Transcranial Doppler (TCD)

Dr. Jaya Hasita

Moderator : Dr. Soumya
History
• Rune Aaslid, in 1982, introduced the transcranial Doppler for
detecting blood flow in the basal intracerebral arteries
• Mark Moehring, in 2002, invented the transcranial
power‑motion mode Doppler (PMD)
Physics
• Based on Doppler principle
 When a sound wave strikes a moving object, such as an
erythrocyte, the reflected wave undergoes a change in
frequency (the Doppler shift ) directly proportional to the
velocity of the reflector

V = (𝑐 × 𝑓 𝑑) /2×𝑓 0 × cos 𝜃

𝑐 is the speed of the incident wave

𝑓0 is the incident pulse frequency
𝜃 is the angle of the reflector
V = (𝑐 × 𝑓 𝑑) /2×𝑓 0 × cos 𝜃
• the angle of the velocity vector of the RBC relative to
the probe can change the perceived velocity by a
factor of cosine of that angle
• best estimation of the velocity is achieved when the
angle is zero
• Beyond an angle of 60 degrees, the velocity is no
longer reliable
Terminologies
• Range gate opening time :
Duration in which the current gets switched off and the
crystals are free to receive the reflected sound waves and
convert them back to electrical signals

• Pulse repetition frequency :

The cycle of causing the piezoelectric crystals to vibrate and
switch off to receive the signals need to be repeated at a
frequency at least twice the highest frequency that needs to
be recorded
• Gain
Amplification of the overall reflected signal
Application – increase the visibility of poor waveform
Drawback – increases the background noise that reduces the
interpretation of the morphology

• Power
It is the intensity of the incident beam of ultrasound
Application – increases penetration
Drawback – causes thermal damage
400 mW/cm2 - 500 mW/cm2
Transorbital insonation power is kept < 70 Mw/CM2
• Sample volume
- Volume of the tissue being insonated by the incident beam
- Usually kept between 2 – 3 mm3

• Filter
- The high pass digital filter applied to remove low frequency
high amplitude artifacts
- range from 0 – 430 Hz
TCD
Examination
Insonation Windows
1. Trans-temporal window
2. Transorbital window
3. Transforaminal window
4. Submandibular window
Trans-temporal Window
• Landmark
lateral canthus of the eye to the tragus above the zygomatic
ridge
• Most commonly used window during TCD studies

• Vessels insonated
MCA
ICA
ACA
PCA
Bi- directional flow of ICA
Downward flow of ACA
 MCA
flow towards the probe
manual compression of
the will obliterate flow in
the MCA either
temporarily
Flow velocity is higher
PCA
flow towards the probe
flow in the PCA will be
either unaffected or
increased flow velocity
will be observed
flow velocities in the PCA
will always be lower than
that in MCA
Transorbital Window
• Insonation should be done at 10% the power used for trans-
temporal insonation
• The probe is placed over the closed eyelid and angled slightly
medially and superiorly
• The most superficial vessel to be insonated is the ophthalmic
artery
Depth < 6 cm with a sharp systolic upstroke

• At the same level beyond 6 cm the ICA siphon may be

insonated
 Bidirectional waveform may be obtained if the sample is
taken exactly at the genu
 Transforaminal window
• Takes advantage of natural bony defect of the foramen
magnum for insonation of the posterior circulation
• Location
infero-medial to the posterior edge of the
mastoid process while angling it horizontally
and medially towards the bridge of the nose
or contralateral eye
• The vertebral artery should be insonated at approximately 5
– 7 cm
angle the probe slightly medially and superiorly to insonate
the basilar artery at a depth of 8 – 10 cm
 Both these arteries will have flow away from the probe

Another method of insonating the BA is by placing the probe 1

cm below the occipital protuberance and directing it towards
the bridge of the nose
Flow directions from
various arterial
segments and depths of
insonation in an average
human skull
Transcranial color coded Doppler ( TCCD)

