Am J Electroneurodiagnostic Techno!

49:14-27. 2009
© ASET, Missouri

Transcranial Doppler Series Part II:

Performing a Transcranial Doppler

Heather A. Nicoletto, BS, RVT and

Marilyn H. Burknnan, BS, RDCS, RVT

Neurodiagnostic Laboratory
Dui<e University Hospitai
Durham, Nortti Caroiina

ABSTRACT. Because of its portahiiity, low cost, and quick, nonin-

vasive nature, transcranial Doppler (TCD) has become a widely utilized
exam to evaluate the basal cerebral arteries for various disease pro-
cesses. The test is considered a "blind" and very difficult study by most
vascular labs. Neurologists commonly order TCD, so the performance of
it is slowly being adopted by neurodia^nostic labs. To perform a quality
TCD, the teclmoiogist must be extremely skilled. The technologist must
know where to place and how to angle the probe in order to insonate the
vessels and mu.st be familiar with the TCD equipment. The technologist
should also have an understanding of what each vessel's waveform
should look like under normal circumstances.

KEY WORDS. Acoustic windows, circle of Willis, transcranial

Doppter.

INTRODUCTION
Transcranial Doppler (TCD) was tlrst demonstrated in 1982. It is fast becoming
a frequently ordered test that is used on patient.s at risk for stroke (Aiexandrov and
Joseph 2000; Fujioka and Douville 1992). TCD is portable, quick, noninvasive,
and inexpensive. TCD is ultrasound that is used to evaluate blood flow in the basal
cerebral arteries and is commonly ordered by neurologists and neurosurgeons. TCD
is considered a "'blind" study. With all other ultrasound studies the vessel lumen is
visualized. This is not the case with TCD. Instead, only a waveform produced by
the moving red blood cells is visualized. Therefore, knowledge of hemodynamics is

Received for publication: December 22. 2008. Accepted for publiciilion: January 9. 2009.

14
 PERFORMING A TRANSCRANIAL DOPPLER 15

crucial to the evaluation of blood flow and the identification of the vessels being
insonated. With all these factors combined, TCD is one of the least favorite exams
for the vascular lab to perform. Because it is part of a thorough neurological exami-
nation, more and more neurodiagnostic laboratories are taking on the performance of
this study.

EQUIPMENT
All TCD equipment shares the same essential components. These components
assist the technologist in obtaining a signal more precisely. Therefore, it is important
to know how to use the components of the TCD equipment.

Pulsed Wave Doppler

Pulsed wave Doppler (PW Doppler) is when pulses of ultrasound generated by the
transducer are sent into the patieni where they produce echoes. These echoes return
to the transducer and are detected and displayed as Doppier waveforms (Kremkau
1995). TCD uses PW Doppler which allows the technologist to change the depth
{in millimeters) and follow a vessel along its course. Each vessel is identified at
certain depths. The middle cerebral artery (MCA) and basilar artery (BA) are long
vessels that are insonated at multiple depths along their course. Pulsed wave Doppler
allows for direction of flow, either toward or away from the probe.

Frequency
Frequency describes how many complete cycles a sound wave goes through in one
second. To insonate deep vessels the technologist should use a low frequency probe.
To insonate shallow vessels use a high frequency probe (Kremkau 1995). The reason
for this is that the frequency of the ultrasound probe is inversely proportional to the
depth of insonation. TCD uses a low frequency probe, 1.5 to 2 MHz. which allows
for insonation of the intracranial vessels that lie deep in the brain.

