Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

ACC 2024 Congress

Catch up on all the top stories and latest evidence in cardiology research with our ACC 2024 Congress hub page.
ADVANCED SEARCH
Log in
Top
The Ultrasound Journal
Published in: The Ultrasound Journal 1/2014

Open Access 01-12-2014 | Original article

Prehospital stroke diagnostics based on neurological examination and transcranial ultrasound

Authors: Moriz Herzberg, Sandra Boy, Thilo Hölscher, Michael Ertl, Markus Zimmermann, Karl-Peter Ittner, Josef Pemmerl, Hendrik Pels, Ulrich Bogdahn, Felix Schlachetzki

Published in: The Ultrasound Journal | Issue 1/2014

Login to get access

Abstract

Background

Transcranial color-coded sonography (TCCS) has proved to be a fast and reliable tool for the detection of middle cerebral artery (MCA) occlusions in a hospital setting. In this feasibility study on prehospital sonography, our aim was to investigate the accuracy of TCCS for neurovascular emergency diagnostics when performed in a prehospital setting using mobile ultrasound equipment as part of a neurological examination.

Methods

Following a ‘911 stroke code’ call, stroke neurologists experienced in TCCS rendezvoused with the paramedic team. In patients with suspected stroke, TCCS examination including ultrasound contrast agents was performed. Results were compared with neurovascular imaging (CTA, MRA) and the final discharge diagnosis from standard patient-centered stroke care.

Results

We enrolled ‘232 stroke code’ patients with follow-up data available in 102 patients with complete TCCS examination. A diagnosis of ischemic stroke was made in 73 cases; 29 patients were identified as ‘stroke mimics’. MCA occlusion was diagnosed in ten patients, while internal carotid artery (ICA) occlusion/high-grade stenosis leading to reversal of anterior cerebral artery flow was diagnosed in four patients. The initial working diagnosis ‘any stroke’ showed a sensitivity of 94% and a specificity of 48%. ‘Major MCA or ICA stroke’ diagnosed by mobile ultrasound showed an overall sensitivity of 78% and specificity of 98%.

