Basic Skill and Interpretation of TCD in Ischemic Stroke

Transcription

1 Journal of the K. S. C. N. Vol. 1, No. 2 Basic Skill and Interpretation of TCD in Ischemic Stroke Yong-Seok Lee, M.D., Seong-Joon Cho* Department of Neurology Seoul Minicipal Boramae Hospital & Eulji General Hospital* - Abstract - Transcranial Doppler ultrasonography (TCD) is a non-invasive and relatively cheap method of evaluating cerebral hemodynamics, allowing repeated measurements and continuous monitoring. Use of low frequency (2 MHz) ultrasound to penetrate bony window, and application of pulsed-wave Doppler mode allowing determination of the depth of the insonated vessels are two technical points. TCD measures velocity rather than flow, and therefore provides an estimation of cerebral blood flow only if vessel diameter remains unchanged. Mean flow velocity (MFV) and pulsatility index (PI) are the most commonly used parameters, which are influenced by various physiological variables and pathologic conditions. In clinical practice, detection of stenosis of the basal intracerebral arteries (>50-60%) is widely used, which is specific though not sensitive. Identification of occlusion or recanalization of vessels in acute stroke may provide useful information for thrombolytic therapy and prognosis. Monitoring of microembolic signal (MES) is a challenging field to detect the high-risk patients in asymptomatic carotid stenosis, and to evaluate the efficacy of anti-thrombotic therapy. CO 2 or acetazolamide reactivity test is a useful method to detect significantly impaired hemodynamic reserve in patients with carotid occlusion, in which surgical revascularization may be beneficial. Newly developed echo-contrast agents and power Doppler instrument, which are expected to overcome the current technical limitation, and further progress of the transcranial color-duplex sonography also light up the future of neurosonology. 210 Journal of the K. S. C. N. 1999

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7 Table 1. Mean flow velocity and PI in Healthy Men 30-49yr (n=29) 50-59yr (n=57) 60-69yr (n=20) MV PI MV PI MV PI MCA 55.8± ± ± ± ± ±0.14 ACA 49.7± ± ± ± ± ±0.18 PCA 30.2± ± ± ± ± ±0.16 C4 49.8± ± ± ± ± ±0.15 OA 16.0± ± ± ± ± ±0.34 VA 27.4± ± ± ± ± ±0.13 BA(P) 33.9± ± ± ± ± ±0.17 BA(D) 38.9± ± ± ± ± ±0.21 Table 2. Mean flow velocity (MFV) and Pulsatility index (PI) in Healthy Young-adult SJ Cho et al. (1998) 20-30yr 31-40yr Men (n=20) Women (n=27) Men (n=25) Women (n=36) MV PI MV PI MV PI MV PI MCA 71.9± ± ± ± ± ± ± ±0.10 ACA 61.7± ± ± ± ± ± ± ±0.12 PCA 31.6± ± ± ± ± ± ± ±0.16 C4 50.1± ± ± ± ± ± ± ±0.11 OA 18.6± ± ± ± ± ± ± ±0.29 BA(P) 40.4± ± ± ± ± ± ± ±0.14 BA(D) 47.0± ± ± ± ± ± ± ±0.13 YS Lee (unpublished) 216 Journal of the K. S. C. N. 1999

8 Table 3. Frequency of Poor Acoustic Temporal Window Age (yr) Sex Number Unilateral PTW Bilateral PTW Total PTW M (0.68%) 3 (2.07%) 4 (2.76%) F (1.03%) 8 (4.10%) 10 (5.13%) Total (0.88%) 11 (3.24%) 14 (4.12%) M (3.60%) 5 (3.60%) 10 (7.19%) F (7.51%) 35 (16.43%) 51 (23.94%) Total (5.97%) 40 (11.36%) 61 (17.33%) M 94 0 (0%) 5 (5.32%) 5 (5.32%) F (10.61%) 22 (16.67%) 36 (27.27%) Total (6.20%) 27 (11.95%) 41 (18.14%) M 13 1 (7.69%) 0 (0%) 1 (7.69%) 80 - F 32 2 (6.25%) 9 (28.13%) 11 (34.38%) Total 45 3 (6.68%) 9 (20.00%) 12 (26.67%) M (1.79%) 13 (3.33%) 20 (5.12%) Total F (5.94%) 74 (12.94%) 108 (18.88%) Total (4.26%) 87 (9.03%) 128 (13.30 %) YS Lee & SJ Cho (unpublished) 217

