Assessment of >50% and <50% Intracranial Stenoses by

Transcranial Color-Coded Duplex Sonography

Ralf W. Baumgartner, MD; Heinrich P. Mattle, MD; Gerhard Schroth, MD

Background and PurposeA favorable risk-benefit ratio for warfarin compared with aspirin has been reported for the
prevention of major vascular events in symptomatic $50% intracranial stenoses. Transcranial color-coded duplex sonography
(TCCS) criteria providing an accurate detection of $50% and ,50% stenoses of the anterior, middle, and posterior cerebral
arteries and basilar and vertebral arteries were evaluated retrospectively with angiography used as the standard of reference.
MethodsProspectively collected TCCS, extracranial color-coded duplex sonography, and intra-arterial digital subtraction
angiography data of 310 patients were reviewed. The patients had angiography for confirmation of symptomatic
extracranial $70% carotid stenoses, symptomatic stenoses (peak systolic velocity higher than the corresponding mean
value 12 SDs of 104 normal subjects), and occlusions of the middle cerebral or basilar artery previously assessed by
ultrasound. The sonographer was not aware of angiographic findings.
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ResultsTCCS would have detected all 31 of $50% intracranial stenoses with 1 false-positive and 35 of 38 ,50%
stenoses with 3 false-positives. One of 69 stenoses (1%) and 280 of 2741 normal arteries (10%) were missed because
of inadequate insonation windows. The corresponding peak systolic velocity cutoffs for $50%/,50% stenoses were
$155/$120 cm/s (anterior cerebral artery), $220/$155 cm/s (middle cerebral artery), $145/$100 cm/s (posterior
cerebral artery), $140/$100 cm/s (basilar artery), and $120/$90 cm/s (vertebral artery).
ConclusionsTCCS may reliably assess $50% and ,50% basal cerebral artery narrowing and prove useful for
noninvasive management of patients with symptomatic intracranial stenoses. (Stroke. 1999;30:87-92.)
Key Words: anticoagulants n aspirin n stenosis n ultrasonography, transcranial

A therosclerotic narrowing of the intracranial cerebral arteries

is assumed to cause approximately 10% of ischemic
strokes.1,2 Secondary stroke prevention in patients with transient
ischemic attack or ischemic stroke caused by a stenosed intra-
cranial artery has been empirical. The recently published
Warfarin-Aspirin Symptomatic Intracranial Disease study, how-
ever, suggests that oral anticoagulation is more effective than
aspirin for preventing major vascular events in patients with
$50% symptomatic intracranial stenoses.3 This study used
catheter angiography for the assessment of cerebral artery
narrowing. Because of the risk, inconvenience, and cost4,5
associated with angiography, the primary use of a noninvasive
diagnostic method such as transcranial color-coded duplex
sonography (TCCS) would be preferable.
Conventional transcranial Doppler sonography is of estab-
lished value for detecting stenoses of the intracranial arter-
ies.6 14 TCCS criteria for detection and quantification of
intracranial stenoses have not yet been established.
The purpose of the present study was to evaluate TCCS
criteria providing the best possible diagnostic accuracy for
detecting $50 and ,50% intracranial stenoses with cerebral
angiography used as the standard of reference.
Subjects and Methods
Patient Recruitment and Inclusion and
Exclusion Criteria
Between November 1992 and December 1996, 310 consecutive
patients (102 women, 208 men; mean6SD age, 56616 years) with
cerebral or ocular ischemic events were first examined by TCCS and
extracranial color-coded duplex sonography (ECCS) and thereafter
by cerebral intra-arterial digital subtraction angiography. Cerebral
angiography was done for confirmation of symptomatic $70%
carotid stenoses, symptomatic stenoses, and occlusions of the middle
cerebral (MCA) or basilar (BA) arteries. Angiograms were done in
symptomatic $70% carotid stenoses for confirmation of ultrasonic
diagnosis before carotid endarterectomy,15 in MCA or BA occlu-
sions with strokes of #6 hours duration to evaluate whether subjects
were candidates for local arterial fibrinolysis,16 and with strokes of
.6 hours duration for diagnostic purposes. TCCS, ECCS, cerebral
angiographic, and the corresponding clinical, CT, or MRI findings
were collected prospectively in a database.
The presenting ischemic ocular or cerebral deficits were classified
as amaurosis fugax (monocular blindness lasting #24 hours), retinal
infarct (monocular blindness lasting .24 hours), transient ischemic
attack (focal neurological deficit lasting #24 hours), or stroke (focal
neurological deficit lasting .24 hours). Two hundred one patients
had ischemic strokes, 78 had transient ischemic attacks, 21 had
amaurosis fugax, and 10 had retinal infarcts. The median interval

