I would like to address the two TCD/TCI issues.

1. Regarding brain death. You may refer to the following paper which
will address all of the questions and concerns using TCD to support the
clinical determination of cerebral circulatory arrest:

Consensus opinion on diagnosis of cerebral circulatory arrest using
Doppler-sonography. Task Force Group on cerebral death of the
Neurosonology Research Group of the World Federation of Neurology
Ducrocq X, Hassler W, Moritake K, Newell D, von Reutern G, Shiogai T,
Smith R. Journal of the Neurological Sciences 159 (1998) 145-150.
Publisher-Elsevier

2. On using duplex only for studies. If you work with geriatric patients
you will not be able to study as many patients because they have small, or
poor windows. These same patients can be studied with the dedicated
systems. What we need is for the duplex manufacturers to recognize this
and either design better imaging transducers (for the head not the heart)
and/or include a good performing, nonimaging Doppler on their systems. HP, Agilent,
Philips has one that works however, the handle is too long as it was first
a cardiac transducer and they never designed it specifically for TCD. This
should be relatively easy for the manufacturers to provide but it is
market driven.
Another thing to assess on the duplex systems is the algorythym for
calculating the time averaged maximum velocity. The newer systems that I
have tried have not been very good. Again this is market driven.

3. CPT codes. There is some confusion on what "monitoring" means. If
you do a full diagnostic study daily to detect vasospasm then the CPT code
would be 93886. If you are doing only a few vessels then it is a limited
study 93888. In general "monitoring" is when you study one or more
vessels, continuously over time. Examples would be monitoring the middle
cerebral artery during CEA.

Colleen Douville
Cerebrovascular Laboratory
Harborview Medical Center
 On Wed, 20 Nov 2002, Rosendahl, Thomas, RN wrote:

> I have a question regarding billing procedures. How do you bill for
> Transcranial Imaging studies when performed on a daily basis . Sometimes
> we'll do over 30 studies for vasospasm monitoring and I'm sure our
> compensation is not sufficient.
> Thanks,
> Tom
> Rosendahl, RN BS RVT
> Cedars-
> Sinai Medical Center
> Los
> Angeles
> > ----------
> > From: kathryn sorrell4[SMTP:[log in to unmask]]
> > Reply To: UVM Flownet
> > Sent: Tuesday, November 19, 2002 6:28 PM
> > To: [log in to unmask]
> > Subject: Re: Transcranial Doppler
> >
> > we started TCD in 1987 or 88 with the "blind" pulsed TCD systems and
> > converted
> > to color duplex TCD in the early 1990's - have never looked back nor
> > regretted
> > the switch to the imaging modality. TCD performed by a duplex system is
> > equally sensitive (once you get over the training hurdles) and much more
> > reassuring to the performing technologists. There are bony and soft
> > tissue
> > landmarks which make identification of the intracranial arteries more
> > certain
> > and reproducible. It's much easier to teach new techs the technique
> > because
> > they can see landmarks where they can direct their search. That
> > said....it
> > does take a command of color doppler to perform these studies effectively;
> > specifically, the technologist should have excellent knowledge of the
> > secondary
> > and tertiary color doppler controls so they can optimize visualization of
> > blood
> > vessels where acoustic windows are limited. Side benefits of the imaging
> > technique include visuzlation of some aneurysms, AVM's, 3-D images of
> > vascular
> > structures (newer software) and other general brain pathology. I believe
> > most
> > major ultrasound vendors sell a low frequency 2 - 2.5 mhz phased probe
> > with
> > software on board to perform TCD. I certainly woulnd't invest in a
> > dedicated
> > non imaging system unless you need it for extended TCD monitoring or don't
> > have
> > sufficient duplex systems to cover your TCD demand. Make sure you have
> > the
> > proper software on the duplex system to perform the time averaged "peak"
> > mean
> > value. This is different from the time-averaged velocity which many
> > systems
> > calculate as part of volume flow calcs.
> > Kathryn
> >
> > "John K. Jain" wrote:
> >
> > > Hello Friends, Colleagues and Fellow Countrymen,
> > >
> > > I have a technical question for you all. Is there anyone who is doing
> > > transcranial with only a duplex scanner? If so what frequency transducer
> > > are make/model of equipment are you using.
> > > Our old transcranial machine went to the boneyard years ago and without
> > > ever having a significant volume of patients to justify replacing it we
> > let
> > > the program go. Now of course there are new nuerosurgeons who are
> > banging
> > > the TCD drum and I am trying to evaluate our options.
> > >
> > > Thank you ahead of time for your help,
> > >
> > > John K Jain
> > >
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