9 01.,,. Cerebral blood flow in Graves disease. 1999;1(1):A8 (abstract). 02.,,. MRI, MRA transcranial Doppler ultrasonography. 1998;16(3): Aaslid R, Markwalder T-M, Helge Nornes. Noninvasive transcranial doppler ultrasound recording of flow velocities in basal cerebral arteries. J Neurosurg 1982;57: Aaslid R, Lindegaard K, Sorteburg W, Nornes H. Cerebral autoregulation dynamics in humans. Stroke 1989;20: Adams RJ, Nichols FT, Hess DC. Normal Values and Physiological Variables. In: Transcranial Doppler, edited by D. Newell and R. Aaslid, Raven Press, New York, 1992; Arnolds BJ, von Reutern G-M. Transcranial doppler sonography. Examination technique and normal reference values. Ultrasound Med & Biol 1986;12(2): Brass LM. Anterior cerebral artery velocity changes in disease of the middle cerebral artery stem. Stroke 1989;20: Brass L, Pavlakis S, DeVivo D, Piomelli S, Mohr J. Transcranial doppler measurements of the middle cerebral artery. Effect of hematocrit. Stroke 1988;19: debray J, Joseph P, Jeanvione H, Maugin D, Dauzat M, Plassard F. Transcranial doppler evaluation of middle cerebral artery stenosis. J Ultrasound Med 1988;7: Demolis P, Chalon S, Giudicelli JF. Repeatability of transcranial doppler measurements of arterial blood flow velocities in healthy subjects. Clinical Science 1993;84: Droste DW, Decker W, Siemens HE, Kaps. Variability of occurrence of embolic signals in long term transcranial Doppler recordings. Neurological Research 1996;18(1): Furst H, Hartl WH, Jansen I, Fink B, Piepgras A, Lauterjung L, Schildberg FW. Pathophysiology of unilateral high-grade carotid artery stenosis: evaluation of intracranial hemodynamics by analysis of velocity waveforms from the middle cerebral artery. Clinical Science 1992;83: Giller CA, Hodges, K, Batjer, HH. Transcranial doppler pulsatility in vasodilation and stenosis. J Neurosurg 1990;72: Gosling RG, Lo TSP, Taylor MG, Padayachee TS. A model of the cerebral vasculature - the significance of the doppler pulsatility index in the basal cerebral arteries. Radiological Sciences, UMDS, (Guy s Campus), London, U.K. presented in Salzburg, 1 1 / 3 0 / Grolimund P, Seiler RW, Aaslid R, Huber P, Zurbruegg H. Evaluation of cerebrovascular disease by combined extracranial and transcranial doppler sonography experience in 1,309 patients. Stroke 1987;18: Grolimund P, Seiler RW. Age dependence of the flow velocity in the basal cerebral arteries -- a transcranial doppler ultrasound study. Ultrasound in Med & Biol ; 1 4 ( 3 ) : Hennerici H, Rautenberg W, Sitzer G, Schwartz A. Transcranial doppler ultrasound for the assessment of intracranial arterial flow velocity - part I: examination of technique and normal values. Surg Neurol 1987;27: Hennerici H, Rautenberg W, Sitzer G, Schwartz A. Transcranial doppler ultrasound for the assessment of intracranial arterial flow velocity - part 2 evaluation of intracranial arterial disease. Surg Neurol 1987;27: Itoh T, Matsumoto M, Handa N, Maeda H, Hougaku H, Hashimoto H, Etani H, Yoshitane T, Kamada T. Rate of successful recording of blood flow signals in the middle cerebral artery using transcranial doppler sonography. S t r o k e 1993 ; 23 : Kleiser B, Widder B. Course of carotid artery occlusions with impaired carbon dioxide reactivity. Stroke 1992;23: Lee YS, Kim BK, Roh JK. Transcranial Doppler ultrasonography diagnostic criteria for migraine : sensitivity and specificity. Neurology 1999;52(6) Supp 2:A208 (abstract) 22. Lindegaard K-F, Bakke SJ, Grolimund P, Aaslid R, Huber P, Nornes H. Assessment of intracranial hemodynamics in carotid artery disease by transcranial doppler ultrasound. J Neurosurg 1985 ; 63 : Lindegaard K, Lundae T, Winerg J, Sjoberg D, Aaslid R, Nornes H. Variations in middle cerebral artery blood flow investigated with noninvasive transcranial blood velocity measurements. Stroke 1987;18: Lindegaard K-F, Bakke SJ, Aaslid R, Nornes H. Doppler diagnosis of intracranial artery occlusive disorders. J Neurol Neurosurg Psychiat 1986;49: Markus H. Transcranial doppler detection of circulating cerebral emboli: a review. Stroke 1993;24: Markus H. Transcranial Doppler Ultrasound. J Neurol Neurosurg Psychiatry 1999;67(2): Mattle H, Grolimund P, Huber P, Struzenegger M, Zurbrugg HR. Transcranial doppler sonographic findings in middle cerebral artery disease. Arch Neurol 1988;45: Mull, Michael. Transcranial doppler ultrasonography versus arteriography for assessment of the vertebrobasilar circulation. J Clin Ultrasound 1990;18: Nelson RJ, Czosnyka M, Pickard JD, Chir M, Maksymowicz W, Perry S, Martin JL, Lovick AHJ. Experimental aspects of cerebrospinal hemodynamics. the relationship between blood flow velocity waveform and cerebral autoregulation. N e u r o s u r g e r y 1992 ; 31 : Park JM, Lee YS, Bae HJ, Yoon BW, Roh JK. Transcranial Doppler sonography in moyamoya disease. N e u r o l o g y 1999 ; 52 Supp 2:A365 (abstract) 31. Powers, Alexandros D. Transcranial doppler monitoring of cerebral flow velocities during surgical occlusion of the carotid artery. Neurosurgery, 1989;25: Ries F. Echocontrast agents in transcranial Doppler sonography. In: Tegeler CH, Babikian VL, Gomez CR, eds. Neurosonology. St Louis: Mosby, 1995: Ringelstein EB, Zeumer H, Poeck K. Non-invasive diagnosis 218 Journal of the K. S. C. N. 1999