Received August 18, 1998; final revision received October 1, 1998; accepted October 1, 1998.
From the Department of Neurology, University Hospital of Zurich (R.W.B.), and Departments of Neurology (H.P.M.) and Neuroradiology (G.S.),
University Hospital of Bern (Switzerland).
Correspondence to Ralf W. Baumgartner, MD, Department of Neurology, University Hospital, Frauenklinikstr 26, CH-8091 Zurich, Switzerland.
E-mail Strusbmg@neurol.unizh.ch
1999 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org

87
 88 Intracranial Stenosis: Transcranial Color Duplex Sonography
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Figure 1. TCCS findings obtained by transtemporal insonation with axial (top 2 color images) and coronal (bottom 2 color images)
scanning planes in a patient with an angiographically proven $50% stenosis of the ACA. The corresponding schemes are on the right
side. Both images on the left side show intrastenotic color and spectral Doppler findings with increased velocities and high-intensity,
low-frequency signals. Both images in the middle show poststenotic color and spectral Doppler findings with normal velocities and
high-intensity, low-frequency signals in the top panel.
between ultrasonic studies and the onset of stroke was 31 days
(range, 2 to 126 days), and that between ultrasonic studies and
cerebral angiography was 2 days (range, 0 to 6 days).
Patients were excluded from the study if the indication for cerebral
angiography was search for a tumor, aneurysm, vasospasm, arterio-
venous fistula, sinovenous thrombosis, or a diagnostic workup of
intracranial hemorrhage and vascular malformation.
ECCS Studies
The extracranial cerebral arteries were examined with an Acuson 128
XP/10 equipped with a 5.0/7.0-MHz linear scan. Ultrasonographic
evaluation of arterial stenoses and occlusions was performed accord-
ing to previously published criteria.17,18
TCCS Studies
The intracranial cerebral arteries were studied with an Acuson 128
XP/10 equipped with a 2.0/2.5-MHz 90 sector scan with the same
Doppler energy output and method of examination as described previ-
ously.19 In brief, the MCA, anterior (ACA), precommunicating (P1),
and postcommunicating (P2) posterior (PCA) cerebral arteries were
insonated through the temporal window with the patient in a supine
position, whereas the BA and intracranial vertebral (VA) arteries were
investigated through the foramen magnum with the patient in a sitting
position. Each large cerebral artery was investigated by spectral Doppler
sonography with the color-coded Doppler signal used as a road map
for the presence of stenoses, occlusions, and cross-flow through the
circle of Willis (see below). Flow direction (antegrade or reversed) and
peak systolic (PSV) and end-diastolic (PDV) velocities were noted for
every insonated artery. In case of suspicion of an intracranial stenosis
(see below), the presence of low-frequency, high-intensity Doppler
signals was also evaluated. Angle correction was performed when the
Doppler sample volume was located within a straight vessel segment
$20 mm in length.20
The sonographer was aware of extracranial ultrasonographic
findings but was blinded to the results of cerebral angiography.
An intracranial stenosis (Figures 1 and 2) was diagnosed during
prospective data collection when spectral Doppler sonography
showed both a focal increase of PSV and/or PDV that was higher
than the mean value 12 SDs for the corresponding cerebral artery of
104 normal subjects reported previously21 and low-frequency, high-
intensity Doppler signals. ACA velocity is often increased in the
presence of cross-flow through the anterior communicating artery22
and in high-grade stenosis or occlusion11,23 of the ipsilateral MCA. A
high-grade stenosis of the MCA was diagnosed with the use of the
velocity cutoffs established by Rother et al.13 P1 PCA velocity is
enhanced in case of collateral flow through the posterior communi-
cating artery to the carotid artery.8,22,24 Consequently, no ACA and
P1 PCA stenoses were diagnosed when TCCS findings suggested the
presence of cross-flow through the anterior communicating artery
and posterior communicating artery, respectively, and no ACA
stenosis was diagnosed when TCCS findings suggested the presence
of high-grade stenosis or occlusion of the ipsilateral MCA.
An intracranial occlusion was diagnosed when the Doppler signal
of the corresponding cerebral artery was lacking and other ipsilateral
basal cerebral arteries were identified.23,25 For diagnosis of occlu-
sions of the intracranial VA or BA, the criteria established by von
Budingen and Staudacher26 also had to be fulfilled. Cross-flow
through the circle of Willis was assessed as reported recently.27
Angiographic Studies
Selective intra-arterial digital subtraction angiography (Philips Diagnost
ARC A) was performed by a femoral artery approach in both ICAs in
all patients, in both VAs in 261 patients, and in 1 VA in 49 patients. The
injected volume of contrast medium was 5 to 8 mL Ultravist 300
(Iopromidum, Schering AG). Standard anteroposterior and lateral views
(5123512 matrix; since December 1993, 102431024 matrix) of the
extracranial and intracranial circulation were obtained routinely. The
angiograms were reviewed retrospectively and independently at sepa-
rate reading sessions by 2 of the authors (H.P.M., G.S.), who were not
aware of ultrasound findings. Extracranial carotid stenosis was mea-
sured by the North American Symptomatic Carotid Endarterectomy
Trial technique.15 For the assessment of intracranial stenosis, the vessel
being evaluated was measured at its point of maximal narrowing and
compared with the angiographically normal section of the vessel
adjacent to the stenosis to determine the degree of stenosis (normal
lumen diameter2residual lumen/normal lumen diameter). Finally, each
intracranial artery was graded separately as follows: no stenosis, stenosis
,50%, stenosis $50%, occlusion.
 Baumgartner et al January 1999 89
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Figure 2. TCCS findings obtained by transtemporal insonation with an axial scanning plane in a patient with an angiographically
proven $50% stenosis of the MCA. The top image gives the color Doppler road map, which shows a focal color abnormality com-
posed of red, orange, yellow, and green related to increased velocities, aliasing, and/or reversed flow and suggests that the MCA is
straight for $20 mm, enabling the use of an angle indicator. The bottom images also show the corresponding Doppler spectra: on the
left normal prestenotic velocities, in the middle increased intrastenotic velocities with high-intensity, low-frequency signals, and on the
right normal poststenotic velocities with high-intensity, low-frequency signals.