Sample Volume
Sample volume allows the technologist to obtain signals at a specific depth.
Sample volume size is measured in millimeters. Doppler waveforms from the area of
the sample volume are presented audibly and visibly. The sample volume can be
made larger allowing the technologist to listen to and view a larger area of the vessel.
When the sample volume is smaller the Doppler signal can be localized more
precisely. Most labs insonate long vessels in specific increments (2 to 5 mm). If you
are recording Doppler waveforms at 5 mm increments and using a sample volume of
 PERFORMING A TRANSCRANIAL DOPPLER

T^ r
65 lnm
40 inin 45 lmn 50 inm 55 inin 60 inin
\'es.sel Depth
B
B

\ I I I I I I 1
35 lnin 40 lnin 45 lmn 50 lnin 55 lnin 60 lnin 65 iiun ~0 lnin

Vessel Depth
FIG. 1. (A) A comparison of 6 mm and 12 mm sample volumes relative to vessel depth.
(B) Comparison of areas of overlapping signals for 6 mm sample volume (A) and 12 mm
sample volume (B).

6 mm, you are overlapping your Doppler signals by only 1 mm. However, if you are
using a 12 mm sample volume, you are overlapping your Doppler signals by 7 mm.
which obtains a duplicate signal (Figure IA und B). The majority of the TCD
will be performed with a sample volume of 6 to 8 mm. If you are having difficulty
obtaining a Doppler signal, increasing the sample volume may be necessary.

Intensity/Power
Intensity (or power) is the energy sent into the tissue by the ultrasound wave
(Tegeler and Eicke 1993). Attenuation is when intensity decreases as it passes
through tissue or bone. Most of the intensity is absorbed and converted to heat.
Because of this, the technologist must keep the safety of the patient in mind. When
scanning through the eye or under the chin there is no bone, so the power should be
 PERFORMING A TRANSCRANIAL DOPPLER 17

kept low. If the power or intensity is high for long periods of time it could injure
the patient. The Food and Drug Administration (FDA) limits the power allowed on
ultrasound equipment, so it should not cause injury. However, when using TCD on
the retromandibular and transorbital windows it is important to keep the power at 10
to 25'í'í (Tegeler and Eicke 1993).

Attenuation
Attenuation is determined by the tissue through which the ultrasound beam travels
and by the depth of the ultrasound beam. Attenuation is low for fluid-filled vessels
and high for muscle, tissues, and bone (Kremkau 1995). Sound travels faster through
bone than it does through muscle or tissue, causing higher attenuation. If a patient
has a thicker temporal bone, the signal will be weaker. As sound travels through
tissue its strength decreases as the distance of travel increases. Insonation of the
basilar artery, which is the deepest vessel lying 80 to \]5 mm within the brain, can
result in a weak returning signal, lurning the gain control up on the TCD equipment
can help overcome weak signals by increasing the intensity of the signal itself
(Figures 2A, 2B, and 2C).

TRANSCRANIAL DOPPLER
Transcranial Doppler i.s performed using a '"blind" technique. Because no vessel
is imaged, corred identification of the vessels depends on multiple factors. These
factors consist of direction of How. depth of insonation. the angle of the TCD probe,
vessel resistance, mean flow velocity, and the acoustic window through which each
vessel is insonated (Table I). Using one of these factors alone is not a reliable guide
to identification, but all of them used together will help you confidently identify each
vessel.

Direction of Flow
Direction of flow means the blood will be flowing either toward or away from the
TCD probe. Normally directed flow in each vessel depends on where the vessel lies
in relationship lo where the probe is placed. On most TCD equipment blood tlow
loward the probe appears as a waveform above the baseline. Flow away from the
probe appears below the baseline.

Depth of ln«ionatioii
The depth of insonation for TCD is measured in millimeters. Each vessel in the
circle of Willis has a different Ictiglh and lies at different depths in relationship to
 PERFORMING A TRANSCRANIAL DORRLER