Conclusions

The study demonstrates the feasibility and high diagnostic accuracy of emergency transcranial ultrasound assessment combined with neurological examinations for major ischemic stroke. Future combination with telemedical support, point-of-care analysis of blood serum markers, and probability algorithms of prehospital stroke diagnosis including ultrasound may help to speed up stroke treatment.
Appendix
Available only for authorised users
Literature
1.
Rothwell PM, Coull AJ, Silver LE, Fairhead JF, Giles MF, Lovelock CE, Redgrave JNE, Bull LM, Welch SJV, Cuthbertson FC, Binney LE, Gutnikov SA, Anslow P, Banning AP, Mant D, Mehta Z: Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study). Lancet 2005,366(9499):1773–1783. doi:10.1016/S0140–6736(05)67702–1 10.1016/S0140-6736(05)67702-1CrossRefPubMed
2.
Saver JL: Time is brain-quantified. Stroke 2005,37(1):263–266. doi:10.1161/01.STR.0000196957.55928.abCrossRefPubMed
3.
Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D: Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008,359(13):1317–1329. doi:10.1056/NEJMoa0804656 10.1056/NEJMoa0804656CrossRefPubMed
4.
Costalat V, Machi P, Lobotesis K, Maldonado I, Vendrell JF, Riquelme C, Mourand I, Milhaud D, Héroum C, Perrigault P, Arquizan C, Bonafé A: Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-patient single-center study: timing, safety, and efficacy. Stroke 2011,42(7):1929–1935. doi:10.1161/STROKEAHA.110.608976 10.1161/STROKEAHA.110.608976CrossRefPubMed
5.
Lichtman JH, Watanabe E, Allen NB, Jones SB, Dostal J, Goldstein LB: Hospital arrival time and intravenous t-PA use in US Academic Medical Centers, 2001–2004. Stroke 2009,40(12):3845–3850. doi:10.1161/STROKEAHA.109.562660 10.1161/STROKEAHA.109.562660CrossRefPubMed
6.
Albers GW, Olivot J: Intravenous alteplase for ischaemic stroke. Lancet 2007,369(9558):249–250. doi:10.1016/S0140–6736(07)60120–2 10.1016/S0140-6736(07)60120-2CrossRefPubMed
7.
Evenson KR, Foraker RE, Morris DL, Rosamond WD: A comprehensive review of prehospital and in-hospital delay times in acute stroke care. Int J Stroke 2009,4(3):187–199. doi:10.1111/j.1747–4949.2009.00276.x 10.1111/j.1747-4949.2009.00276.xPubMedCentralCrossRefPubMed
8.
Meyer BC: Telestroke evolution: from maximization to optimization. Stroke 2012,43(8):2029–2030. doi:10.1161/STROKEAHA.112.662510 10.1161/STROKEAHA.112.662510PubMedCentralCrossRefPubMed
9.
Puolakka T, Väyrynen T, Häppölä O, Soinne L, Kuisma M, Lindsberg PJ: Sequential analysis of pretreatment delays in stroke thrombolysis. Acad Emerg Med 2010,17(9):965–969. doi:10.1111/j.1553–2712.2010.00828.x 10.1111/j.1553-2712.2010.00828.xCrossRefPubMed
10.
Teuschl Y, Brainin M: Stroke education: discrepancies among factors influencing prehospital delay and stroke knowledge. Int J Stroke 2010,5(3):187–208. 10.1111/j.1747-4949.2010.00428.xCrossRefPubMed
11.
Holscher T, Schlachetzki F, Zimmermann M, Jakob W, Ittner KP, Haslberger J, Bogdahn U, Boy S: Transcranial ultrasound from diagnosis to early stroke treatment. 1. Feasibility of prehospital cerebrovascular assessment. Cerebrovasc Dis 2008,26(6):659–663. doi:10.1159/000166844 10.1159/000166844CrossRefPubMed
12.
Machi P, Costalat V, Lobotesis K, Maldonado IL, Vendrell JF, Riquelme C, Bonafé A: Solitaire FR thrombectomy system: immediate results in 56 consecutive acute ischemic stroke patients. J Neurointerv Surg 2012,4(1):62–66. doi:10.1136/jnis.2010.004051 10.1136/jnis.2010.004051PubMedCentralCrossRefPubMed
13.
Ahmed N, Wahlgren N, Brainin M, Castillo J, Ford GA, Kaste M, Lees KR, Toni D: Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Stroke 2009,40(7):2442–2449. doi:10.1161/STROKEAHA.109.548602 10.1161/STROKEAHA.109.548602CrossRefPubMed
14.
