Neurosonology in acute stroke patients Školoudík D. Department of Neurology University Hospital...
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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
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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
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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
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CarotidsCarotids
StenosisStenosis OcclusionOcclusion DissectionDissection ArteriitisArteriitis
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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!!!!!!
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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
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Vertebral arteriesVertebral arteries
StenosisStenosis OcclusionOcclusion Steal syndomSteal syndom DissectionDissection
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EyeholeEyehole
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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
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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
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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
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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
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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
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stenosis poststenoticstenosis poststenotic
• PSV-S/PSV-Z = 267.1/70.4 = 3.78 … grade III
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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
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AngiopathyAngiopathy
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HaemorrhageHaemorrhage
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Increasing of intracranial pressureIncreasing of intracranial pressure
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Thrombosis of cerebral sinusesThrombosis of cerebral sinuses
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LimitationLimitation
Dependence on sonographer Dependence on sonographer experienceexperience
Insufficient bone window (8 – 20%)Insufficient bone window (8 – 20%)
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female
%
male
age (years)
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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
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MonitoringMonitoring
Monitoring HITS / MESMonitoring HITS / MES
Monitoring of artery recanalizationMonitoring of artery recanalization
Sonothrombotripsy, Sonothrombotripsy, sonothrombolysissonothrombolysis
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MicroembolusMicroembolus
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MicroembolusMicroembolus
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