In acute stroke, different sonographic methods can be used to assess structural and hemodynamic compromise. Structural abnormalities of brain parenchyma such as primary intracerebral hemorrhage (ICH) and epiphenomena such as midline shift can be detected by native transcranial B-mode ultrasound. Moreover, transcranial Doppler provides a functional approach to intracranial hemodynamics and may assist in predicting ICH growth and global intracranial pressure increase. New ultrasound technologies allow the visualization of ultrasound contrast agents in the cerebral microcirculation. According to recent data, ultrasound perfusion imaging provides additional information for the diagnosis of ICH and may differentiate ischemic from hemorrhagic stroke. This review summarizes the impact of these different transcranial ultrasound methods on diagnosis and monitoring of ICH.

Carandang R, Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Kannel WB, Wolf PA: Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years. JAMA 2006;296:2939–2946.
Bejota Y, Rouauda O, JDuriera J, Cailliera M, Marieb C, Freyszc M, Yeguiayanc JM, Chantegretc A, Ossebya G, Moreaua T, Girouda M: Decrease in the stroke case fatality rates in a French population-based twenty-year study: a comparison between men and women. Cerebrovasc Dis 2007;24:439–444.
Qureshi AI, Suri MF, Nasar A, Kirmani JF, Ezzeddine MA, Divani AA, Giles WH: Changes in cost and outcome among US patients with stroke hospitalized in 1990 to 1991 and those hospitalized in 2000 to 2001. Stroke 2007;38:2180–2184.
Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, Skolnick BE, Steiner T; for the Recombinant Activated Factor VII ICH Trial Investigators: Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2005;352:777–785.
Wahlgren N, Ahmed N, Dávalos A, Ford GA, Grond M, Hacke W, Hennerici MG, Kaste M, Kuelkens S, Larrue V, Lees KR, Roine RO, Soinne L, Toni D, Vanhooren G; SITS-MOST investigators: Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet 2007;369:275–282.
Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M; American Heart Association, American Stroke Association Stroke Council; High Blood Pressure Research Council; Quality of Care and Outcomes in Research Interdisciplinary Working Group: Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38:2001–2023.
Seidel G, Kaps M, Dorndorf W: Transcranial color-coded duplex sonography of intracerebral hematomas in adults. Stroke 1993;24:1519–1527.
Seidel G, Gerriets T, Kaps M, Missler U: Dislocation of the third ventricle due to space occupying stroke evaluated by transcranial duplex sonography. J Neuroimaging 1996;6:227–230.
Becker G, Winkler J, Hofmann E, Bogdahn U: Differentiation between ischemic and hemorrhagic stroke by transcranial color-coded real-time sonography. J Neuroimaging 1993;3:41–47.
Mäurer M, Shambal S, Berg D, Woydt M, Hofmann E, Georgiadis D, Lindner A, Becker G: Differentiation between intracerebral hemorrhage and ischemic stroke by transcranial color-coded duplex-sonography. Stroke 1998;29:2563–2567.
Meyer K, Seidel G, Knopp U: Transcranial sonography of brain tumors in the adult: an in vitro and in vivo study. J Neuroimaging 2001;11:287–292.
Tang SC, Huang SJ, Jeng JS, Yip PK: Third ventricle midline shift due to spontaneous supratentorial intracerebral hemorrhage evaluated by transcranial color-coded sonography. J Ultrasound Med 2006;25:203–209.
Kern R, Perren F, Schoeneberger K, Gass A, Hennerici M, Meairs S: Ultrasound microbubble destruction imaging in acute middle cerebral artery stroke. Stroke 2004;35:1665–1570.
Seidel G, Meyer-Wiethe K, Berdien G, Hollstein D, Toth D, Aach T: Ultrasound perfusion imaging in acute middle cerebral artery infarction predicts outcome. Stroke 2004;35:1107–1111.
Eyding J, Krogias C, Schollhammer M, Eyding D, Wilkening W, Meves S, Schroder A, Przuntek H, Postert T: Contrast-enhanced ultrasonic parametric perfusion imaging detects dysfunctional tissue at risk in acute MCA stroke. J Cereb Blood Flow Metab 2006;26:576–582.