A
cnVs • < - 40
IM
100
50

SO
100
0 1 Ï 3 4 5 6 J B 9
1• to*

Date 7/14/2008 1:09:54 PM MeanAp

Probe 2PW Max 88/B
SamirieVc Mean &4J1)
31 Uin 46«)
ISPTA 720 PI 0,66/18.6
50 D/S
Sc8te|Hc) 7519
Label MCA R

c
150

i
Lkkl
SO
100
' .20

Date 7/14/20081:10:51 PW MeanAp

Probe 2PW Max 93/0
S^iiple Volume[min] 6 Mean 67«
Gaml%l 31 Min 49A)
ISPTA 720 PI 065A),00
Deplli(mm] 50 D/S
Scalo^HíJ 7519
Label MCA R

FIG. 2A, A transcranial Doppler signal that is weak {or attenuated). Turning up the gain
control would improve signal strength,
FIG. 2B, A transcranial Doppler signal that is overgained. Turning down the gain contro!
would eliminate the background speckling and clean up the signal,
FIG, 2C. A transcranial Doppler signal with proper gain. The signal is strong with no
background speckling,

probe location. For example, the portion of the anterior cerebral artery {ACA) that
TCD can insonate is much shorter than the middle cerebral artery (MCA), Because
of this TCD can only pick up about 5 mm of the ACA, however, it can pick up about
20 mm of the MCA. The ACA lies deeper within the brain than most of the MCA so
it will be insonated at a deeper depth.

Angle ofthe TCD Probe

Each vessel in the circle of Willis lies at a different angle in relationship to
the TCD probe. Some vessels will require that the probe be angled anteriorly, while
others will need a more posterior, inferior, or superior angle.
 PERFORMING A TRANSCRANIAL DOPPLER 19

Table 1. Eacit vessel is insonaled ihmu^ii specific windows and at specific depths, ¡denlifiralloii
of tiie ves.set is made using liie tieptii. mean flow veiocity. direciicm of fiow and wuvcfonn
resistance.
Direciiuri ol
Artery Window Depih ML'an Veiocity Flow ties) stance
KCICA Relromandibular 45-50 nim 30 + / - 9 cm/sec Away Low
MCA Transiempond 30-65 mm 55 + /— 12 cm/sec Toward Low
ACA Transtcmporai 6()-75 mm 50 + /— 11 cm/sec Away Low
PC A PI Trans temporal 60-70 mm 39 + / - 10 cm/sec Toward Low
PCA P2 Transtemporal 60-70 mm 40 + / - 10 cm/sec- Away Low
OA Transorbital 45-55 mm 21 + /— 5 cm/sec Toward High
Supraclinoid ICA Transorbital 65-80 mm 41 + / - 1 i cm/scc Away Low
Püra.se[lar ICA Transorbital 65-80 mm 47 + / - 14 cm/sec Toward Low
VA Translbraminal 60-7.'i mm 38 + / - iO cm/sec Away Low
BA Transforaminal SO-120 mm 41 + / - 10 cm/scc Awav 1 .ov\

E C I C A - exiracranial internal carotid urtery; M C A - middle cerebral arlery; ACA - anterior

cerebral artery; P C A - posterior cerebral artery; O A - ophthalmic artery; ICA - internal carotid
artery; VA - vertebral artery; BA - basilar artery

Vessel Resistance
Vessel resistance refers to how pulsatile the waveform is. In other words, is there
more or less diastolic flow? High resistance vessels are those vessels that feed the
periphery, such as the face. arms, and legs. A high resistance flow signal is one that
has very little or no forward diastolic flow or that has a flow reversal during early
diastole (Figure 3A). Low resistance vessels feed areas of the body that demand
the most oxygen, such as the kidney, liver, and brain. A low resistance flow signal
has continuous forward flow during diastole which prt)vides a tnore constant blood
supply to the organ (Figure 3B).