Statistical Analysis
Differences of cerebral artery velocities in patients without, with
,50%, and with >50% intracranial stenoses at angiography were
compared by nonparametric ANOVA (Mann-Whitney U test). The
same statistical test was used to compare intrastenotic MCA veloc-
ities and the degree of intracranial stenosis at angiography in patients
with and without additional 70% to 100% obstructions of the
ipsilateral extracranial carotid arteries. The nonparametric Spearman
rank correlation coefficient was used to assess consistency of
interpretation of cerebral angiograms between both observers.28
Two-sided probability value of ,0.05 was considered significant.
Results
Angiography showed intracranially 69 stenoses (31 $50%,
38 ,50%) in 51 patients (16%) and 20 occlusions in 18
patients (6%). Thirty-nine patients had 1, 8 patients had 2, 2
patients had 3, and another 2 patients had 4 stenoses. Ten
stenoses were located in the ACA, 29 in the MCA, 15 in the
PCA, 7 in the BA, and 8 in the VA. Sixteen patients had 1
occlusion, and 2 patients had 2 occlusions. One occlusion was
located in the ACA, 8 were located in the MCA, 2 in the distal
P2 PCA, 3 in the BA, and 6 in the VA.
TCCS identified 2461 of 2741 intracranial arteries (90%)
examined by cerebral angiography. In detail, TCCS identified
515 of 620 ACAs (83%), 563 of 620 MCAs (91%), 557 of
620 PCAs (90%), 291 of 310 BAs (94%), and 535 of 571
VAs (94%).
According to the criteria shown in Tables 1 and 2, TCCS
would have detected 66 of 69 stenoses (96%) with 4 false-
positives; 1 narrowed ACA was missed because of an
inadequate temporal bone window. In addition, 18 of 20
occlusions (90%) were identified by ultrasound.
PSVs in arteries with $50%, with ,50%, and without
stenoses are reported in Table 3. PDVs are not reported

