2. Orbital Window
• Transorbital Doppler sonography is used for investigating the OphA
and the carotid siphon.
• The patient is in the supine position, and the vessels are identified
by the depth of insonation and direction of blood flow.
• Flow towards the probe is assumed to come from the OphA or C4
segment of the internal carotid artery (ICA; lower carotid siphon),
whereas the upper carotid siphon (C2 segment of the ICA) leads to
Doppler signals being directed away from the probe.
• Transorbital ultrasound is assumed to
be safe when the lowest emission
energies are used, and the insonation
time is as short as possible.
• For safety reasons, the use of echo
contrast agents is prohibited.
4. Temporal Bony Window
• The posterior coronal plane
depicts the PCA, distal
basilar artery (BA), M2 and
M3 MCA, and horizontal
segment of the petrosal part
of the ICA.
• Transtemporal insonation is performed using axial and coronal
planes.
• The axial mesencephalic plane depicts the midbrain, which is
hypoechogenic and shaped like a butterfly, the sphenoidal (M1) and
insular (M2) parts of the MCA, A1 ACA, the terminal segment (C1)
of the ICA, and postcommunicating (P2) PCA
• The anterior coronal plane shows M1 MCA, A1 ACA, C1 ICA, parts
of the carotid siphon, and C5 ICA.
5. Temporal Bony Window
• With advancing age, and especially in postmenopausal women, the temporal
bone window becomes smaller or may even disappear, and the frequency of
ultrasonic detection of intracranial vessels decreases.
• Consequently, vascular structures located in the periphery of the insonation
field, such as the petrosal part, C5 and the siphon of the ICA, A2 ACA, M3
and M2 MCA, P3 PCA, the straight-, and transverse sinus will be missed in
older patients.
• The temporal window is better in men than women, and in white compared
to black and Asiatic patients
• Temporal squama thickness of 2.7mm was associated with a good window,
and values of 5.0mm permitted just a partial transcranial study
• 1-MHz probes increase the diagnostic yield of transcranial ultrasound in
patients presenting with absent or insufficient temporal bone windows at
transtemporal insonation with 2-MHz probes.
7. Foramen Magnum Window
• Transforaminal (transnuchal) insonation is performed
with an axial scanning plane, and allows the distinction of
the atlas loop (V3) and the intracranial segment (V4) of
both vertebral arteries (VA), and the BA
9. Intracranial Occlusion
• TCD diagnosis of intracranial cerebral artery occlusion is
established by the absence of Doppler signals in a
cerebral artery of a patient with an appropriate acoustic
window proven by the detection of at least one ipsilateral
cerebral artery.
• TCCDS diagnosis of intracranial occlusion is based on
the absence of color and spectral Doppler signals in the
occluded vessel, whereas the adequate insonation
window can also be demonstrated by depicting adjacent
intracranial veins or structures
10. Intracranial cerebral artery stenosis
• It is not possible to differentiate cerebral artery narrowing due to a
vasospasm and stenosis as well as embolic from atherosclerotic
stenoses.
• Vasospasm and stenoses due to cerebral embolism typically
recanalize within days, weeks, or months.
• In contrast, atherosclerotic stenoses are assumed to show no
recanalization.
14. Intracranial cerebral artery stenosis
Transtemporal color duplex
sonography with an axial plane shows
a 50% stenosis of the sphenoidal
segment of the middle cerebral
artery with increased intrastenotic
flow velocities (a),
and decreased flow velocities and
pulsatility distal to the stenosis (b).
15. Carotid Artery Stenosis
Longitudinal US image of right common carotid
artery ( C ) and internal carotid artery ( I ) showed
a large heterogeneous plaque at the origin
of the internal carotid artery with calcified and
fibrolipoid components( arrows ).
Longitudinal color Doppler US images showed a
heterogeneous plaque with apparent severe luminal
narrowing ( arrows ) at internal carotid artery origin.
Note color aliasing at the point
of maximal stenosis ( arrow)
16. Carotid Artery Stenosis
Power Doppler US images showed a
heterogeneous plaque with apparent
severe luminal narrowing ( arrows ) at
internal carotid artery origin.
Duplex Doppler image showed a
peak systolic velocity of 418 cm/s at
the point of maximal stenosis. This
velocity represents severe stenosis
(more than 70 %).
17. Carotid Artery Stenosis
Two centimeter distal to the stenosis, duplex
Doppler showed a peak systolic velocity of 82
cm/s, within normal limits, but with turbulent
flow features.
Digital angiography con firmed a severe stenosis
in the proximal internal carotid artery ( arrow ).
An endovascular stent was placed.
