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P39 Background: Hyperacute neurovascular imaging has  great potential to help clinicians better tailor stroke therapy. Future  decisions to use intravenous and/or intra-arterial lytics may depend on  site of MCA occlusion. TCD has not been seriously considered as such a  technique because of the misconception TCD is too operator dependent  and not reliable. We evaluated if our acute stroke TCD service could  accurately and reliably identify MCA occlusion.Methods: A  series of acute stroke patients underwent TCD examination by 1 of 3  stroke physicians or 1 stroke nurse. MRA was also performed at a time  closely corresponding to TCD exam. Blind to MRA findings and patient  info except symptom side, all 4 sonographers independently interpreted  the TCD exam for presence of MCA occlusion using previously established  TCD criteria and evaluated TIBI flow grades (5 normal waveform, 4  stenotic, 3 dampened, 2 blunted, 1 minimal, 0 absent) at 65, 55, 45 mm  MCA depths. This result was compared to blinded neuroradiologists MRA  interpretation for M1-MCA and distal MCA occlusion.Results: 37 cases compared. Mean age 67, median baseline NIHSS 8. Median symptom  onset to TCD 5.9 hours and MRA 6.3 hours. Median time between TCD and  MRA 1.3 hours. TPA treatment preceded or occurred during TCD or MRA  imaging in 27% of cases. MRA identified 19 MCA occlusion (12 M1-MCA, 7  distal MCA) and 18 no MCA occlusion. Comparing all sonographer TCD  interpretations (n=148) with MRA the sensitivity, specificity, PPV, NPV  for MCA occlusion was: 82%, 81%, 82%, 81% respectively. Intraclass  correlation coefficent for TIBI flow grades at prox, mid, distal MCA  depths was : 0.73,0.84,0.83. Median TIBI scores at these 3 MCA depths  respectively were: 5,5,5 when no MCA occlusion on MRA, 3,3,3 if distal  MCA occlusion and 2,2,2 if M1-MCA occlusion.Conclusion: TCD  showed good accuracy at identifying MCA occlusion compared to MRA when  TCD was performed and interpreted by a stroke clinician/nurse. TIBI  flow grades were reliably identified and appear potentially useful to  discriminate between normal MCA, and proximal or distal MCA occlusion.  TCD is a useful bedside tool that could aid future stroke  treatment.

A stroke neurologist/nurse operated acute stroke TCD service can reliably identify MCA occlusion when compared to MRA.