title: Contrast-enhanced transcranial color-coded duplexsonography in stroke patients with limited bone windows.
abstract: OBJECTIVE
  Thickening of the temporal bone in stroke-age patients may obviate sonographic evaluation of the circle of Willis in 20% to 30% of patients. We assessed the diagnostic efficacy of contrast-enhanced transcranial color-coded duplexsonography (TCCD) for noninvasive evaluation of the circle of Willis in stroke patients with limited bone windows.
  
  
  METHODS
  Of 171 consecutive patients who presented with ischemic symptoms in the middle cerebral artery (MCA) territory, 49 patients (32 female, 17 male; age range, 70.5+/-10.6 years) had no detectable colorflow signals from the circle of Willis by TCCD because of limited acoustic windows. These 49 patients received an IV injection of a sonographic contrast-enhancing agent, Levovist (Schering; Berlin, Germany), and were re-examined. Correlative imaging studies of the circle of Willis were obtained in 42 of 49 of these patients.
  
  
  RESULTS
  In 38 of 49 patients, contrast-enhanced TCCD enabled full visualization of the circle of Willis bilaterally; in an additional five patients, contrast-enhanced TCCD revealed only the portion of the circle of Willis ipsilateral to the probe through one temporal bone. In six of these 43 patients, contrast-enhanced TCCD showed MCA stenosis and MCA occlusion in three; three of the six cases of MCA stenosis and all three cases of the MCA occlusion were found on the symptomatic side. In six of 49 patients, no colorflow signals were obtained after contrast enhancement. All contrast-enhanced TCCD findings were confirmed by CT angiography, transfemoral digital subtraction angiography, MR angiography, or a combination of all three correlative studies. Levovist produced no serious adverse events.
  
  
  CONCLUSIONS
  In stroke-age patients with limited acoustic windows, contrast-enhancement with Levovist can markedly increase the sensitivity of TCCD and increase the detection of clinically relevant intracranial arterial disease.
authors.affiliation: Department of Neurology, University of Technology, Dresden, Germany.
authors.forename: G
authors.initials: G
authors.lastname: Gahn
authors.forename: J
authors.initials: J
authors.lastname: Gerber
authors.forename: S
authors.initials: S
authors.lastname: Hallmeyer
authors.forename: G
authors.initials: G
authors.lastname: Hahn
authors.forename: R H
authors.initials: RH
authors.lastname: Ackerman
authors.forename: H
authors.initials: H
authors.lastname: Reichmann
authors.forename: R
authors.initials: R
authors.lastname: von Kummer
mesh_terms: D000368:Aged; D015901:Angiography, Digital Subtraction; D002533:Cerebral Angiography; D002941:Circle of Willis / Q000000981:diagnostic imaging*; D003287:Contrast Media; D005260:Female; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D011134:Polysaccharides; D020521:Stroke / Q000175:diagnosis / Q000000981:diagnostic imaging*; D013701:Temporal Bone / Q000000981:diagnostic imaging; D014057:Tomography, X-Ray Computed; D018616:Ultrasonography, Doppler, Duplex
chemical_list: D003287:Contrast Media; D011134:Polysaccharides; C059891:SHU 508