Complete Basilar Artery Assessment by Transcranial Color-Coded Duplex Sonography Using the Combined Transforaminal and Transtemporal Approach

Abstract

Purpose: Visualization of the basilar artery (BA) by transcranial color-coded duplex sonography (TCCD) can be challenging. The detection of stenosis or occlusion of the BA often has to rely on indirect signs like a highly pulsatile flow in the vertebral arteries. In case of a distal BA occlusion, however, the flow of the VAs can even be normal. The aim of our TCCD study was to visualize a maximum length of the BA combining the customarily used transforaminal appraoch for the proximal part and the less well known transtemporal coronal approach for the distal BA segment.

Materials and Methods: TCCD was performed in 60 subjects with a good temporal bone window. Detectable extracranial or intracranial pathology was previously excluded. The BA was insonated using the transforaminal and transtemporal insonation plane and the visible length was measured. In one subject MRA was performed to substantiate our findings.

Results: The BA was visualized in all subjects via both approaches. The maximal detectable BA length via the transforaminal and transtemporal approach was 26 ± 8 mm and 18 ± 5 mm, respectively. Assuming a previously reported average anatomical total BA length of 33 ± 6 mm, we supposed complete vessel visualization in 44 subjects (73 %).

Conclusion: The combined transforaminal and transtemporal insonation approach may permit total BA insonation, thus facilitating the evaluation of BA pathology.

Zusammenfassung

Ziel: Die Darstellung der BA in der TCCD stellt eine besondere Herausforderung dar. Häufig gelingt es nur über indirekte Zeichen, wie erhöhte Pulsatilität in der A. vertebralis (VA), Hinweise für eine Basilaristhrombose zu finden. Bei einer distalen Okklusion der BA kann jedoch der Fluss in der VA normal sein. Ziel unserer Arbeit war die Darstellung einer möglichst großen Länge der BA unter Kombination der transforaminalen Beschallung für die proximale und der transtemporalen koronaren Insonation für die distale BA.

Material und Methoden: Wir untersuchten 60 Probanden in der TCCD mit einem guten temporalen Knochenfenster. Detektierbare extra- und intrakranielle Gefäßpathologien wurden zuvor ausgeschlossen. Die BA wurde transforaminal und transtemporal dargestellt und die sichtbare Länge bestimmt. In einem Fall wurde eine MRA zum unterstützenden Vergleich hinzugezogen.

Ergebnisse: Die BA konnte in allen 60 Fällen über beide Untersuchungsebenen dargestellt werden. Die maximale im Farbbild darstellbare Länge betrug transforaminal 26 ± 8 mm und transtemporal 18 ± 5 mm. Unter Annahme einer mittleren anatomischen Länge der BA von 33 ± 6 mm konnte die BA bei 44 Probanden komplett dargestellt werden (73 %).

Schlussfolgerung: Die Kombination aus transforaminaler und transtemporaler TCCD-Untersuchung ermöglicht die komplette BA-Insonation, wodurch eine BA-Pathologie besser beurteilt werden kann.

Key words

ultrasound power Doppler - vascular - blood vessels - anatomy

• References

• 1 Brandt T, Knauth M, Wildermuth S et al. CT angiography and Doppler sonography for emergency assessment in acute basilar artery ischemia. Stroke 1999; 30: 606-612
• 2 Stolz E, Nückel M, Mendes I et al. Vertebrobasilar Transcranial Color-Coded Duplex Ultrasonography: Improvement with Echo Enhancement. Am J Neuroradiol 2002; 23: 1051-1054
• 3 Kermer P, Wellmer A, Crome O et al. Transcranial color-coded duplex sonography in suspected acute basilar artery occlusion. Ultrasound Med Biol 2006; 32: 315-320
• 4 Becker G, Lindner A, Bogdahn U. Imaging of the vertebrobasilar system by transcranial color-coded real-time sonography. J Ultrasound Med 1993; 12: 395-401
• 5 Brunner-Beeg F, von Reutern GM. Farbduplexsonograpie des intrakraniellen vertebrobasilären Systems: Verbesserung der Darstellung durch Echosignalverstärker. Ultraschall in Med 1999; 20: 83-86
• 6 Smoker W, Price M, Keyes W et al. High-Resolution Computed Tomography of the Basilar artery: 1. Normal size and position. Am J Neuroradiol 1986; 7: 55-60
• 7 Huber P. Radiological anatomy and topography of cerebral vessels. In: Huber P, Krayenbühl H, Yasargil MG, (eds.) Cerebral Angiography. Stuttgart, Germany: Thieme; 1982: 74-160
• 8 Schulte-Altedorneburg G, Droste DW, Popa V. Visualization of the basilar artery by transcranial color-coded duplex sonography: comparison with postmortem results. Stroke 2000; 31: 1123-1127
• 9 Hoksbergen AWJ, Legemate DA, Ubbink DT et al. Success rate of Transcranial color-coded duplex ultrasonography in visualizing the basal cerebral arteries in vascular patients over 60 years of age. Stroke 1999; 30: 1450-1455
• 10 Kaps M, Seidel G, Bauer T et al. Imaging of the intracranial vertebrobasilar system using color-coded ultrasound. Stroke 1992; 23: 1577-1582
• 11 Schöning M, Walter J. Evaluation of the vertebrobasilar-posterior system by transcranial color-coded duplex sonography. Stroke 1992; 23: 1280-1286
• 12 Martin PJ, Evans DH, Naylor AR. Transcranial color-coded sonography of the basal cerebral circulation, Reference data from 115 volunteers. Stroke 1994; 25: 390-396
• 13 Baumgartner RW, Mattle HP, Aaslid R. Transcranial color-coded duplex sonography, Magnetic Resonance Angiography, and Computed Tomography Angiography: Methods, Applications, Advantages, and Limitations. J Clin Ultrasound 1995; 23: 89-111
• 14 Bogdahn U, Becker G, Winkler J et al. Transcranial color-coded real-time sonography in adults. Stroke 1990; 21: 1680-1688
• 15 Postert T, Przuntek H, Meves S et al. Power Doppler compared to color-coded duplex sonography in the assessment of the basal cerebral circulation. Journal of Neuroimaging 1997; 7: 221-226
• 16 Postert T, Federlein J, Przuntek H et al. Power-based versus conventional transcranial color-coded duplex sonography in the assessment of the vertebrobasilar-posterior system. J Stroke Cerebrovasc Dis 1997; 6: 398-404
• 17 Postert T, Braun B, Federlein J et al. Comparison of Transcranial Power Doppler and contrast-enhanced color-coded sonography in the identification of intracranial arteries. J Ultrasound Med 1998; 17: 91-96
• 18 Iglseder B, Huemer M, Staffen W et al. Imaging the basilar artery by contrast-enhanced color-coded ultrasound. Journal of Neuroimaging 2000; 10: 195-199
• 19 Droste DW, Nabavi DG, Kemeny V. Echocontrast enhanced transcranial color-coded duplex offers improved visualization of the vertebrobasilar system. Acta Neurologica Scandinavica 1998; 98: 193-199
• 20 Valdueza JM, Schreiber SJ, Roehl J, Klingebiel R. Neurosonology and neuroimaging of stroke. Stuttgart–New York: Thieme; 2008