Aaslid R, Markwalder TM, Nornes H: Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 1982;57:769–774.
Bogdahn U, Becker G, Winkler J, Greiner K, Perez J, Meurers B: Transcranial color-coded real-time sonography in adults. Stroke 1990;12:1680–1688.
Seidel G, Kaps M, Gerriets T: Potential and limitations of transcranial color-coded sonography in stroke patients. Stroke 1995;26:2061–2066.
Martí-Fàbregas J, Belvís R, Guardia E, Cocho D, Muñoz J, Marruecos L, Martí-Vilalta JL: Prognostic value of Pulsatility Index in acute intracerebral hemorrhage. Neurology 2003;61:1051–1056.
Martí-Fàbregas J, Belvís R, Guardia E, Cocho D, Martí-Vilalta JL: Relationship between transcranial Doppler and CT data in acute intracerebral hemorrhage. Am J Neuroradiol 2005;26:113–118.
Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G: Volume of intracerebral hemorrhage: a powerful and easy-to use predictor of 30-day mortality. Stroke 1993;24:987–993.
Mayer SA, Lignelli A, Fink ME, Kessler DB, Thomas CE, Swarup R, Van Heertum RL: Perilesional blood flow and edema formation in acute intracerebral hemorrhage: a SPECT study. Stroke 1998;29:1791–1798.
Gosling RG, King DH: Arterial assessment by Doppler-shift ultrasound. Proc R Soc Med 1974;67:447–449.
Pourcelot L: Applications cliniques de l’examen Doppler transcutané. INSERM 1974;34:213–240.
Klingelhöfer J, Conrad B, Benecke R, Sander D, Markakis E: Evaluation of intracranial pressure from transcranial Doppler studies in cerebral disease. J Neurol 1988;235:159–162.
Ursino M, Giulioni M, Lodi CA: Relationship among cerebral perfusion pressure, autoregulation, and transcranial Doppler waveform: a modelling study. J Neurosurg 1998;89:255–266.
Mayer SA, Thomas CE, Diamond BE: Asymmetry of intracranial hemodynamics as an indicator of mass effect in acute intracerebral hemorrhage. A transcranial Doppler study. Stroke 1996;27:1788–1792.
Klingelhöfer J, Sander D: Doppler CO2 test as an indicator of cerebral vasoreactivity and prognosis in severe intracranial hemorrhages. Stroke 1992;23:962–966.
Dussik KT: Über die Möglichkeit, hochfrequente mechanische Schwingungen als diagnostisches Hilfsmittel zu verwenden. Ges Neurol Psychiatr 1942;174:153–168.
Pape KE, Blackwell RJ, Cusick G, Sherwood A, Houang MT, Thorburn RJ, Reynolds EO: Ultrasound detection of brain damage in preterm infants. Lancet 1979;8129:1261–1264.
Hintz SR, O’Shea M: Neuroimaging and neurodevelopmental outcomes in preterm infants. Semin Perinatol 2008;32:11–19.
Postert T, Federlein J, Przuntek H, Büttner T: Insufficient and absent acoustic temporal bone window: potential and limitations of transcranial contrast-enhanced color-coded sonography and contrast-enhanced power-based sonography. Ultrasound Med Biol 1997;23:857–862.
Wijnhoud AD, Franckena M, van der Lugt A, Koudstaal PJ, Dippel ED: Inadequate acoustical temporal bone window in patients with a transient ischemic attack or minor stroke: role of skull thickness and bone density. Ultrasound Med Biol 2008;34:923–929.
Butzer JF, Cancilla PA, Cornell SH: Computerized axial tomography of intracerebral hematoma. A clinical and neuropathological study. Arch Neurol 1976;33:206–214.
Fiebach JB, Schellinger PD, Gass A, Kucinski T, Siebler M, Villringer A, Olkers P, Hirsch JG, Heiland S, Wilde P, Jansen O, Röther J, Hacke W, Sartor K; Kompetenznetzwerk Schlaganfall B5: Stroke magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage: a multicenter study on the validity of stroke imaging. Stroke 2004;35:502–506.
Kern R, Perren F, Kreisel S, Szabo K, Hennerici M, Meairs S: Multiplanar transcranial ultrasound imaging: standards, landmarks and correlation with magnetic resonance imaging. Ultrasound Med Biol 2005;31:311–315.