Brunser AM, Lavados PM, Hoppe A, Lopez J, Valenzuela M, Rivas R: Accuracy of transcranial Doppler compared with CT angiography in diagnosing arterial obstructions in acute ischemic strokes. Stroke 2009,40(6):2037–2041. 10.1161/STROKEAHA.108.542704CrossRefPubMed
15.
Boddu DB, Sharma VK, Bandaru VCSS, Jyotsna Y, Padmaja D, Suvarna A, Kaul S: Validation of transcranial Doppler with magnetic resonance angiography in acute cerebral ischemia. J Neuroimaging 2011,21(2):e34-e40. 10.1111/j.1552-6569.2009.00412.xCrossRefPubMed
16.
Tsivgoulis G, Sharma VK, Lao AY, Malkoff MD, Alexandrov AV: Validation of transcranial Doppler with computed tomography angiography in acute cerebral ischemia. Stroke 2007,38(4):1245–1249. doi:10.1161/01.STR.0000259712.64772.85 10.1161/01.STR.0000259712.64772.85CrossRefPubMed
17.
Allendoerfer J, Goertler M, von Reutern G: Prognostic relevance of ultra-early doppler sonography in acute ischaemic stroke: a prospective multicentre study. Lancet Neurol 2006,5(10):835–840. doi:10.1016/S1474–4422(06)70551–8 10.1016/S1474-4422(06)70551-8CrossRefPubMed
18.
Malferrari G, Bertolino C, Casoni F, Zini A, Sarra VM, Sanguigni S, Pratesi M, Lochner P, Coppo L, Brusa G, Guidetti D, Cavuto S, Marcello N: The eligible study: ultrasound assessment in acute ischemic stroke within 3 hours. Cerebrovasc Dis 2007,24(5):469–476. 10.1159/000108922CrossRefPubMed
19.
Kaps M, Stolz E, Allendoerfer J: Prognostic value of transcranial sonography in acute stroke patients. Eur Neurol 2008,59(Suppl 1):9–16.CrossRefPubMed
20.
Chernyshev OY, Garami Z, Calleja S, Song J, Campbell MS, Noser EA, Shaltoni H, Chen C, Iguchi Y, Grotta JC, Alexandrov AV: Yield and accuracy of urgent combined carotid/transcranial ultrasound testing in acute cerebral ischemia. Stroke 2005,36(1):32–37. doi:10.1161/01.STR.0000150496.27584.e3 10.1161/01.STR.0000150496.27584.e3CrossRefPubMed
21.
Postert T, Braun B, Meves S, Köster O, Przuntek H, Weber S, Büttner T: Contrast-enhanced transcranial color-coded sonography in acute hemispheric brain infarction. Stroke 1999,30(9):1819–1826. 10.1161/01.STR.30.9.1819CrossRefPubMed
22.
Zanette EM, Fieschi C, Bozzao L, Roberti C, Toni D, Argentino C, Lenzi GL: Comparison of cerebral angiography and transcranial Doppler sonography in acute stroke. Stroke 1989,20(7):899–903. 10.1161/01.STR.20.7.899CrossRefPubMed
23.
von Reutern G, Goertler M, Bornstein NM, Del Sette M, Evans DH, Hetzel A, Kaps M, Perren F, Razumovky A, von Reutern M, Shiogai T, Titianova E, Traubner P, Venketasubramanian N, Wong LKS, Yasaka M: Grading carotid stenosis using ultrasonic methods. Stroke 2012,43(3):916–921. doi:10.1161/STROKEAHA.111.636084 10.1161/STROKEAHA.111.636084CrossRefPubMed
24.
Arning C, Widder B, von Reutern GM, Stiegler H, Görtler M: Ultraschallkriterien zur Graduierung von Stenosen der A. carotis interna - Revision der DEGUM-Kriterien und Transfer in NASCET-Stenosierungsgrade (Revision of DEGUM ultrasound criteria for grading internal carotid artery stenoses and transfer to NASCET measurement). Ultraschall Med 2010,31(3):251–257. doi:10.1055/s-0029–1245336 10.1055/s-0029-1245336CrossRefPubMed
25.
Barber PA, Demchuk AM, Zhang J, Buchan AM: Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS study group. Alberta stroke programme early CT score. Lancet 2000,355(9216):1670–1674. 10.1016/S0140-6736(00)02237-6CrossRefPubMed
26.
Fiebach J: CT and diffusion-weighted MR imaging in randomized order: diffusion-weighted imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischemic stroke. Stroke 2002,33(9):2206–2210. doi:10.1161/01.STR.0000026864.20339.CB 10.1161/01.STR.0000026864.20339.CBCrossRefPubMed
27.
Barlinn K, Alexandrov AV: Vascular imaging in stroke: comparative analysis. Neurotherapeutics 2011. doi:10.1007/s13311–011–0042–4
28.
