Differentiation Between Intracerebral Hemorrhage and Ischemic Stroke by Transcranial Color-Coded Duplex-Sonography

Abstract

Background and Purpose-The differential diagnosis of intracerebral hemorrhage versus ischemic stroke has critical implications for stroke management. Transcranial color-coded duplex sonography (TCCS) has been shown to identify intracerebral hemorrhages and intracerebral vessel occlusions. We conducted this study to evaluate the sensitivity and specificity of TCCS in this differential diagnosis and in the detection of stroke complications. Methods-One hundred fifty-one patients (58 women, 93 men; mean age, 65.6 years [range, 32 to 89 years] ) with acute hemiparesis were enrolled in this prospective study. On admission all patients had a complete neurological examination. A cranial CT scan and a sonographic examination of the brain parenchyma and all extracranial and intracranial cerebral arteries were conducted. The sonographer was blinded for the radiological findings. Results-According to CT criteria, 60 patients had an intracerebral hemorrhage and 67 patients had an ischemic stroke, and in 24 patients CT findings were inconclusive, showing neither bleeding nor an ischemic stroke. On sonographic examination, 18 patients (12%) had no sufficient acoustic bone window. Of the remaining 133 patients, 126 (95%) were diagnosed correctly by sonography in agreement with CT. Sonography missed 3 atypical bleedings (2 with upper parietal location). In 4 patients without bleeding, an intracerebral hemorrhage was suspected by TCCS because of increased white matter echo density due to microangiopathy. Stroke complications depicted by CT (disturbance of cerebrospinal fluid circulation, hemorrhagic transformation, midline shift, ventricular bleeding) (nϭ54) were correctly shown by TCCS in 45 patients (83%). No complication was missed that would have required further treatment. Conclusions-In comparison to the "gold standard" of CT, TCCS identified stroke complications and differentiated between intracerebral hemorrhage and ischemic stroke with reasonable sensitivity. Thus, if CT is not readily available, TCCS may complement clinical examination in patients with acute stroke. In addition, it may also be useful in detecting stroke complications in the follow-up of stroke patients. (Stroke. 1998;29:2563-2567.)

Assessment: Transcranial Doppler ultrasonography: [RETIRED]

“…Most of the experience with (contrast-enhanced) TCCS in hemorrhagic cerebrovascular disease is in patients with aneurysmal SAH. [143][144][145][146][147][148] A marked increase in the echodensity of the basal cisterns or ventricular system indicates the presence of blood in the subarachnoid or intraventricular space, respectively. 147 TCCS can detect 76 to 91% of nonthrombosed intracranial aneurysms of Ն6 mm in size [144][145][146][147] ; use of ECA or power Doppler may increase the rate of detection, including aneurysms Ͻ5 mm in size.…”

“…146,147 TCCS may detect VSP in major branches of the circle of Willis following SAH. 143,148 Limited data suggest that sensitivity and specificity of TCCS for detection of intracranial ICA and MCA VSP are excellent. 148 However, no data exist to compare the utility of (contrastenhanced) TCCS with conventional TCD in this setting.…”

Transcranial Duplex Sonography for Monitoring Hyperacute Intracerebral Hemorrhage

“…Although CT 9 and MRI 10 have shown high accuracy in hyperacute ICH diagnosis, TDS has some potential advantages, including the concomitant assessment of brain hemodynamics and the feasibility to be performed at the patient's bedside. 11,12 The aim of this study was to correlate ICH volume and ICH enlargement measured by TDS and CT scan in patients with supratentorial ICH evaluated within the first 3 hours after symptom onset.…”

Sonographic Monitoring of Midline Shift in Space-Occupying Stroke

“…It reveals reliable information regarding the lateral displacement of the third ventricle as a criterion for midline shift (MLS) in space-occupying hemispheric stroke. [5][6][7][8] Lateral displacement of midline structures resulting from progressive postischemic edema has been found to correlate closely with a poorer outcome in stroke patients. 5,7,9,[10][11][12][13][14] In a subgroup of stroke patients with rapid progressive edema, the mortality rate reaches 80% as the result of axial brain stem herniation.…”