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Friday, June 21, 2019

Anatomical terminology

From Wikipedia, the free encyclopedia

Anatomical terminology is a form of scientific terminology used by anatomists, zoologists, and health professionals such as doctors.
 
Anatomical terminology uses many unique terms, suffixes, and prefixes deriving from Ancient Greek and Latin. These terms can be confusing to those unfamiliar with them, but can be more precise, reducing ambiguity and errors. Also, since these anatomical terms are not used in everyday conversation, their meanings are less likely to change, and less likely to be misinterpreted.

To illustrate how inexact day-to-day language can be: a scar "above the wrist" could be located on the forearm two or three inches away from the hand or at the base of the hand; and could be on the palm-side or back-side of the arm. By using precise anatomical terminology such ambiguity is eliminated.

An international standard for anatomical terminology, Terminologia Anatomica has been created.

Word formation

Anatomical terminology has quite regular morphology, the same prefixes and suffixes are used to add meanings to different roots. The root of a term often refers to an organ or tissue. For example, the Latin names of structures such as musculus biceps brachii can be split up and refer to, musculus for muscle, biceps for "two-headed", brachii as in the brachial region of the arm. The first word describes what is being spoken about, the second describes it, and the third points to location.

When describing the position of anatomical structures, structures may be described according to the anatomical landmark they are near. These landmarks may include structures, such as the umbilicus or sternum, or anatomical lines, such as the midclavicular line from the centre of the clavicle. The cephalon or cephalic region refers to the head. This area is further differentiated into the cranium (skull), facies (face), frons (forehead), oculus (eye area), auris (ear), bucca (cheek), nasus (nose), oris (mouth), and mentum (chin). The neck area is called the cervix or cervical region. Examples of structures named according to this include the frontalis muscle, submental lymph nodes, buccal membrane and orbicularis oculi muscle

Sometimes, unique terminology is used to reduce confusion in different parts of the body. For example, different terms are used when it comes to the skull in compliance with its embryonic origin and its tilted position compared to in other animals. Here, Rostral refers to proximity to the front of the nose, and is particularly used when describing the skull. Similarly, different terminology is often used in the arms, in part to reduce ambiguity as to what the "front", "back", "inner" and "outer" surfaces are. For this reason, the terms below are used:
Other terms are also used to describe the movement and actions of the hands and feet, and other structures such as the eye.

History

International morphological terminology is used by the colleges of medicine and dentistry and other areas of the health sciences. It facilitates communication and exchanges between scientists from different countries of the world and it is used daily in the fields of research, teaching and medical care. The international morphological terminology refers to morphological sciences as a biological sciences' branch. In this field, the form and structure are examined as well as the changes or developments in the organism. It is descriptive and functional. Basically, it covers the gross anatomy and the microscopic (histology and cytology) of living beings. It involves both development anatomy (embryology) and the anatomy of the adult. It also includes comparative anatomy between different species. The vocabulary is extensive, varied and complex, and requires a systematic presentation. 

Within the international field, a group of experts reviews, analyzes and discusses the morphological terms of the structures of the human body, forming today's Terminology Committee (FICAT) from the International Federation of Associations of Anatomists (IFAA). It deals with the anatomical, histological and embryologic terminology. In the Latin American field, there are meetings called Iberian Latin American Symposium Terminology (SILAT), where a group of experts of the Pan American Association of Anatomy (PAA) that speak Spanish and Portuguese, disseminates and studies the international morphological terminology. 

The current international standard for human anatomical terminology is based on the Terminologia Anatomica (TA). It was developed by the Federative Committee on Anatomical Terminology (FCAT) and the International Federation of Associations of Anatomists (IFAA) and was released in 1998. It supersedes the previous standard, Nomina Anatomica. Terminologia Anatomica contains terminology for about 7500 human gross (macroscopic) anatomical structures. For microanatomy, known as histology, a similar standard exists in Terminologia Histologica, and for embryology, the study of development, a standard exists in Terminologia Embryologica. These standards specify generally accepted names that can be used to refer to histological and embryological structures in journal articles, textbooks, and other areas. As of September 2016, two sections of the Terminologia Anatomica, including central nervous system and peripheral nervous system, were merged to form the Terminologia Neuroanatomica.

Recently, the Terminologia Anatomica has been perceived with a considerable criticism regarding its content including coverage, grammar and spelling mistakes, inconsistencies, and errors.

Location

Anatomical terminology is often chosen to highlight the relative location of body structures. For instance, an anatomist might describe one band of tissue as "inferior to" another or a physician might describe a tumor as "superficial to" a deeper body structure.

Anatomical position

The anatomical position, with terms of relative location noted.
 
Anatomical terms used to describe location are based on a body positioned in what is called the standard anatomical position. This position is one in which a person is standing, feet apace, with palms forward and thumbs facing outwards. Just as maps are normally oriented with north at the top, the standard body "map," or anatomical position, is that of the body standing upright, with the feet at shoulder width and parallel, toes forward. The upper limbs are held out to each side, and the palms of the hands face forward.

