are often used for pressure gradient and orifice size estimations. Although these equations are used in everyday echocardiography, misunderstanding and misuses of the equations are common because the assumptions and limitations of these equations are fully appreciated. Further, haemodynamics is not a single concept. Rather, it is a collection of different concepts and that makes learning and teaching haemodynamics as one of least appealing but most challenging area in echocardiography. This chapter revisits the basic concepts of haemodynamics and their applications in echocardiography.
Cardiac mechanics
Authors: Huang Stephen
Published: March 2020

Cardiac mechanics involves the study of the mechanical properties of the heart (ventricles) as a pump, and the physical factors that alter these properties. Neurohumoral factors aside, the function of the heart is determined by its intrinsic physical properties as well as extrinsic physical factors. The intrinsic properties include ventricular wall stress, elastance (stiffness) of the ventricle, contractility, and heart rate. The main extrinsic physical factors are blood volume, vessels properties, and extracardiac pressures. This chapter will review these intrinsic properties and how they interact with extrinsic factors to alter the cardiac (pump) function. Neurohumoral factors are excluded in this consideration. LaPlace’s law will be introduced to explain the idea of ventricular wall stress, hence the concepts of preload and afterload. The left ventricular pressure–volume relationship will be reviewed to explain how preload, afterload, and ventricular contractility interact and affect stroke volume. Finally, for completeness, the Frank–Starling relationship and Guyton’s venous return graph will be covered to explain steady state cardiac output.
Left ventricular systolic function
Authors: Fletcher Nick
Published: March 2020

Left ventricular systolic function assessment is an essential component of the echocardiographic assessment of the critically ill patient. A wide range of diseases from sepsis to coronary ischaemia can affect the left ventricle (LV). An understanding of the events and timings in LV systole within the cardiac cycle is important, together with an appreciation of LV anatomy and geometry. Advanced echocardiography requires the competence to obtain all the imaging planes relevant to the LV in transthoracic (TTE) and transoesophageal (TOE) echocardiography. Ejection fraction is currently regarded as the gold standard for LV function and biplane Simpson’s method is the most accurate way to measure this at the critical care bedside, although newer applications such as strain may become more widely used in future. Imaging can be technically difficult in critically ill patients and a detailed knowledge of sources of technical error and physiological confounders is crucial. For the same reason, a knowledge of the alternative methods of LV systolic assessment to employ is also important. Many intrinsic diseases of the heart will be encountered in daily practice and require communication and referral to cardiologists. It is important in this setting that both clinicians are able to converse in the universal language of echocardiography. A comprehensive knowledge of regional wall anatomy and function will enable prompt diagnosis and management of coronary syndromes, particularly as onset of dysfunction can be rapid and serious in critical illness. Finally, an understanding of LV function and assessment in the context of sepsis syndromes is a key concept.
Left ventricular diastolic function
Authors: Hilton Andrew
Published: March 2020

Abnormalities of diastolic function in the critically ill have been demonstrated to be associated with important intensive care outcomes such as mortality and ventilator weaning failure. The assessment of left ventricular (LV) diastolic function refers requires the analysis of the onset, pattern, and termination of left ventricular filling as determined by the time course and magnitude of the pressure gradient between the left atrium (LA) and LV. Echocardiographic two-dimensional and Doppler findings can provide an indirect assessment of the pattern of LV filling and LA–LV pressure gradients. Current guidelines suggest as a minimum the measurement of LA area and volume, mitral inflow velocities, mitral annular velocities, and tricuspid regurgitant flow velocity (as an indirect assessment of left atrial pressure). Other measurable parameters are also available (e.g. pulmonary venous inflow velocities, isovolumic relaxation time, Colour M-mode mitral propagation velocity) and these may help in identifying and characterizing diastolic dysfunction. Generally, however, they are more difficult to perform. Irrespective of the echocardiographic findings measured and the guidelines followed, there is a paucity of data that validates either the individual measures or the guidelines themselves in the critically ill.
Pulmonary hypertension
Authors: Slama Michel , Maizel Julien
Published: March 2020