18. Carotid Artery Stenosis
Measurement of fibrous cap thickness in a carotid atheromatous plaque by
a new semi-automatic system. Fibrous cap is defined as the hyperechoic
structure existing between two anechoic surroundings (blood and lipid
core).
19. Carotid Artery Stenosis
Schematic examples of intra-arterial angiographic measurements for the degree
of stenosis for different configurations of ICA lesions. N ‘NASCET method’; E ‘ECST
method
NASCET method describes
predominantly the hemodynamic
significance of ICA stenosis (relation
of the inflow to outflow diameter)
1/3
ESCT method reflects more the
amount of atherosclerotic
tissue at the stenosed segment
1/2
20. Carotid Artery Stenosis
Nonstenotic ICA plaque without
hemodynamic changes, plaque
length is about 15mm, plaque
thickness 3.9 mm;
approximately 60–70%
ICA stenosis
approximately 90% ICA
stenosis
proximal ICA occlusion
The upper panel shows
longitudinal color
Doppler-assisted duplex
imaging where right is
proximal
The bottom left panel
shows the transverse
view of the narrowest part
of the stenosis and cross-
sectional luminal area
reduction measurement
The bottom right panel
displays the Doppler shift
recording and
spectrum analysis, the
maximum peak systolic shift
is given in kilo Hertz (kHz).
21. Carotid Artery Dissection
Longitudinal color Doppler ultrasound of the right
internal carotid artery demonstrating a low-reflective
intramural hematoma ( arrows ) compressing the true
lumen of the internal carotid artery 2 cm cranially from
the bulb. These findings are strongly suggestive of
internal carotid artery dissection with intramural
hematoma.
Color and spectral Doppler ultrasound of
internal carotid artery immediately
proximal to the lesion shows a high-
resistance triphasic waveform.
22. Carotid Artery Dissection
Spectral Doppler at the point of
maximal lumen stenosis shows
a very high peak systolic velocity (4
m/s).
Digital angiography confirmed an irregular
stenosis ( arrowheads ) starting 2 cm distal
to the carotid bulb.
23. Carotid Artery Dissection
Color duplex sonography (power Doppler imaging) with
longitudinal (a) and axial (b) planes
shows a spontaneous dissection of the cervical internal carotid artery.
•Luminal narrowing and the hypoechogenic and thickened vessel wall (white
arrows) begin distal to the carotid bulb.
•The unequivocal depiction of the border between the vessel wall and the
lumen including the presence of an intimal reflex (arrowheads) suggests that
mural thickening is mainly due to a wall hematoma and not an intraluminal
thrombus.
24. Cross-Flow through the Circle of
Willis
• Crossflow through the anterior communicating artery
was diagnosed in the presence of reversed flow in the
ACA located on the side of the obstructed carotid artery.
• If this ACA was missed, decrease of flow velocity in the
homolateral MCA during digital compression of the
contralateral common carotid artery was used for
diagnosis.
• The corresponding sensitivity was 98%, specificity 100%,
PPV 100%, and NPV 98%.
• Ultrasound contrast agents increase the detection rate of
Willisian collaterals compared to nonenhanced TCCDS
25. Extracranial-Intracranial Bypass
• Catheter- and MR-based angiography are typically used to evaluate
the postoperative bypass patency.
• Short-term effects of ECIC bypass on cerebral hemodynamics have
been investigated with various neuroradiologic techniques, including
positron-emission tomography (PET), single-photon emission CT
(SPECT), and xenon-enhanced CT scanning, these modalities are
complicated, expensive, time consuming, and invasive because
they expose patients to radiation, making them ill suited for use in
the outpatient setting or for long-term routine follow-up of ECIC
bypass.
• The ipsilateral STA mean blood flow velocity is a highly sensitive
parameter to predict regional cerebral blood flow (rCBF) in the
ipsilateral middle cerebral artery (MCA) territory at 14 days after
ECIC bypass in patients with internal carotid artery occlusion or
middle cerebral artery stenosis.
26. Transcranial Doppler Sonography
In Underwent Decompressive
Craniectomy For Traumatic Brain
Injury
• Cerebral blood flow (CBF) velocity by means of
transcranial Doppler sonography (TCD) can be
performed in patients post decompressive craniectomy
for traumatic brain injury
27. Transcranial Doppler Sonography
In Underwent Decompressive
Craniectomy For Traumatic Brain
Injury
Transcranial Doppler spectral waveforms obtained from the right middle cerebral artery of patient
A, before decompressive craniectomy, the cerebral circulation was characterized by reduced blood flow
velocity and high pulsatility index (PI) (18 cm/s and 7.09, respectively).
Note that during the diastolic phase, the blood flow velocity decreases continuously reaching zero value,
and straight away, there is a reversion of flow direction (see arrow).
This finding can indicate the presence of critical intracranial hypertension with a severe impairment of
cerebral blood flow.
B, immediately after surgery, the blood flow was restored to a unidirectional pattern, with more acceptable
flow dynamics in terms of flow velocity and PI (65 cm/s and 0.92, respectively).
28. Acute Stroke: Perfusion Imaging
• Ultrasound perfusion imaging of the human brain is a new semi-
invasive bedside technique based on the detection of ultrasound
contrast agent (UCA) in the brain tissue to evaluate brain perfusion.
• Current UCAs consist of microbubbles composed of a gas that is
associated with various types of shells for stabilization.
• Because of their small size, they can pass through the
microcirculation several times, thus representing optimum blood
pool tracers.
• Multiple pulse technologies receive contrast-agent-specific signals
in the fundamental frequency band (so-called nonlinear fundamental
signals) with a higher sensitivity than conventional single-pulse
approaches.
• As a measure of energy impinging on the tissue, the mechanical
index (MI) is defined as the peak pressure of a longitudinal
ultrasound wave propagating in a uniform medium divided by the
square root of the center frequency of the transmitted ultrasound
pulse
29. Acute Stroke: Perfusion Imaging
a Follow-up CT, 48 h after symptom onset, of a 67-
year-old woman suffering from middle cerebral artery
occlusion.
Ultrasound perfusion imaging (Harmonic imaging
1.8/3.6 MHz, MI 1.6, 2.4 ml SonoVueTM bolus
injection, investigation depth 10 cm, frame rate 0.67
Hz) was performed 2.5 h after symptom onset.
b Contrast image with area of reduced contrast
enhancement in the middle cerebral artery territory.
Parametric images:
c Pixelwise peak intensity image showing the area
of reduced signal enhancement (dark) in the middle
cerebral artery territory,
d time to peak image showing the dark blue area of
delayed perfusion, invalid data being displayed in
gray,
e area under the curve image, and
f slope image.
30. Sonothrombolysis:
Experimental Evidence
• The combination of ultrasound with thrombolytic agents
may enhance the potential benefit by means of enzyme-
mediated thrombolysis.
• When ultrasound is applied externally through skin or
chest, attenuation will be very low.
• Attenuation, however, is significantly higher if penetration
through the skull is required.
• Attenuation is frequency dependent, with ultrasound
intensity being 10% of the output intensity for diagnostic
frequencies (1 MHz).
• This ratio nearly reverses in the kiloHertz range (500
kHz).
31. Sonothrombolysis:
Experimental Evidence
• Ultrasound insonation is efficient for accelerating
enzymatic thrombolysis within a wide range of
intensities, from 0.5W/cm2 (MI 0.3) to several watts per
square centimeter, particularly in the non focused
ultrasound field.
• Insonation with ultrasound increased tPA-mediated
thrombolysis up to 20% in a static model, while it
enhanced the recanalization rate from 30 to 90% in a
flow model.
• Most studies demonstrated the potential usefulness of
ultrasound for the treatment of arterial or venous
thrombosis.
• Ultrasound may also have pro-thrombic effects.
32. Sonothrombolysis:
Experimental Evidence
Flow rate over time in a tube model. Measurement of recanalization after complete occlusion from a
fibrin clot in different treatment groups:
spontaneously (A), when treating with rt-PA only (B), when treating with rt-PA and ultrasound (1
MHz pulsed wave) (D)*, and (C) when treating with rt-PA and ultrasound (1 MHz pulsed wave)
transcranially (cadaver skull bone). The addition of ultrasound to tPA treatment showed a further
decrease of recanalization time.
33. Application of Ultrasound through
the Skull
• Within 0.25- and 6.0-MHz ultrasound frequencies, the increase of
insertion loss through the skull is not only roughly proportionally
related to an increased intensity, but also directly linked to the
thickness of the diploë and the skull bone
• Ultrasound at low to mid-kiloHertz frequencies and suggest that
only those frequencies may reach the brain and intracranial vessels
with thermally acceptable levels.
The diagram demonstrates the attenuation
of ultrasound through the skull
dependent on the used frequency, showing
the strong reversed correlation between
decrease of intensity and increase of
frequency.
34. Endovascular Application of
Ultrasound
• Miniaturized transducers have also been attached to
catheters for direct endovascular use, offering the
potential of localized ultrasound thrombolysis, while
avoiding attenuation of intensity through the skull and
reducing insonation of the surrounding tissue.
• The potential endovascular use of microcatheters for
acute stroke treatment is limited to specialized centers
and a broader applicability seems unrealistic.
35. Acute Stroke: Therapeutic
Transcranial Doppler Sonography
• Proximal intracranial occlusion is a target for more advanced
reperfusion strategies, among them ultrasound-enhanced
thrombolysis
• High frequencies lead to greater attenuation of ultrasound, lower
frequencies may be harmful due to tissue heating.
• The TRUMBI study, a phase II clinical trial testing the use of low
frequency ultrasound insonation in acute stroke patients treated with
i.v. t-PA, showed a significant increase in hemorrhage, both
symptomatic and asymptomatic
• Phase II randomized controlled trial CLOTBUST (Combined
Lysis of Thrombus in Brain Ischemia using Transcranial Ultrasound
and Systemic TPA), which demonstrated that enhancement of the
thrombolytic activity of tPA could be safely achieved by using higher
frequency (2 MHz) and low intensity (<700 mW/cm2) single element
pulsed-wave ultrasound
36. Acute Stroke: Therapeutic
Transcranial Doppler Sonography
• A phase III trial has been planned for quite some time
and protocols have been published. The problem,
however, is still the lack of an investigator independent
device.
• CLOTBUST-Hands Free Initial Safety Testing of a
Novel Operator-Independent Ultrasound Device in
Stroke-Free Volunteers study published in 2013
showed all subjects were safely insonated with no
adverse effects as indicated by the neurological
examinations during, immediately after the exposure,
and at 24 hours, and no abnormality of the blood brain
barrier was found on any of the MRIs.
37. Acute Stroke: Therapeutic
Transcranial Doppler Sonography
TCDS of the circle of Willis,
showing an occlusion of the MCA-
M1 (left).
Please note the missing Doppler
spectra and the lateral fissure
displayed as an echogenic
structure marked by the arrows in
the detail of the picture showing
the occlusion (middle).
Reconstituted flow after
recanalization with normalized
Doppler spectra (right).
38. Cerebral Aneurysms
• The prime criterion for the diagnosis of an aneurysm is a
color-coded appendix connected with a vessel; additional
criteria are
– (1) a red and a blue zone within the lumen of the aneurysm due
to bidirectional flow within larger aneurysms and
– (2) a circular echogenic structure in B-mode imaging,
demonstrated by fast switching from color-coded mode to B-
mode.
• Aneurysms with thrombosed components appear as an
echogenic, often calcified shell, which surrounds the less
echogenic thrombosed portions.
• The maximum diameter of the color-coded lumen of the
aneurysm should be measured in two planes.
39. Cerebral Aneurysms
Middle cerebral artery aneurysm. Coronal
plane section, insonation through the
temporal bone window: the arrow indicates
a large aneurysm of the middle cerebral
artery with a bicolored zone, which results
from simultaneous inflow and outflow within
the aneurysmal lumen. The echo-intense
small structure in the midline is caused by
the cerebral falx.
40. Cerebral Aneurysms
Basilar artery aneurysm. Transversal
insonation plane, insonation through
the temporal bone window: this figure
demonstrates the circle of Willis with
a giant aneurysm (surrounded by
dotted line) at the top of the basilar
artery compressing the brain stem.
LMCA =Left middle cerebral artery;
LACA = left anterior cerebral artery;
RMCA =right middle cerebral artery;
F = frontal; T = temporal.
41. Cerebral Aneurysms
Thrombosed aneurysm. Transversal
insonation plane, insonation through the
temporal bone window: this figure shows a
particularly thrombosed large aneurysm
(arrows) of the distal segment of the
internal carotid artery. Half of the aneurysm
is occluded by thrombosed (black signal)
and calcified material (bright signal), while
blood flow is detectable in the other half of
the lesion. The bright signal in frontomedial
position to the aneurysm is the base of the
skull (os sphenoidale).
F = Frontal, T = temporal.
43. Cerebral Arteriovenous
Malformations
• Using TCCS, large (4 cm) cerebral arteriovenous
malformations (AVMs) can be depicted by B-mode
imaging as echodense areas interspersed with zones of
lower echo intensity.
• The color-coded illustration of intravascular flow
phenomena allows the distinct identification of the major
feeding vessels, venous drainage, and vascular
convolution of the AVM.
• Information on hemodynamics, such as the blood supply
of the angioma, may be obtained by analysis of the
Doppler spectrum, in addition to color-coded
identification of flow direction.
45. Cerebral Arteriovenous
Malformations
Arteriovenous malformation, transverse.
Transversal insonation through the
temporal bone reveals a large
arteriovenous malformation with convolutes
of arterial and venous vessels in the
temporal lobe and the basal ganglia.
Aliasing phenomena reflect increased
flow velocities in all vessels. The echo-
intense (bright) signal at the bottom of the
figure is caused by the contralateral
temporal bone.