TRANSCRANIAL DOPPLER ULTRASOUND INTRODUCTION TO TCD INTERPRETATION

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1 TRANSCRANIAL DOPPLER ULTRASOUND INTRODUCTION TO TCD INTERPRETATION

2 ---Rune Aaslid First TCD Publication 1982

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

4 BLOOD FLOW VELOCITY A specific velocity does not correspond with a specific blood flow Changes in velocity reflect proportional changes in flow

5 BLOOD FLOW VELOCITY Changes in flow velocity occur when: There is a change in vessel caliber There is a change in volume flow

6 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

7 TCD APPLICATIONS Other reported uses: Assess of collateral pathways Subclavian steal assessment Evaluate Sickle Cell patients Evaluate patients with carotid dissections Aid in classification of strokes

8 TCD MONITORING Assess mechanical compression of the vertebral arteries Assess vasomotor reactivity (VMR, BHI ) Detection of emboli (HITS) Patent Foramen Ovale evaluation TCD ultrasound enhanced thrombolysis

9 BASIC TCD WAVEFORM

10

11 Aaslid

12

13 THE DOPPLER EFFECT Allows the determination of the direction of blood flow Allows the determination of the velocity (speed) of the blood flow

14 DOPPLER EFFECT Direction of Blood Flow Blood flow toward the transducer is normally displayed above the baseline Blood flow away from the transducer is normally displayed below the baseline

15

16

17

18 ANGLE OF INSONATION

19 SAMPLE VOLUME Length in mm Sample Volume Size = Length of Sample Volume

20 FAST FOURIER TRANSFORM (FFT) Allows real-time digital analysis of the velocity components of the Doppler signal

21

22 DIAGNOSTIC PARAMETERS Peak Systolic Velocity End Diastolic Velocity Mean Velocity Pulsatility Vs Vd Vm PI, RI Systolic Upstroke --

23 Peak Systolic Velocity

24 End Diastolic Velocity

25 Mean Velocity Vm = Vs Vd / 3 + Vd

26 Systolic Upstroke

27 SYSTOLIC UPSTROKE Normal Upstroke Delayed Upstroke

28 PULSATILITY Describes the relative differences between Vs and Vd Largely dependent on peripheral resistance Influenced by various physiological changes, pathologies and cardiac status

29 PULSATALITY CHANGES PI (Gosling) RI (Pourcelot) Vs -Vd / Vm Vs -Vd / Vs

30 TYPICAL PI VALUES

31 CAUSES OF INCREASED PI Bradycardia Aortic valve incompetence Increased ICP Hyperventilation Increased peripheral resistance (vasoconstriction of the microcirculation)

32 CAUSES OF DECREASED PI Proximal stenosis AVM Hypercapnia Decreased peripheral resistance (vasodilitation of the microcirculation)

33 PULSATILITY INDEX Look for side to side differences Look for differences between vessels Look for changes over time

34 LAMINAR FLOW FLOW IS SMOOTH NOT TURBULANT

35 TURBULENCE Doppler Bruit Harmonic Bruit (Musical Murmur) Can be the result of pathology Can occur in normal individuals when intracranial flow is high

36 TRANSCRANIAL DOPPLER THE NORMAL EXAM

37 Transcranial Doppler Typical Depths and Mean Velocities Velocities and depths noted in this presentation are taken from Ringelstein Depths can vary considerably due to head size, especially post-craniotomy Velocities outside of the reported range should not automatically be assumed to be abnormal

38 From Transcranial Doppler, ed. Newell, Aaslid

39 TCD - APPROACHES Transtemporal Transorbital Suboccipital Submandibular (For MCA/ICA ratio) Extracranial ICA (Ex-ICA)

40 TRANSCRANIAL DOPPLER ACCESS ROUTES

41 TRANSTEMPORAL APPROACH Middle Cerebral Artery Anterior Cerebral Artery Terminal Internal Carotid Artery Posterior Cerebral Artery Communicating Arteries MCA ACA T-ICA PCA Anterior Communicating Artery ACoA Posterior Communicating Artery PCoA

42 CRITERIA FOR VESSEL IDENTIFICATION Depth of the sample volume Direction of flow Traceability of the vessel Transducer angulation Spatial relationship of spectra

