Published Online
on February 24, 2005

A more recent version of this article appeared on April 1, 2005

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Submitted on July 27, 2004
Revised on October 7, 2004
Accepted on October 20, 2004

Derivation of Transcranial Doppler Criteria for Rescue Intra-arterial Thrombolysis. Multicenter Experience From the Interventional Management of Stroke Study

Maher Saqqur MD; Ashfaq Shuaib MD, FRCPC; Andrie V. Alexandrov MD; Michael D. Hill MD; Sergio Calleja MD; Thomas Tomsick MD; Joseph Broderick MD; and Andrew M. Demchuk MD^*

From the Department of Medicine (Neurology) (M.S., A.S.,), University of Alberta, Alberta, Canada; University of Texas-Houston Medical School (A.V.A., S.C.), Houston, Tex; the Department of Clinical Neurosciences (M.D.H., A.M.D.), University of Calgary, Alberta, Canada; the Department of Medicine and Department of Community Health Sciences (M.D.H.), University of Calgary; and the University of Cincinnati (T.T., J.B.), Ohio.

^* To whom correspondence should be addressed. E-mail: ademchuk{at}ucalgary.ca.

Background and Purpose--Transcranial Doppler (TCD) has the potential to identify acute stroke patients with arterial occlusion when treatment with intravenous recombinant tissue plasminogen activator (rtPA) may fail to open the vessel. We examined clinical utility and prognostic value of TCD flow findings in patients enrolled in an intravenous/intra-arterial rtPA pilot trial (Interventional Management of Stroke [IMS] study).

Methods--Patients enrolled in the IMS trial who underwent urgent TCD performed before intra-arterial rtPA treatment were included. TCD findings were analyzed by a mean flow velocity (MFV) ratio using reciprocal middle carotid artery (MCA) depths bilaterally (affected MCA-to-contralateral MCA MFV ratio [aMCA/cMCA MFV ratio]). The clinical utility of TCD was determined by its ability to predict outcome and identify a proximal arterial occlusion that requires intra-arterial lysis per protocol.

Results--Twenty-nine of 80 patients enrolled in IMS trial had pre-intra-arterial lysis TCD (mean age, 61±11; men-to-women ratio: 17:12; median baseline National Institutes of Health Stroke Score, 17). No temporal window was found in 3 patients (10%). Cerebral angiography was performed at mean 174±36 minutes from stroke onset. TCD was performed at median 93.5 minutes from onset. The aMCA/cMCA MFV ratio <0.6 had a sensitivity of 94% (95% confidence interval [CI], 63% to 99%), specificity of 100% (97.5%; lower CI of 54%), positive predictive value of 100% (lower CI, 80%); and negative predictive value of 86% (CI, 42% to 99%) for identifying proximal occlusion in the anterior circulation that require intra-arterial lysis. All patients with absent MCA flow (n=6) had poor outcomes (modified Rankin Scale 3) (P=0.014).

Conclusion--TCD is a useful modality for evaluating the arterial circulation in acute ischemic stroke patients; it may have significant potential as a screening tool for intravenous/intra-arterial lysis protocols.

Key words: diagnosis • thrombolysis • ultrasonography, Doppler, transcranial

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