A
• <- 40

LLUM.iJ!
Extv 4lA«*ëc
I
Date 7/14/2008 1:43:55 PM UdeanAp Date 7/14/2008 1:29:13 PM MeanAp
Probe 8PW Max 39« Probe 2PW Max 1t)3/33
Sample Vokii 8 Mean 9/1 S a n ^ Vokime|mni) 8 Mean 74/16
Gain|%) 38 Mm 0/0 Gain[%| 19 Mm 55/0
ISPTA 240 PI 4.27/6,59 ISPTA 720 PI 0.65/2,11
p[| 12 D/S Depth[mm| 50 D/S
Scals|Hz| ItKX» Scale(hlz) 7519
Label Posterior Tibial L t-abel MCA L

FIG. 3A. A high resistance flow signal from a peripheral artery in the leg. Note the
reversal of flow in early diastole and minimal forward flow in late diastole.
FIG. 3B. A low resistance flow signal from the middle cerebral artery. Note that there is
continuous forward flow throughout diastole.
20 PERFORMING A TRANSCRANIAL DOPPLER

Mean Flow Velocity

Unlike other ultrasound measurements. TCD does not use the absolute systolic or
diastolic flow velocities to determine normal or abnormal flow. Instead it uses time
averaged maximum mean velocity (or mean How velocity for short). The mean flow
velocity (MFV) is calculated as:
MFV = (systolic velocity—diastolic velocity/3) +diastolic velocity
(Katz and Alexandrov 2003, Saver and Fetdmann 1993).
Each vessel has its own range of normal tlow velocities and this is one thing that
can be used to help identify a vessel (Table 1 ).

ACOUSTIC WINDOWS
The acoustic windows are the areas on the head through which the TCD ultra-
sound beam can most easily travel. They are made up of naturally occurring foramina
(bone openings) or regions where the cranial bone is relatively thin (Fujioka
and Douville 1992). The acoustic windows used in TCD are the retromandibular
(or submandibular), the transtemporal, the transorbital, and the transforaminal
(or suboccipital).

The Retromandibular Window

The retromandibular window, also called the submandibular window, is located
under the chin at the angle of the jaw. This window is used to identify the extracra-
nial internal carofid artery (ECICA). Set the power setting to 10 to 25%. Place the
probe at the angle of the jaw with the probe pointing superior and slightly medial
(Figure 4). This vessel will be found flowing away from the probe at a depth of 45
to 50 mm. Make sure that the vessel being insonated has a low resistance waveform.
If you see a high resistance waveform it may be the external carotid artery instead.

The Transtemporal Window

The transtemporal window allows insonation of the MCA. ACA. and posterior
cerebral artery (PCA). The transtemporal window can be subdivided into three
regions: anterior, preauricular (in front of the ear), and posterior region. Angling of
the probe for each vessel will be different depending on which part of the transtem-
poral window provides the strongest signal. The entire region between the ear and
along the zygomatic bone (cheekbone) should be explored to obtain the strongest
possible signal (Figure 5).
 PERFORMING A TRANSCRANIAL DOPPLER 21

FIG. 4. The retromandibular (submandibular) window. Place the probe under the chin at
the angle of the jaw and point the probe superiorly and slightly medial.

Generally the preauricular (or middle) window will be the one used the most. This
window lies directly in front of the ear just superior to the zygomatic arch. The probe
angle in this region of the transtemporal window will be straight in or slightly
anterior and superior for the MCA and ACA. It will be posterior for the PCA.
The posterior window is the second most common window and lies just above the
ear. The probe angle will be anterior and slightly superior for the MCA and ACA.
It will be straight in or slightly posterior for the PCA.
The anterior window lies next to the lateral corner of the eye. The MCA and ACA
will be found by angling the probe posteriorly. The PCA may be diiftcult to insonate
from this window because of the extreme posterior angle needed. In fact, you may
not be able to find it at all.
Many times it may be necessary to use a combination of the regions of the trans-
temporal window. For example, the MCA and ACA may be easily insonated from the
anterior window, but the PCA may be found easier in the posterior window.
Begin the examination on the transtemporal window by locating the MCA at a
depth of 50 mm. Make small, slow angle adjustments to locate the strongest signal.
Adjust your depth to follow the MCA its entire length (usually 30 to 65 mm).
22 PERFORMING A TRANSCRANIAL DOPPLER

FIG. 5. The transtemporal window using the preauricular region. Piace the probe in front
of the ear just above the cheekbone (zygomatic arch).