• Superimposes the flow information gained through TCD over

the surrounding anatomical structure

• Provides an anatomically clearer picture of the blood vessel

that aids in identification of the blood vessel

• Able to obtain angle corrected velocities

 TCD
2 Mhz probe used
provides only velocity information of the
intracranial vessels
identification of blood vessels depends
- depth of acquisition of signal
- direction of flow of RBCs
- approximate orientation of the probe on the
patient’s skull
- waveform characteristics
Not possible in this modality
TCCD
2 Mhz phased array probe is used
provides parenchymal imaging with a structural
flow map of cerebral vessels
identification of blood vessels depends
- TCD charateristics
- superimposes this flow information over the
surrounding anatomical structures
Ability to obtain angle corrected velocities
TCD Waveform Morphology
Divided into 4 parts
1. Beginning of systole
2. Peak systole
3. Dicrotic notch
4. End diastole
2 3
1 4
Flow Characteristics of specific vessels
External Carotid artery Internal Carotid Artery

Smaller diameter Larger diameter

Sharp systolic upstroke Milder systolic upstroke

High peak systolic velocity

Sharp diastolic downstroke Gentle diastolic downstroke

Low to nil end diastolic velocity Higher end diastolic velocity

Normal Spectral Waveform
• Peak systolic velocity (PSV in cm/s)
- This is the first peak on a TCD waveform from each cardiac cycle
- A rapid upstroke represents the absence of a severe stenotic lesion
between the insonated intracranial arterial segment and heart
Normal Spectral Waveform
• End‑diastolic velocity (EDV in cm/s)
- The end‑diastolic flow velocity (EDV) lies between 20 and 50% of the
peak systolic velocity (PSV) values
- indicating a low resistance intracranial arterial flow pattern
Normal Spectral Waveform
• Mean flow velocity (MV in cm/s)
MV ( cm/s) = EDV + 1/3 ( PSV – EDV )
- MCA has highest MFV among all major intracranial arteries
FV (measured)=FV (actual)×cosine (angle of insonation)

Two problems due to angle of insonation

1.inaccurate readings as it brings inter‑observer variation
2. makes the repetition of test erroneous
Factors influencing MFV
• Spectral envelop
The highest frequency shift/velocity at each time point that
is plotted on the same time velocity graph as a line outlining
the waveform
• Aliasing artifact or the Wrap around artifact :
Peaks of the TCD waves wrap around the scale of the waveform
and are visible at the bottom of the screen
Effect of physiological variables on
Waveform
• Age
- velocities increase to a maximum at 6-10 yrs of age
- lifetime of gradual reduction of 0.3-0.5% per year

• Gender
- Women have 10-15% higher flow velocities compared to
men
• Pregnancy
- There is a reduction in MCA MV, SV, RI and PI over the course of
gestation
- DV is does not change

• Hematocrit
- hemodilution and hematocrit reduction leads to an increase in blood
flow velocities
- Velocities increase 20% with reduction in hematocrit from 40 to 30%
 TCD Indices – Pulsatility Index (PI)
• Gosling’s index
• Numerical representation of systolic and diastolic velocities to
change in pulsatility characteristics of blood vessels with
increase in downstream resistance

PI = (SV – DV)/MV

• Normal range of PI is between 0.5 – 1.19

• Independent from angle of insonation

• Proximal vessel stenosis or occlusion causes reactionary

downstream vasodilation and PI decreases below 0.5

• increased downstream resistance causes PI to rise above

1.19
 TCD Indices – Resistivity Index
• Also known as Pourcelot Index

RI = (SV-DV)/SV

• Values > 0.8 mean increased distal vascular resistance

 TCD Indices – Lindegaard Ratio (LR)

LR = MCA MV : Extracranial ICA MV

• value > 3 is indicative of mild to moderate vasospasm

• > 6 indicative of severe vasospasm

MCA velocity Degree of
Vasospasm LR Degree of
120 – 150 cm/sec mild
vasospasm

>3 Mild to
150 – 200 cm/sec moderate
moderate

> 200 cm/sec severe

>6 severe
 TCD Indices – Modified Lindeegard Ratio (LR)

modified LR = BA MV : (average of bilateral VA MV)

• To study Basilar artery vasospasm

Modified Degree of Vasospasm

LR
2 – 2.5 Mild
2.5 – 3 Moderate
>3 Severe
 TCD Indices – Sloan’s Hemispheric Index
• To identify ACA vasospasm

