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The Ultrasound Brain Helmet: Early Human Feasibility Study of

Multiple Simultaneous 3D Scans of Cerebral Vasculature
Brooks D. Lindsey*,1Nikolas M. Ivancevich*, John Whitman*, Edward Light*, Matthew
Fronheiser*, Heather A. Nicoletto†, Daniel T. Laskowitz†, Stephen W. Smith*
*Department of Biomedical Engineering, Duke University, Durham, NC, USA;
†Division of Neurology, Duke University Medical Center, Durham, NC, USA
We describe early stage experiments to test the feasibility of an ultrasound brain helmet to produce multiple
simultaneous real-time 3D scans of the cerebral vasculature from temporal and suboccipital acoustic windows of the
skull. The transducer hardware and software of the Volumetrics Medical Imaging real-time 3D scanner were modified to
support dual 2.5 MHz matrix arrays of 256 transmit elements and 128 receive elements which produce two simultaneous
64° pyramidal scans. The real-time display format consists of two coronal B-mode images merged into a 128° sector,
two simultaneous parasagittal images merged into a 128° x 64° C-mode plane, and a simultaneous 64° axial image.
Real-time 3D color Doppler images acquired in initial clinical studies after contrast injection demonstrate flow in several
representative blood vessels. An offline Doppler rendering of data from two transducers simultaneously scanning via the
temporal windows provides an early visualization of the flow in vessels on both sides of the brain. The long-term goal is
to produce real-time 3D ultrasound images of the cerebral vasculature from a portable unit capable of internet
transmission, thus enabling interactive 3D imaging, remote diagnosis and earlier therapeutic intervention. We are
motivated by the urgency for rapid diagnosis of stroke due to the short time window of effective therapeutic intervention.
Keywords: Transcranial, ultrasound contrast, intracranial arteries, 3D imaging, phase aberration

A wide variety of cerebrovascular diseases which swiftly inhibit brain function and arise from disruption of the
blood supply to the brain are collectively termed stroke. Stroke is the third-leading cause of death in the U.S.,
responsible for 160,000 deaths in the year 2000 with a prevalence of 11.3 per 1000, or 4,000,000 individuals. It is the
leading cause of disability among adults in the United States, costing some $56 billion per year [1].
At present, intravenous treatment with the thrombolytic drug, tissue plasminogen activator (tPA) is the only
USFDA-approved pharmacologic intervention demonstrated to improve mortality and functional outcome in ischemic
stroke; however, intravenous thrombolysis is only effective when administered within three hours of the onset of
symptoms [2]. Currently tPA may be underutilized by physicians due to the fact that observable symptoms vary widely
depending on the location of cerebral ischemia, indicating a need for a diagnostic tool providing speed and accuracy
sufficient to tailor the treatment to the individual patient during stroke onset and progression. Prolific advances in
neuroimaging including visualization of cerebrovascular changes via computed tomography angiography (CTA),
magnetic resonance angiography (MRA), and traditional digital subtraction angiography have enabled a more complete
understanding of the pathophysiology of stroke and have improved the safe management of stroke patients [3].
To this set of innovations we contribute our ultrasonic imaging system capable of providing multiple threedimensional scans as a real-time, portable, non-invasive technology for the rapid evaluation of stroke patients. Providing
an ultrasound solution addresses concerns associated with the cost, availability, complexity, and ease of use of these
other modalities. We believe that the flexibility and portability of modern ultrasound systems make this modality a
Corresponding Author: Brooks Lindsey, Box 90281, Duke University, Durham, NC 27705. Tel: (919) 660-5449,
Fax: (919) 684-4488, Email:
Medical Imaging 2009: Ultrasonic Imaging and Signal Processing, edited by Stephen A. McAleavey, Jan D'hooge
Proc. of SPIE Vol. 7265, 726503 · © 2009 SPIE · CCC code: 1605-7422/09/$18 · doi: 10.1117/12.810644