Using the standard anatomical position reduces confusion. It means that regardless of the position of a body, the position of structures within it can be described without ambiguity.

Regions

The human body is shown in anatomical position in an anterior view and a posterior view. The regions of the body are labeled in boldface.
 
In terms of anatomy, the body is divided into regions. In the front, the trunk is referred to as the "thorax" and "abdomen". The back as a general area is the dorsum or dorsal area, and the lower back is the lumbus or lumbar region. The shoulder blades are the scapular area and the breastbone is the sternal region. The abdominal area is the region between the chest and the pelvis. The breast is also called the mammary region, the armpit as the axilla and axillary, and the navel as the umbilicus and umbilical. The pelvis is the lower torso, between the abdomen and the thighs. The groin, where the thigh joins the trunk, are the inguen and inguinal area. 

The entire arm is referred to as the brachium and brachial, the front of the elbow as the antecubitis and antecubital, the back of the elbow as the olecranon or olecranal, the forearm as the antebrachium and antebrachial, the wrist as the carpus and carpal area, the hand as the manus and manual, the palm as the palma and palmar, the thumb as the pollex, and the fingers as the digits, phalanges, and phalangeal. The buttocks are the gluteus or gluteal region and the pubic area is the pubis

Anatomists divide the lower limb into the thigh (the part of the limb between the hip and the knee) and the leg (which refers only to the area of the limb between the knee and the ankle). The thigh is the femur and the femoral region. The kneecap is the patella and patellar while the back of the knee is the popliteus and popliteal area. The leg (between the knee and the ankle) is the crus and crural area, the lateral aspect of the leg is the peroneal area, and the calf is the sura and sural region. The ankle is the tarsus and tarsal, and the heel is the calcaneus or calcaneal. The foot is the pes and pedal region, and the sole of the foot the planta and plantar. As with the fingers, the toes are also called the digits, phalanges, and phalangeal area. The big toe is referred to as the hallux.

Abdomen

Abdominal regions are used for example to localize pain.

To promote clear communication, for instance about the location of a patient’s abdominal pain or a suspicious mass, the abdominal cavity can be divided into either nine regions or four quadrants.
Quadrants
The abdomen may be divided into four quadrants, more commonly used in medicine, subdivides the cavity with one horizontal and one vertical line that intersect at the patient’s umbilicus (navel). The right upper quadrant (RUQ) includes the lower right ribs, right side of the liver, and right side of the transverse colon. The left upper quadrant (LUQ) includes the lower left ribs, stomach, spleen, and upper left area of the transverse colon. The right lower quadrant (RLQ) includes the right half of the small intestines, ascending colon, right pelvic bone and upper right area of the bladder. The left lower quadrant (LLQ) contains the left half of the small intestine and left pelvic bone.
Regions
The more detailed regional approach subdivides the cavity into nine regions, with two vertical and two horizontal lines drawn according to landmark structures. The vertical; or midclavicular lines, are drawn as if dropped from the midpoint of each clavicle. The superior horizontal line is the subcostal line, drawn immediately inferior to the ribs. The inferior horizontal line is called the intertubercular line, and is to cross the iliac tubercles, found at the superior aspect of the pelvis. The upper right square is the right hypochondriac region and contains the base of the right ribs. The upper left square is the left hypochondriac region and contains the base of the left ribs. 

The epigastric region is the upper central square and contains the bottom edge of the liver as well as the upper areas of the stomach. The diaphragm curves like an upside down U over these three regions. The central right region is called the right lumbar region and contains the ascending colon and the right edge of the small intestines. The central square contains the transverse colon and the upper regions of the small intestines. The left lumbar region contains the left edge of the transverse colon and the left edge of the small intestine. The lower right square is the right iliac region and contains the right pelvic bones and the ascending colon. The lower left square is the left iliac region and contains the left pelvic bone and the lower left regions of the small intestine. The lower central square contains the bottom of the pubic bones, upper regions of the bladder and the lower region of the small intestine.

Standard terms

When anatomists refer to the right and left of the body, it is in reference to the right and left of the subject, not the right and left of the observer. When observing a body in the anatomical position, the left of the body is on the observer’s right, and vice versa. 

These standardized terms avoid confusion. Examples of terms include:
  • Anterior and posterior, which describe structures at the front (anterior) and back (posterior) of the body. For example, the toes are anterior to the heel, and the popliteus is posterior to the patella.
  • Superior and inferior, which describe a position above (superior) or below (inferior) another part of the body. For example, the orbits are superior to the oris, and the pelvis is inferior to the abdomen.
  • Proximal and distal, which describe a position that is closer (proximal) or further (distal) from the trunk of the body. For example, the shoulder is proximal to the arm, and the foot is distal to the knee.
  • Superficial and deep, which describe structures that are closer to (superficial) or further from (deep) the surface of the body. For example, the skin is superficial to the bones, and the brain is deep to the skull. Sometimes profound is used synonymously with deep.
  • Medial and lateral, which describe a position that is closer to (medial) or further from (lateral) the midline of the body. For example, the nose is medial to the eyes, and the thumb is lateral to the other fingers.
  • Ventral and dorsal, which describe structures derived from the front (ventral) and back (dorsal) of the embryo, before limb rotation.
  • Cranial and caudal, which describe structures close to the top of the skull (cranial), and towards the bottom of the body (caudal).
  • Occasionally, sinister for left, and dexter for right are used.
  • Paired, referring to a structure that is present on both sides of the body. For example, the hands are paired structures.