Sloan’s hemispheric index = ACA MV : Extracranial ICA MV

• Sloan’s ratio > 4 + ACA mean velocity > 80 cm/sec is indicative

of vasospasm
 Method of TCCD examination
3 planes of observation from trans-temporal window*

1. A 0 degree axial plane going through

the mesencephalon

2. A 10-15 degree axial plane going through

diencephalon

3. A further 10-15 degree axial plane going

through cella media

*European Transcranial Color-Coded Duplex Sonography Study Group

Transforaminal Insonation
Clinical Applications of TCD
Tests for Autoregulation

Static Dynamic
Autoregulation Autoregulation

Static autoregulatory index Transient hyperemic response test

Thigh cuff deflation test

Transient Hyperemic Response (THR) test
• Test of dynamic autoregulation
Thigh cuff deflation test
• Normal dRoR is 20%/ sec
 Static Autoregulatory Index
Static Autoregulatory index = % change in CVR / % Change in CPP

• Tested by induction of 20 mmHg raise in MBP through 0.01%

Phenylephrine infusion through simultaneous recording of FV

• Inference :
- 0 -> nil autoregulation
- <0.4 -> impaired autoregulation
- 1 -> intact autoregulation
Tests for CO2 reactivity

• Involves recording a baseline measurement of velocity in MCA

• Applying a stimulus which either decreases or increases CO2

and recording velocity again at specified time intervals

• The stimuli include

- variation of respiratory/ventilatory pattern
- inspired CO2 (usually 5% CO2 with 95% oxygen)
- pharmacologically by administration of acetazolamide
Breath holding index (BHI)

• used to detect impaired cerebral vasomotor reserve (VMR)

to predict cerebral ischemia by inducing cerebral vasodilation
using breath holding technique

• Patient is asked to hold breath at end inspiration and hold for

30 sec or as long as they can while MCA is insonated and
velocities recorded

BHI = (CBV Max – CBV Min)/Breath holding time * 100

• BHI values
- > 0.6 is expected
- < 0.6 is impaired VMR
- < 0.2 indicates severe impairment

• Drawbacks
- high inter and intra-individual variability
- variability due to position of patient
- Valsalva effect from holding breath at end inspiration may lead to
change in MCA flow and velocities
CO2 challenge VMR index

• CO2 is administered as a 5% mixture with oxygen for 3

minutes and EtCO2 is ensured to have increased by 10 mm
Hg
• MCA velocities are taken at 2.5 minutes and the patient is
then asked to hyperventilate to reduce the EtCO2 by 10 mm
Hg below baseline
 (Hypercapnic CBV − Hypocapnic CBV)/( Baseline CBV) * 100

Interpretation
- > 70% is normal
- 70 – 40 % is mild impairment
- 40 – 15 % is moderate impairment
- < 15 % is severe
 TCD in Subarachnoid Haemorrhage

• One of the primary causes of morbidity following SAH is delayed

cerebral ischemia caused by cerebral vasospasm
• TCD for MCA vasospasm detection has been found to have
- poor sensitivity (67%)
- good specificity (99%)
- positive predictive value (97%)

Lysakowski C, Walder B, Costanza MC, Tramèr MR. Transcranial Doppler versus angiography in patients with
vasospasm due to a ruptured cerebral aneurysm: A systematic review. Stroke 2001;32:2292–8.
Procedure
Diagnostic criteria
TCD Monitoring of Intracranial Pressure
• Non-invasive method for detecting raised ICP
• Pulsatility Index (PI) provides useful information about ICP
 Flow Characteristics with increasing ICP
• High pulsatility of waveform
- Seen in high resistance vessels
- The systolic upstroke and diastolic
downstroke becomes sharper
- Increase in peak systolic velocity and
reduction in end diastolic velocity
- Seen when ICP is 40 mm Hg
- The pulsatility and resistivity indices
also increase
 Flow Characteristics with increasing ICP

• Oscillating flow pattern:

- ICP > diastolic blood pressure
- anterograde flow during systole
- retrograde flow in diastole
- systolic velocity = diastolic velocity
.. no cerebral perfusion
 Flow Characteristics with increasing ICP

