TRANSCRANIAL DOPPLER ULTRASOUND

INTRODUCTION TO TCD
Nicolet Vascular, Inc. A Division of VIASYS HEALTHCARE

WHAT IS TCD?
TCD (Transcranial Doppler) is a non-invasive assessment of cerebral blood flow in the basal cerebral arteries
Utilizes low frequency Doppler ultrasound

WHAT IS TCD?
Uses 2 MHz pulsed Doppler ultrasound
Passes through cranial windows Provides information regarding velocity and direction of cerebral blood flow

Middle Cerebral Artery

BLOOD FLOW VELOCITY

Changes in flow velocity occur when:
There is a change in vessel caliber There is a change in volume flow

TRANSCRANIAL DOPPLER
Non-invasive Painless Inexpensive Can provide instantaneous and continuous cerebral blood flow information Can be used in any hospital environment Safe

DEVELOPMENT OF TCD
1982 Dr. Rune Aaslid
First publication Transtemporal Approach

1984 Dr. Merrill Spencer

First publication Transorbital Approach

1986 Dr. M. Von Reutern

First publication Suboccipital Approach

1983 First commercial TCD unit (EME)

TCD APPLICATIONS
Accepted applications *(AAN):
Detect intracranial stenosis Follow the time course of vasospasm Confirm the diagnosis of brain death Assist in the detection an management of AVMs
*American Academy of Neurology

TCD APPLICATIONS
Other reported uses:
Assess of collateral pathways Assess autoregulation and vasomotor reactivity ICU monitoring (effects of ICP) Surgical monitoring (CEA, CABG) Detection of emboli (HITS) Aid in classification of strokes

TCD APPLICATIONS
Other reported uses:
Subclavian steal assessment Assess mechanical compression of the vertebral arteries Evaluate Sickle Cell patients Evaluate patients with carotid dissections

TCD APPLICATIONS
Assess the effects of pharmacological interventions

Research applications
Surgical monitoring

INTRAOPERATIVE MONITORING APPLICATIONS

Carotid Endarterectomy Carotid Stenting Coronary Artery Bypass Surgery Cardiac Valve Surgery Abdominal Aortic Aneurysm Liver Transplants Orthopedic Surgery

TCD MONITORING
Patent Foramen Ovale evaluation
Implantable cardioverter defibrillator testing Any procedure where knowledge of the state of blood flow to the brain is of critical importance

TRANSCRANIAL DOPPLER
EXAMINATION TECHNIQUE

TCD - APPROACHES
Transtemporal
Transorbital

Suboccipital (Transforaminal)
Submandibular

TRANSCRANIAL DOPPLER ACCESS ROUTES

TRANSTEMPORAL APPROACH
Middle Cerebral Artery Anterior Cerebral Artery Terminal Internal Carotid Artery Posterior Cerebral Artery Communicating Arteries
Anterior Communicating Artery Posterior Communicating Artery

MCA ACA T-ICA PCA

ACoA PCoA

CRITERIA FOR VESSEL IDENTIFICATION

Depth of the sample volume Direction of flow Traceability of the vessel Transducer angulation Spatial relationship of spectra Response to carotid or vertebral oscillations or compressions

TRANSTEMPORAL WINDOWS

FW

Frontal

AW MW PW PW MW

AW

Middle Cerebral Artery

MCA / ACA

Anterior Cerebral Artery

Posterior Cerebral Artery P1

TRANSORBITAL APPROACH
Ophthalmic Artery Internal Carotid Artery Parasellar Genu Supraclinoid OA Siphon

Ophthalmic Artery

Carotid Siphon - Genu

SUBOCCIPITAL APPROACH
Vertebral Artery VA

Basilar Artery

BA

Vertebral Artery

Basilar Artery

NORMAL VELOCITY RELATIONSHIPS

MCA > ACA > PCA PCA ~ VA and BA

PRIMARY DIAGNOSTIC FEATURES

Changes in velocity Changes in pulsatility Changes in systolic upstroke Changes in flow direction Side to side differences Embolic phenomena (HITS)