Becker G, Winkler J, Bogdahn U: Transcranial color-coded real time sonography in adults. 2. Cerebral hemorrhage and tumors. Ultraschall Med 1991;12:211–217.
Niesen WD, Burkhardt D, Hoeltje J, Rosenkranz M, Weiller C, Sliwka U: Transcranial grey-scale sonography of subdural haematoma in adults. Ultraschall Med 2006;27:251–255.
Berger C, Fiorelli M, Steiner T, Schäbitz WR, Bozzao L, Bluhmki E, Hacke W, von Kummer R: Hemorrhagic transformation of ischemic brain tissue: asymptomatic or symptomatic? Stroke 2001;33:1330–1335.
Libman R, Kwiakowski T, Lyden P, Grotta JC, Tilley BC, Fagen SC, Levine SR, Broderick JP, Lin Y, Lewandowski C, Frankel MR; NINDS rt-PA Stroke Study Group: Asymptomatic hemorrhagic transformation of cerebral infarction does not worsen long-term outcome. J Stroke Cerebrovasc Dis 2005;14:50–54.
Dzialowski I, Pexman JH, Barber PA, Demchuk AM, Buchan AM, Hill MD, Cases Investigators: Asymptomatic hemorrhage after thrombolysis may not be benign: prognosis by hemorrhage type in the Canadian alteplase for stroke effectiveness study registry. Stroke 2007;38:75–79.
Kimura K, Iguchi Y, Shibazaki K, Aoki J, Terasawa Y: Hemorrhagic transformation of ischemic brain tissue after t-PA thrombolysis as detected by MRI may be asymptomatic, but impair neurological recovery. J Neurol Sci 2008;272:136–142.
Paciaroni M, Agnelli G, Corea F, Ageno W, Alberti A, Lanari A, Caso V, Micheli S, Bertolani L, Venti M, Palmerini F, Biagini S, Comi G, Previdi P, Silvestrelli G: Early hemorrhagic transformation of brain infarction: rate, predictive factors, and influence on clinical outcome. Results of a prospective multicenter study. Stroke 2008;39:2249–2256.
Seidel G, Cangür H, Albers T, Meyer-Wiethe K: Transcranial sonographic monitoring of hemorrhagic transformation in patients with acute middle cerebral artery infarction. J Neuroimaging 2005;15:326–330.
Seidel G, Cangür H, Albers T, Burgemeister A, Meyer-Wiethe K: Acute hemispheric ischemic stroke: sonographic evaluation of hemorrhagic transformation and arterial reopening. Stroke 2008, DOI: 10.1161/STROKEAHA.108.516799.
Burns PN: Harmonic imaging with ultrasound contrast agents. Clin Radiol 1996;51(suppl 1):50–55.
Della Martina A, Meyer-Wiethe K, Allémann E, Seidel G: Ultrasound contrast agents for brain perfusion imaging and ischemic stroke therapy. J Neuroimaging 2005;15:217–223.
Meairs S: Contrast-enhanced ultrasound perfusion imaging in acute stroke patients. Eur Neurol 2008;59(suppl 1):17–26.
Miller DL, Averkiou MA, Brayman AA, Everbach EC, Holland CK, Wible JH Jr, Wu J: Bioeffects considerations for diagnostic ultrasound contrast agents. J Ultrasound Med 2008;27:611–632.
Droste DW, Boehm T, Ritter MA, Dittrich R, Ringelstein EB: Benefit of echo contrast-enhanced transcranial arterial color-coded duplex ultrasound. Cerebrovasc Dis 2005;20:332–336.
Foster FS, Burns PN, Simpson DH, Wilson SR, Christopher DA, Goertz DE: Ultrasound for the visualization and quantification of tumor microcirculation. Cancer Metastasis Rev 2000;19:131–138.
Harrer JU, Mayfrank L, Mull M, Klötzsch C: Second harmonic imaging: a new ultrasound technique to assess human brain tumour perfusion. J Neurol Neurosurg Psychiatry 2003;74:333–338.
