Transcranial Doppler (TCD) ultrasonography is a noninvasive ultrasound study, which has been extensively applied on both outpatient and inpatient settings. It involves the use of a low-frequency (≤2 MHz) transducer, placed on the scalp, to insonate the basal cerebral arteries through relatively thin bone windows and to measure the cerebral blood flow velocity and its alteration in many different conditions. In neurointensive care setting, TCD is useful for both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, and brain stem death. It also allows to investigate the cerebrovascular autoregulation in setting of carotid disease and syncope. In this review, we will describe physical principles underlying TCD, flow indices most frequently used in clinical practice and critical care applications in Neurocritical Unit care.

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Knowledge of variations of azygos and hemiazygos veins is of importance to cardiothoracic surgeons and radiologists during various surgical, radiological, and echography techniques. We report some unique variations of azygos system of veins observed during dissection classes for undergraduate medical students. The azygos vein was formed as usual by the union of right subcostal and ascending lumbar veins. The vein ascended upward and to the left to reach the midline at the level of the 9 ^th thoracic vertebra. After ascending till 5 ^th thoracic vertebra, it gradually inclined to the right of midline and terminated by opening into the superior vena cava at the level of the 3 ^rd thoracic vertebra. There was no major variation in the tributaries of the azygos vein on the right side, except that the right superior intercostal vein crossed behind the azygos vein from right to left and opened into the left side of the azygos vein. Further, two anastomotic veins connected the 10 ^th , 11 ^th and 12 ^th posterior intercostal veins with each other to form two anastomotic circles on the right side of 10 ^th to 12 ^th thoracic vertebrae. The hemiazygos vein bifurcated on the left side of the 10 ^th thoracic vertebra and the two ends opened into the azygos vein at the level of 9 ^th and 10 ^th thoracic vertebrae forming a venous circle in front of the 10 ^th thoracic vertebra. The course of accessory hemiazygos vein was noteworthy. Instead of its classic descending course, the vein ascended upward from the left side of the 8 ^th thoracic vertebra till the 6 ^th thoracic vertebra before opening into the azygos vein.

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Restrictive cardiomyopathy (RCM) is a relatively rare form of cardiomyopathy with high mortality which is characterized by impaired filling of the ventricles in the presence of normal wall thickness and systolic function. RCM is generally seen in association with infiltrative, storage, or systemic diseases. We present a rare case of familial RCM with pregnancy which was successfully managed.

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Background and Objectives: The metabolic syndrome (MS) is a condition associated with the clustering of risk factors including high blood pressure (BP), abdominal obesity, glucose intolerance, and dyslipidemia; which increases cardiovascular morbidity and mortality. High burden of subclinical disease component of MS contributes to the increased risk by causing left ventricular (LV) hypertrophy, thereby affecting long-term prognosis. This cross-sectional study uncovers the role of LV hypertrophy (LVH) and LV mass index (LVMI) in patients with MS in comparison to hypertensive patients. Subjects and Methods: A total of fifty North Indians, out of which 25 subjects were cases with the MS (obesity, dyslipidemia, glucose intolerance/diabetes with hypertension) and rest of the 25 subjects were control with hypertensive patients were included in the study and assessed for LVH and LVMI by two-dimensional echocardiography. Data were analyzed by SPSS version 21.0 based program. Results: MS cases had a significantly higher mean LVMI (49.60 ± 21.23 g/m ^2.7 ) (P < 0.05), also higher exposure rate of LVH with 11 cases (44%) and relative risk of 1.38 (odds ratio 1.67, 95% confidence interval 0.53-5.29) than controls with hypertensive patients. Among LVH patients, mean LVMI was highest in MS cases with males (50.31 ± 26.03 g/m ^2.7 ), high body mass index >30 kg/m ² (51.14 ± 22.08 g/m ^2.7 ), FBS ≤ 140 mg/dl (53.72 ± 27.91 g/m ^2.7 ), high TG > 150 mg/dl (50.00 ± 22.09 g/m ^2.7 ), and low HDL (male <40, female <50 mg/dl) (57.22 ± 27.23 g/m ^2.7 ) than controls with hypertension; respectively (P > 0.05, not significant). Conclusion: MS, as a clustering of cardiovascular risk factors, is associated with higher LVM and prevalence of LVH. Therefore, high BP, increased waist circumference, dyslipidemia, and hyperglycemia separately and additively contributes to LVH suggesting that optimal BP control along with weight loss, lipid lowering agents, and euglycemic state may contribute to regression of LVH and LVM.