10 of intracranial lesions in the vertebrobasilar system. A comparison of doppler sonographic and angiographic findings. Stroke 1985;16(5): Ringelstein EB, Sievers C, Ecker S, Schneider PA, Otis SM. Noninvasive assessment of CO-induced cerebral vasomotor response in normal individuals and patients with internal carotid artery occlusions. Stroke 1988;19: Ringelstein EB. A Practical Guide to Transcranial doppler Sonography. In: Noninvasive Imaging of Cerebrovas. Dis. 1990; Jesse Weinberger, editor, Alan R Liss. 36. Ringlestein EB, Biniek R. Weiller C, et al. Type and extent of hemispheric brain infarctions and clinical outcome in early and delayed middle cerebral artery recanalization. Neurology 1992;42: Schneider PA, Rossman M, Bernstein E, Torem S, Ringelstein E, Otis S. Effect of internal carotid artery occlusion on intracranial hemodynamics. Transcranial doppler evaluation and clinical correlation. Stroke 1988;19: Siebler M, Sitzer M, Steinmetz H. Detection of intracranial emboli in patients with symptomatic extracranial carotid artery disease. S t r o k e 1992 ; 23 : Siebler M, Nachtmann A, Sitzer M, et al. Steinmetz H. Cerebral microembolism and the risk of ischaemia in asymptomatic high-grade internal carotid artery ischaemia. S t r o k e 1995;26: Sorteberg W, Langmoen IA Lindegaard KF, Nornes H. Side-toside differences and day-to-day variations of transcranial doppler parameters in normal subjects. J Ultrasound Med 1990 ; 9 : Sorteberg W, Lindegaard K, Rootwelt D, Dahl A, Nyberg- Hansen R, Russell D, Nornes H. Effect of acetazolamide on cerebral blood velocity and regional cerebral blood flow in normal subjects. Acta Neurochir 1989;97: White RP, Markus HS. Non-invasive determination of impaired dynamic cerebral autoregulation in carotid artery stenosis. Stroke 1997;28: Widder B, Paulat K, Hackspacher J, Mayr E. Transcranial doppler CO test for the detection of hemodynamically critical carotid artery stenoses and occlusions. Eur Arch Psychiatr Neurol Sci 1986;236: