Middle Cerebral Artery Doppler

Nafisa Dajani/M.D
Maternal Fetal Medicine
Department of Obstetrics and Gynecology
University of Arkansas for Medical Sciences

Uses Of MCA in Obstetrics

Evaluation of IUGR
Evaluation of fetal anemia

 Location: MCA is
the middle branch
from the circle of
Willis that courses
anteriorly and
temporally

Why the Interest in the MCA?

The MCA bed has attracted investigators for
its ability for auto regulation
Vasodilatation assures continued supply of
glucose and oxygen ( IUGR with brain sparing)
The MCA is easy to identify
Doppler measurements have satisfactory
reproducibility with appropriate training

Is this new?
Studies in the 90s have shown repeatedly
abnormally low PI in 30-54% of IUGR. The
mean systolic velocity was also higher in
SGA fetuses. And fetal blood sampling
indicated a relationship between fetal
hypoxemia and MCA PI that was strongest
when PI was 2-4 standard deviations
below the normal range

PI, S/D
Pulsatility : frequency change
The PI is a reflection of downstream
resistance (S-D)/S
Normally there is a decrease in diastolic
brain flow at 25-30 weeks (more
resistance, incr.PI) correlating with an
increase in fetal cerebral cellular
multiplication, followed by a progressive
decrease in resistance (decr. PI)

Normal

With hypoxia there is cerebral

vasodilatation, so initially the
diastolic flow may be in the
normal range ,when the
vasodilatation ability is
exhausted as with fetal acidosis
the resistance starts increasing
again.

IUGR

 The redistribution in hypoxemic

fetuses may be transient (PI
decreases). With worsening
hypoxemia, the PI may increase and
diastolic flow may be reversed. This
may precede intrauterine death

How to Measure MCA dopplers

Enlarge the circle of Willis ( 75% of image)
Image the whole vessel if possible
Align vessel parallel to the ultrasound
beam, angle zero for best measurement
Measure close to the exit point from the
internal carotid
Avoid measuring during fetal breathing,
hiccups, or movement

How to measure the MCA dopplers

Middle cerebral artery
peak systolic velocity:
technique and
variability.
J Ultrasound Med. 2005
Apr;24(4):425-30.
Mari G, Abuhamad AZ,
Cosmi E, Segata M,
Altaye M, Akiyama M.

Figure 1. Circle of
Willis. The letters
indicate the 4 points
assessed for
variability

Figure 1. Circle of Willis. The letters

indicate the 4 points assessed for
variability

Why are MCA dopplers important

for the management of IUGR
MCA PI has a 98% negative predictive
value for major adverse perinatal
outcomes <32 weeks gestation
Abnormally low MCA dopplers are an early
sign of fetal response to hypoxia and is
generally preceded by an abnormal
umbilical artery dopplers and decreased
fetal AC measurements

MCA Doppler's
PI a sensitive indicator of fetal hypoxia as
measured by concomitant cordocentesis
evaluation
Precedes abnormal fetal testing by 2-3
weeks
When abnormal it should lead to
interaction of other dopplers in the fetal
circulation to evaluate the degree of
compromise and better timing of delivery

The sequence of changes in

Doppler and biophysical
parameters as severe fetal
growth restriction worsens
A. A. Baschat, U. Gembruch* and C. R.
Harman
Ultrasound in Obstetrics and Gynecology
Volume 18 Page 571 - December 2001

Figure 4 The percentage of abnormal Doppler findings in individual vessels and

the incidence of a biophysical profile score below 6 (*) in the week prior to delivery.
, umbilical artery absent or reversed end-diastolic flow; , abnormal middle
cerebral artery flow; , abnormal inferior vena cava flow; , abnormal ductus
venosus flow; , umbilical vein pulsations. Deterioration of Doppler findings
precedes decline in biophysical profile score.

How Can Doppler Studies and

Biophysical Profile be combined
Doppler studies and the BPP can
independently identify fetuses at risk. They
are not always concordant
Concordance occurs in about 44%
Marked discordance in 17%
The BPP is maintained longer
Doppler and biophysical profile in growth restricted fetuses. A
Baschat. Ultrasound Obstet Gynecol. 2006 Jan;27(1):41-7.

MCA Dopplers and Fetal

Anemia

Causes of fetal anemia

30,000 fetuses are at risk of anemia from
RBC alloimmunization each year in the
USA
Other causes of anemia include parvo
virus infections, fetomaternal hemorrhage,
non-immune hydrops, twin-twin
transfusion, etc

Anemia and MCA dopplers

1990 G.Mari proposed the use of MCA
dopplers for the diagnosis of anemia
!0 years later a collaborative multicenter
study, 110 fetuses with isoimmunization
and 265 fetuses normal, all underwent
cordocentesis and MCA doppler studies

Figure 2. ReceiverOperating-Characteristic
Curves for the Peak
Velocity of Systolic
Blood Flow in the Middle
Cerebral Artery for the
Prediction of Mild,
Moderate, and Severe
Fetal Anemia.

 The sensitivity of the peak systolic velocity for the

prediction of moderate anemia (a hemoglobin
concentration of less than 0.65 times the median)
and severe anemia (a hemoglobin concentration of
less than 0.55 times the median) in the fetuses
without hydrops was 100 percent (95 percent
confidence interval, 86 to 100), with a false positive
rate of 12 percent. The positive and negative
predictive values were 65 percent and 100 percent,
respectively.

Studies that have found no

correlation between anemia and
doppler studies have used the PI and
RI which are angle-independent
indexes, and thus independent of
blood velocity.

 The risk of anemia was high in fetuses

with a peak systolic velocity of 1.50 times
the median or higher. Fetuses with
values below 1.50 either did not have
anemia or had only mild anemia. The fact
that this test does not predict mild
anemia well is not clinically important,
because no intervention is indicated in
fetuses with mild anemia,

 the MCA PSV was effective for

accurate diagnosis of fetal anemia
and avoided 70% of invasive
procedures.

 Mari reported MCA PSV is superior to

optical density measurement at 450 nm in
terms of assessing fetal anemia secondary
to red cell alloimmunization.
Pereira et al also reported that the MCA
PSV is better than amniocentesis in the
diagnosis of fetal anemia.
Additionally, a recent multicenter study
assessed both the MCA PSV and
amniocentesis in fetuses undergoing
cordocentesis reported that the sensitivity
of MCA PSV for the detection of severe
anemia was better than that of
amniocentesis.

 MCA PSV is still accurate

after intrauterine
transfusion

 MCA after 35 weeks is

not accurate

Middle cerebral artery peak systolic

velocity: is it the standard of care for the
diagnosis of fetal anemia?
J Ultrasound Med. 2005 May;24(5):697702. Review.

 Should all obstetricians and

gynecologists in the United States and
elsewhere in the world assess the
MCA PSV for the diagnosis of anemia?
The answer is no because today there
are not enough sonographers and
sonologists trained to assess the MCA
PSV.