Neurovascular Ultrasound in Acute Stroke: Emergency Department Applications - Stroke EXTRA Supplement (Stroke CME)

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Publication Date: May 2024 (Volume 26, Supplement 5)

CME Credits: 4 AMA PRA Category 1 Credits™ and 4 AOA Category 2-B CME credits. CME expires 05/15/2027.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Stroke CME credits, subject to your state and institutional approval.

Authors

Grigory Ostrovskiy, MD

Neurointensivist and Emergency Physician, Division of Neurocritical Care, Departments of Neurology & Emergency Medicine, Hackensack University Medical Center; Assistant Professor, Departments of Neurology, Neurosurgery & Emergency Medicine,Hackensack Meridian School of Medicine, Hackensack, NJ

Alexandra S. Reynolds, MD, RPNI

Associate Professor of Neurosurgery and Neurology, Mount Sinai Health System, New York, NY

Aarti Sarwal, MD, FNCS, FAAN, FCCM, RPNI

Professor, Neurology (Neurocritical Care), Atrium Wake Forest School of Medicine, Winston Salem, NC

Peer Reviewers

Ryan Hakimi, DO, MS, NVS, RPNI, CPB, FNCS, FCCM, FAAN

Professor, Department of Medicine (Neurology Division), University of South Carolina School of Medicine-Greenville; Director, Transcranial Ultrasound Services, Greenville, SC

Jennifer H. Kang, MD

Neurointensivist, Pulmonary Critical Care, Kaiser Permanente, Fontana, CA

Abstract

Acute stroke is one of the most common neurologic emergencies encountered by emergency clinicians. While point-of-care ultrasound has been a core part of emergency clinicians’ training and practice for many years, the use of specialized ultrasound modalities in the care of acute ischemic stroke has not been as widely adopted. This review discusses the use of ultrasound in acute stroke, with a focus on applications of interest to emergency clinicians. Transcranial Doppler, carotid Doppler, microembolic signal detection, transthoracic echocardiography, evaluation for collateral circulation, and optic nerve sheath diameter measurement are discussed in a case-based format, with a focus on practical applications for emergency clinicians.

Introduction

Acute stroke is one of the most common neurologic emergencies and causes of significant disability worldwide.¹ Thrombolysis and mechanical thrombectomy, the mainstays of acute ischemic stroke care, are time-sensitive interventions and therefore require rapid evaluation in the emergency department (ED). While the initial evaluation of patients suspected of suffering from acute stroke has been standardized and operationalized by most institutions through “code stroke” or “brain code” protocols, computed tomography (CT)-based imaging is sometimes not immediately available or may not reveal the cause of the neurological change.

Emergency clinicians are responsible for the care of most acute stroke patients presenting to EDs in the United States. Their role in acute stroke care, as well as expertise in point-of-care ultrasound (POCUS), makes the use of ultrasound in the care of acute stroke patients a topic of interest for emergency clinicians. Currently, neurovascular ultrasound (ie, transcranial Doppler [TCD] and carotid ultrasound) in stroke is primarily performed by neurovascular sonographers in an accredited neurovascular ultrasound laboratory. However, emergency clinicians need to be aware of the indications for performing neuro-ultrasound in acute stroke patients. This review will discuss the use of ultrasound in patients with acute ischemic strokes and transient ischemic attacks (TIAs), utilizing clinical cases to answer some key questions:

Does neurovascular ultrasound have a role in the emergency triage of an acute stroke patient in the era of CT angiogram (CTA)-based screening of large vessel occlusion?
Can TCD and carotid ultrasound help in the evaluation and management of acute stroke in the ED?
Can TCD and optic nerve sheath diameter help in the emergent evaluation and management of cerebral edema?

Accreditation:

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