Transcranial Doppler

Ribo M, Molina CA, Rovira A, Quintana M, Delgado P, Montaner J, Grive E, Arenillas JE, Alvarez-Sabin J. Safety and efficacy of intravenous tissue plasminogen activator stroke treatment in the 3- to 6-hour window using multimodal transcranial Doppler/MRI selection protocol. Stroke 2005 36 602-606. 

The Combined Lysis of Thrombus in Brain Ischemia Using Transcranial Ultrasound and Systemic rt-PA (CLOTBUST) study was a phase II randomized trial which compared continuous transcranial Doppler ultrasound insonation, in subjects with ultrasound evidence of MCA occlusion being given IV rt-PA, to sham insona-tion. ° There was an increased rate of arterial recanalization with the continuous insonation (49% vs. 30%, p = 0.03) and no increased risk of sICH. 

The GP Ilb-IIIa complex inhibitor Tirofiban has been used as an adjunct to thrombolysis in a number of small case series reports." A small transcranial Doppler (TCD) study suggests that it reduces microembolization from unstable carotid plaque." In an open pilot smdy, Tirohban administered within 9 hours after stroke onset blocked the conversion of ischemic penumbra to mature infarction." A phase III study (SETIS) has started recruiting patients to investigate its efficacy versus aspirin within the 6-hour window. 

The relationship between LAA and early recurrence is likely to be largely mediated by arterial embolism from atherosclerotic plaque, although recurrent low-flow stroke may also occur due to severe vessel stenosis or occlusion. In recently symptomatic individuals with moderate-or-severe ICA stenosis, platelet-fibrin embolic signals (ES) are commonly detected in the MCA using transcranial Doppler (TCD) ultrasound and have been reported to independently predict a fivefold increase in 90-day recurrence. " ... 

Trendelenberg position, in order to help perfuse the ischemic brain regions. Wojner-Alexander et studied 20 stroke patients with transcranial Doppler (TCD) of the middle cerebral artery (MCA), measuring mean flow velocities (MFV) at 30°, 15°, and 0° head of bed elevation. The MFV improved in all patients by lowering the head of bed, and three patients demonstrated immediate neurological improvement when lowered to 0°. 

Ultrasound Carotid non-invasive studies and transcranial Doppler... 

CTA and MRA are described in more detail in Chapter 2 therefore, this section will focus on CDUS. CDUS is widely available, well-validated, and is free of the risks and complications of radiographic contrast administration. Using ROC analysis, velocity criteria for detecting a residual lumen diameter of <1.5 mm have been developed based on pathological correlation with CEA plaques.In addition, transcranial Doppler can play an adjunctive role in dehning the hemodynamic signihcance of a lesion. ... 

Can U, Furie KL, Suwanwela N, Southern JF, Macdonald NR, Ogilvy CS, Buonanno FS, Koroshetz WJ, Kistler JP. Transcranial Doppler ultrasound criteria for hemodynamically significant internal carotid artery stenosis based on residual lumen diameter calculated from en bloc endarterectomy specimens. Stroke 1997 28(10) 1966-1971. 

Evaluation Perform computed tomography (CT) scan and MRI for evaluation of acute event. Perform magnetic resonance angiography for asymptomatic infarction. Perform transcranial Doppler to detect abnormal velocity and identify high-risk patients. Perform electroencephalography if there is a history of seizure. 

Early detection of ischemic stroke can be done with the use of transcranial Doppler ultrasonography. In the Stroke Prevention Trial in Sickle Cell Anemia (STOP) study, screening with this method followed by transfusion significantly reduced the incidence of stroke.29 Screening is recommended in all patients over 2 years of age. 

Transcranial Doppler can determine the presence of intracranial sclerosis (e.g., middle cerebral artery stenosis). 

Stein E, Pankiewicz J, Harsch HH, Cho JK, Fuller SA, Hoffmann RG, Hawkins M, Rao S, Bandettini PA, Bloom AS (1998) Nicotine-induced limbic cortical activation in the human brain a functional MRI smdy. Am J Psychiatry 155 1009-1015 Sziraki I, Lipovac MN, Hashim A, Sershen H, Allen D, Cooper T, Czobor P, Lajtha A (2001) Differences in nicotine-induced dopamine release and nicotine pharmacokinetics between Lewis and Fischer 344 rats, Neurochem Res 26 609-617 Terborg C, Birkner T, Schack B, Witte OW (2002) Acute effects of cigarette smoking on cerebral oxygenation and hemodynamics a combined study with near-infrared spectroscopy and transcranial Doppler sonography, J Neurol Sci 205 71-75 Thompson JC, WUby G, Stough C (2002) The effects of transdermal nicotine on inspection time. Hum Psychopharmacol 17 157-161... 

K2. Kalvach, R, Adam, R, Fayad, R, Dickey, R, and Kisiel, D., Imaging, transcranial Doppler and CSF cytology in subarachnoid hemorrhage. In 1st American-Czech and Slovak Neuroscience Symposium. 5, (1993). 

Gilgun-Sherki, Y., E. Melamed, R. Mechoulam, and D. Offen. The CBl cannabinoid receptor agonist, HU-210, reduces levodopa-induced rotations in 6-hydroxydopamine-lesioned rats. Pharmacol Toxicol 2003 93(2) 66—70. Pryce, G., Z. Ahmed, D. L. Hankey, et al. Cannabinoids inhibit neurodegeneration in models of multiple sclerosis. Brain 2003 126(Pt. 10) 2191-2202. Mathew, R. J., W. H. Wilson, and R. Davis. Postural syncope after marijuana a transcranial Doppler study of the hemodynamics. Pharmacol Biochem Behav 2003 75(2) 309-318. 

CA042 Perod, A. L., A. E. Roberts, and W. M. McKinney. Caffeine can affect velocity in the middle cerebral artery during CA052 hyperventilation, hypoventilation, and thinking a transcranial Doppler study. J Neuroimaging 2000 10(1) ... 

Vos JA, van den BergJC, Ernst SM, et al. Carotid angioplasty and stent placement comparison of transcranial Doppler US data and clinical outcome with and without filtering cerebral protection devices in 509 patients. Radiology 2005 234 493 -99,... 

Mathew RJ, Wilson WH, Davis R. Postural syncope after marijuana a transcranial Doppler study of the hemodynamics. Pharmacol Biochem Behav 2003 75 309-18. 

The cause of cocaine-related stroke and transient ischemic attacks has been studied by transcranial Doppler sonography, a continuous measure of cerebral blood flow velocity, to monitor the course of cerebral hemodynamic changes during acute intravenous injection of placebo, and of cocaine 10, 25, and 50 mg in seven cocaine abusers (150). There was a significant increase in mean and systolic velocity (lasting about 2 minutes) with all doses of cocaine but not with placebo. Cocaine produced an immediate brief period of vasoconstriction... 

Indirect assessment of perfusion reserve can be achieved by using transcranial Doppler ultrasound, single-photon emission CT, PET, dynamic CT or functional MRI to measure... 

Shiogai T, Koshimura M, Murata Y et al. (2003). Acetazolamide vasoreactivity evaluated by transcranial harmonic perfusion imaging relationship with transcranial Doppler sonography and dynamic CT. Acta Neurochirurgia Supplement 86 57-62 Stam J (2005). Thrombosis of the cerebral veins and sinuses. New England Journal of Medicine 352 1791-1798... 

Zanette EM, Robert C, Mancini G et al. (1995). Spontaneous middle cerebral artery reperfusion in ischaemic stroke. A follow-up study -with transcranial Doppler. Stroke 26 430-433... 

Kizer JR, Devereux RB (2005). Clinical practice. Patent foramen ovale in young adults with unexplained stroke. New England Journal of Medicine 353 2361-2372 Koennecke H, Mast H, Trocio SH et al (1998). Frequency and determinants of microembolic signals on transcranial Doppler in unselected patients with acute carotid territory ischemia. A prospective study. Cerebrovascular Diseases 8 107-112... 

Schmahmann JD (2003). Vascular syndromes of the thalamus. Stroke 34 2264-2278 Schulz UG, Rothwell PM (2001). Major variation in carotid bifurcation anatomy a possible risk factor for plaque development Stroke 32 2522-2529 Scott BL, Jankovic J (1996). Delayed-onset progressive movement disorders after static brain lesions. Neurology 46 68-74 Wardlaw JM, Merrick MV, Ferrington CM et al. (1996). Comparison of a simple isotope method of predicting likely middle cerebral artery occlusion with transcranial Doppler ultrasound in acute ischaemic stroke. Cerebrovascular Diseases 6 32-39 Wardlaw JM, Lewsi SC, Dennis MS etal. (1999). Is it reasonable to assume a particular embolic source from the type of stroke Cerebrovascular Diseases 9(Supp 1) 14... 

Despite these limitations, duplex sonography is a remarkably quick and simple investigation in experienced hands, and it is neither unpleasant nor risky. Very rarely, the pressure of the Doppler probe on the carotid bifurcation can dislodge thrombus, or cause enough carotid sinus stimulation to lead to bradycardia or hypotension (Rosario et al. 1987 Friedman 1990). The same conceivably applies to the various arterial compression maneuvres that may be carried out during transcranial Doppler, and any such compression should be avoided in patients who may have carotid bifurcation disease. 

Despite the fact that transcranial Doppler sonography, like positron emission tomography, has increased our knowledge of the cerebral circulation in health and disease, and even though it is inexpensive and quite widely available and repeatable on demand (unlike positron emission tomography), it stiU has rather a minor role in routine clinical management. 

Possible indications for transcranial Doppler ultrasound in routine clinical practice (Babikian etat 1997 Molloy and Markus 1999 Alexandrov etaf 2004 Kim etat 2005 Dittrich et at 2006 Markus 2006) include ... 

Dahl A, Russell D, Rootwelt KC et al (1995). Cerebral vasoreactivity assessed with transcranial Doppler and regional cerebral blood flow measurements dose serum concentration and time course of the response to acetazolamide. Stroke 26 2302-2306... 

Markus HS (1999). Transcranial Doppler ultrasound. Journal of Neurology, Neurosurgery and Psychiatry 67 135-137... 

Markus HS (2006). Can microemboli on transcranial Doppler identify patients at increased stroke risk Nature Clinical Practice in Cardiovascular Medicine 3 246-247... 

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