Burke JF, Sussman JB, Morgenstern LB, Kerber KA: Time to stroke magnetic resonance imaging. J Stroke Cerebrovasc Dis 2012. doi:10.1016/j.jstrokecerebrovasdis.2012.03.012
29.
von Kummer R, Bourquain H, Bastianello S, Bozzao L, Manelfe C, Meier D, Hacke W: Early prediction of irreversible brain damage after ischemic stroke at CT. Radiology 2001,219(1):95–100. 10.1148/radiology.219.1.r01ap0695CrossRefPubMed
30.
Muir KW, Buchan A, von Kummer R, Rother J, Baron J: Imaging of acute stroke. Lancet Neurol 2006,5(9):755–768. doi:10.1016/S1474–4422(06)70545–2 10.1016/S1474-4422(06)70545-2CrossRefPubMed
31.
Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk A, Hill MD, Patronas N, Latour L, Warach S: Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet 2007,369(9558):293–298. 10.1016/S0140-6736(07)60151-2PubMedCentralCrossRefPubMed
32.
Wardlaw JM, Mielke O: Early signs of brain infarction at CT: observer reliability and outcome after thrombolytic treatment—systematic review. Radiology 2005,235(2):444–453. doi:10.1148/radiol.2352040262 10.1148/radiol.2352040262CrossRefPubMed
33.
Bhatia R, Hill MD, Shobha N, Menon B, Bal S, Kochar P, Watson T, Goyal M, Demchuk AM: Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke 2010,41(10):2254–2258. doi:10.1161/STROKEAHA.110.592535 10.1161/STROKEAHA.110.592535CrossRefPubMed
34.
Rahme R, Abruzzo TA, Martin RH, Tomsick TA, Ringer AJ, Furlan AJ, Carrozzella JA, Khatri P: Is intra-arterial thrombolysis beneficial for M2 occlusions? Subgroup (M2) analysis of the PROACT-II trial. Stroke 2013,44(1):240–242. doi:10.1161/STROKEAHA.112.671495 10.1161/STROKEAHA.112.671495PubMedCentralCrossRefPubMed
35.
Kase CS, Furlan AJ, Wechsler LR, Higashida RT, Rowley HA, Hart RG, Molinari GF, Frederick LS, Roberts HC, Gebel JM, Sila CA, Schulz GA, Roberts RS, Gent M: PROACT II Cerebral hemorrhage after intra-arterial thrombolysis for ischemic stroke: the PROACT II trial. Neurology 2001,57(9):1603–1610. 10.1212/WNL.57.9.1603CrossRefPubMed
36.
Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, Jauch EC, Jovin TG, Yan B, Silver FL, von Kummer R, Molina CA, Demaerschalk BM, Budzik R, Clark WM, Zaidat OO, Malisch TW, Goyal M, Schonewille WJ, Mazighi M, Engelter ST, Anderson C, Spilker J, Carrozzella J, Ryckborst KJ, Janis LS, Martin RH, Foster LD, Tomsick TA: IMS III endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013,368(10):893–903. doi:10.1056/NEJMoa1214300 10.1056/NEJMoa1214300PubMedCentralCrossRefPubMed
37.
Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, Boccardi E, SYNTHESIS Expansion Investigators: Endovascular treatment for acute ischemic stroke. N Engl J Med 2013,368(10):904–913. doi:10.1056/NEJMoa1213701 10.1056/NEJMoa1213701PubMedCentralCrossRefPubMed
38.
Mikulik R, Alexandrov AV, Ribo M, Garami Z, Porche NA, Fulep E, Grotta JC, Wojner-Alexandrov AW, Choi JY: Telemedicine-guided carotid and transcranial ultrasound: a pilot feasibility study. Stroke 2006,37(1):229–230. doi:10.1161/01.STR.0000196988.45318.97 10.1161/01.STR.0000196988.45318.97CrossRefPubMed
39.
Ziegler V, Rashid A, Müller-Gorchs M, Kippnich U, Hiermann E, Kögerl C, Holtmann C, Siebler M, Griewing B: Einsatz mobiler computing-systeme in der präklinischen schlaganfallversorgung. Ergebnisse aus der stroke-angel-initiative im rahmen des BMBF-projekts PerCoMed (Mobile computing systems in preclinical care of stroke. Results of the stroke angel initiative within the BMBF project PerCoMed). Anaesthesist 2008,57(7):677–685. doi:10.1007/s00101–008–1395-x 10.1007/s00101-008-1395-xCrossRefPubMed
40.
Ebinger M, Rozanski M, Waldschmidt C, Weber J, Wendt M, Winter B, Kellner P, Baumann A, Malzahn U, Heuschmann PU, Fiebach JB, Endres M, Audebert HJ: PHANTOM-S: the prehospital acute neurological therapy and optimization of medical care in stroke patients - study. Int J Stroke 2012,7(4):348–353. doi:10.1111/j.1747–4949.2011.00756.xPubMed