Acute pulmonary hypertension (PH) is common in ICU patients, particularly in septic shock, acute respiratory distress syndrome (ARDS), pulmonary embolism, and cardiac heart failure. Although many patients with lung diseases develop chronic PH, primary pulmonary arterial hypertension is less frequent, but still can be observed in ICU patients. Pulmonary arterial pressure (PAP) can be assessed using continuous-wave Doppler with the help of colour Doppler. Tricuspid regurgitation can be recorded with systolic as well as mean PAP estimated respectively from maximal and mean velocity of flow. Excellent correlations with invasive methods were found despite PAP increasing with age, body mass, and arterial hypertension. Pulmonary regurgitation is useful to estimate diastolic, mean, and systolic PAP. The right ventricular outflow tract flow can be used to rule out or rule in PH. Also, isovolumic contraction time on tissue Doppler imaging (TDI) tricuspid annular velocities allows prediction of systolic PAP (sPAP). Chronic and acute PH are usually associated with dilation of the right ventricle, atrium, and inferior vena cava as well as paradoxical septal movement. Right ventricular hypertrophy, right ventricular systolic function, and the size of the left ventricle can help to differentiate chronic from acute PH.
Preload and fluid responsiveness
Authors: Vignon Philippe
Published: March 2020

Critical care echocardiography (CCE) provides various parameters to assess fluid requirement in critically ill patients with circulatory compromise. Static parameters are based on both the measurement of the size of left ventricular cavity at end-diastole and of the inferior vena cava at end-expiration. Although low values are indicative of overt hypovolemia, static indices reflecting left ventricular preload and venous return fail to accurately predict fluid responsiveness. Accordingly, dynamic parameters based on heart–lung interactions have been validated, mostly in patients with septic shock. In mechanically ventilated patients, respiratory variations of the size of both superior and inferior vena cava, and of Doppler velocity recorded in the left ventricular outflow tract are proposed to predict fluid responsiveness. Due to their intrinsic respective limitations, these dynamic indices are complementary and can be used concomitantly according to the clinical presentation. Passive leg raise can be used in ventilated or in spontaneously breathing patients to predict fluid responsiveness. In addition, CCE accurately evaluates both the efficacy and tolerance of fluid challenges and provides a non-invasive monitoring of haemodynamics in unstable patients.
Pericardial effusion and cardiac tamponade
Authors: Hilton Andrew
Published: March 2020

Cardiac tamponade results from an increase in pericardial pressure that is sufficient to impede cardiac filling, resulting in high venous filling pressures, low cardiac output, and end-organ hypoperfusion. Most often this is due to the accumulation of a pericardial effusion though there are other possible causes. Patients usually present with features of cardiogenic shock, though some may initially be normotensive or hypertensive. Echocardiography can diagnose the presence of pericardial disease, especially pericardial effusion. Any associated haemodynamic sequelae can often be inferred by static and dynamic two-dimensional echocardiographic and Doppler measured intracardiac flow velocity abnormalities. These include atrial and ventricular wall inversion or collapse, and increased respiratory phasic flow velocities in tricuspid and mitral inflow. The concepts of transmural pressure, pericardial restraint, interventricular dependence, and cardiorespiratory interactions underpin the understanding and limitations of these echocardiographic findings. However, the impact of positive pressure ventilation remains problematic with respect to the interpretation of Doppler-derived intracardiac flow velocity variation. Echocardiography can also identify conditions that may confound the interpretation of accepted echocardiographic criteria (e.g. right ventricular hypertrophy, hypovolaemia, isolated chamber compression after cardiac surgery) and diagnose conditions that may mimic or exaggerate tamponade pathophysiology such as large compressive pleural effusion. Finally, echocardiographic criteria can aid stratification of the risk of tamponade in patients with pericardial effusion, and if necessary, guide percutaneous pericardiocentesis.
Adult congenital heart disease
Authors: Hilton Andrew
Published: March 2020

The prevalence of congenital heart disease (CHD) in adults is increasing and many of these are likely to be admitted to the intensive care unit (ICU). Some of these patients may have undiagnosed CHD, usually relatively simple lesions such as atrial and ventricular septal defects. Occasionally, these may be more complex lesions (e.g. Ebstein’s anomaly) that even if unrecognized earlier in life can still allow survival into adulthood. Whether simple or complex, CHD can complicate the management of the critically ill patient, particularly if shunting or heart failure is present. The critical care echocardiographer is required to both recognize both normal anatomical variation and definite abnormal structural abnormalities in the adult patient. The aim of this chapter is to familiarize the echocardiographer with common anatomical variants, such as remnants of the right valve of the sinus venosus and crista terminalis, and present a careful and systematic approach to echocardiographic examination that may reliably identify relatively simple undiagnosed CHD in the adult.
Miscellaneous
Authors: McLean Anthony
Published: March 2020