Axes

Each locational term above can define the direction of a vector, and pairs of them can define axes, that is, lines of orientation. For example, blood can be said to flow in a proximal or distal direction, and anteroposterior, mediolateral, and inferosuperior axes are lines along which the body extends, like the X, Y, and Z axes of a Cartesian coordinate system. An axis can be projected to a corresponding plane.

Planes

The three anatomical planes of the body: the sagittal, transverse (or horizontal), frontal planes
 
Anatomy is often described in planes, referring to two-dimensional sections of the body. A section is a two-dimensional surface of a three-dimensional structure that has been cut. A plane is an imaginary two-dimensional surface that passes through the body. Three planes are commonly referred to in anatomy and medicine:
  • The sagittal plane is the plane that divides the body or an organ vertically into right and left sides. If this vertical plane runs directly down the middle of the body, it is called the midsagittal or median plane. If it divides the body into unequal right and left sides, it is called a parasagittal plane, or less commonly a longitudinal section.
  • The frontal plane is the plane that divides the body or an organ into an anterior (front) portion and a posterior (rear) portion. The frontal plane is often referred to as a coronal plane, following Latin corona, which means "crown".
  • The transverse plane is the plane that divides the body or organ horizontally into upper and lower portions. Transverse planes produce images referred to as cross sections.

Functional state

Anatomical terms may be used to describe the functional state of an organ:

Anatomical variation

The term anatomical variation is used to refer to a difference in anatomical structures that is not regarded as a disease. Many structures vary slightly between people, for example muscles that attach in slightly different places. For example, the presence or absence of the palmaris longus tendon. Anatomical variation is unlike congenital anomalies, which are considered a disorder.

Movement

Body Movements I.jpg
Body Movements II.jpg

Joints, especially synovial joints allow the body a tremendous range of movements. Each movement at a synovial joint results from the contraction or relaxation of the muscles that are attached to the bones on either side of the articulation. The type of movement that can be produced at a synovial joint is determined by its structural type.

Movement types are generally paired, with one being the opposite of the other. Body movements are always described in relation to the anatomical position of the body: upright stance, with upper limbs to the side of body and palms facing forward.

General motion

Terms describing motion in general include:
  • Flexion and extension, which refer to a movement that decreases (flexion) or increases (extension) the angle between body parts. For example, when standing up, the knees are extended.
  • Abduction and adduction refers to a motion that pulls a structure away from (abduction) or towards (adduction) the midline of the body or limb. For example, a star jump requires the legs to be abducted.
  • Internal rotation (or medial rotation) and external rotation (or lateral rotation) refers to rotation towards (internal) or away from (external) the center of the body. For example, the Lotus position posture in yoga requires the legs to be externally rotated.
  • Elevation and depression refer to movement in a superior (elevation) or inferior (depression) direction. Primarily refers to movements involving the scapula and mandible.

Special motions of the hands and feet

These terms refer to movements that are regarded as unique to the hands and feet:
  • Dorsiflexion and plantarflexion refers to flexion (dorsiflexion) or extension of the foot at the ankle. For example, plantarflexion occurs when pressing the brake pedal of a car.
  • Palmarflexion and dorsiflexion refer to movement of the flexion (palmarflexion) or extension (dorsiflexion) of the hand at the wrist. For example, prayer is often conducted with the hands dorsiflexed.
  • Pronation and supination refer to rotation of the forearm or foot so that in the anatomical position the palm or sole is facing anteriorly (supination) or posteriorly (pronation) . For example, if a person makes a "thumbs up" gesture, supination will cause the thumb to point away from the body midline and the fingers and plam to be upwards, while pronation will cause the thumb to point towards the body midline with the back of the hand upwards.
  • Eversion and inversion refer to movements that tilt the sole of the foot away from (eversion) or towards (inversion) the midline of the body.

Muscles

The biceps brachii flex the lower arm. The brachioradialis, in the forearm, and brachialis, located deep to the biceps in the upper arm, are both synergists that aid in this motion.
 
Muscle action that moves the axial skeleton work over a joint with an origin and insertion of the muscle on respective side. The insertion is on the bone deemed to move towards the origin during muscle contraction. Muscles are often present that engage in several actions of the joint; able to perform for example both flexion and extension of the forearm as in the biceps and triceps respectively. This is not only to be able to revert actions of muscles, but also brings on stability of the actions though muscle coactivation.