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While warfarin therapy is efficacious in treating left atrial (LA) thrombus formation in patients with nonvalvular atrial fibrillation (AF), it does not affect red cell aggregation in vitro or LA spontaneous echo-contrast in patients. In this patient with left ventricular (LV) dysfunction secondary to AF, we observed the disappearance of dense echo-contrast in the atrial appendage after therapy with dabigatran and not with well-controlled warfarin. This allowed us to analyze accurately the appendage with three-dimensional (3D) transesophageal echocardiography (TEE) excluding thrombi and to perform electrical cardioversion to obtain a significant improvement of LV function. This case demonstrates the capability of dabigatran and not of warfarin in reducing the intense spontaneous echocontrast in atrial appendage and the ability of 3D TEE in analyzing accurately the appendage, excluding thrombi to safely perform cardioversion.

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Background: Hypertension (HTN), probably, is the most common public health problem among developed countries. Rapid diagnosis and effective treatment of HTN have not truly stopped the rapid rate of mortality and morbidity caused by HTN. Vascular wall changes are one of the most important and mortal complications of HTN. Ultrasonography was used for the evaluation of this vessel wall disorder by assessing the thickness of the intima and media layer. Objective: The objective of this study was to compare the Carotid intima Media Thickness (CIMT) in hypertensive patients and the control group. Methods: In a case-control study, 43 patients with documented primary HTN and 43 healthy subjects were assessed as control. Their HTN was controlled by the administration of drugs. The mean age was 53.9 years. The intima-media thickness (IMT) of internal and common carotid and outer vessel diameter were assessed by one radiologist. Results: CAIMT in all carotid arteries in the case group was more than that of the controls (P < 0.05). It was found that there was no difference between the length of having HTN and mean CAIMT in the hypertensive, except the right internal carotid (P = 0.024). Conclusion: The present study found that the mean CAIMT of all carotid arteries in HTN was more than that of the controls. Moreover, the duration of the HTN can accelerate the atherosclerosis process in hypertensive patients.

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We report a case illustrating a 39-year-old man with delayed presentation of severe pulmonary valve (PV) stenosis, clinical evidence of congestive right heart failure in the form of enlarged liver, raised jugular venous pressure, and anasarca without cyanosis. Echocardiography (echo) was used both for diagnosis and monitoring this patient as main tool. The contractile reserve of the right ventricle (RV) was evaluated by infusion of dobutamine and diuretic for 4 days before pulmonary balloon valvotomy. Both the tricuspid annular peak systolic excursion and diastolic (diastolic anterograde flow through PV) function of RV improved after percutaneous balloon pulmonary valvotomy. These improvements were clinically apparent by complete resolution of anasarca, pericardial effusion, and normalization albumin-globulin ratio. The periprocedural echo findings were quite unique in this illustration.

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Myxomas are the most common cancerous nonneoplasms among the rare heart's tumors. Usually, they are located in the left atrium (LA). They are more frequent in women than in men and ranged in age from 30 to 50 years. Rarely, myxoma is completely asymptomatic and in that case represents a fortuitous discovery. However, usually, it is characterized by several symptoms as fatigue, dyspnea, chest pain, dizziness, cough, and sometimes, by sudden death. We refer on a case of LA myxoma found in a woman without symptoms but having a systolic precordial murmur. Two-dimensional echocardiography (2-DE) shown an unknown giant LA myxoma, almost completely occupying the atrial cavity. 2-D left atrial longitudinal speckle tracking echocardiography first allowed to note the changes in the percentage of "reservoir," "conduit," and "booster pump" phases of the left atrial function respect to normal subjects, revealing LA dysfunction. Three-dimensional echocardiography (3-DE) shown left atrial mass and its attachment to the atrial septum better than 2-DE. Furthermore, 3-DE allowed to define the shape of LA myxoma and its 3-D, irregular contour.

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