Prognostic relevance of ultra-early doppler sonography in acute ischaemic stroke: a prospective multicentre study

BACKGROUND Ischaemic stroke can result from a temporary or permanent occlusion of intracranial arteries. In the hyperacute stage of the disease cerebrovascular ultrasound can be used to determine the vascular pathology, but the significance of very early findings on ultrasound is unclear. The present study aimed to assess the prognostic value of doppler ultrasonography within the first hours after stroke for functional outcome. METHODS In a prospective multicentre design, patients with clinical signs of ischaemic anterior-circulation stroke were examined by doppler ultrasonography of the intracranial and extracranial arteries. Patients were separated into three groups according to the findings: normal middle-cerebral artery (MCA); branch occlusions; or a main-stem occlusion. The primary endpoint was functional outcome at 3 months. Logistic regression was used to test the association between the ultrasound diagnosis and functional outcome. RESULTS 361 patients were identified with moderate to severe clinical deficits (National Institutes of Health Stroke Scale score 5-25). Of these, 121 (34%) had a normal MCA, 176 (48%) had branch occlusions, 7 (2%) had severe MCA stenosis, and 57 (16%) had a main-stem occlusion. 50 of the 57 (88%) patients with main-stem occlusion were dead or dependent 3 months after stroke. An occlusion of the main stem of the MCA within 6 h after stroke was an independent predictor for poor outcome (p=0.0006). 50% of patients with ultrasonographic diagnosis of branch occlusions and 63% with normal MCA had a good outcome. Combination of CT scan without early signs of infarction and a normal MCA resulted in a predictive value of 71% for a good functional outcome. INTERPRETATION Cerebrovascular ultrasonography provides additional functional prognostic information in the hyperacute stage of ischaemic stroke. The technique is practical in a well-resourced unit, can be used to identify patients with high risk for poor functional outcome, and thus would be an appropriate investigation for future trials.

[1]  A. Alexandrov,et al.  Deterioration following spontaneous improvement : sonographic findings in patients with acutely resolving symptoms of cerebral ischemia. , 2000, Stroke.

[2]  G. Lenzi,et al.  Comparison of cerebral angiography and transcranial Doppler sonography in acute stroke. , 1989, Stroke.

[3]  M. Goertler,et al.  Design of a multicentre study on neurosonology in acute ischaemic stroke. A project of the neurosonology research group of the World Federation of Neurology. , 2002, European journal of ultrasound : official journal of the European Federation of Societies for Ultrasound in Medicine and Biology.

[4]  Mahoney Fi,et al.  FUNCTIONAL EVALUATION: THE BARTHEL INDEX. , 1965 .

[5]  A. Alexandrov,et al.  Improving the Predictive Accuracy of Recanalization on Stroke Outcome in Patients Treated With Tissue Plasminogen Activator , 2003, Stroke.

[6]  H. Schouten,et al.  Interobserver agreement for the assessment of handicap in stroke patients. , 1988, Stroke.

[7]  Hashem Shaltoni,et al.  Yield and Accuracy of Urgent Combined Carotid/Transcranial Ultrasound Testing in Acute Cerebral Ischemia , 2005, Stroke.

[8]  H. Przuntek,et al.  Insufficient and absent acoustic temporal bone window: potential and limitations of transcranial contrast-enhanced color-coded sonography and contrast-enhanced power-based sonography. , 1997, Ultrasound in medicine & biology.

[9]  R. Higashida,et al.  Intra-arterial Prourokinase for Acute Ischemic Stroke: The PROACT II Study: A Randomized Controlled Trial , 1999 .

[10]  M. Kaps,et al.  Feasibility and validity of transcranial duplex sonography in patients with acute stroke , 2002, Journal of neurology, neurosurgery, and psychiatry.

[11]  B. Censori,et al.  Transcranial doppler in acute ischemic stroke of the middle cerebral artery territories , 1993, Acta neurologica Scandinavica.

[12]  T. Brott,et al.  Improved Reliability of the NIH Stroke Scale Using Video Training , 1994, Stroke.

[13]  Gerhard Schroth,et al.  NIHSS Score and Arteriographic Findings in Acute Ischemic Stroke , 2005, Stroke.

[14]  C. Wallesch,et al.  Diagnostic impact and prognostic relevance of early contrast-enhanced transcranial color-coded duplex sonography in acute stroke. , 1998, Stroke.

[15]  J. Bray,et al.  Quantification of Atheromatous Stenosis in the Extracranial Internal Carotid Artery , 1995 .

[16]  B. Widder,et al.  Differentiating subtotal carotid artery stenoses from occlusions by colour-coded duplex sonography , 1994, Journal of Neurology.

[17]  The 'herald hemiparesis' of basilar artery occlusion. , 1988, Archives of neurology.

[18]  A. Demchuk,et al.  Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility. , 2001 .

[19]  P. Akins,et al.  Intra-arterial prourokinase for acute ischemic stroke. , 2000, JAMA.

[20]  A. Demchuk,et al.  Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy , 2000, The Lancet.

[21]  G. Sette,et al.  Acute ischemic strokes improving during the first 48 hours of onset: predictability, outcome, and possible mechanisms. A comparison with early deteriorating strokes. , 1997, Stroke.

[22]  G. Schroth,et al.  Assessment of >/=50% and <50% intracranial stenoses by transcranial color-coded duplex sonography. , 1999, Stroke.

[23]  M. Ermani,et al.  The Quest for Early Predictors of Stroke Evolution: Can TCD Be a Guiding Light? , 2000, Stroke.