Agonist and antagonist muscles

The muscle performing an action is the agonist, while the muscle which contraction brings about an opposite action is the antagonist. For example, an extension of the lower arm is performed by the triceps as the agonist and the biceps as the antagonist (which contraction will perform flexion over the same joint). Muscles that work together to perform the same action are called synergists. In the above example synergists to the biceps can be the brachioradialis and the brachialis muscle.

Skeletal and smooth muscle

The skeletal muscles of the body typically come in seven different general shapes. This figure shows the human body with the major muscle groups labeled.
 
The gross anatomy of a muscle is the most important indicator of its role in the body. One particularly important aspect of gross anatomy of muscles is pennation or lack thereof. In most muscles, all the fibers are oriented in the same direction, running in a line from the origin to the insertion. In pennate muscles, the individual fibers are oriented at an angle relative to the line of action, attaching to the origin and insertion tendons at each end. Because the contracting fibers are pulling at an angle to the overall action of the muscle, the change in length is smaller, but this same orientation allows for more fibers (thus more force) in a muscle of a given size. Pennate muscles are usually found where their length change is less important than maximum force, such as the rectus femoris.

Skeletal muscle is arranged in discrete muscles, an example of which is the biceps brachii. The tough, fibrous epimysium of skeletal muscle is both connected to and continuous with the tendons. In turn, the tendons connect to the periosteum layer surrounding the bones, permitting the transfer of force from the muscles to the skeleton. Together, these fibrous layers, along with tendons and ligaments, constitute the deep fascia of the body.

Joints

Movement is not limited to only synovial joints, although they allow for most freedom. Muscles also run over symphysis, which allow for movement in for example the vertebral column by compression of the intervertebral discs. Additionally, synovial joints can be divided into different types, depending on their axis of movement.

Membranes

Serous membrane

A serous membrane (also referred to as a serosa) is a thin membrane that covers the walls of organs in the thoracic and abdominal cavities. The serous membranes have two layers; parietal and visceral, surrounding a fluid filled space. The visceral layer of the membrane covers the organ (the viscera), and the parietal layer lines the walls of the body cavity (pariet- refers to a cavity wall). Between the parietal and visceral layers is a very thin, fluid-filled serous space, or cavity. For example, the pericardium is the serous cavity which surrounds the heart.
  • Visceral and parietal describe structures that relate to an organ (visceral), or the wall of the cavity that the organ is in (parietal). For example, the parietal peritoneum surrounds the abdominal cavity.

Additional images

Electrical conduction system of the heart

From Wikipedia, the free encyclopedia

Electrical conduction system of the heart
RLS 12blauLeg.png
Heart; conduction system. 1. SA node. 2. AV node. 3. Bundle of His. 8. Septum
Details
Identifiers
Latinsystema conducens cordis
MeSHD006329
TAA12.1.06.002
FMA9476

The electrical conduction system of the heart transmits signals generated usually by the sinoatrial node to cause contraction of the heart muscle. The pacemaking signal generated in the sinoatrial node travels through the right atrium to the atrioventricular node, along the Bundle of His and through bundle branches to cause contraction of the heart muscle. This signal stimulates contraction first of the right and left atrium, and then the right and left ventricles. This process allows blood to be pumped throughout the body.

The conduction system consists of specialised heart muscle cells, and is situated within the myocardium. There is a skeleton of fibrous tissue that surrounds the conduction system which can be seen on an ECG. Dysfunction of the conduction system can cause irregular, fast, or slow heart rhythms.

Structure

Overview of the system of electrical conduction which maintains the rhythmical contraction of the heart
 
Electrical signals arising in the SA node (located in the right atrium) stimulate the atria to contract. Then the signals travel to the atrioventricular node (AV node), which is located in the interatrial septum. After a delay, the electrical signal diverges and is conducted through the left and right bundle of His to the respective Purkinje fibers for each side of the heart, as well as to the endocardium at the apex of the heart, then finally to the ventricular epicardium; causing its contraction. These signals are generated rhythmically, which in turn results in the coordinated rhythmic contraction and relaxation of the heart. 

On the microscopic level, the wave of depolarization propagates to adjacent cells via gap junctions located on the intercalated disc. The heart is a functional syncytium (not to be confused with a true "syncytium" in which all the cells are fused together, sharing the same plasma membrane as in skeletal muscle). In a functional syncytium, electrical impulses propagate freely between cells in every direction, so that the myocardium functions as a single contractile unit. This property allows rapid, synchronous depolarization of the myocardium. While advantageous under normal circumstances, this property can be detrimental, as it has potential to allow the propagation of incorrect electrical signals. These gap junctions can close to isolate damaged or dying tissue, as in a myocardial infarction (heart attack).

Development

Embryologic evidence of generation of the cardiac conduction system illuminates the respective roles of this specialized set of cells. Innervation of the heart begins with a brain only centered parasympathetic cholinergic first order. It is then followed by rapid growth of a second order sympathetic adrenergic system arising from the formation of the thoracic spinal ganglia. The third order of electrical influence of the heart is derived from the vagus nerve as the other peripheral organs form.