Vicenzini E, Ricciardi MC, Puccinelli F, Lenzi GL: Cerebral perfusion in a high-grade glioma evaluated with sonographic contrast pulse sequencing technology. J Ultrasound Med 2006;25:1215–1218.
Vicenzini E, Delfini R, Magri F, Puccinelli F, Altieri M, Santoro A, Giannoni MF, Bozzao L, Di Piero V, Lenzi GL: Semiquantitative human cerebral perfusion assessment with ultrasound in brain space-occupying lesions: preliminary data. J Ultrasound Med 2008;27:685–692.
Kern R, Kablau M, Sallustio F, Fatar M, Stroick M, Hennerici MG, Meairs S: Improved detection of intracerebral hemorrhage with transcranial ultrasound perfusion imaging. Cerebrovasc Dis 2008;26:277–283.
Kern R, Krogias C, Meyer-Wiethe K, Renault G, Kablau M, Sallustio F, Eyding J, Meves S, Seidel G, Meairs S: Diagnosis of acute ischemic vs. hemorrhagic stroke with transcranial ultrasound imaging – a prospective multi-center study. Cerebrovasc Dis 2006;21(suppl 4):34.
Skyba DM, Price RJ, Linka AZ, Skalak TC, Kaul S: Direct in vivo visualization of intravascular destruction of microbubbles by ultrasound and its local effects on tissue. Circulation 1998;98:290–293.
Hynynen K, McDannold N, Martin H, Jolesz FA, Vykhodtseva N: The threshold for brain damage in rabbits induced by bursts of ultrasound in the presence of an ultrasound contrast agent (Optison). Ultrasound Med Biol 2003;29:473–481.
Schlachetzki F, Hölscher T, Koch HJ, Draganski B, May A, Schuierer G, Bogdahn U: Observation on the integrity of the blood-brain barrier after microbubble destruction by diagnostic transcranial color-coded sonography. J Ultrasound Med 2002;21:419–429.
Jungehulsing GJ, Brunecker P, Nolte CH, Fiebach JB, Kunze C, Doepp F, Villringer A, Schreiber SJ: Diagnostic transcranial ultrasound perfusion-imaging at 2.5 MHz does not affect the blood-brain barrier. Ultrasound Med Biol 2008;34:147–150.
Stroick M, Alonso A, Fatar M, Griebe M, Kreisel S, Kern R, Gaud E, Arditi M, Hennerici M, Meairs S: Effects of simultaneous application of ultrasound and microbubbles on intracerebral hemorrhage in an animal model. Ultrasound Med Biol 2006;32:1377–1382.
Fatar M, Stroick M, Griebe M, Alonso A, Kreisel S, Kern R, Hennerici M, Meairs S: Effect of combined ultrasound and microbubbles treatment in an experimental model of cerebral ischemia. Ultrasound Med Biol 2008;34:1414–1420.
Vignon F, Aubry JF, Tanter M, Margoum A, Fink M: Adaptive focusing for transcranial ultrasound imaging using dual arrays. J Acoust Soc Am 2006;120:2737–2745.
Klötzsch C, Bozzato A, Lammers G, Mull M, Lennartz B, Noth J: Three-dimensional transcranial color-coded sonography of cerebral aneurysms. Stroke 1999;30:2285–2290.
Coupé P, Hellier P, Morandi X, Barillot C: Probe trajectory interpolation for 3D reconstruction of freehand ultrasound. Med Image Anal 2007;11:604–615.
Maciak A, Kier C, Seidel G, Meyer-Wiethe K, Hofmann UG: Detecting stripe artifacts in ultrasound images. J Digit Imaging 2007, DOI: 10.1007/s10278-007-9049-0.
Alonso A, Della Martina A, Stroick M, Fatar M, Griebe M, Pochon S, Schneider M, Hennerici M, Allémann E, Meairs S: Molecular imaging of human thrombus with novel abciximab immunobubbles and ultrasound. Stroke 2007;38:1508–1514.
Martin MJ, Chung EM, Goodall AH, Della Martina A, Ramnarine KV, Fan L, Hainsworth SV, Naylor AR, Evans DH: Enhanced detection of thromboemboli with the use of targeted microbubbles. Stroke 2007;38:2726–2732.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.