TABLE 1. Ultrasonic Detection of >50% Intracranial Stenoses (n531) With Angiography as

Standard of Reference
Ultrasound Angiography

PSV Cutoff, Sensitivity, Specificity, Positive Predictive Negative Predictive Mean6SD Degree
cm/s % % Value, % Value, % No. (Range)
ACA $155 100 100 100 100 4 6068 (5271)
MCA $220 100 100 100 100 11 67611 (5080)
PCA $145 100 100 100 91 10 6367 (5072)
BA $140 100 100 100 100 3 67614 (5385)
VA $120 100 100 100 100 3 69614 (5584)
 90 Intracranial Stenosis: Transcranial Color Duplex Sonography

TABLE 2. Ultrasonic Detection of <50% Intracranial Stenoses (n538) With Angiography as

Standard of Reference
Ultrasound Angiography

PSV Cutoff, Sensitivity, Specificity, Positive Predictive Negative Predictive Mean6SD Degree
cm/s % % Value, % Value, % No. (Range)
ACA* $120 100 99 73 100 5 38612 (2047)
MCA $155 94 100 95 100 18 3668 (2248)
PCA $100 100 100 100 100 5 29612 (1341)
BA $100 100 100 100 100 4 3364 (2937)
VA $90 100 100 100 100 5 3266 (2539)
*One stenosed anterior cerebral artery was missed because of an inadequate temporal bone window.

because they were not found to be as sensitive and accurate as range, 30% to 80%) additional 70% to 100% carotid
the PSV values for the assessment of stenoses. obstruction.

Ultrasonic Detection of >50% Stenoses Ultrasonic Detection of Intracranial Occlusions

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When we use the PSV cutoff values given in Table 1 as
diagnostic criteria, TCCS would have detected all 31 stenoses
with 1 false-positive PCA stenosis. The false-positive PCA
stenosis was insonated 4 days before angiography and
showed a PSV of 154 cm/s; no angle correction was done.
Reexamination 1 day after angiography showed a PSV of
128 cm/s.
Ultrasonic Detection of <50% Stenoses
Using the PSV cutoff values reported in Table 2 as diagnostic
criteria provided 2 false-negative MCA and 3 false-positive
ACA stenoses; no angle corrections were done. Both false-
negative stenoses were located in MCAs with downward
convex courses at angiography. In 1 false-positive ACA
stenosis, the contralateral ACA was hypoplastic at angiogra-
phy, and PSV was 48 cm/s. The other 2 false-positive ACA
stenoses had symmetrical ACA diameters at angiography,
and the contralateral ACA showed PSVs of 78 to 85 cm/s.
Intrastenotic PSVs in the MCAs of 7 Patients
With and 22 Patients Without Additional 70% to
100% Obstructions of the Ipsilateral Extracranial
Carotid Arteries
Intrastentotic PSVs were slower in MCAs with (mean6SD,
174624 cm/s; range, 157 to 215 cm/s) compared with MCAs
without (mean6SD, 237673 cm/s; range, 172 to 400 cm/s)
additional 70% to 100% carotid obstructions (P,0.05). The
degree of narrowing showed a nonsignificant trend to be
lower in MCAs with (mean6SD, 3964%; range, 36% to
41%) compared with MCAs without (mean6SD, 55616%;
Ultrasound detected 18 of 20 angiographically confirmed
occlusions. Ultrasound misdiagnosed no stenosis as occlu-
sion. Conversely, 2 occlusions located in the distal P2 PCA
were missed.
Interobserver Variability in the Interpretation of
Cerebral Angiograms
The Spearman rank correlation coefficient between both
readers of angiograms was statistically significant for differ-
entiating between no stenoses, stenoses ,50%, stenoses
>50%, and occlusions (r50.93, P,0.0001).
Discussion
With the use of the diagnostic criteria elaborated in this study,
TCCS would have detected all $50% intracranial stenoses
with 1 false-positive and 92% of ,50% intracranial stenoses
with 3 false-positives. In addition, 90% of intracranial occlu-
sions were identified by ultrasound.
Adequate Doppler signals were obtained in 68 of 69
angiographically proven intracranial stenoses (99%). This
finding is probably incidental because the detection rate for
the different cerebral arteries was 83% to 94%, which is in
accord with previous TCCS studies reporting rates of 80% to
98%.22,25,29 31 Recent studies using echo contrast agents
provided conclusive TCCS examinations in 67% to 72% of
patients with ischemic cerebrovascular disease and
ultrasound-refractory temporal windows,32,33 suggesting that
the evaluation of intracranial arteries may become possible in
most patients with ischemic stroke.