Function

Action potential generation

Cardiac muscle has some similarities to neurons and skeletal muscle, as well as important unique properties. Like a neuron, a given myocardial cell has a negative membrane potential when at rest. Stimulation above a threshold value induces the opening of voltage-gated ion channels and a flood of cations into the cell. The positively charged ions entering the cell cause the depolarization characteristic of an action potential. Like skeletal muscle, depolarization causes the opening of voltage-gated calcium channels and release of Ca2+ from the t-tubules. This influx of calcium causes calcium-induced calcium release from the sarcoplasmic reticulum, and free Ca2+ causes muscle contraction. After a delay, potassium channels reopen, and the resulting flow of K+ out of the cell causes repolarization to the resting state.

There are important physiological differences between nodal cells and ventricular cells; the specific differences in ion channels and mechanisms of polarization give rise to unique properties of SA node cells, most important, the spontaneous depolarizations necessary for the SA node's pacemaker activity.

Requirements for effective pumping

In order to maximize efficiency of contractions and cardiac output, the conduction system of the heart has:
  • Substantial atrial to ventricular delay. This will allow the atria to completely empty their contents into the ventricles; simultaneous contraction would cause inefficient filling and backflow. The atria are electrically isolated from the ventricles, connected only via the AV node which briefly delays the signal.
  • Coordinated contraction of ventricular cells. The ventricles must maximize systolic pressure to force blood through the circulation, so all the ventricular cells must work together.
    • Ventricular contraction begins at the apex of the heart, progressing upwards to eject blood into the great arteries. Contraction that squeezes blood towards the exit is more efficient than a simple squeeze from all directions. Although the ventricular stimulus originates from the AV node in the wall separating the atria and ventricles, the Bundle of His conducts the signal to the apex.
    • Depolarization propagates through cardiac muscle very rapidly. Cells of the ventricles contract nearly simultaneously.
    • The action potentials of cardiac muscle are unusually sustained. This prevents premature relaxation, maintaining initial contraction until the entire myocardium has had time to depolarize and contract.
  • Absence of tetany. After contracting, the heart must relax to fill up again. Sustained contraction of the heart without relaxation would be fatal, and this is prevented by a temporary inactivation of certain ion channels.

ECG

The ECG complex. P=P wave, PR=PR interval, QRS=QRS complex, QT=QT interval, ST=ST segment, T=T wave
 
Principle of ECG formation. Note that the red lines represent the depolarization wave, not bloodflow.

An electrocardiogram is a recording of the electrical activity of the heart.

SA node: P wave

Under normal conditions, electrical activity is spontaneously generated by the SA node, the cardiac pacemaker. This electrical impulse is propagated throughout the right atrium, and through Bachmann's bundle to the left atrium, stimulating the myocardium of the atria to contract. The conduction of the electrical impulses throughout the atria is seen on the ECG as the P wave.

As the electrical activity is spreading throughout the atria, it travels via specialized pathways, known as internodal tracts, from the SA node to the AV node.

AV node and bundles: PR interval

The AV node functions as a critical delay in the conduction system. Without this delay, the atria and ventricles would contract at the same time, and blood wouldn't flow effectively from the atria to the ventricles. The delay in the AV node forms much of the PR segment on the ECG, and part of atrial repolarization can be represented by the PR segment. 

The distal portion of the AV node is known as the bundle of His. The bundle of His splits into two branches in the interventricular septum: the left bundle branch and the right bundle branch. The left bundle branch activates the left ventricle, while the right bundle branch activates the right ventricle.

The left bundle branch is short, splitting into the left anterior fascicle and the left posterior fascicle. The left posterior fascicle is relatively short and broad, with dual blood supply, making it particularly resistant to ischemic damage. The left posterior fascicle transmits impulses to the papillary muscles, leading to mitral valve closure. As the left posterior fascicle is shorter and broader than the right, impulses reach the papillary muscles just prior to depolarization, and therefore contraction, of the left ventricle myocardium. This allows pre-tensioning of the chordae tendinae, increasing the resistance to flow through the mitral valve during left ventricular contraction. This mechanism works in the same manner as pre-tensioning of car seatbelts.

Purkinje fibers/ventricular myocardium: QRS complex

The two bundle branches taper out to produce numerous Purkinje fibers, which stimulate individual groups of myocardial cells to contract.

The spread of electrical activity through the ventricular myocardium produces the QRS complex on the ECG

Atrial repolarization occurs and is masked during the QRS complex by ventricular depolarization on the ECG.

Ventricular repolarization

The last event of the cycle is the repolarization of the ventricles. It is the restoring of the resting state. In the ECG, repolarization includes the J point, ST segment, and T and U waves.