Although not commonly encountered in daily clinical practice, with the exception of atheromatous disease in the older population, disorders of the thoracic aorta often present dramatically and require urgent evaluation. Echocardiography is ideally suited for this purpose, particularly in the critical care setting where both transthoracic echocardiogram (TTE) and transoesophageal echocardiography (TOE) can play important roles in the bedside diagnosis and management of afflicted patients. An understanding of the anatomical relationships of the aorta within the thoracic cavity is important, in addition to specific pertinent findings within each of the different pathologies. The physician should be on the alert for complications following acute myocardial infarction and echocardiography is central to the majority of diagnoses. A baseline echo for all critically ill patients who have suffered an infarction is recommended. Constrictive pericarditis, when encountered is usually unexpected, and can be life-threatening if not diagnosed quickly in the critical care setting. As such, the physician needs to know certain echocardiographic features that assist in the diagnosis.
Hypotension
Authors: Colreavy Frances
Published: March 2020

In critically ill patients it is imperative to resolve and treat the cause of haemodynamic shock as quickly as possible in order to save lives and minimize end-organ damage. Intensive Care doctors trained to perform echocardiography can rapidly diagnose and effect management changes in hypotensive patients. A goal-directed approach is required seeking to urgently identify and differentiate distinct clinical syndromes that may occur in this setting. Such an approach utilizes the primary transthoracic echocardiographic subcostal, parasternal, and apical windows and identifies the key issues that can be addressed in the available views. Key to the success of goal-directed echocardiography is the integration of clinical and echocardiographic data in each individual patient. Keeping an open mind regarding the coexistence of more than one cause of hypotension and the need for more comprehensive echocardiography testing is important. Specific situations such as papillary muscle rupture, localized tamponade following cardiac surgery and prosthetic valve malfunction are more reliably diagnosed using the transoesophageal approach. Some diagnoses, such as aortic dissection, acute mitral or aortic regurgitation and acute cardiomyopathy require a multidisciplinary approach and immediate consultation with Cardiology and cardiothoracic services will be required. The simultaneous interpretation of echocardiographic images and the institution of active management are what distinguish critical care echocardiography.
Acute pulmonary embolism
Authors: McLean Anthony
Published: March 2020

Pulmonary embolism in conjunction with deep venous thrombosis comes under the diagnostic category of venous thromboembolism, a condition with an overall annual incidence of 100–200 per 100 000 people. Acute pulmonary embolus is not uncommon in the critical care population and autopsy series reveal it is frequently undiagnosed this setting. Echocardiography plays a vital role as in the diagnosis and risk stratification, and can be applied in a rapid and non-invasive manner. To assist in appropriately timed management the advanced practitioner needs a wide range of skills using M-mode, 2D, Doppler, and tissue Doppler imaging to fully evaluate the pathophysiological effects of an acute pulmonary embolus.
Septic shock
Authors: Chew Michelle S.
Published: March 2020

Failure or dysfunction of the cardiovascular system is the defining feature of septic shock. While there is now evidence for the central role of the heart in the pathophysiology of septic shock, it is important to remember that it is only one component of the cardiovascular system. Thus, it is often impossible to distinguish between the direct effects of sepsis on the heart and its responses to other changes in the cardiovascular system. Systolic, diastolic, left, and right heart functions are variably affected and are not mutually exclusive. They may be associated with rises in cardiac troponins and may be associated with underlying cardiovascular disease. Current evidence suggests left ventricular systolic dysfunction (assessed as reduced ejection fraction) is not associated with increased mortality, while diastolic dysfunction seems to be more predictive. Right heart failure occurs commonly, even with lung-protective ventilation strategies. Echocardiography is currently the only bedside technique providing comprehensive information regarding heart function during sepsis. In combination with information obtained with pulmonary arterial catheterization, it may be used to monitor the effects of fluid loading, mechanical ventilation, and vasopressor/inotropic therapy in the patient with septic shock. Future areas of research include (1) the development of a universal definition for septic cardiomyopathy; (2) investigating methods for distinguishing sepsis-specific changes from underlying disease; (3) investigating the relationship between cardiac biomarkers and echocardiographic changes; (4) investigating new echocardiographic markers of systolic and diastolic function; (5) integration of lung-protective mechanical ventilation and haemodynamic management strategies guided by echocardiographic findings.
Acute respiratory failure
Authors: Balik Martin
Published: March 2020

