Detection of middle cerebral artery emboli during carotid endarterectomy using transcranial Doppler ultrasonography

The purpose of our study was to define the signal characteristics and clinical circumstances associated with emboli detected in the middle cerebral artery using 2-MHz pulsed transcranial Doppler ultrasound in patients undergoing carotid endarterectomy. Signals designating emboli were transients displaying harmonic qualities the signatures of which were clearly different from those of mechanical and electronic artifacts. We reviewed the audio/video tape recordings from 91 patients for signals of air bubble emboli occurring upon release of common carotid artery crossclamps; recordings from 35 patients (38%) demonstrated air bubble emboli. Transients with signatures identical to those of air bubble emboli were also discovered when bubbles in the bloodstream were improbable; we defined these transients as representing formed-element emboli. Such signals were found in recordings from 24 patients (26%), and they occurred before (both spontaneously and upon common carotid artery compression), during, and after surgical dissection. Signals indicating formed-element emboli were associated with intraluminal platelet thrombus, with ulcerations in the carotid artery, and with transient ischemic attacks or stroke. Most postoperative formed-element emboli did not cause symptoms but, when persisting for hours, they were associated with strokes and cerebral infarction. This Doppler ultrasound method of detecting emboli will be useful in the study of stroke mechanisms and as a clinical test to guide the medical and surgical treatment of patients at risk of stroke.