The transthoracically measured PQRS portion of an electrocardiogram is chiefly influenced by the sympathetic nervous system. The T (and occasionally U) waves are chiefly influenced by the parasympathetic nervous system guided by integrated brainstem control from the vagus nerve and the thoracic spinal accessory ganglia

An impulse (action potential) that originates from the SA node at a relative rate of 60-100bpm is known as normal sinus rhythm. If SA nodal impulses occur at a rate less than 60bpm, the heart rhythm is known as sinus bradycardia. If SA nodal impulses occur at a rate exceeding 100bpm, the consequent rapid heart rate is sinus tachycardia. These conditions are not necessarily bad symptoms, however. Trained athletes, for example, usually show heart rates slower than 60bpm when not exercising. If the SA node fails to initialize, the AV junction can take over as the main pacemaker of the heart. The AV junction consists of the AV node, the bundle of His, and the surrounding area; it has a regular rate of 40 to 60bpm. These "junctional" rhythms are characterized by a missing or inverted P wave. If both the SA node and the AV junction fail to initialize the electrical impulse, the ventricles can fire the electrical impulses themselves at a rate of 20 to 40bpm and will have a QRS complex of greater than 120 ms. This is necessary for the heart to be in good function.

Clinical significance

Arrhythmia

An 'arrhythmia' refers to an abnormal rhythm or speed of rhythm of the heartbeat. An abnormal rhythm or speed is defined as one which is not physiological.

Speed

A resting heart that beats slower than 60 beats per minute, or faster than 100 beats per minute, is regarded as having an arrhythmia. A heartbeat slower than 60 beats per minute is known as bradycardia, and a heartbeat faster than 100 is known as a tachycardia.

Physiological

Some individuals, for example trained athletes, may have heart beats slower than 60 beats per minute when not exercising. If the SA node fails to initialize, the AV junction can take over as the main pacemaker of the heart. The AV junction "surrounds" the AV node (the AV node is not able to initialize its own impulses) and has a regular rate of 40 to 60 bpm. These "junctional" rhythms are characterized by a missing or inverted P-Wave. If both the SA node and the AV junction fail to initialize the electrical impulse, the ventricles can fire the electrical impulses themselves at a rate of 20 to 40 bpm and will have a QRS complex of greater than 120 ms.

Pacemakers

In the event of arrhythmia, a pacemaker may be surgically inserted into the conduction system.

Transcranial Doppler

From Wikipedia, the free encyclopedia

Transcranial Doppler
Medical diagnostics
Transcranial doppler.jpg
Transcranial Doppler insonation of the cerebral circulation
ICD-9-CM88.71
MeSHD017585
LOINC24733-8, 39044-3, 30880-9

Transcranial doppler ultrasound analyzer of blood velocity
 
Transcranial Doppler (TCD) and transcranial color Doppler (TCCD) are types of Doppler ultrasonography that measure the velocity of blood flow through the brain's blood vessels by measuring the echoes of ultrasound waves moving transcranially (through the cranium). These modes of medical imaging conduct a spectral analysis of the acoustic signals they receive and can therefore be classified as methods of active acoustocerebrography. They are used as tests to help diagnose emboli, stenosis, vasospasm from a subarachnoid hemorrhage (bleeding from a ruptured aneurysm), and other problems. These relatively quick and inexpensive tests are growing in popularity. The tests are effective for detecting sickle cell disease, ischemic cerebrovascular disease, subarachnoid hemorrhage, arteriovenous malformations, and cerebral circulatory arrest. The tests are possibly useful for perioperative monitoring and meningeal infection. The equipment used for these tests is becoming increasingly portable, making it possible for a clinician to travel to a hospital, to a doctor's office, or to a nursing home for both inpatient and outpatient studies. The tests are often used in conjunction with other tests such as MRI, MRA, carotid duplex ultrasound and CT scans. The tests are also used for research in cognitive neuroscience (see Functional transcranial Doppler, below).

Methods

Two methods of recording may be used for this procedure. The first uses "B-mode" imaging, which displays a 2-dimensional image of the skull, brain, and blood vessels as seen by the ultrasound probe. Once the desired blood vessel is found, blood flow velocities may be measured with a pulsed Doppler effect probe, which graphs velocities over time. Together, these make a duplex test. The second method of recording uses only the second probe function, relying instead on the training and experience of the clinician in finding the correct vessels. Current TCD machines always allow both methods.

How it works

The ultrasound probe emits a high-frequency sound wave (usually a multiple of 2 MHz) that bounces off various substances in the body. These echoes are detected by a sensor in the probe. In the case of blood in an artery, the echoes have different frequencies depending on the direction and speed of the blood because of the Doppler effect. If the blood is moving away from the probe, then the frequency of the echo is lower than the emitted frequency; if the blood is moving towards the probe, then the frequency of the echo is higher than the emitted frequency. The echoes are analysed and converted into velocities that are displayed on the unit's computer monitor. In fact, because the probe is pulsed at a rate of up to 10 kHz, the frequency information is discarded from each pulse and reconstructed from phase changes from one pulse to the next.