Acute respiratory failure is a common reason for admission to the intensive care ward and it is frequently accompanied by haemodynamic instability. Obligatory assessments in every patient should include left ventricular function, left atrial and left ventricular filling pressures in addition to an assessment of right ventricular function and the pulmonary circulation. A systematic echo protocol is warranted to judiciously decide on treatment strategy, including optimization of the patient’s preload, contractility, heart rate, and afterload. This allows for a more effective management of the respiratory disequilibrium, which can continue to be monitored by ultrasound examination. Monitoring of lung parenchyma and pleural space adds to the echo derived information and assist the physician in deciding on an optimal ventilation strategy, need for bronchoscopy, pleural drainage, and patient positioning including proning. The appropriateness of prescribed therapy for the acute respiratory failure can then be monitored by echocardiography and lung ultrasonography to optimize pulmonary gas exchange without haemodynamic deterioration and conversely improve the patient’s haemodynamic status without adding an unnecessary burden onto the respiratory system. After respiratory failure responds to treatment, echocardiography can then assist with the weaning and subsequent withdrawal of mechanical ventilatory support. Where respiratory failure does not respond to conventional measures, a rapid assessment with echocardiography and chest ultrasound helps to decide whether to proceed to extracorporeal life support and, if adopted, its optimal configuration.
Echocardiography in trauma
Authors: Nanjayya Vinodh
Published: March 2020

Trauma is a major cause of morbidity and mortality across the globe. Patients with trauma may have blunt or penetrating, cardiac, or non-cardiac injuries. Echocardiography has a role to play in the evaluation of a cardiac as well as non-cardiac trauma patient, not only in the trauma resuscitation phase but also during the critical illness period. Often, time is very limited and detailed echocardiography is possible only in the postresuscitation phase. In a resuscitation scenario, focused assessment protocols are used to evaluate for life-threatening cardiac injuries. In the postresuscitation phase, echocardiography may help by unmasking a pre-existing cardiac pathology or trauma related pathology which may influence management. Transoesophageal echocardiography should be considered if transthoracic views are inadequate. Echocardiography may also diagnose a cardiac pathology related to the critical illness like pulmonary embolism or critical care cardiomyopathy. The main emphasis of this chapter is on traumatic cardiac and aortic injuries.
Strain imaging in right ventricle assessment
Authors: Orde Sam
Published: March 2020

The right ventricle is now recognized as being integral to cardiac mechanics and analysis of its function is an essential part of any echocardiogram performed in the critically ill patient. However, it has a complex triangular conical shape and is located retrosternally making it difficult to image. Unlike the left ventricle (LV) with its myocardial fibres in many different directions, the right ventricle (RV) has a predominance of longitudinal fibres with most of its movement being in a basal to apex direction. This makes it sensitive to analysis with speckle tracking echocardiography analysis of longitudinal strain: commonly reported as right ventricle free wall strain. Strain is a measure of relative myocardial deformation analysed through tracking of the speckles that make up the myocardium on the two-dimensional B-mode image. It is a postprocessing imaging tool and experience in echocardiography is required before tackling this form of assessment. Strain is sensitive, reproducible, angle independent, not prone to translational error like other conventional echocardiography tools and most importantly can recognize cardiac dysfunction and mechanics that cannot be described by other non-invasive imaging techniques. No echocardiography parameter used to assess right ventricle function is perfect, including right ventricle strain assessment. However its advantages are witnessed by the fact that it has entered clinical practice (exclusively to cardiology departments at this stage) in many larger centres around the world.
Contrast echocardiography
Authors: Orde Sam
Published: March 2020

