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INTRODUCTION TO TCD
Nicolet Vascular, Inc. A Division of VIASYS HEALTHCARE
WHAT IS TCD?
TCD (Transcranial Doppler) is a non-invasive assessment of cerebral blood flow in the basal cerebral arteries
Utilizes low frequency Doppler ultrasound
WHAT IS TCD?
Uses 2 MHz pulsed Doppler ultrasound
Passes through cranial windows Provides information regarding velocity and direction of cerebral blood flow
TRANSCRANIAL DOPPLER
Non-invasive Painless Inexpensive Can provide instantaneous and continuous cerebral blood flow information Can be used in any hospital environment Safe
DEVELOPMENT OF TCD
1982 Dr. Rune Aaslid
First publication Transtemporal Approach
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
TCD APPLICATIONS
Other reported uses:
Assess of collateral pathways Assess autoregulation and vasomotor reactivity ICU monitoring (effects of ICP) Surgical monitoring (CEA, CABG) Detection of emboli (HITS) Aid in classification of strokes
TCD APPLICATIONS
Other reported uses:
Subclavian steal assessment Assess mechanical compression of the vertebral arteries Evaluate Sickle Cell patients Evaluate patients with carotid dissections
TCD APPLICATIONS
Assess the effects of pharmacological interventions
Research applications
Surgical monitoring
TCD MONITORING
Patent Foramen Ovale evaluation
Implantable cardioverter defibrillator testing Any procedure where knowledge of the state of blood flow to the brain is of critical importance
TRANSCRANIAL DOPPLER
EXAMINATION TECHNIQUE
TCD - APPROACHES
Transtemporal
Transorbital
Suboccipital (Transforaminal)
Submandibular
TRANSTEMPORAL APPROACH
Middle Cerebral Artery Anterior Cerebral Artery Terminal Internal Carotid Artery Posterior Cerebral Artery Communicating Arteries
Anterior Communicating Artery Posterior Communicating Artery
TRANSTEMPORAL WINDOWS
FW
Frontal
AW MW PW PW MW
AW
MCA / ACA
TRANSORBITAL APPROACH
Ophthalmic Artery Internal Carotid Artery Parasellar Genu Supraclinoid OA Siphon
Ophthalmic Artery
SUBOCCIPITAL APPROACH
Vertebral Artery VA
Basilar Artery
BA
Vertebral Artery
Basilar Artery
TRANSCRANIAL DOPPLER
COLLATERAL CIRCULATION
Severe Stenosis
TCD exam: Abnormal Changes in Doppler spectral waveform shape Changes in flow patterns (Collateral)
WAVEFORM CHANGES
Decreased velocity Delayed systolic upstroke Decreased pulsatility
Normal MCA
Abnormal MCA
COLLATERAL SOURCES
Collateral detectable by TCD include:
Circle of Willis, including the vertebrobasilar system
ECA to ICA collateral via the ophthalmic artery
COLLATERAL SOURCES
Collateral not detectable by TCD include:
Branches of the ECA connecting to branches of the vertebral artery
Leptomeningeal anastomoses
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)
TRANSCRANIAL DOPPLER
EMBOLI DETECTION
(HITS)
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
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)
EMBOLI DETECTION
Carotid artery stenosis
Arterial dissection Post endarterectomy
Transcranial Doppler
Paradoxical Stroke and PFO Evaluation
Ischemic Stroke
Represents the third greatest cause of death in the western word Is the greatest cause of functional incapacity Origin is undetermined in 40% of cases according to conventional etiological criteria
Sacco R.L.,et al, Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann. Neurol. 1989:25:382-390
Cryptogenic Stroke
Stroke of unknown etiology
Suspicion of paradoxical brain emboli arising from the venous circulation Emboli from the venous system can pass to the arterial circulation through a PFO (Patent foramen ovale)
R MCA
L MCA
TRANSCRANIAL DOPPLER
Transcranial Doppler
Can aid in timing of other necessary tests