41.
Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M, Schlechtriemen T, Roth C, Papanagiotou P, Grunwald I, Schumacher H, Helwig S, Viera J, Körner H, Alexandrou M, Yilmaz U, Ziegler K, Schmidt K, Dabew R, Kubulus D, Liu Y, Volk T, Kronfeld K, Ruckes C, Bertsch T, Reith W, Fassbender K: Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol 2012,11(5):397–404. doi:10.1016/S1474–4422(12)70057–1 10.1016/S1474-4422(12)70057-1CrossRefPubMed
42.
Skorning M, Bergrath S, Rörtgen D, Brokmann J, Beckers S, Protogerakis M, Brodziak T, Rossaint R: “E-Health“ in der Notfallmedizin - das Forschungsprojekt Med-on-@ix. Anaesthesist 2009,58(3):285–292. doi:10.1007/s00101–008–1502-z 10.1007/s00101-008-1502-zCrossRefPubMed
43.
Weber JE, Ebinger M, Rozanski M, Waldschmidt C, Wendt M, Winter B, Kellner P, Baumann A, Fiebach JB, Villringer K, Kaczmarek S, Endres M, Audebert HJ: Prehospital thrombolysis in acute stroke: results of the PHANTOM-S pilot study. Neurology 2013,80(2):163–168. 10.1212/WNL.0b013e31827b90e5CrossRefPubMed
44.
Silva GS, Farrell S, Shandra E, Viswanathan A, Schwamm LH: The status of telestroke in the United States: a survey of currently active stroke telemedicine programs. Stroke 2012,43(8):2078–2085. doi:10.1161/STROKEAHA.111.645861 10.1161/STROKEAHA.111.645861CrossRefPubMed
45.
Liman TG, Winter B, Waldschmidt C, Zerbe N, Hufnagl P, Audebert HJ, Endres M: Telestroke ambulances in prehospital stroke management: concept and pilot feasibility study. Stroke 2012,43(8):2086–2090. doi:10.1161/STROKEAHA.112.657270 10.1161/STROKEAHA.112.657270CrossRefPubMed
46.
Reiner-Deitemyer V, Teuschl Y, Matz K, Reiter M, Eckhardt R, Seyfang L, Tatschl C, Brainin M: Helicopter transport of stroke patients and its influence on thrombolysis rates: data from the Austrian Stroke Unit Registry. Stroke 2011,42(5):1295–1300. 10.1161/STROKEAHA.110.604710CrossRefPubMed
47.
Audebert HJ, Schenkel J, Heuschmann PU, Bogdahn U, Haberl RL: Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. Lancet Neurol 2006,5(9):742–748. doi:10.1016/S1474–4422(06)70527–0 10.1016/S1474-4422(06)70527-0CrossRefPubMed
48.
van Zon K, Lord WP, Lagor C, Theiss S, Brosig T, Siebler M: Stroke navigator—a clinical decision support system for acute stroke. AMIA Annu Symp Proc 2008, 6: 1227.
Metadata
Title
Prehospital stroke diagnostics based on neurological examination and transcranial ultrasound
Authors
Moriz Herzberg
Sandra Boy
Thilo Hölscher
Michael Ertl
Markus Zimmermann
Karl-Peter Ittner
Josef Pemmerl
Hendrik Pels
Ulrich Bogdahn
Felix Schlachetzki
Publication date
01-12-2014
Publisher
Springer Milan
Published in
The Ultrasound Journal / Issue 1/2014
Electronic ISSN: 2524-8987
DOI
https://doi.org/10.1186/2036-7902-6-3

Other articles of this Issue 1/2014

The Ultrasound Journal 1/2014 Go to the issue

Original article

Is B-mode ultrasound alone a sufficient screening tool for carotid stenosis? A pilot study

Original article

Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation

Case report

Point-of-care ultrasound detection of tracheal wall thickening caused by smoke inhalation

Case report

The role of ultrasound in the management and diagnosis of infectious mononucleosis

Case report

Case report: transient small bowel intussusception presenting as right lower quadrant pain in a 6-year-old male

Original article

Detection of soft tissue foreign bodies by nurse practitioner-performed ultrasound

ACC 2024 Congress Coverage

Cardiology Video

Highlights from the ACC 2024 Congress

Watch now

Watch official videos from the ACC congress summarizing key highlights from the last year in heart failure, cardiomyopathies, valvular disease, pulmonary vascular disease, and pediatric cardiology.

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits