Perspectives in Medicine (2012) 1, 3438

Bartels E, Bartels S, Poppert H (Editors):

New Trends in Neurosonology and Cerebral Hemodynamics an Update.
Perspectives in Medicine (2012) 1, 3438

journal homepage: www.elsevier.com/locate/permed

Brain tissue perfusion monitoring using Sonopod for

transcranial color duplex sonography
Toshiyuki Shiogai a,, Mari Koyama a, Mayumi Yamamoto a,
Kenji Yoshikawa b, Toshiki Mizuno c, Masanori Nakagawa c

a
Department of Clinical Neurosciences, Kyoto Takeda Hospital, Minamikinuta-cho 11, Nishinanajo, Shimogyo-ku, Kyoto 600-8884,
Japan
b
Department of Stroke Medicine, Hoshigaoka Kouseinenkin Hospital, Hoshigaoka 4-8-1, Hirakata City, Osaka 573-8511, Japan
c
Department of Neurology, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto
602-8566, Japan

KEYWORDS Summary
Transcranial color Objective: We have introduced and improved a transducer holder, named the Sonopod, for
duplex sonography; transcranial color duplex sonography (TCDS) monitoring via both temporal/foraminal windows
Transducer holder (TW/FW). The objective is to clarify clinical usefulness and identify problems in TCDS-Sonopod
(Sonopod); monitoring during the evaluation of brain tissue perfusion.
Brain tissue Methods: Brain tissue perfusion monitoring was evaluated in 11 patients (ages 3194, mean 66).
perfusion; After a bolus intravenous Levovist , power modulation imaging (PMI) in all cases was evaluated
Acetazolamide in comparison with second harmonic imaging (SHI) in two cases at the diencephalic horizontal
vasoreactivity; plain via the TWs on the basis of timeintensity curves (TICs) in ve regions of interest (ROIs);
Second harmonic bilateral basal ganglia (BG) and thalamus (Th), and contra-lateral temporal lobe (TL). After a
imaging; SONOS5500 S3 transducer was installed in the Sonopod, acetazolamide (ACZ) cerebral vasore-
Power modulation activity utilizing PMI was evaluated in 10 cases via the bilateral (ve cases) and unilateral (ve
imaging cases) TWs. A total of 30 TICs were evaluated before/after ACZ administration.
Results: (1) All patients could be monitored continuously by one examiner. (2) We conrmed
that PMI proves superior to SHI in quantitative evaluation of the bilateral hemispheres via the
unilateral TWs. (3) Brain tissue perfusion could be precisely quantied before/after ACZ in the
same ROIs. (4) TIC base-line drifts during monitoring were observed in 4 (seven TICs) of 10 (30
TICs) patients. However, xed-probe shifts during monitoring were easily readjustable and the
TIC recovered to the base-line in all cases. (5) Due to re-xation needed for contralateral TW
monitoring, it was not possible to evaluate completely in the same ROIs.
Conclusions: TCDS-Sonopod monitoring succeeds in continuously and quantitatively evaluating
precise and reproducible intracranial hemodynamics in the brain tissue.
2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

Introduction
Corresponding author. Tel.: +81 75 312 7001;
Compared to conventional transcranial Doppler sonogra-
fax: +81 75 325 2295.
phy (TCD), transcranial color duplex sonography (TCDS) is
E-mail address: [email protected] (T. Shiogai).

2211-968X 2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

doi:10.1016/j.permed.2012.03.001
Brain tissue perfusion monitoring using Sonopod for transcranial color duplex sonography 35

Figure 1 Transducer holder (Sonopod) for transcranial color Figure 2 TCDS-Sonopod monitoring in sitting position via both
duplex sonography (TCDS) monitoring. We have developed and temporal (a) and foraminal (b) windows.
improved the transducer holder (Sonopod) for TCDS monitoring
(a and b). Material and methods

