Patient with intracranial hemorrhage and arteriovenous malformation detected with transcranial color duplex sonography – case report
Introduction: Transcranial color duplex sonography represents a non-invasive diagnostically method which allows visualization of the brain arteries on the basis of the skull through color-coding of the flow rate. The arteries of the Willis’ circle (circulus arteriosus cerebri) can be identified through their anatomic localization in relation to brain stem structures and by determining the direction of flow. During examination the ultrasound beam passes through natural cranial openings, or windows, which are areas of the cranium where the bone is the thinnest (transtemporal, tansorbital and transoccipital windows). During hemodynamic analysis on the Doppler wave, the following basic parameters are analyzed: systolic speed peak, median speed, spectral distribution of the frequencies, direction of flow, Doppler indexes (index of pulsation and index of asymmetry).
Goal: The goal is to show the diagnostic application of transcranial color duplex sonography in detection of morphologic and hemodynamic changes of the intracranial arteries in patients with stroke.
Material and methods: We represent 62-year old patient who has been hospitalized due to acute paralysis of the left limbs, slurred speech and headache. Neurological examination on admission: left-sided hemiplegia, dysarthria, headache. At admission a CT was made with finding clearly limited hyperdense change – intracerebral hemorrhage with perifocal edema without evident mass effect on the adjacent brain structures. A neurosurgeon was consulted who said that there are no indications for operation. Significant information: history of CVI before 18 years, with left limbs weaknesses (no medical documentation). Transcranial color duplex sonography was made whit detected area of mixed arterial and venous signal, with increased flow rate and turbulence through transtemporal sonographic window. Because of that a CT angiography of the intracranial blood vessels was indicated which found an pial arteriovenous malformation with big nidus and dilated and tortuous vein which flows to v. Galeni. Arteriovenous malformation receives blood through the right a. cerebri media, right a. carotis posterior and also cross-filling through the left a. carotis interna and aa. comunicantes anterior.
Results: On discharge improved neurological condition, patient was with residual left sided hemiparesis and discreet dysarthria – mRS score 3.
Discussion: Transcranial color duplex sonography is a non invasive method of evaluation of intracranial blood flow, especially in patients with stroke. It helps if selection is made for patients that should undergo additional invasive radiological tests such as CT angiography.
Key words: arteriovenous malformation, transcranial color duplex sonography