• Systolic spikes:
- occurs ICP approaches the systolic
blood pressure
- solitary systolic spikes of amplitude
< 50 cm/sec and duration of less
than 200 msec become apparent
TCD in Sickle Cell Disease
• sickle-cell disease (SCD) carry a significant stroke risk
• 11% of all homozygous sickle cell (HbSS) patients develop
ischemic stroke before the age of 20 years
• These strokes primarily result from stenosis or occlusion of
the distal intracranial internal carotid arteries and/or
proximal MCA
 • TCD can identify children with *
- high risk of the first-ever stroke
- those in need of blood transfusion

*Adams RJ, McKie VC, Hsu L, Files B, Vichinsky E, Pegelow C, et al. Prevention of a first stroke by
transfusions in children with sickle cell anemia and abnormal results on transcranial Doppler
ultrasonography. N Engl J Med 1998;339:5-11
 Criteria for detection of patients at risk of cerebrovascular events:
1. Mean flow velocity 190 cm/s (in any vessel)
2. Low velocity in the MCA <70 cm/s
3. Right/Left MCA ratio <0.5
4. ACA/MCA ratio >1.2 on the same side
5. Inability to detect an MCA in the presence of a demonstrated
ultrasound window
6. Velocity in the Ophthalmic artery > Velocity of the Ipsilateral MCA
7. Max velocity of PCA/VA/BA > Max velocity of MCA,
8. Turbulence
9. PCA visualized without the MCA
*Adams RJ, McKie VC, Hsu L, Files B, Vichinsky E, Pegelow C, et al. Prevention of a first stroke by transfusions in
children with sickle cell anemia and abnormal results on transcranial Doppler ultrasonography. N Engl J Med
1998;339:5-11
STOP classification for risk stratification and treatment strategy

Classification Time-averaged mean of the Treatment stratergy

maximum (TAMM)
velocities of the MCA

Normal <170 cm/s Repeat TCD if indicated

Conditional 170-200 cm/s Repeat TCD in 2 weeks if no

previous records are
available

Abnormal >200 cm/s Urgent blood transfusion

 Cerebral Ischemic Stroke
• TCD in intracranial steno-occlusive diseas can be used for
- Diagnosis
- follow up
- prognostication

• MCA stenosis can be diagnosed with 86% sensitivity and 99%

specificity *

* Alexandrov A V, Bladin CF, Norris JW. Intracranial blood flow velocities in acute ischemic stroke. Stroke 1994;25:1378–
83
Flow characteristics
in a stenosed vessel
 Prognostic criteria for stroke TCD
1. Good prognosis for a normal TCD waveform at 6 hours post
ischemic event*

2. MCA occlusion within 6 hours of stroke onset is a modest

predictor of haemorrhagic transformation with PPV of 72% **

*Toni D, Fiorelli M, Zanette EM, Sacchetti ML, Salerno A, Argentino C, et al. Early spontaneous improvement and
deterioration of ischemic stroke patients. A serial study with transcranial Doppler ultrasonography. Stroke
1998;29:1144–8
**Tsivgoulis G, Alexandrov A V, Sloan MA. Advances in transcranial Doppler ultrasonography. Curr Neurol Neurosci Rep
2009;9:46–54
 Prognostic criteria for stroke TCD

3. MCA mean FV < 30 cm/sec within 12 hours of stroke onset

is a poor prognosis indicator *

4. Presence of microemboli is predictive of recurrence of

stroke/TIA**

*Halsey JH. Prognosis of acute hemiplegia estimated by transcranial Doppler ultrasonography. Stroke 1988;19:648–9
** Valton L, Larrue V, le Traon AP, Massabuau P, Géraud G. Microembolic signals and risk of early recurrence in patients
with stroke or transient ischemic attack. Stroke 1998;29:2125–8
Detection of Spontaneous Emboli
• Emboli can originate from
- atherosclerotic plaques
- interventional procedures involving carotid arteries
- right to left (R-L) cardiac shunts

• By composition microemboli can be solid or gaseous

Microembolic signals on TCD are characterized as high
intensity transient signals (HITS)- The International Cerebral
Hemodynamics Society
- Transienct (usually <0.1 s)
- High intensity (> 3 dB above the background power – more
redder or brighter)
- Usually unidirectional
- unrelated to cardiac
cycle
- Specific audio quality
sounds like “chirps”
 Diagnostic criteria for various disorders