Brain tissue perfusion monitoring was evaluated in 11

able to measure much more accurately on the basis of patients (ages 3194, mean 66). Details of patient demo-
angle-collected velocities in the intracranial major vessels. graphics are shown in Table 1. After a 5 ml-bolus Levovist
Furthermore, TCDS is able to visualize intracranial lesions injection (2.5 g, 400 mg/ml) via the antecubital vein, power
in stroke [1], severe head injury [2], and other neurologi- modulation imaging (PMI) in all cases in comparison with
cal disorder cases [3]. Utilizing ultrasound contrast agents
(UCA), TCDS has been able to evaluate brain tissue perfusion
non-invasively, particularly in ischemic stroke patient inves- Table 1 Patient demographics.
tigations [4,5]. Possibilities of quantitative measurements Total patients: n = 11
have been evaluated in an identical way to neuroradio- Causes of brain injury
logical perfusion imaging, based on the bolus dye-dilution Cerebral infarction 8
principle. However, quantitative reliability has not yet been (atherothrombotic 5, lacunar
established, due to problems of skull- and depth-dependent 2, embolic 1)
ultrasound attenuation, shadowing effects, bubble satura- Hypertensive putaminal 1
tion, and low data reproducibility (the latter due to UCA hemorrhage
administration methods, transducer xation, data analysis, Ruptured anterior 1
etc.) [4,5]. communicating aneurysm
Transducer holders or probe xation devices for conven- Chronic subdural hematoma 1
tional TCD monitoring have been introduced into clinical Ages: 3194 years (mean 66)
settings [69]. However, a transducer holder for TCDS has Gender: male 9, female 2
yet to be clinically introduced. We have developed and Monitoring (via temporal window)
improved such a transducer holder (Sonopod) (Fig. 1) for Perfusion imaging
TCDS monitoring via both temporal and foraminal windows Power modulation imaging 9
(TW and FW) (Fig. 2). only
To overcome the inherent problems and establish the Second harmonic imaging 2
clinical signicance of transcranial ultrasound perfusion and Power modulation
imaging, we have clinically introduced the Sonopod for imaging
TCDS monitoring [10,11] and evaluated acetazolamide Acetazolamide vasoreactivity 10 (30 TIC analyses)
(ACZ) vasoreactivity [12,13]. The objective of this study test (bilateral 5, unilateral 5)
is to clarify clinical usefulness and identify problems in TIC base-line drift during 4 (7 TIC analyses)
TCDS-Sonopod monitoring in the evaluation of brain tissue monitoring
perfusion.
36 T. Shiogai et al.

Figure 3 TCDS-Sonopod monitoring in supine position via the

temporal window.

second harmonic imaging (SHI) in the initial two cases were

evaluated in the supine position via TWs (Fig. 3). Both
imaging types were visualized by an integrated backscat-
ter method. The transmitting and receiving frequencies of
Figure 4 Hand-held monitoring via the left temporal windows
PMI and SHI were 1.7/1.7 MHz and 1.3/2.6 MHz, respec-
utilizing second harmonic imaging (SHI) and power modulation
tively. The investigation depth was 16 cm with a focus of
imaging (PMI). Hand-held monitoring of brain tissue perfusion
8 cm. Settings were mechanical index 1.6, system gain 75,
via the left TW utilizing SHI (a) and PMI (b) are depicted in a
and compression 70. ACZ cerebral vasoreactivity, before
post-operative patient with an anterior communicating artery
and after 500 mg Diamox intravenous injection, was eval-
aneurysm. TICs derived from the ve ROIs, placed in the bilat-
uated in 10 cases utilizing a SONOS5500 S3 transducer
eral BG and Th, and contra-lateral TL, are shown in the lower
(Philips Electronics Japan, Ltd.) installed in the Sonopod.
panels. TICs have drifted from the base-line and are unstable
Timeintensity curves (TICs) on the diencephalic horizontal
due to patients movements.
plain were evaluated before and after ACZ in ve regions
of interest (ROI); bilateral basal ganglia (BG) and thalamus
(Th), and contra-lateral temporal lobe (TL). A total of 30
TICs with a duration of 10 min via the bilateral (ve cases)
and unilateral (ve cases) TWs were analyzed before and
after ACZ.

Results

Hand-held monitoring utilizing PMI and SHI

Conventional SHI and PMI utilizing hand-held monitoring

were compared in two cases. In the visualization of the
contralateral hemispheres via the unilateral TWs, PMI was
superior to SHI as shown in the upper panels of Fig. 4a and
b. As shown in the lower panels of the quantitative TIC
evaluations in both PMI and SHI, peak intensity (PI) in the
contralateral hemisphere ROIs was lower than in the ipsi-
lateral hemisphere ROIs. During hand-held monitoring, TICs
were not always stable in all cases and drifted from the
base-line due to patients movements as shown in the lower
panels of Fig. 4.

Sonopod ACZ monitoring utilizing PMI

Figure 5 Sonopod acetazolamide (ACZ) vasoreactivity test
All patients could be tted and monitored continuously utilizing PMI. Sonopod monitoring of brain tissue perfusion via
by one examiner. Brain tissue perfusion could be precisely the right TW utilizing PMI before (a) and after (b) ACZ adminis-
quantied before/after ACZ in the same ROI as shown in tration, demonstrated in a postoperative patient with chronic
Fig. 5. Due mainly to patients movements, drifts from the subdural hematoma. TICs are completely stable during 10 min
base-line were observed in the TICs of 4 (seven TIC analyses) of monitoring.
Brain tissue perfusion monitoring using Sonopod for transcranial color duplex sonography 37