The MCA waveform will be low resistance and flowing toward the probe. At a depth
of 60 to 75 mm a waveform going away from the probe will begin to appear. This is
the bifurcation of the internal carotid artery (ICA) into the MCA and ACA. Be aware
that many times you will see a signal going away from the probe at a depth of 55 mm.
This is the anterior temporal branch of the MCA. Do not mistake it for the ACA.
To obtain the strongest ACA signal it may be necessary to find the MCA signal and
then angle the probe slightly more anterior and superior.
Both the PI and P2 segments of the PCA are insonated at a depth of 60 to 70 mm.
The PI segment will be flowing toward the probe and the P2 segment will be tlowing
away from the probe. From the MCA and ACA bifurcation, angle the probe posterior
{toward the ear). The P2 segment may be found by angling the probe slightly more
posterior and superior from the PI segment signal.

The Transorbital Window

Insonation of the ophthalmic artery (OA) and carotid siphon is done through the
transorbital window. Using only a small amount of ultrasound gel. gently place the
 RERFORMING A TRANSCRANIAL DOPPLER 23

FIG. 6, The transorbital w i i i t l ü w . Place ilie p t o h e ciiteijtly over the closed eyelid angling
straight in or slightly medial.

probe on the closed eyelid ( Figure 6). Make sure that the power level is turned down
to 10 to 259Í- to protect the eye.
The OA is insonaled by angling the probe straight into the eye at a depth of 45
to 55 mm. This vessel feeds the eye. therefore, the vt/aveform is high resistance and
travels toward the probe.
The carotid siphon is insonated at a depth of 65 tn 80 mm. The probe angle will
vary but generally is somewhat medial. The supraclinoid portion of the carotid
siphon flows away from the probe. The paraselhir portion ofthe carotid siphon flows
toward the probe. If there are signals flowing both toward and away from the probe
this is the gcnu portion ofthe carotid sipht)n. Make sure the signal is a low resistance
waveform.

The Transfora menai Window

The transforamenal (siihoccipital ) window is used to insonate the vertebral arteries
(VA) and basilar artery {HA). This window uses the foramen magnum to obtain the
24 PERFORMiNG A TRANSCRANiAL DOPPLER

FIG. 7. The transforaminal (suboccipital) window. Place the probe centrally on the back
of the neck just below the bony cranium. Angle the probe superiorly like you are aiming
toward the bridge of the nose.

Doppler signals. To use this window palpate for the soft spot in the middle of
the neck below the bony cranium. Place the probe at the top and center of this area
(Figure 7).
The intracranial VA is insonated by angling the probe to the right for the right
vertebral and to the left for the left vertebral. You may also place the probe to the right
side or left side at the top of the foramen magnum. However, make sure to angle
straight in or only slightly medial to itisonate the coiresponding VA. The VA will be
found at a depth of 60 to 15 mrn and is a low resistance signal flowing away frotn the
probe. The vertebral atlas, or extracranial vertebral aitery (ECVA). is insonated at a
depth of 45 to 55 mm. Move the probe laterally along the base of the skull. Palpate
the base of the skull for a srnail indention and angle the probe straight in. Flow in the
ECVAs may flow either toward or away from the probe. This happens because the
vessel curves as it enters the skull.
Follow one of the VAs deeper until you get to a depth of about 7fi to 80 mm. This
is the depth where the bilateral VAs join to fortn the BA. The BA is often tortuous
(curves and dives along its course) so it may be necessary to angle the probe in
different directions to follow its course. Chatigc yt)ur depth and continue to follow
 PERFORMING A TRANSCRANIAL DOPPLER 25

the course of the BA from a depth of 75 mm to 100 to 115 mm. BA flow is low
resistance and moves away from the probe.