Echocardiography in the intensive care unit (ICU) is notorious for being difficult to perform, leading to frustratingly non-diagnostic studies with a lack of confidence in findings. The use of ultrasound contrast to enhance these images has the potential to salvage inconclusive studies and change management in critically ill patients. Ultrasound contrast, once ‘activated’, produces tiny microspheres containing an inert gas with a stabilizing shell with a diameter of approximately 1–5 μ‎m. Injected intravenously they pass through the pulmonary microcirculation into the systemic circulation. They last approximately 3–5 minutes and remain entirely in the vascular space. The gas is released unchanged by the lungs and the stabilizing shell is typically metabolized by the reticuloendothelial system or by fatty acid metabolism. These agents are essentially safe in the critically ill. Minor side effects occur in 1–2% and are alleviated by ceasing administration. There is a 1 in 10 000 chance of an anaphylaxis-type reaction and hence cardiopulmonary monitoring for at least 30 minutes after administration is recommended, along with suitable resuscitation measures to deal with this unlikely occurrence. Contrast-enhanced echocardiography can help to accurately detect the endocardial border, ventricular dysfunction, regional wall motion abnormalities, left ventricle thrombi, abnormal masses, and enhance Doppler signals among other potential benefits. In addition, the use of contrast can prevent further investigations and transfer which may be detrimental to the critically ill patient.
3D echocardiography in intensive care
Authors: Yastrebov Konstantin
Published: March 2020

Three-dimensional echocardiography (3DE) is a rapidly expanding modality with great potential. 3DE, as with 2D, is based on basic principles of ultrasound physics. Sequential ultrasound beams are emitted from piezoelectric elements and received echoes are analysed by computers using specialized algorithms, creating pictures on a screen. Current routine utilization and research of 3DE in intensive care is limited. Technical problems, lack of equipment and training among intensive care practitioners are the major limiting factors. This chapter examines the main principles of 3DE, specific terminology, current advantages and limitations, as well as projected future applications. Application areas of three-dimensional transthoracic echocardiography (3D TTE) and three-dimensional transoesophageal echocardiography (3D TOE) in intensive care are outlined.
Accreditation in advanced critical care echocardiography
Authors: Mclean Anthony
Published: March 2020

The development of smaller, mobile, sophisticated ultrasound machines has been central to echocardiography becoming an everyday tool in the intensive care setting. However, the parallel process of ensuring quality studies are obtained from these machines places a focus on training standards for the doctors operating them. In response, credentialing and certification programmes in advanced critical care echocardiography have come into existence around the world, and although they are not identical, the programmes share many of the same features whether it is run in France, Scotland, Australia, the United States, or elsewhere. The challenge of determining the optimum training programme is an ongoing process and will no doubt evolve further over time. Yet the development of the programmes to date demonstrate how far critical care physicians have come over the past two decades in achieving quality care in the use of echocardiography.
General principles of urological surgery
Authors: Biers Suzanne , Armenakas Noel , Lamb Alastair , Mark Stephen , Reynard John , Sullivan Mark , Turner Kevin , Turney Ben
Published: March 2020

This chapter covers the general principles of urological surgery, from preparation of the patient, antibiotic prophylaxis, general surgical complications, fluid balance, and management of shock to antiplatelet drugs and anticoagulation. It highlights potential issues in patients where there are other underlying health issues.
Basic urological surgical skills and equipment
Authors: Biers Suzanne , Armenakas Noel , Lamb Alastair , Mark Stephen , Reynard John , Sullivan Mark , Turner Kevin , Turney Ben
Published: March 2020

This chapter covers techniques, indications, and useful guides for common urological skills and equipment. It has topics on catheters, including techniques for urethral and suprapubic catheterization, and how to deal with complications, stents, lasers and diathermy, sterilization, urological incisions, and small bowel surgery. Highly illustrated, it serves as a useful primer.
Bladder outlet obstruction and transurethral surgery
Authors: Biers Suzanne , Armenakas Noel , Lamb Alastair , Mark Stephen , Reynard John , Sullivan Mark , Turner Kevin , Turney Ben
Published: March 2020

This chapter covers indications for treatment of lower urinary tract symptoms (LUTS) or benign prostatic hyperplasia (BPH). It then discusses transurethral resection of the prostate (TURP) and bladder tumours (TURBT), alongside their complications. It also covers minimally invasive surgical management of BPH, invasive alternatives, open prostatectomy, simple retropubic prostatectomy, urethral stricture disease, and perineal urethrostomy.
Laparoscopic and robotic urological surgery
Authors: Biers Suzanne , Armenakas Noel , Lamb Alastair , Mark Stephen , Reynard John , Sullivan Mark , Turner Kevin , Turney Ben
Published: March 2020

Laparoscopy has been a relatively recent development in the treatment of urological pathology. This chapter has been updated from previous editions to include a greater focus on robotic surgery. From a general overview of the history of laparoscopic and robotic surgery, it covers the essential equipment, methods of laparoscopic access, and basic skills before outlining the indications, contraindications, and operative techniques for 13 different operations.