TABLE 3. PSVs in Intracranial Arteries With >50% Stenoses, <50% Stenoses, and No Stenoses at Angiography
Degree of Stenosis at Angiography P

$50% ,50% 0% $50% vs ,50% $50% vs 0% ,50% vs 0%

ACA 189634 (155227) 128615 (109145) 81618 (33135) ,.05 ,.0001 ,.0001
MCA 301649 (221400) 176624 (141217) 100620 (58151) ,.0001 ,.0001 ,.0001
PCA 199617 (176228) 127617 (112154) 63612 (36100) ,.01 ,.0001 ,.0001
BA 194646 (144248) 119617 (109139) 64616 (28100) ,.05 ,.01 ,.001
VA 191666 (123256) 10064 (94104) 47614 (2089) ,.05 ,.01 ,.001
Values are mean6SD PSV (range).

The low number of false-negative intracranial stenoses
found in this study may be related to the angiographically
proven absence of branch occlusions in the territory of the
narrowed arteries. Multiple MCA branch occlusions are
associated with decreased velocities in the MCA main stem14
and in our experience may cause normal intrastenotic veloc-
ities and false-negative TCCS findings in case of MCA main
stem narrowing. The principal reason for the absence of
intracranial branch occlusions was that most TCCS investi-
gations were performed in the chronic phase of cerebral
infarction, when branch occlusions were already recana-
lized.34,35 Another explanation for the low number of false-
negative stenoses is that the color Doppler signal was used as
a road map to visualize both the vascular anatomy and focal
areas with increased flow velocities. Thus, the sonographer
was able to investigate all vessel segments by spectral
Doppler sonography and to estimate whether the placement
of the angle indicator was adequate (Figure 1) or not (Figure
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2). When a stenosis was located in a curved segment and
prevented the use of angle correction, the position of the
ultrasound probe was changed to obtain the smallest in-
sonation angle possible. It is important to note that intraste-
notic velocity increase may persist for a few centimeters
(jet) and surpass the anatomic extent of narrowing.36 The
jet is likely to increase the probability of detecting a stenosis
and may lead to a more favorable angle of insonation in
curved vessels. Nevertheless, TCCS missed 2 ,50% stenoses
located in MCAs with downward convex courses at angiog-
raphy. This suggests that the absence of angle correction
resulted in the failure to detect both MCA stenoses and that
stenoses located in curved intracranial arteries may represent
a diagnostic pitfall of TCCS.
Interestingly, no intracranial stenosis would have been
missed in patients with additional $70% stenoses of the
ipsilateral extracranial carotid artery. As expected, intraste-
notic MCA velocities were lower in patients with compared
with those without additional $70% ipsilateral carotid steno-
ses (P,0.05). This finding may also have resulted from the
trend of patients with additional $70% carotid stenoses to
have a lower average degree of MCA stenosis at angiography.
There were 1 false-positive $50% P2 PCA stenosis and 3
false-positive ,50% ACA stenoses in this series. Inade-
quately high insonation angles may result in the measurement
of high flow velocities and false-positive stenoses. No angle
correction was performed in ACA stenoses (Figure 2) and the
false-positive PCA stenosis because the angle corrector was
only used when color Doppler imaging suggested the pres-
ence of straight vessel segments $20 mm in length.20 Thus,
inadequately high insonation angles were probably not the
cause of the false-positive stenoses. TCCS may misdiagnose
intracranial stenoses in conditions with increased cerebral
blood flow, such as cross-flow through the circle of Willis,
leptomeningeal anastomoses supplied by the ACA in the
presence of high-grade stenosis or occlusion of the MCA, and
arteriovenous malformation.8,11,23,37,38 No ACA stenosis was
diagnosed when ultrasonic findings indicated the presence of
collateral flow through the anterior communicating artery or
high-grade stenosis or occlusion of the ipsilateral MCA.
Patients with angiographic signs of arteriovenous malforma-
Baumgartner et al January 1999 91
tions were excluded. Thus, increased blood flow is a very
unlikely explanation for the false-positive stenoses. Asym-
metrical ACAs are associated with higher velocities in the
larger vessel.39 This might be the cause in 1 false-positive
,50% ACA stenosis since the contralateral ACA was hyp-