43 Middle Cerebral Artery Depth: mm Mean velocity: 55 +/- 12 cm/sec

44 MCA - Distal

45 MCA / ACA Depth: mm

46 Anterior Cerebral Artery Depth: mm Mean velocity: 50 +/- 11 cm/sec

47 Terminal ICA Depth: mm

48 Posterior Cerebral Artery P1 Depth: mm Mean velocity: 39 +/- 10 cm/sec

49 PCA P2

50 TRANSTEMPORAL - Anterior MCA Both ACAs MCA/ACA MCA-dist DIAGRAM/SIGNALS ALL VESSELS - SUMMARY ACA T-ICA

51 TRANSTEMPORAL - Posterior PCA P1 Both PCAs - midline PCA P2

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

53 Ophthalmic Artery Depth: mm Mean velocity: 21 +/- 5 cm/sec

54 Carotid Siphon - Parasellar Depth: mm Mean velocity: 47 +/- 14 cm/sec

55 Carotid Siphon - Genu

56 Carotid Siphon Supraclinoid Mean velocity: 41 +/- 11 cm/sec

57 TRANSORBITAL VESSELS

58 SUBOCCIPITAL APPROACH Vertebral Artery Basilar Artery VA BA

59 Vertebral Artery Depth: mm Mean velocity: 38 +/- 10 cm/sec

60 Basilar Artery Proximal Depth: mm Mean velocity: 41 +/- 10 cm/sec

61 SUBOCCIPITAL VESSELS BA VA VA VA VA

62 NORMAL VELOCITY RELATIONSHIPS MCA > ACA > PCA PCA ~ VA and BA

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

64 TRANSCRANIAL DOPPLER INTRACRANIAL STENOSIS

65 INTRACRANIAL STENOSIS Causes Atherosclerosis Intraluminal thromboembolism Arterial dissection Moyamoya disease Vasculitis Vasospasm Extrinsic vessel compression

66 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

67 TCD WAVEFORMS WITH INTRACRANIAL STENOSIS

68 From Fujioka / Pacific Vascular, Inc.

69 INTRACRANIAL OCCLUSION

70

71 MCA OCCLUSION Lack of signal at the appropriate location Identification of neighboring vessels Possible increased pulsatility index proximally

72

73 ACA OR PCA OCCLUSION UNRELIABLE

74 TRANSCRANIAL DOPPLER VASOSPASM - SUBARACHNOID HEMORRHAGE

75 VASOSPASM Complication associated with subarachnoid hemorrhage (SAH) Multifactorial, multistage process

76 SUBARACHNOID HEMORRHAGE Causes Ruptured Aneurysm Trauma AVM Tumor Spontaneous bleed

77

78 VASOSPASM Initially, probably vasoconstriction secondary to vasoactive substances released with the breakdown of subarachnoid blood Leads to degeneration and inflammatory reactions of the vessel wall Results in an organic vasculopathy with structural wall changes and lumenal narrowing (Seiler, Aaslid)

79 ANGIOGRAPHIC VASOSPASM

80 VESSEL IN VASOSPASM NORMAL VESSEL

81 TIME COURSE OF VASOSPASM DAYS FOLLOWING SAH Transcranial Doppler, ED. Newell & Aaslid

82 VASOSPASM (MCA) TCD Mean Velocities Mild Moderate Severe > 120 cm/sec > cm/sec > 200 cm/sec

83 VASOSPASM Treatment Hypertension Hemodilution Triple H Therapy Hypervolemia Intracranial angioplasty

84 FACTORS AFFECTING CBF Cardiac Output Systemic Blood Pressure Blood Volume Arterial Oxygen Tension Carbon Dioxide Tension ICP Viscosity

85 HYPEREMIA

86 CEREBRAL BLOOD FLOW STUDY

87 VASOSPASM vs HYPEREMIA TCD diagnosis uses MCA/ICA Ratio (Lindegaard Ratio or Hemispheric Ratio) MCA = Highest mean velocity of the MCA ICA = Highest mean velocity of the submandibular ICA (using 2 MHz probe) - at a depth of +/- 50 mm - at a 0 degree angle

88

89 MCA / ICA RATIO TYPICAL VALUES 1.7 +/- 0.4

90 MCA / ICA RATIO MCA/ICA < 3.0 = Hyperemia MCA/ICA > 3.0 = Vasospasm MCA/ICA > 6.0 = Severe Spasm

91 VASOSPASM TCD Criteria - MCA Velocity < 120 cm/sec MCA / ICA ratio < 3.0 Interpretation Normal, nonspecific elevation of velocity or distal MCA spasm > 120 cm/sec MCA vasospasm (proximal segment) > 200 cm/sec > 6.0 Severe MCA vasospasm

92 VASOSPASM TCD Criteria ACA 130 cm/sec (no MCA and/or ICA spasm) (with MCA and/or ICA spasm) Vasospasm Vasospasm vs Collateral Flow PCA 110 cm/sec (no MCA and/or ICA spasm) (with MCA and/or ICA spasm) Vasospasm Vasospasm vs Collateral flow (Sloan et al)

93 VASOSPASM TCD Criteria VA 80 cm/sec (no MCA and/or ICA spasm) (with MCA and/or ICA spasm Vasospasm Vasospasm vs Collateral Flow BA 95 cm/sec (no MCA and/or ICA spasm) (with MCA and/or ICA spasm) Vasospasm Vasospasm vs Collateral flow (Sloan et al)

94 CASE 2

95 Day 2 SP SAH Left Right

96 Day 5 SP SAH Left Right

97 CASE 4 L-MCA Aneurysm clipped

98 Day 5 SP SAH Left Right

99 Day 6 SP SAH Left Right

100 Day 7 SP SAH Left Right

101 CASE 6 SP L MCA Aneurysm Clipping

102 Day 11 SP SAH MCA MCA Left Right

103 TRANSCRANIAL DOPPLER HEAD TRAUMA

104 HEAD TRAUMA Problems associated with head trauma: Vasospasm Hyperemia Increased ICP Arterial dissection / occlusion Cerebral circulatory arrest

105 TCD CPP Doppler Waveforms ABP CPP = MAP - ICP CPP ICP

106 TRANSCRANIAL DOPPLER Cerebral Circulatory Arrest

107 CEREBRAL CIRCULATORY ARREST

108 TCD - BRAIN DEATH Brain death is a clinical diagnosis TCD is a confirmatory test TCD can detect cerebral circulatory arrest

109 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

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

111 Progression of Waveforms to Cerebral Circulatory Arrest

112 TRANSCRANIAL DOPPLER EMBOLI DETECTION (HITS)

113 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

114 EMBOLI Symptomatic patients and patients with high degrees of carotid stenosis associated with higher frequency of emboli One embolus does not equal one stroke Multiple micro emboli may be asymptomatic

115 EMBOLI DETECTION Carotid artery stenosis Arterial dissection Post endarterectomy Heart valve replacement Patent foramen ovale Atrial fibrillation Significant CHF Endocarditis Acute MI

116 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)

117 TCD - HITS

118 Emboli / Atrial Fibrillation

119 TRANSCRANIAL DOPPLER COLLATERAL CIRCULATION

120 CAROTID OBSTRUCTION EFFECTS Factors affecting cerebral blood flow: Degree of proximal stenosis Size and extent of collateral channels

121 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)

122 WAVEFORM CHANGES Decreased velocity Delayed systolic upstroke Decreased pulsatility

123 DOPPLER WAVEFORM CHANGES Normal MCA Abnormal MCA

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

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

126 No Hemodynamically Significant Extracranial Stenosis P1 = P2 P3 = P4 No significant flow across the Communicating Arteries

127 With a Hemodynamically Significant Extracranial Stenosis L-ICA Stenosis > 80% P1 P2 P3 = P4 Flow across the Communicating Arteries from areas of higher pressure to areas of lower pressure is seen

128 Normal Direction of Flow

129 ACA CROSSOVER

130 ACA CROSSOVER Reversed flow in ipsilateral ACA Increased velocity in contralateral ACA (ACA > MCA by at least 25%) Must have patent ACoA

131 From Fujioka, / Pacific Vascular, Inc.

132 PCA COLLATERAL

133 PCA COLLATERAL Increased velocity in the PCAs (PCA > MCA) Must have patent PCoA(s)

134 CASE STUDY Bilateral Extracranial Internal Carotid Occlusions

135 ACA - Reversed Posterior Circulation Collateral ACA Normal Direction (Inverted) Right MCA Left MCA Right PCA Left PCA Basilar From von Reutern, von Budingen, Ultrasound techniques In cerebral vascular diagnosis

136 Collateral Flow With Common Carotid Compressions Fujioka

137 COLLATERAL VIA OA

138 ECA TO ICA COLLATERAL Reversed ophthalmic artery Decreased pulsatility in ophthalmic artery Ophthalmic artery diminishes/reverses with compression of ECA branches

139

140 Normal Ophthalmic Artery Flow Direction Reversed Ophthalmic Artery Flow Direction

141 CASE STUDY COLLATERAL

142 Left Right MCA Bifurcation Not Shown obtained ACA PCA OA SIPHON VA BA

143 TRANSCRANIAL DOPPLER VERTEBRAL TO SUBCLAVIAN STEAL

144

145

146 Vertebral Artery Waveforms with Subclavian Stenosis

147 CASE STUDY SUBCLAVIAN STEAL

148 V-B Junction Basilar Artery Left Vertebral Right Vertebral

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