Because the bones of the skull block most of the transmission of ultrasound, regions with thinner walls (called insonation windows), which offer the least distortion to the sound waves, must be used for analyzing. For this reason, recording is performed in the temporal region above the cheekbone/zygomatic arch, through the eyes, below the jaw, and from the back of the head. Patient age, sex, race, and other factors affect bone thickness and porosity, making some examinations more difficult or even impossible. Most can still be performed to obtain acceptable responses, sometimes requiring using alternative sites from which to view the vessels.

Implantable transcranial Doppler

Sometimes a patient's history and clinical signs suggest a very high risk of stroke. Occlusive stroke causes permanent tissue damage over the following three hours (maybe even 4.5 hours), but not instantly. Various drugs (e.g. aspirin, streptokinase, and tissue plasminogen activator (TPA) in ascending order of effectiveness and cost) can reverse the stroke process. The problem is how to know immediately that a stroke is happening. One possible way is the use of an implantable transcranial Doppler device "operatively connected to a drug delivery system". Battery-powered, it would use an RF link to a portable computer running a spectral analysis routine together with input from an oximeter (monitoring the degree of blood oxygenation, which a stroke might impair) to make the automatic decision to administer the drug.

Functional transcranial Doppler (fTCD)

Functional transcranial Doppler sonography (fTCD) is a neuroimaging tool for measuring cerebral blood flow velocity changes due to neural activation during cognitive tasks. Functional TCD uses pulse-wave Doppler technology to record blood flow velocities in the anterior, middle, and posterior cerebral arteries. Similar to other neuroimaging techniques such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), fTCD is based on a close coupling between regional cerebral blood flow changes and neural activation. Due to a continuous monitoring of blood flow velocity, TCD offers better temporal resolution than fMRI and PET. The technique is noninvasive and easy to apply. Blood flow velocity measurements are robust against movement artifacts. Since its introduction the technique has contributed substantially to the elucidation of the hemispheric organization of cognitive, motor, and sensory functions in adults and children. fTCD has been used to study cerebral lateralization of major brain functions such as language, face processing, color processing, and intelligence. Moreover, most established neuroanatomical substrates for brain function are perfused by the major cerebral arteries that could be directly insonated. Lastly, fTCD has been used as a brain-computer interface modality.

Functional transcranial Doppler spectroscopy (fTCDS)

Spectral density plots right and left middle cerebral arteries cross-amplitude plots in men.
 
