NeurosonologNeurosonology in acute y in acute stroke patientsstroke patients

ŠŠkoloudík D.koloudík D.

Department of NeurologyDepartment of NeurologyUniversity Hospital Ostrava University Hospital Ostrava && Olomouc Olomouc

NeurosonologyNeurosonology

Duplex sonography of cervical Duplex sonography of cervical arteriesarteries

Duplex sonography of eyehole Duplex sonography of eyehole (ophthalmic artery, optical nerve)(ophthalmic artery, optical nerve)

Transcranial DopplerTranscranial Doppler Transcranial duplex sonographyTranscranial duplex sonography

MethodologyMethodology

Necessity of fast diagnostic – Necessity of fast diagnostic – occlusion or stenosis of cervical or occlusion or stenosis of cervical or intracranial artery for a choosing the intracranial artery for a choosing the best therapeutical method best therapeutical method

Examination must not exceed 5 – 10 Examination must not exceed 5 – 10 minutesminutes

Echocontrast agent useEchocontrast agent use

CarotidsCarotids

StenosisStenosis OcclusionOcclusion DissectionDissection ArteriitisArteriitis

Evaluation of stenosisEvaluation of stenosis

PSV – best correlation with DSA PSV – best correlation with DSA (sensitivity, specificity approx. 90%)(sensitivity, specificity approx. 90%)

EDVEDV PSV ICA/PSV CCA, EDV ICA/EDV CCAPSV ICA/PSV CCA, EDV ICA/EDV CCA Lumen reduction, area Lumen reduction, area

CalcificationCalcification!!!!!!

Chronic vs. acute occlusionChronic vs. acute occlusion

B-mode (anechogenic acute B-mode (anechogenic acute thrombus)thrombus)

Collateral flowCollateral flow Asymmetric PSV in MCA´sAsymmetric PSV in MCA´s

Vertebral arteriesVertebral arteries

StenosisStenosis OcclusionOcclusion Steal syndomSteal syndom DissectionDissection

EyeholeEyehole

TCCS/TCDTCCS/TCD 1-4/2 MHz probe, (MI 1.5, TIS 1.2)1-4/2 MHz probe, (MI 1.5, TIS 1.2) TCCS: B-mode, M-mode, color mode, TCCS: B-mode, M-mode, color mode,

power mode, Doppler modepower mode, Doppler mode TCD: Doppler mode, Power M-modeTCD: Doppler mode, Power M-mode Acoustic window - temporal, Acoustic window - temporal,

suboccipital, frontal, occipital, orbital, suboccipital, frontal, occipital, orbital, submandibularsubmandibular

Acute strokeAcute stroke Occlusion of intracranial stenosisOcclusion of intracranial stenosis Intracranial artery stenosisIntracranial artery stenosis Hemodynamic changes (e.g. ICA Hemodynamic changes (e.g. ICA

occlusion)occlusion) HITS / MESHITS / MES HaemorhageHaemorhage AngiopathyAngiopathy Intracranial hypertensionIntracranial hypertension

Artery occlusionArtery occlusion Main: B-mode (MCA), Doppler mode Main: B-mode (MCA), Doppler mode

(no flow in occlusion, low PSV and (no flow in occlusion, low PSV and high PI, RI proximaly to the high PI, RI proximaly to the occlusion)occlusion)

Other: color mode, power mode, Other: color mode, power mode, detection of collateralsdetection of collaterals

Occlusion of MCA branchesOcclusion of MCA branches

Asymmetry in PSV (Zanette index Asymmetry in PSV (Zanette index 1.3, 30% site-to-site difference, TIBI 1.3, 30% site-to-site difference, TIBI criteria)criteria)

Increase of PI a RIIncrease of PI a RI

Artery stenosis - dg. criteriaArtery stenosis - dg. criteria MainMain: local jet with PSV ratio more : local jet with PSV ratio more

than 1.5than 1.5 OtherOther: turbulent flow, aliasing in : turbulent flow, aliasing in

color mode, lumen narrowing in color mode, lumen narrowing in power modepower mode

stenosis poststenoticstenosis poststenotic

• PSV-S/PSV-Z = 267.1/70.4 = 3.78 … grade III

Grading of stenosisGrading of stenosis US AGUS AG

Grade I: PSV index 1.5-1.99 … 20-39%Grade I: PSV index 1.5-1.99 … 20-39% Grade II: PSV index 2.0-2.99 … 40-59%Grade II: PSV index 2.0-2.99 … 40-59% Grade III: PSV index Grade III: PSV index >> =3.0 … =3.0 … >>= 60%= 60%

Correlation: Correlation:

kappa coefficient: 0.68kappa coefficient: 0.68

AngiopathyAngiopathy

HaemorrhageHaemorrhage

Increasing of intracranial pressureIncreasing of intracranial pressure

Thrombosis of cerebral sinusesThrombosis of cerebral sinuses

LimitationLimitation

Dependence on sonographer Dependence on sonographer experienceexperience

Insufficient bone window (8 – 20%)Insufficient bone window (8 – 20%)

female

%

male

age (years)

Echocontrast agentsEchocontrast agents

Bolus injection - 0.2-0.5 ml Optison Bolus injection - 0.2-0.5 ml Optison (1:10) nebo 0.5ml SonoVue(1:10) nebo 0.5ml SonoVue

BloomingBlooming!! Increasing of a Doppler signal for Increasing of a Doppler signal for

about 1 minuteabout 1 minute

MonitoringMonitoring

Monitoring HITS / MESMonitoring HITS / MES

Monitoring of artery recanalizationMonitoring of artery recanalization

Sonothrombotripsy, Sonothrombotripsy, sonothrombolysissonothrombolysis

MicroembolusMicroembolus

MicroembolusMicroembolus

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