Transcranial Doppler Correlation with Angiography in Detection of Basilar Artery Stenosis Tae-Kyu Yang, Al-An Seo, In-Young Yeo, Hyung-Do Kim. Woo-Sang Jung, Jung-Mi Park, Ok-Jun Kim. Byung-Ok Choi* Department of Oriental Internal Medicine, Pundang CHA Oriental Hospital, College of Medicine, Pochon CHA University Department of Neurology, Pundang CHA Hospital, College of Medicine, Pochon CHA University* Objectives : Transcranial doppler(TCD) is a convenient non-invasive screening tool for intracranial stenoses. Several studies regarding the diagnostic value of TCD for detection of middle cerebral artery(MCA) stenosis have been published, Moreover, there have been few studies for basilar artery(BA) stenosis. So we aimed to evaluate the diagnostic accuracy of TCD in detecting BA stenosis among ischemic stroke patients when mean flow velocity(MFV) criteria was applied to them. Methods : Fifty-eight ischemic stroke patients(40 men and 18 women, mean age of 61.5) who underwent both cerebral angiography and TCD were observed. TCD was performed a mean of 5 days after angiography and TCD interpretation was performed according to standard criteria. Results : When we used MFV cutoff of 60cm/s in BA as the criteria for stenosis, 4 of 9 stenoses of any degree were detected by TCD with 6 out of 49 false positives. For BA stenosis, TCD had a sensitivity of 44%, specificity of 88%, positive predictive value 40%, negative predictive value 90% in this study. Conclusions : TCD may be a less effective screening test for BA stenosis when MFV criteria is used alone. To help avoid false negative results, examination for internal carotid artery(ICA) abnormalities shoud be performed before TCD. Key Words: Intracranial stenosis, transcranial doppler(TCD), basilar artery , . 1982 Aaslid 1 (transcranial doppler, TCD) 2MHz : 2002 9 13 : 2002 10 14 (stenosis) (occlusion) , : , 351 (vasospasm) , (Tel:031-780-6287, E-mail: [email protected]) (emboli) , 689 .2 .3 BA angiography TCD TCD (mean flow velocity, MVF) >60cm/s .4 . , , ( digital subtraction angiography( DSA), 160mm/Hg, 90mm/Hg computed tomographic angiography( CTA), magnetic resonance angiography( MRA) ) ( 2 angiography TCD 200mg/dl ) (middle cerebral artery, MCA) , , homocysteine . (vertebral artery, VA) (basilar artery, BA) . 230mg/L , 200mg/L BA TCD . 15 mol/L . TCD Mann-Whitney U test 0.05 . 2001 12 1 2002 7 31 58 20 MRA transfemoral cerebral 38 large angiography(TFCA) 58 artery disease 10 , small artery disease 39 , . cardiogenic 5 , 4 . TCD 40 , 18 . 61.52( 12.01) 27 89 . , 37 , 18 , TCD Companion (Nicolet Biomedical, 13 , 9 , USA) angiog- 3 .(Table 1) Angiography raphy . BA TCD 2 26 TCD 5.12( 5.65) . 58 (suboccipital window) angiography BA 9 , 80mm (depth) 49 TCD BA (false positive) 6 , (false negative) 5 MFV 690 Table 1. General Characteristics of Subjects Table 2. TCD Accuracy Compared with Angiography to Differentiate Normal Versus Stenosis No. Age, yr 61.52( 12.01) Angiography Stenosis Normal Gender, Male 40 TCD Hypertension 37 Stenosis 4 6 DM 18 Normal 5 43 Hyperlipidemia 9 Total 9 49 Hypercholesterolemia 13 Hyperhomocysteinemia 3 Table 3. MFV, PI And Depth Between Stenosis And Normal TCD findings TCD TCD Normal Stenosis MFV(cm/s) 31.27 60.33 PI* 0.8731 0.8422 Depth(mm) 78.71 79.56 *: P>0.05 by Mann-Whitney U test for normal vs. stenosis monitoring screening . BA TCD TCD 7 (sensitivity) 44%, (specificity) 88% , (positive predictive value) 40%, Brain CT, MRI, TCD (negative predictive value) 90% .(Table 2) Pulsatility index( PI) TCD 8 TCD MFV 31.27cm/s, 60.33cm/s .(Table 3) . TCD MFV PI MFV TCD PI angiography .5 MFV PI . .9-23 (temporal window) TCD .5 MRA 6 , TCD .9 MRA 50 . 691 TCD MRA Tettonborn 25 76%, . MCA 86% . MFV >80cm/s Felberg (false positive) 44% 10 50% MCA MFV >100cm/s Gao 11 MRA . vertebrobasilar system >50% MCA MFV >140cm/s internal carotid artery( . ICA) ICA MFV . 20 MCA MFV TCD angiography PI Pulsatility transmission index(PTI, angiography %), ACA/MCA velocity ratio, PCA/MCA velocity TCD ratio, ACA velocities ratio(ACAVR) . 