Facial Paradigms
 
Conventional FTCD has limitations for the study of cerebral lateralization. For example, it may not differentiate the lateralising effects due to stimulus characteristics from those due to light responsiveness, and does not distinguish between flow signals emanating from cortical and subcortical branches of the cerebral arteries of the circle of Willis. Each basal cerebral artery of the circle of Willis gives origin to two different systems of secondary vessels. The shorter of these two is called the ganglionic system, and the vessels belonging to it supply the thalami and corpora striata; the longer is the cortical system, and its vessels ramify in the pia mater and supply the cortex and subjacent brain substance. Furthermore, the cortical branches are divisible into two classes: long and short. The long or medullary arteries pass through the grey substance and penetrate the subjacent white substance to the depth of 3–4 cm. The short vessels are confined to the cortex. Both cortical and ganglionic systems do not communicate at any point in their peripheral distribution, but are entirely independent of each other, having between the parts supplied by the two systems, a borderline of diminished nutritive activity. While, the vessels of the ganglionic system are terminal vessels, the vessels of the cortical arterial system are not so strictly "terminal". Blood flow in these two systems in the middle cerebral artery (MCA) territory supplies 80% of both hemispheres, including most neural substrates implicated in facial processing, language processing and intelligence processing at cortical and subcortical structures. The measurements of mean blood flow velocity (MFV) in the MCA main stem could potentially provide information about downstream changes at cortical and subcortical sites within the MCA territory. Each distal arm of the MCA vascular system could be separated into "near" and "far" distal reflection sites for the cortical and ganglionic (subcortical) systems, respectively. To accomplish this objective, one method is to apply Fourier analysis to the periodic time series of MFV acquired during cognitive stimulations. Fourier analysis would yield peaks representing pulsatile energy from reflection sites at various harmonics, which are multiples of the fundamental frequency. McDonald in 1974 showed that the first five harmonics usually contain 90% of the entire pulsatile energy within the system of pressure/flow oscillations in the peripheral circulation. It could be presumed that each arm of the vascular system represents a single viscoelastic tube terminated by impedance, creating a single reflection site. Psychophysiologic stimulation induced vasomotor activity at each terminal site sets up a standing sinusoidal wave oscillation, comprising a summation of waves due to effects of incident, reflected, and re-reflected waves from distal to proximal point of measurement. fTCDS studies are performed with the participant placed in a supine posture with their head up at about 30 degrees. The probe holder headgear (e.g. LAM-RAK, DWL, Sipplingen, Germany) are used with a base support on two earplugs and on the nasal ridge. Two 2-MHz probes are affixed in the probe holder and insonation performed to determine the optimal position for continuous monitoring of both MCA main stems at 50 mm depth from the surface of the probe. A serial recording of MFV for each stimulus is acquired and latter used for Fourier analysis. Fourier transform algorithm uses standard software (for example, Time series and forecasting module, STATISTICA, StatSoft, Inc.). The most efficient standard Fourier algorithm requires that the length of the input series is equal to a power of 2. If this is not the case, additional computations have to be performed. To derive the required time series, the data were averaged in 10-second segments for 1-minute duration or each stimulus, yielding 6 data points for each participant and a total of 48 data points for all eight men and women, respectively. Smoothing the periodogram values was accomplished using a weighted moving average transformation. Hamming window was applied as a smoother. The spectral density estimates, derived from single series Fourier analysis, were plotted, and the frequency regions with the highest estimates were marked as peaks. The origins of the peaks are of interest in order to determine the reliability of the present technique. The fundamental (F), cortical (C) or memory (M), and subcortical (S) peaks occurred at regular frequency intervals of 0.125, 0.25, and 0.375, respectively. These frequencies could be converted to Hz, assuming that the fundamental frequency of cardiac oscillation was the mean heart rate. The fundamental frequency (F) of the first harmonic could be determined from the mean heart rate per second. For example, a heart rate of 74 bpm, suggests 74 cycles/60 or 1.23 Hz. In other words, the F-, C-, and S-peaks occurred at multiples of the first harmonic, at second and third harmonics, respectively. The distance of the reflection site for F-peak could be presumed to emanate from a site at D1 = wavelength/4 = cf/4 = 6.15 (m/s)/(4×1.23 Hz) = 125 cm, where c is the assumed wave propagation velocity of the peripheral arterial tree according to McDonald, 1974. Given the vascular tortuosity, the estimated distance approximates that from the measurement site in the MCA main stem, to an imaginary site of summed reflections from the upper extremities, close to the finger tips when stretched sideways. The C-peak occurred at the second harmonic, such that the estimated arterial length (using common carotid c = 5.5 m/s) was given by D2 = wavelength/8 = cf2/8 = 28 cm, and a frequency f of 2.46 Hz. The distance approximates the visible arterial length from the main stem of the MCA, through vascular tortuosity and around the cerebral convexity, to the end vessels at distal cortical sites such as the occipito-temporal junction on carotid angiograms of adults. The S-peak occurred at the third harmonic, and may have arisen from an estimated site at D3= wavelength/16 = cf3/16 = 9.3 cm and a frequency f3 of 3.69 Hz. The latter approximates the visible arterial length of the lenticulostriate vessels from the main stem of the MCA on carotid angiograms. Although not displayed, the fourth harmonic would be expected to arise from the MCA bifurcation in closest proximity to the measurement site in the main stem of the MCA. The pre-bifurcation length from the measurement point would be given by D4 = wavelength/32 = cf4/32 = 3.5 cm and a frequency f4 of 4.92 Hz. The calculated distance approximates that of the segment of MCA main stem just after the carotid bifurcation, where probably the ultrasound sample volume was placed, to the MCA bifurcation. Thus, these estimates approximate actual lengths. However, it has been suggested that the estimated distances may not correlate exactly with known morphometric dimensions of the arterial tree according to Campbell et al., 1989. The method was first described by Philip Njemanze in 2007, and was referred to as functional transcranial Doppler spectroscopy (fTCDS). fTCDS examines spectral density estimates of periodic processes induced during mental tasks, and hence offers a much more comprehensive picture of changes related to effects of a given mental stimulus. The spectral density estimates would be least affected by artefacts that lack periodicity, and filtering would reduce the effect of noise. The changes at the C-peak may show cortical long-term potential (CLTP) or cortical long-term depression (CLTD), which has been proposed to be suggest equivalents of cortical activity during learning and cognitive processes. The flow velocity tracings are monitored during paradigm 1 comprising a checkerboard square as object perception are compared to whole face (paradigm 2) and facial element sorting task (paradigm 3). Fast Fourier transform calculations are used to obtain the spectral density and cross amplitude plots in the left and right middle cerebral arteries. The C-peak also called memory (M-peak) cortical peak could be seen arising during paradigm 3, a facial element sorting task requiring iterative memory recall as a subject constantly spatially fits the puzzle by matching each facial element in paradigm 3 to that stored in memory (Paradigm 2) before proceeding to form the picture of the whole face.

Accuracy

Although TCD is not so accurate due to relative velocity of blood flow, but it is still useful for diagnosis of arterial occlusions in patients with acute ischemice stroke, especially for middle cerebral artery. A research has been done to compare Power Motion Doppler of TCD (PMD-TCD) with CT angiography (CTA), both are valid, but PMD-TCD accuracy is not higher than 85 percent. The advantages of PMD-TCD is portable, so can be used in bed side or in emergency room, no radiation as CTA, so can be repeated, if necessary for monitoring and less expensive than CTA or Magnetic Resonance Angiography.

Handedness

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