durability [7]. The durability of a prototype of this trans-

ducer, the Sonopod, has been proven, with no problems
in our four-year experience. However, it is still so heavy
that long-time TW monitoring in the sitting position will
probably result in discomfort caused by fatigue of the neck
muscles. This problem will be improved in changing mate-
rials from heavy stainless steel to light weight aluminum,
titanium, or similar. For FW monitoring, the Sonopod is
unable to be applied in a supine position, therefore patients
should be instructed to lie down semi-laterally. It is nec-
essary to tighten four screws during setup of the Sonopod
and this may prove a slight time-consuming drawback while
searching for appropriate location of vessels or anatomical
places. In our experience however, we were usually ready
for monitoring in around 510 min. Improvements of the
Figure 6 Sonopod PMI monitoring before ACZ administration.
Sonopod have been planned for the SONOS 5500 S3 trans-
Sonopod PMI monitoring of brain tissue perfusion via the left
ducer (Philips), compatibility with multiple probes and costs
TW before ACZ administration is shown in a patient with right
of marketing the products should be conrmed in the near
putaminal hemorrhage. TICs have drifted from the baseline due
future.
to patients movements, but have been returned to the base-
line easily through readjustment of xed-probe positions during
monitoring.
Comparison of SHI and PMI
out of 10 (30 TIC analyses) patients. However, xed-probe Since the clinical introduction of transcranial ultrasound
shifts due to patients movements during monitoring were perfusion imaging of brain tissue, depth dependant ultra-
easily re-adjustable and the TICs could be returned to sound attenuation has been the most challenging problem
the baseline in all patients as shown in Fig. 6. Regard- for qualitative and quantitative evaluation [17,18]. In our
ing contralateral TW monitoring in the ve bilaterally ACZ study, signicant depth dependant PI attenuation on the TICs
examined patients, it was not possible to evaluate precisely was observed in both image types, particularly in the con-
in the same ROI locations due to Sonopod re-xation. tralateral hemisphere. In the pioneering work utilizing SHI
with Levovist by Postert et al. [17], not only PI but also
Discussion the area under the TIC was shown to be signicantly higher
in the BG and white matter ROIs than in the Th ROI. Fur-
thermore, SHI utilizing an alternative UCA (Optison) showed
Transducer holder for TCD and TCDS
signicantly higher Th ROI in the ipsilateral hemisphere than
in the contralateral hemisphere [18]. More recent studies
Transducer holders or probe xation devices for conven-
utilizing phase-inversion harmonic imaging (PIHI) utilizing
tional TCD monitoring have been introduced into clinical
Optison and SonoVue [19] showed typical depth dependant PI
settings. Previously, for the examination of neonates, a
attenuation in the contralateral hemisphere rather than the
hood-like probe xation device via the transfontanellar win-
ipsilateral hemisphere in bilateral or unilateral (ipsilateral)
dow has been investigated [14]. Trials in adult patients have
approaches. A bilateral approach utilizing PIHI [19,20] has
focused not only on the middle cerebral artery (MCA) via
been suggested for evaluating contralateral hemispheres.
the TWs [7,15], but also in the vertebrobasilar arteries via
Our previous study of ultrasound perfusion imaging also
the FW for high intensity transient signals (HITS) monitoring
showed that PMI utilizing transient response high power
[16]. More recently, a commercially available head-frame
images is superior to conventional SHI in evaluation of
(Marc 600, Spencer Technologies) for monitoring via the
the contra-lateral cerebral hemisphere [21]. This study
TWs has been used for detection of recanalization in the
reconrmed that result. However, limitations of the con-
MCA during tissue plasminogen activator studies [6]. Fur-
tralateral approach, e.g. shadowing [19], have been pointed
thermore, a long-term ambulatory TCD monitoring device
out [5].
placed on a spectacle frame has been introduced for HITS
detection in the MCAs via the TWs [9]. A modied head-
frame combining two Spencer Technologies head-frames
for both the TWs and FW has been tried for vasoreactivity ACZ vasoreactivity utilizing PMI
tests [8].
Our TCDS transducer xation device, the Sonopod, is In order to overcome the problems in quantifying brain tissue
able to monitor not only via the TWs, but also via the perfusion, e.g. depth dependant ultrasound attenuation, we
FW (Fig. 2). A further important advantage is long-duration have applied transcranial ultrasound perfusion imaging to
stable TCDS monitoring that implies accurate quantitative the ACZ vasoreactivity test [10,13]. In ACZ vasoreactivity
measurements in the major cerebral arteries and brain tis- tests, the same ROI placements before and after ACZ are
sue. Proposed criteria for probe-holding systems include very important for accurate quantication. From this point
ease of application, stability during patient movement, of view, the Sonopod is very useful for precise quantication
low-cost, compatibility with multiple probes, comfort and of brain tissue perfusion.
38 T. Shiogai et al.

Conclusions [11] Shiogai T, Koyama M, Yamamoto M, Yoshikawa K, Mizuno T,

Nakagawa M. Monitoring of brain tissue perfusion utilizing
Sonopod for transcranial color duplex sonography. Cerebrovasc
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