title: Diagnostic TCD for intracranial stenosis in acute stroke patients: experience from a tertiary care stroke center in Karachi, Pakistan.
abstract: BACKGROUND
  Stroke is a common cause of morbidity and mortality around the world. Intracranial large artery atherosclerosis (ICAD) is a frequent etiology of stroke in the South Asian population. There is a need for widely available screening tools to identify patients that are at high risk of stroke due to ICAD for aggressive risk management. This study describes the experience of using the transcranial Doppler (TCD) as a screening tool for this purpose at a tertiary care hospital in a developing country.
  
  
  METHODS
  86 Patients admitted with stroke due to ICAD underwent TCD for six arteries (Right and left middle cerebral arteries, right and left anterior cerebral arteries, right and left posterior cerebral arteries) in addition to the magnetic resonance angiography (MRA) that is done routinely at the stroke center. Arteries were labeled with either <50 or >50% stenosis by TCD using two separate criteria. These findings were compared with those from the MRA which was used as the gold standard. The proportion of patients that had complete exams (all six arteries insonated by TCD) was reported. The success rate of each TCD criteria in detecting arteries with >50% stenosis was also calculated.
  
  
  RESULTS
  There was an attempt to visualize 516 arteries (86 patients with 6 arteries each) of which 375 (72.7%) were successfully insonated. 38 of the 86 (55.8%) patients had complete examinations. MRA reported 43 (8.3%) arteries as stenosed >50%. The TCD did not categorize any artery as stenosed using either criterion and hence failed to classify any stenosed artery correctly. The positive predictive and sensitivity was 0 for this study and the negative predictive value was 93.3%.
  
  
  CONCLUSIONS
  This study indicates the poor sensitivity of TCD to be a reliable screening tool for the presence of ICAD in the South Asian population in a real life clinical setting.
authors.affiliation: Stroke Service, Stroke Fellowship Program, International Cerebrovascular Translational Clinical Research Training Program, Fogarty International Center and The National Institute of Neurologic Disorders and Stroke, Section of Neurology, Department of Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan. ayeesha.kamal@aku.edu.
authors.forename: Ayeesha Kamran
authors.initials: AK
authors.lastname: Kamal
authors.affiliation: Stroke Service, Section of Neurology, Department of Medicine, Aga Khan University, Karachi, Pakistan. hasanrehman89@gmail.com.
authors.forename: Hasan
authors.initials: H
authors.lastname: Rehman
authors.affiliation: Stroke Service, Section of Neurology, Department of Medicine, Aga Khan University, Karachi, Pakistan. nasirmustafaspan@gmail.com.
authors.forename: Nasir
authors.initials: N
authors.lastname: Mustafa
authors.affiliation: Epidemiology and Biostatistics, Section of Neurology, Department of Medicine, Aga Khan University, Karachi, Pakistan. Bilal.ahmed@aku.edu.
authors.forename: Bilal
authors.initials: B
authors.lastname: Ahmed
authors.affiliation: Data Management Stroke Service, Section of Neurology, Department of Medicine, Aga Khan University, Karachi, Pakistan. muhammad.jan@aku.edu.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Jan
authors.affiliation: Stroke Service, Section of Neurology, Department of Medicine, Aga Khan University, Karachi, Pakistan. dr_mfaisal@hotmail.com.
authors.forename: Faisal
authors.initials: F
authors.lastname: Wadivalla
authors.affiliation: Stroke Service, Section of Neurology, Department of Medicine, Aga Khan University, Karachi, Pakistan. doctor_gr8@hotmail.com.
authors.forename: Syed
authors.initials: S
authors.lastname: Kamran
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000175:diagnosis; D002536:Cerebral Arteries / Q000473:pathology; D002560:Cerebrovascular Circulation; D003251:Constriction, Pathologic / Q000175:diagnosis* / Q000000981:diagnostic imaging; D005260:Female; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D010154:Pakistan; D011237:Predictive Value of Tests; D020521:Stroke / Q000175:diagnosis* / Q000000981:diagnostic imaging; D062606:Tertiary Care Centers; D018608:Ultrasonography, Doppler / Q000379:methods*; D014505:Urban Population