3 2 TCD BA Vertebrobasilar system 1 TCD MCA PI 1.65 . Homocysteine TCD . TCD BA . 19 TCD VA .13 24 , BA MCA BA MFV 35.3 9.28cm/s angiography TCD MFV 60cm/s BA . BA 60cm/s Rorick 15 BA TCD MFV 70cm/s angiography BA 8 2 , MFV 30 6 (hyperemia) . vertebrobasilar system Cher 21 vertebrobasilar . ischemia DSA TCD 87%, 80%, 93%, 67% BA 692 Oppenheimer SM. TCD, MRA and MRI in acute cerebral ischemia. Acta Neurol Scand 1999;99(1):65- 58 76. anigiography TCD , BA TCD 10. Felberg RA, Christou I, Demchuk AM, Malkoff M, Alexandrov AV. Screening for intracranial stenosis MFV 60cm/ 44%, with transcranial Doppler: the accuracy of mean flow 88%, 40%, 90% . velocity thresholds. J Neuroimaging 2002;12(1):9-14. TCD MFV BA 11. Gao S, Lam WW, Chan YL, Liu JY, Wong KS. screening Optimal values of flow velocity on transcranial ICA Doppler in grading middle cerebral artery stenosis in . comparison with magnetic resonance angiography. J Neuroimaging 2002;12(3):213-8. 12. Hennerici M, Rautenberg W, Sitzer G, Schwartz A. Transcranial Doppler ultrasound for the assessment of 1. Aaslid R, Markwalder T-M, Nornes H. Non-invasive intracranial arterial flow velocity--Part 1. Examination transcranial doppler ultrasound recording of flow technique and normal values. Surg Neurol 1987;27(5): velocity in basal cerebral arteries. J Neurosurg 439-48. 1982;57:769-74. 13. Mull M, Aulich A, Hennerici M. Transcranial Doppler 2. ultrasonography versus arteriography for assessment of 1999;1(1):60-3. the vertebrobasilar circulation. J Clin Ultrasound 3. Transcranial Doppler Ultrasonography (TCD) 1990;18(7):539-49. 14. Soustiel JF, Shik V, Shreiber R, Tavor Y, Goldsher D. 1999;1(1):39-46. Basilar vasospasm diagnosis: investigation of a 4. Babikian V. Transcranial doppler evaluation of patients modified Lindegaard Index based on imaging studies with ischemic cerebrovascular disease. In:Babikian V, and blood velocity measurements of the basilar artery. et al. Transcranial doppler ultrasonography. St Louis: Stroke 2002;33(1):72-7. Mosby; 1993, p.87-104. 15. Rorick MB, Nichols FT, Adams RJ. Transcranial 5. , . TCD Doppler correlation with angiography in detection of . 1999;1(2):210-9. intracranial stenosis. Stroke 1994;25(10):1931-4. 6. , , , . 16. Alexandrov AV, Demchuk AM, Wein TH, Grotta JC. 1999;1(2):189- Yield of transcranial Doppler in acute cerebral 91. ischemia. Stroke 1999;30(8):1604-9. 7. , , , . 17. Suwanwela NC, Suwanwela N, Phanthumchinda K. TCD . 1996;17(1):171-89. Comparison of transcranial Doppler ultrasound and 8. , . (TCD) computed tomography angiography in symptomatic . 1999;20(2): middle cerebral artery stenosis. Australas Radiol 39-46. 2000;44(2):174-7. 9. Razumovsky AY, Gillard JH, Bryan RN, Hanley DF, 18. Demchuk AM, Christou I, Wein TH, Felberg RA, 693 Malkoff M, Grotta JC, Alexandrov AV. Accuracy and Transcranial doppler sonography and CT angiography criteria for localizing arterial occlusion with transcranial in patients with atherothrombotic middle cerebral Doppler. J Neuroimaging 2000;10(1):1-12. artery stroke. Am J Neuroradiol 2002;23(8):1352-5. 19. , , , , , . 23. de Bray JM, Missoum A, Dubas F, Emile J, Lhoste P. Detection of vertebrobasilar intracranial stenoses: 2000;2(1):53-6. transcranial Doppler sonography versus angiography. J 20. Dong-Wha Kang, Yong-Seok Lee, Byung-Woo Yoon, Ultrasound Med 1997;16(3):213-8. Jae-Kyu Roh. Diagnostic accuracy of transcranial 24. , , . MRI, MRA doppler for detection of the proximal middle cerebral Transcranial Doppler Ultrasonography artery stenosis. 1999;1(2):192-6. 1998;16(3):264- 21. Cher LM, Chambers BR, Smidt V. Comparison of 70. transcranial Doppler with DSA in vertebrobasilar 25. Tettonborn B, Estol C, DeWitt D, Kraemer G, Pessin ischaemia. Clin Exp Neurol 1992;29:143-8. M, Capalan L. Accuracy of transcranial doppler in the 22. Suwanwela NC, Phanthumchinda K, Suwanwela N. vertebrobasilar circulation. J Neurol 1990;237:1159-65. 694.