Yield of Transcranial Doppler in Acute Cerebral Ischemia

Abstract

Background and Purpose —The objective of this study was to evaluate the yield of emergent transcranial Doppler (TCD) for the evaluation of acute cerebral ischemia. Methods —We performed urgent bedside non–contrast-enhanced TCD in patients with acute cerebral ischemia before or immediately after baseline CT scanning. A fast-track scanning protocol (≤15 minutes) and detailed diagnostic criteria were developed for portable single-channel TCD testing. TCD results were compared with angiography. Results —Of 130 consecutive patients studied, 36 were eligible for thrombolytic therapy; 46 with ischemic strokes and 48 with transient ischemic attacks were not eligible for thrombolysis. TCD identified occlusions in 69% of thrombolysis-eligible patients, compared with 24% and 0% of patients with strokes and transient ischemic attacks, respectively, not eligible for thrombolysis ( P <0.01). Stenosis was present in 17%, 33%, and 35%, and normal vessels were found in 14%, 43%, and 65% in the respective patient subgroups. TCD also identified abnormal pulsatility of flow (12 patients), abnormal flow velocities (12), microembolic signals (5), or early recanalization (5) (34 of 130; 26%). In 65% of all patients, TCD was compared with angiography (digital subtraction angiography, MR angiography, or CT angiography). Despite a 15% rate of absent temporal windows, TCD had 88% accuracy for abnormal (occlusion and stenosis) versus normal vessels: sensitivity 87.5%, specificity 88.6%, positive predictive value 87.5%, and negative predictive value 88.6%. Conclusions —A proximal occlusion on TCD was found in 69% of thrombolysis-eligible patients. In 26% of all patients, TCD provided further relevant information that, in addition to angiography, helped to refine the severity of a stenosis and determine stroke pathogenesis. Emergent TCD is both sensitive and specific in determining arterial occlusion and stenosis in acute cerebral ischemia.