The Clinical Contribution of Neurovascular Ultrasonography in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE Patients with acute ischemic stroke receive computed tomography angiogram (CTA) and digital subtraction angiogram (DSA) for clinical evaluation. Current guidelines lack in defining indications for transcranial Doppler (TCD) and/or carotid duplex ultrasonography (CUS) in acute stroke evaluation or follow-up cerebrovascular imaging after reperfusion. We investigated the clinical utility of performing additional TCD/CUS after reperfusion in guiding postacute care stroke management. METHODS Retrospective review of acute ischemic stroke patients admitted to a comprehensive stroke center with CTA head and neck and/or DSA followed by TCD/CUS. Cases were reviewed by two authors to determine if TCD/CUS provided additional diagnostic information to aid management. A nominal group process, using a third author, achieved consensus in cases of disagreements. RESULTS Only 25 of 198 patients had CTA or DSA followed by TCD/CUS. Ten (40%) cases showed new clinical information from CUS aiding management. Of those with TCD, 5 patients (22.7%) had findings that impacted management. These clinical scenarios included detection of mobile thrombus requiring anticoagulation; distinguishing carotid near-occlusion from occlusion; confirming hemodynamic significance of intra/extracranial stenosis helping emergent stenting/endarterectomy; detecting hyperperfusion on TCDs causing symptoms; and establishing chronicity of carotid stenosis based on collateral flow patterns, which deferred further intervention. DISCUSSION Our experience shows that TCD/CUS may offer additional diagnostic information assisting postacute care management in small subset of patients with acute ischemic stroke. Larger studies are needed to research the clinical impact and cost-effectiveness of additional imaging and inform clinical guidelines for selecting patients who will benefit from these additional studies.