Transcranial Doppler Ultrasonography
Transcranial Doppler ultrasonography is a noninvasive method of analyzing blood flow in the brain.
The blood that flows through the brain distributes nutrients to the brain and removes wastes. This flow maintains the high rate of metabolism necessary for the brain to function. Restrictions in blood flow may occur from vessel narrowing (stenosis), clot formation (thrombosis), blockage (embolism), or blood vessel rupture (hemorrhage). Lack of sufficient blood flow (ischemia) threatens brain tissue and may cause a stroke.
The flow of blood through the arteries in the brain can be analyzed using transcranial Doppler ultrasonography (TCD). TCD is a form of ultrasound, in which high frequency sound waves bounce off or pass through body tissues. While most other types of ultrasonography create images of the tissue being studied, the results of TCD are audible sounds that the examiner listens to and records.
Doppler ultrasonography uses what is called the Doppler effect to measure the rate and direction of blood flow in the vessels. Just as a siren's pitch sounds higher when its source is moving toward you and lower as it moves away, so too will ultrasound waves change pitch, or frequency, as they bounce off the red blood cells moving in the blood. It is these pitch changes that produce the audible sounds during the exam.
Changes in frequency can be used to measure both the direction and the speed of blood flow. Faster blood flow causes a greater change in frequency. Combined with other tests, this information can be used to locate restrictions in the blood vessels in the brain, and to track
Ultrasonography procedures are safe, noninvasive, and painless. No special precautions are necessary.
TCD is done with either one or two probes placed against the skin. The examiner spreads a clear gel on the areas of the head where the probe will be placed. Usually, the probes are placed on the temple, on the base of the skull at the back of the neck, and over the closed eyelid. In these places, there is the least amount of thick protective bone and the sound waves can penetrate the best. The examiner adjusts the probe position and orientation to direct the sound waves toward the blood vessels of interest. Finding the best approach may take some time. A compression test may be performed during the exam. In this test, the main artery in the neck (carotid artery) is briefly compressed, and changes in blood flow patterns are observed. A full TCD exam may last 30–45 minutes, and often longer in patients with disease.
No special preparation is needed. The patient should remove contact lenses, and may wish to avoid the use of eye makeup, since the gel is likely to smear it.
The gel is washed off with soap and water. No other after care is needed.
TCD is noninvasive and has no risks. A compression test is occasionally, though very rarely, hazardous for a patient with narrowed arteries (atherosclerosis), since the increased pressure may dislodge a piece of the substance that causes the narrowing (plaque).
TCD produces an audible sound that varies with the heartbeat. It also varies depending on the direction and rate of flow through the vessel being examined. Each of the vessels in the brain has a characteristic direction of flow, which can be detected by TCD. Flow rates are somewhat variable from person to person.
Lack of flow indicates a vessel has been completely blocked (although absence of a signal may also be due to absorption of sound waves by bone). If blood flows in the wrong direction or alternates between normal and reverse flow, it may mean there is a blockage elsewhere. This happens because blood is rerouted due to abnormalities in pressure caused by the blockage.
If the speed of flow is increased, it may mean that blood is flowing through a restricted area that is just "upstream" from the probe. Intuitively, one might think that a restricted blood vessel would cause the speed of blood flow to slow down. However, the opposite is true. This is because the same amount of blood going through a narrower opening must go faster. Increased speed is also seen if a vessel is carrying rerouted blood.
Office Practice of Neurology. Ed. Martin Samuels and Steven Feske. New York: Churchill Livingstone, 1996.
von Reutern, G. M., and H. J. von Budingen. Ultrasound Diagnosis of Cerebrovascular Disease. New York: Georg Thieme Verlag, 1993.