ADDITIONAL TECHNIQUES
There are several other techniques that may be used to identify vessels. Oscillation
maneuvers, probe location, and patient positioning may be helpful when trying to
locate and identify vessels.

Oscillations
Oscillation maneuvers may help identify certain vessels. The terminal ICA (TICA)
can sometimes be mistaken for the PCA because both lie at a posterior angle.
The PCA is fed by the posterior circulation, thus the vertebral artery can be oscillated
at the atlas loop to distinguish the TICA from the PCA. This is done by placing
the forefinger at the small notch at the base of the skull on either the right or left
side. Make firm tapping motions on the notch. This will send oscillations through the
VA, BA. and into the PCA waveform. It will not send oscillations into the TICA.
therefore helping you identify the PCA with confidence. Keep in mind that if there is
a fetal origin to the PCA (the PCA arises from the ICA) these oscillations will not
show up in the waveform.
The common carotid artery (CCA) may also be oscillated to help identify vessels
in the anterior circulation. This is often done when trying to identify collateral flow.
If oscillations are to be done on the CCA make sure there is no disease in the CCA
or ICA ihal can be knocked loose by the oscillations. Do the oscillations very low on
the neck, placing your finger near the collarbone. If there is question about whether
disease exists, do not do the oscillations. Figure 8 illustrates how oscillations appear
as sawtooth notches in the Doppler waveform.

Date 7/14/2008 2:50:56 PM MeanAp

Probe 2PW Max 109/34
Sample Vohjme|mm] 8 Mean 77/17
Gain[%| 19 Min 52/0
ISPTA 720 PI 074/2.00
Depth|mmJ 50 D/S
Scaie(Hz| 6536

FIG. 8. The middle cerebral artery showing oscillations from tapping on the ¡psilateral
common carotid artery. Note the sawtooth appearance of the oscillations.
26 PERFORMING A TRANSCRANIAL DOPPLER

Patient Positioning
The basilai- aitery is often a difficult vessel to insonate due to its depth. If the
patient is able to roll over onto his side, have him do so. Tucking the chin toward the
chest helps open up the window to the foramen magnum. If the patient must stay
supine and can't tuck his chin, use a rolled up towel to prop his head making sure to
keep the neck exposed.

Probe Positioning
At the deepest portion of the basilar artery it may be helpful to slide the probe
down the neck slightly. Increasing the sample volume may also help. Keep in mind
that as you make the sample volume bigger you are overlapping Doppler signals.

TECHNICAL DIFFICULTIES
Bone attenuates iiltrasoiuid making penetratit>n difficull. If the temporal bone
is thick (hyperostosis). insonation of the MCA, ACA, and PCA is not possible.
This occurs most in elderly women, African American women of any age, and Asian
men. Studies from various centers have reported hyperostosis rates ranging from 5%
to 19% (Saver and Feldmann 1993).
Tortuosity also makes insonation of vessels difficult. It is assumed in TCD that the
angle of insonation is 0 degrees (Katz and Alexandrov 2003). This is based on the
probe looking directly down the pipe of the vessel (being parallel to the vessel
and flow ). If the vessel is tortuous and lies perpendicular to the probe it is difficult to
insonate that portion of the vessel.

CONCLUSION
The accuracy of transcraniai Doppler is very operator dependent and the learning
curve is very long. The length of time it takes to achieve competency depends upon
the number of studies performed each day and the quality of supervision. The most
significant challenge is vessel identification. With practice, experience, and the use
of the techniques discussed, the neurodiagnostic technologist can become proficient
in the performance of TCD.

ACKNOWLEDGEMENTS
We would like to thank the Duke University Hospital Neurodiagnostic Lab staff
for their suppoit and especially Rebecca Rendahl. R. EEG T. RPSGT. BS and Mike
Blake. BS for their assistance with this paper.
 PERFORMING A TRANSCRANIAL DOPPLER 27

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