TRANSCRANIAL DOPPLER
COLLATERAL CIRCULATION

Effects of Extracranial Carotid Stenosis / Occlusion

Factors affecting cerebral blood flow:
Degree of proximal stenosis Size and extent of collateral channels

EFFECTS OF CAROTID STENOSIS

Mild to Moderate Stenosis (< +/- 75%)
TCD exam: Essentially normal

Severe Stenosis

(> +/- 75%)

TCD exam: Abnormal Changes in Doppler spectral waveform shape Changes in flow patterns (Collateral)

WAVEFORM CHANGES
Decreased velocity Delayed systolic upstroke Decreased pulsatility

DOPPLER WAVEFORM CHANGES

Normal MCA

Abnormal MCA

COLLATERAL SOURCES
Collateral detectable by TCD include:
Circle of Willis, including the vertebrobasilar system
ECA to ICA collateral via the ophthalmic artery

COLLATERAL SOURCES
Collateral not detectable by TCD include:
Branches of the ECA connecting to branches of the vertebral artery
Leptomeningeal anastomoses

INTRACRANIAL STENOSIS
Focal elevated velocities above adjacent segments
Side to side differences exceeding normal variation
(usually > 15% or 30 cm/sec between right and left MCA)

Downstream effects: Turbulence Delayed systolic upstroke Decreased velocity

TCD WAVEFORMS WITH INTRACRANIAL STENOSIS

INTRACRANIAL STENOSIS Causes

Atherosclerosis Intraluminal thromboembolism Arterial dissection Moyamoya disease Vasculitis Vasospasm Extrinsic vessel compression

TRANSCRANIAL DOPPLER
EMBOLI DETECTION
(HITS)

EMBOLIC EVENTS
Foreign solids and / or gaseous materials within the blood stream Reflect sound waves more intensely than surrounding red blood cells Characterized by an audible chirp and simultaneous visual HIT on the screen

TCD - EMBOLI DETECTION

Can detect the presence of embolic signals caused by the presence of a variety of materials, both gaseous and solid Cannot determine the size of an embolus Cannot determine the composition of an embolus

Can detect particles as small as 50 microns

EMBOLI RECOGNITION
International Consensus Committee
Short < 0.1 second, 3-60 dB transients
Unidirectional in spectra Occur randomly in cardiac cycles Change frequency within spectrum Audible sound: chirps, clicks, plunks Solid vs. air emboli distinguished by circumstance (solid designated when there is no
invasion of vasculature)

EMBOLI DETECTION
Carotid artery stenosis
Arterial dissection Post endarterectomy

Patent foramen ovale

Atrial fibrillation Significant CHF Endocarditis Acute MI

Heart valve replacement

MCA Microembolic Signal

(MES)

Transcranial Doppler
Paradoxical Stroke and PFO Evaluation

Ischemic Stroke
Represents the third greatest cause of death in the western word Is the greatest cause of functional incapacity Origin is undetermined in 40% of cases according to conventional etiological criteria
Sacco R.L.,et al, Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann. Neurol. 1989:25:382-390

Cryptogenic Stroke
Stroke of unknown etiology
Suspicion of paradoxical brain emboli arising from the venous circulation Emboli from the venous system can pass to the arterial circulation through a PFO (Patent foramen ovale)

Paradoxical Brain Emboli (PBE)

Emboli whose source is not from an identifiable source in the arterial system Also referred to as venous-to-arterial emboli

Positive TCD Bubble Test

Shower Type HITS with Valsalva Maneuver

R MCA

L MCA

TRANSCRANIAL DOPPLER

Cerebral Circulatory Arrest

TCD - BRAIN DEATH

Brain death is a clinical diagnosis TCD is a confirmatory test TCD can detect cerebral circulatory arrest

Transcranial Doppler
Can aid in timing of other necessary tests

Helpful in following potential organ donors

Useful when patients are being treated with barbiturates which affect EEG

CEREBRAL CIRCULATORY ARREST

TCD Evaluation Bilateral study including posterior circulation Oscillating flow pattern persists over time (20 30 minutes minimum)

CEREBRAL CIRCULATORY ARREST