From the Departments of Neurology, University of Münster (Germany),
and Schering Deutschland GmbH, Berlin.
Correspondence to Darius G. Nabavi, MD, Department of Neurology, University of Münster, Albert Schweitzer-Str 33, 48129 Münster, Germany. E-mail: nabavi{at}uni-muenster.de
Background and
Purpose—Ultrasonography (US) is a well-established method used to
assess the brain-supplying arteries in the acute stroke setting.
However, several technical and anatomic limitations are known to reduce
its diagnostic accuracy and confidence level. Echocontrast
agents (ECA) are known to improve the signal-to-noise ratio by
enhancing the intensity of the reflecting Doppler signal. We
undertook this prospective study to evaluate the diagnostic
value of ECA in a consecutive, nonselected cohort of acute stroke
patients with insufficient native US investigations.
Methods—During a 1-year period, 25 patients were examined
within 48 hours of the onset of stroke. The need for ECA was due to an
insufficient transtemporal (n=18), transforaminal (n=4), or
extracranial (n=3) imaging of arteries potentially involved in the
ischemic event. In 12 patients, a diagnostic
suspicion could natively be raised, whereas in the other 13 patients,
the strongly reduced image quality did not allow for any neurovascular
conclusions. Four grams of Levovist was injected at a concentration of
200 mg/mL and 400 mg/mL for the extracranial and
transcranial insonations, respectively. The effect of the
echocontrast enhancement was assessed with respect to (1) signal
enhancement, (2) image quality, (3) final diagnostic
confidence, and (4) the need for additional neurovascular imaging
methods.
Results—In all but one patient (96%), a strong signal
enhancement was noted, leading to a moderate (n=11) or strong
improvement (n=10) of the transcranial image quality. Thus
in a total of 18 patients (72%), the echoenhancement provided a
neurovascular diagnosis of sufficient confidence. This led to the
confirmation of the previously suspected findings and disclosed three
further occlusions and four stenoses of the intracranial
arteries. In contrast, for the three extracranial examinations the
image quality was not sufficiently improved because of persistent color
artifacts derived from adjacent neck vessels. Besides the seven
patients with inconclusive examinations, five patients with conclusive
echoenhanced US studies (48% in total) demanded additive neurovascular
imaging studies, based on the clinical decision of the attending
physicians. This led to confirmation of all high-confident sonographic
diagnoses.
Conclusions—In summary, in approximately three fourths of our
acute stroke patients with insufficient native US investigations,
echocontrast enhancement enabled a reliable neurovascular diagnosis,
allowing the cancellation of additive neurovascular imaging procedures
in half of our cohort. Our preliminary results suggest that ECA can
reasonably support the early cerebrovascular workup in the acute stroke
setting.
© 1998 American Heart Association, Inc.
Original Contributions
Potential and Limitations of Echocontrast-Enhanced Ultrasonography in Acute Stroke Patients
A Pilot Study
Key Words: contrast media • ultrasonics • stroke • cerebral arteries
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