Differentiation Between Ischemic and Hemorrhagic Stroke by Transcranial Color‐coded Real‐time Sonography

Abstract

Transcranial color-coded real-time sonography was applied to 20 patients with ischemic stroke and 28 patients with spontaneous intracerebral hemorrhage. In all patients the sonographic diagnosis corresponded closely to cranial computed tomography findings. Recent hemorrhages were visualized as a hyperechodense mass. The high contrast to minor echodense adjacent parenchyma led to a clear sonographic distinction. Older clots were characterized by a continuous decrease of echodensity and subsequently were interspersed by hypoechodense zones. In the acute stage of ischemic infarction, the vessel occlusion (17/20) and collateral vascular supply (10/20) could be depicted in the color-B-mode in two perpendicular planes and further verified by the Doppler mode. Brain edema was not visualized. Although in the acute stage no change of echo texture was observed within the infarction, hyperechodense regions (7/11) could be observed in some patients during the time course. Complications of intracerebral hemorrhage and ischemic stroke, such as disturbance of cerebrospinal fluid circulation, midline shift, and compression of adjacent territories, were depicted by transcranial color-coded sonography. These preliminary results illustrate that transcranial color-coded real-time sonography may be helpful in the early noninvasive differential diagnosis as well as long-term follow-up in patients with cerebrovascular disorders.

Differentiation Between Intracerebral Hemorrhage and Ischemic Stroke by Transcranial Color-Coded Duplex-Sonography

“…Its echo density is comparable to that of the falx cerebri or the choroid plexus. 10 In contrast, the sonographic diagnosis of an acute ischemic stroke is primarily based on vascular occlusion, ie, on the lack of blood flow in an occluded vessel as demonstrated by color Doppler and PW Doppler in the absence of a sonographic hyperechoic lesion ( Figure 2). Additional criteria include evidence of collateral flow and reduction of brain pulsation in the distribution of the affected vessel.…”

“…If an occluded vessel is recanalized in the acute stage of ischemic infarction, 18 brain echo density is not altered, and therefore no sonographic clue points toward a cerebral infarction. 9,10 While an occlusion of smaller branches of the basal cerebral arteries cannot be detected by TCCS, a comparison of MR angiography and TCCS demonstrated equal sensitivity of both methods in the identification of vascular occlusions of the major basal cerebral arteries. 19 TCCS provides a real-time display of the affected brain and of intracerebral complications in the course of the disease, such as a disturbance of CSF circulation and spaceoccupying effects.…”

Transcranial Duplex Sonography for Monitoring Hyperacute Intracerebral Hemorrhage

“…7,8 This technique allows examining not only the extent of ICH, but also the presence of ventricular invasion and midline shift. Although CT 9 and MRI 10 have shown high accuracy in hyperacute ICH diagnosis, TDS has some potential advantages, including the concomitant assessment of brain hemodynamics and the feasibility to be performed at the patient's bedside.…”

Transcranial Ultrasound from Diagnosis to Early Stroke Treatment

“…In case of rtPA, intracranial hemorrhages have to be excluded prior to rtPA administration by cranial computed tomography [19], which implies that it cannot be administered prior to admission. TCCS has been shown to be a reliable diagnostic tool to assess the intracranial vasculature in acute stroke [2, 4,20,21,22,23]. Since portable duplex ultrasound devices are available and used for prehospital diagnostics [24, 25], it seems reasonable to test whether intracranial vascular assessment in acute stroke can already be done at the site of the emergency and/or during the transport to the hospital.…”