1. Carotid atherosclerotic disease

- Insonate MCA on the side of critical ICA stenosis for atleast
30 minutes
- > 2 HITS/hour is associated with increased risk of future
stroke*

* Forteza AM, Babikian VL, Hyde C, Winter M, Pochay V. Effect of time and cerebrovascular symptoms of the
prevalence of microembolic signals in patients with cervical carotid stenosis. Stroke 1996;27:687–90.
 Diagnostic criteria for various disorders

2. Cardiac Shunts
• TCD is considered to be more sensitive and specific than
transesophageal echocardiography for RLS detection*
• Can be used for quantifying its functional-potential

*Jauss M, Kaps M, Keberle M, Haberbosch W, Dorndorf W.A comparison of transesophageal echocardiography and
transcranial Doppler sonography with contrast medium in the detection of patent foramen ovale. Stroke 1994;25:1265-7.
Head Injury
1. In the initial 24 hrs following the injury, there is a reduction
in cerebral blood flow (CBF) with maintenance of flow
velocities (FV)

2. 1-2 days post injury, there occurs a hyperemic phase with

increase in both CBF and FV.

3. After day 4, there is the vasospastic phase, with reduction

in CBF and continued increases in FV until 2 weeks post injury
Use of TCD in head injury
Detection of hyperventilation : Low FV and high PI
Assessment of autoregulation and cerebrovascular
reactivity to CO2
Detection traumatic internal carotid artery dissection
- High asymmetry between bilateral MCA flow velocities
(>25%)
- low ipsilateral PI (< 0.8)
 Prognostication and triage
Brain Death
• TCD based diagnosis of brain death rests on proof of
cessation of intracranial blood flow due to high ICP
• Charateristics
- systolic spikes with diastolic flow reversal
- small systolic spikes with no diastolic flow
- complete loss of intracranial flow with presence of
extracranial components
Systolic spikes
Carotid endarterectomy (CEA)
Utility of TCD in this procedure is at three levels
1. Decision of shunt placement
- post clamping MCA velocities <30% of the pre values for >5
minutes

2. Detection of microemboli

3. Detection of cerebral hyperperfusion

- MCA velocities > 150% of pre-clamp values
• Limitations :
- technical difficulty of keeping the TCD probe fixed at the
exact position
- non-dependence of postoperative outcome on TCD guided
shunt placement
Summary of the uses of TCD
• Diagnosis of extracranial and intracranial stenosis and
occlusion

• Detection and monitoring of vasospasm following

aneurysmal subarachnoid haemorrhage

• Detection of PFO and RLS

• Detection and counting of emboli

Summary of the uses of TCD
• Evaluation of the brain vasomotor reserve

• Support for brain death diagnosis

• Monitoring during carotid endarterectomy or carotid

stenting

• Screening children with sickle cell disease uses of TCD

Limitations of TCD
• highly operator dependent
• handheld technique requires detailed three-dimensional
knowledge of cerebrovascular anatomy and its variations
• 10 to 15% rate of inadequate acoustic windows prevalent in
Blacks, Asians, and elderly women
• measurements are limited to the large basal arteries
• provide an index of global rather than local cerebral blood
flow velocity
Refrences
• Cottrell and Patel’s neuroanesthesia 6th edition

• Transcranial doppler: Technique and common findings (Part

1) Lokesh Bathala, Annals of Indian Academy of Neurology,
April-June 2013, Vol 16, Issue 2

• Transcranial Doppler: Techniques and advanced applications:

Part 2 Arvind K. Sharma, Annals of Indian Academy of
Neurology, January-March 2016, Vol 19, Issue 1
• Jawad Naqvi, Kok Hooi Yap, Gulraiz Ahmad, Jonathan
Ghosh, "Transcranial Doppler Ultrasound: A Review of the
Physical Principles and Major Applications in Critical
Care", International Journal of Vascular Medicine, vol. 2013

• Marda MK, Prabhakar H. Transcranial Doppler. J

Neuroanaesthesiol Crit Care 2015;2:215-20

• NIMHANS Transcranial Doppler Course 2019

Thank You