oplastic and showed slow velocities. Intracranial vasospasm,
vasculitis, and thromboembolism may change the degree of
luminal narrowing over time. Patients with cerebral vaso-
spasm and vasculitis were excluded. However, recanalization
is the most likely cause of the false-positive PCA stenosis
because the follow-up TCCS examination performed 1 day
after cerebral angiography indicated the regression to a
,50% stenosis.
Cerebral angiography was used as the standard of reference
in the present study. Nevertheless, this technique may have
some limitations. Biplanar assessment of intracranial stenoses
is mostly not obtainable,12 and reliable measurement of
intrastenotic diameter is often difficult because of the small
vessel size. Conversely, velocities measured by ultrasound
are inversely proportional to the diameter squared of the
insonated vessel. TCCS may thus be more sensitive for
detection of ,50% intracranial stenoses by principles of
mathematics over angiography that measures diameter only.
However, there are no data available to prove this hypothesis.
This or interindividual differences in arterial diameter13 may
be the cause of the other 2 false-positive ,50% ACA
stenoses.
It is remarkable that no intracranial stenosis was misdiag-
nosed as occlusion. Conversely, ultrasound missed 2 occlu-
sions located in the distal P2 PCA, probably because the
adjacent superior cerebellar artery was misinterpreted as
PCA. Because of the low number of cerebral artery occlu-
sions observed in this study, the diagnostic accuracy for
ultrasonic assessment was not calculated.
As expected, the prevalences for intracranial stenoses and
occlusions were higher than those found in previous investi-
gations.40 42 Difference in patient selection is the most likely
cause since cerebral angiography was only performed when
ultrasound suggested the presence of extracranial or intracra-
nial occlusive vascular disease.
The Warfarin-Aspirin Symptomatic Intracranial Disease
study3 reported a favorable risk-benefit ratio for warfarin
compared with aspirin for the prevention of major vascular
events in patients with symptomatic 50% to 99% intracranial
stenoses. The present results indicate that TCCS may provide
a reliable and noninvasive assessment of such patients and
supply the information needed to initiate adequate medical
treatment. Intracranial stenoses may regress by recanalization
of thromboembolic material.35 A recent study has shown
good reproducibility for TCCS velocity measurements.43
Thus, repetitive TCCS examinations in patients with symp-
tomatic $50% stenoses may detect the regression to ,50%
(R.W. Baumgartner, unpublished data, 1994) and prevent the
inappropriate long-term use of anticoagulation and its well-
known adverse effects.
Because the diagnostic accuracy for TCCS diagnosis of
intracranial $50% stenoses is unlikely to be 100% in clinical
practice, some patients might erroneously receive warfarin
instead of aspirin and vice versa. Consequently, in case of
 92 Intracranial Stenosis: Transcranial Color Duplex Sonography
TCCS findings, which are close to the cutoff PSV values for
$50% stenoses, angiographic evaluation may be taken into
consideration.
The main limitation of TCCS was the difficulty in differ-
entiating between patients with normal and ,50% stenosed
arteries. To our knowledge, there is no study suggesting that
both groups of patients should have different treatments.
Thus, we assume that this limitation is not relevant. Another
drawback of TCCS is the temporal bony window, which
prevents the reliable detection of stenoses located in branches
of the basal cerebral arteries, such as the insular segment of
the MCA or the pericallosal artery.
In conclusion, we have elaborated TCCS criteria for
detecting $50% and ,50% intracranial stenoses. The criteria
require prospective testing in an angiography-correlated
study because they may prove useful for noninvasive assess-
ment and long-term management of patients with symptom-
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atic intracranial stenoses.
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 Assessment of 50% and <50% Intracranial Stenoses by Transcranial Color-Coded
Duplex Sonography
Ralf W. Baumgartner, Heinrich P. Mattle and Gerhard Schroth
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Stroke. 1999;30:87-92
doi: 10.1161/01.STR.30.1.87
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