TRANSCRANIAL DOPPLER

- Dr Himanshu Soni
History of Doppler
 Christian Doppler, 1842, at Royal
Bohemian Society, described the
effect.
 1959, Satomora & Kaneko, used
Doppler ultrasound to measure
cerebral blood flow but concluded
unsurmountable!
 Introduction of B-mode imaging
 Sono thrombolysis ...
B-mode Ultrasonography
 Principle – the variable acoustic
impedance that different body tissues
possess naturally.
 Standard display –
 Color – direction of flow
 Saturation – magnitude of signal
 B-mode display has become standard
Intraoperative
ultrasonography
 Provides real time images of
intradural, intraspinal images
 Craniotomy or laminectomy is required
 Useful for tumors, cysts, abscesses,
vascular malformations, hematomas
 Subcortical lesions – 7-10 MHz
 Deeper lesions – lower frequency
transducer ( 3 MHz )
 Evaluate extent of resection
 Rubin & Duhrmann et al, 186 patients,
found IOUS more useful for small
subcortical lesions.
 Useful to correct brain shift after
craniotomy in stereotaxis.
 micro-Doppler sonography – vessels
<1mm can be discretely insonated.
Duplex ultrasonography
 Doppler integrated with B-mode
imaging means duplex USG.
 Uses one transduder (5-7 MHz).
 Display screen
 Color – direction of the flow
 Saturation – degree of frequency shift
 Brightness – turbulence
 Limitation – assess only small area
 Solution – Color flow imaging
Transcranial doppler
 Aaslid and colleagues – 1982,
introduced TCD ultrasonography
 Uses 2 MHz probe for better
penetration.
 Visualisation of IC vasculature.
Windows
 Trans temporal
 MCA, ACA, ICA, proximal PCA
 Trans orbital
 Ophthalmic artery, intracavernous &
supraclinoid part of ICA.
 Trans occipital
 2 vertebral arteries, basilar artery.

 The distal arteries become vertically

oriented, so beyond the scope of
TCD..
Measurements
 Doppler signal contains
 Ultrasound frequency shifts
 Blood flow velocity
 Total average velocity, vessel diameter and
angle of Insonation.
 Multi channel recordings – allows
detection of emboli
TCD in Stroke / CVD
 Characteristic waveforms –
 Gentle broadening in downward slope of
systolic peak and early diastole – moderate
(<50% reduction in diameter)
 Spectral broadening increases with increasing
stenosis.
 Severe stenosis (>90%), blood flow is limited
despite compensation, resulting in decrease in
magnitude.
Parameters – stenosis
severity
 Degress of stenosis by B-mode
 Peak systolic frequency (velocity)
 Peak diastolic frequency
 End-diastolic frequency
 Ratio of systolic frequency betn ICA,
CCA
 Ratio of diastolic frequecy between
ICA & CCA
 Peak systolic & end-diastolic
frequency most important.
 All these, raise the sentivity from 84%
to 99%
Angiography vs TCD
 Correlation between TCD and
Angiography is excellent with Carotid
US capable of detecting stenosis with
100% sensitivity & specificity.
 Angiography provides little physiologic
information – about flow and no insight
nature of the plaque.
 Compared with surgical findings,
angiography is also less sensitive to
duplex US in detecting stenosis (91%
vs 99%)
 Compared after direct anatomic
examination of the plaque after removal,
it was noted that
 The duplex scanning not only was as
sensitive as angiography in detecting
greater than 50% luminal narrowing.
 Offers 96% sensitivity and 100%
specificity,
 Duplex is more accurate in detecting
smaller plaque ulcerations
 More accurate in predicting vessel wall
irregularities.
Intracranial stenosis
 Mainly caused by – atherosclerosis
 Other causes – moyamoya disease,
arterial dissection, vasculitis,
preeclampsia, sickel cell disease,
arterial emboli
 Accuracy of TCD for diagnosing
intracranial stenosis revealed a
sensitivity of 73% and specificity of
95%.
 It is worth performing a TCD in
patients with CV symptoms, without
Intracranial hemodynamics
 In occlusive disease, TCD helps in
determination of
 Collateral patterns
 Hemodynamic changes in distal vascular
territories.
 Evaluation of Vasomotor Reserve
(VMR)
 Changes in velocity through a vessel is
proportional to changes in flow, provided, the
vessel diameter is normal.
 Changes in the blood flow velocity through the
MCA can reflect relative changes in blood flow
in that artery as a result of alterations in CO2
concentration or acetazolomide or
 Carotid flow compensation
 Crossover through Acom and reversed flow in
the proximal ACA ipsilateral to the occlusion.
 Forward flow in the Pcom ipsilateral to the
occlusion
 Reeversed flow in ipsilateral ophthalmic artery.
Cerebral autoregulation
 TCD can be used to determine
autoregulation noninvasively in the
MCA perfusion territories.
 Autoregulation is absent in patients
with severly impaired CO2 reactivity
Positional vertebral artery
Occl.
 Impaired collateral pathways from
anterior circulation with positional
obstruction of one or both VA.
 MC due to cervical spondylosis
 TCD monitoring of PCA bilaterally in
various head positioning can be
useful.
 Diagnostic finding is transiend drop in
PCA velocity with head turning and
rebound hyperemia on return.
Intracranial emboli
 Intracranial microemboli have been detected
in patients with atrial fibrillation, prosthetic
heart valves,carotid stenosis, fibromuscular
dysplasia, arterial dissection and intracranial
stenosis, as well as during invasive
procedures such as angiography, angioplasty,
and vascular and heart surgery and after
aneurysm treatment.
 Monitoring of emboli with TCD has played a
useful role in identifying the site of active
embolization in the arterial system in patients
with transient ischemic attack or recent
stroke, distinguishing embolic versus
hemodynamic causes of stroke and transient
ischemic attack.
Cerebral Vasospasm
 While managing patient at risk for
cerebral vasospasm, TCD and
cerebral blood flow maeasurements
are useful to determine the state of
contraction of the basal intracranial
vessels, as well as the response of
cerebral blood flow.
Effect of Vessel narrowing on
Blood flow velocity
 Normally, average flow velocity in the
MCA is 62 cm/s.
 Velocities >120 cm/s indicate
vasospasm.
 Those >200 cm/s correlate with
severe vasospasm on angiography.
 Degree of vasospasm with TCD
velocities are best correlated with
MCA and distal ICA.
 The peak incidence of vasospasm
occurs initiallly 3 days after SAH adn
appeared to be maximal between 6-8
days and reduced by day 12.
 While considering the treatment of
vasospasm, its useful to consider the
effects of these on TCD values.
Intracranial aneurysms
 Not useful for screening
 Two-Dimensional TransCranial Color-
coded Sonography – increased
sensitivity.
 Aneurysms in the range from 3 to 16
mm were detected in TCCS
Raised ICP
 Early rise in ICP – pulsatility index
increaed with progressive reduction in
diastolic velocity and no change in
mean velocity.
 With further increase in ICP –
reduction in mean velocity adn
incerease in pulsatile index.
Thank you