Proc. of SPIE Vol. 7265 726503-1
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speeding diagnosis for this time-critical disease. 1. Proc. In 2008. and lesion vascularity for tumors [5] and the analysis of intracranial aneurysms[6. in the first human trial of real-time 3D transcranial ultrasound. Hanley and Hacke cite the Genentech Stroke survey which demonstrated that the mean time from stroke symptom onset to a CT exam was 4 hours. already exceeding the time window set by the National Institute of Neurological Disorders and Stroke for use of thrombolytic tPA [2]. (VMI. In our laboratories we have concentrated on real-time 3D ultrasound scanning. In a single subject. 9] and commercialized by Volumetrics Medical Imaging. Anterior (A1) and posterior (P1) cerebral arteries contributing to the Circle of Willis (black ring) for pre-correction (A) and post-correction (B) scans. MA). the transcranial ultrasound examination.strong candidate for use in the pre-hospital and emergency room on 12/04/2014 Terms of Use: http://spiedl. In recently published findings. In addition.6%. It is a bedside technology ideal for the restless or uncooperative patient and retains widespread use for acute and intensive care applications. and low cost. has been a valuable tool for the diagnosis and evaluation of stroke [4]. as well as for therapy monitoring and perioperative management. This is combined with the administration of microbubble contrast agent to improve visual assessment of cerebrovascular disease using color and spectral Doppler. originally developed at Duke University [8. Durham. portable. P1 Al EDT Li w Al Al Ml Fig. Inc. and parasagittal planes of the human brain as well as steerable 3D spectral Doppler traces and 3D color flow images of cerebral vessels in seventeen normal subjects [11]. offline reconstructed 3D transcranial US scanning achieved by rotation of the transducer or electromagnetic positioning of the transducer has shown advantages in the assessment of collateral circulation. of SPIE Vol. coronal. For example. the number of voxels above the Doppler signal reject threshold increased by 38. 7265 726503-2 Downloaded From: http://proceedings. In 2004 we described real-time 3D scans of the brain [10]. NC). the corrected images yielded an increase in detected cerebral vessels as determined by blinded observations of two neurosonologists (Figure 1).spiedigitallibrary. the diagnosis of vascular anatomy. Billerica. in which a sonographer examines the major cerebral arteries through the temporal and suboccipital acoustic windows of the skull. It is our contention that real-time 3D transcranial ultrasound technology with improved image quality via correction of the phase aberration due to the skull bone meets these requirements. All transcranial ultrasound is real-time. 7]. The state of the art in transcranial ultrasound consists of a phased-array sector scan operating at approximately 2 MHz applied to the temporal and suboccipital acoustic windows. we used our scanner from the temporal and suboccipital acoustic windows with Definity contrast agent enhancement (Lantheus Medical Imaging. We used the echo signals from the brain tissue combined with the multi-lag least-means-squares cross-correlation algorithm [12-14] previously adapted to 3D ultrasound [15]. In comparing the control and post-skull correction 3D ultrasound angiograms. Middle cerebral arteries (M1) are also indicated. we showed human in vivo correction of the phase aberration of the skull. results suggesting that phase correction of Doppler data from both sides of the Circle of Willis may yield increased sensitivity to flow in ipsilateral vessels. non-invasive. to produce simultaneous transcranial images in the Mi . A B P1 7. Since the 1980s.

to be used for spectral Doppler measurements of cerebral blood flow or therapeutic applications such as ultrasound-enhanced thrombolysis [16]. and a steerable 3D ultrasound beam. Boyertown. coronal. shown in blue.array N Axial ParaSag ittal Coronal Fig. we show an illustrative axial image of the Circle of Willis (CW). using two simultaneous Volumetrics 3D scanners running asynchronously. we show. METHODS Our 3D ultrasound system scans a full 64° pyramid using a matrix (checkerboard) array transducer at up to 30 volumes per second. Proc. we simply scanned the brain of a human subject. Figure 3D shows the color Doppler 3D rendering of the vertebral arteries (VA) joining to form the basilar artery (BA).org/ on 12/04/2014 Terms of Use: http://spiedl. 3D color flow imaging. Schematic of 2D matrix array scanning a pyramid and displaying simultaneous axial. who had given informed consent per the IRB-approved protocol [11]. Figure 2B is a photograph of the VMI matrix array probe which is used for real-time 3D scanning in both cardiac as well as transcranial applications. Figure 2A shows a schematic of the matrix phased array transducer producing such a pyramidal scan and displaying two simultaneous orthogonal B-mode images. and posterior cerebral arteries. middle. a 3D ultrasound angiogram. becomes clear: three matrix array transducers (T1-3) mounted in a simple helmet to produce three simultaneous 3D ultrasound scans of the brain through the temporal and suboccipital windows of the skull. in Figure 3B. In the first experiment of our feasibility study. corresponding to parasagittal image planes. This view can be tilted and rotated to examine the vasculature from any perspective. The video output of the two displays was fed into a video screen splitter (MicroImage. a coronal view of that same MCA demonstrating patency as the vessel makes its tortuous path toward the outer surface of the brain. the ipsilateral middle cerebral artery (MCA) and contralateral skull (CS) from a normal subject.spiedigitallibrary. Figure 3C shows the offline 3D-rendered view of the contralateral skull and cerebral vasculature from the same subject. a matrix transducer probe on the temporal acoustic window produced useful color Doppler data from the cerebral vessels of the Circle of Willis in axial and coronal image planes allowing identification of anterior. After a Definity contrast injection. of SPIE Vol. a second matrix array on the suboccipital window produced the coronal and parasagittal image planes. By manipulating the thickness and orientation of the simultaneous coronal slice from the real-time 3D scan.5 MHz matrix array. In like manner.This progression led us to this study: an ultrasound brain helmet which would include multiple simultaneous real-time 3D scans of the cerebral vasculature from the temporal and suboccipital acoustic windows of the skull. Real-time display options in our 3D scanner also include 3D volume rendering. From these images. 2. In Figure 3A. PA) so that the image planes from two simultaneous 3D scans could be viewed on a single television monitor. the concept of the brain helmet. as well as steerable spectral Doppler (blue). and parasagittal scans. B) Photograph of . 7265 726503-3 Downloaded From: http://proceedings. 2A. Hardware and software modifications of the Volumetrics scanner to achieve dual simultaneous 3D scans with 3D color Doppler from matrix arrays as well as feasibility testing in early human trials are described herein. for another subject scanned from the suboccipital window. corresponding to axial and coronal image planes. Our long-term goal for the brain helmet is to produce real-time 3D ultrasound images of the complete cerebral vasculature with internet transmission of images to a stroke center. enabling remote diagnosis and earlier therapeutic intervention. as well as two C-mode planes. 2-0 . Simultaneously. yielding views of a vertebral artery and the atlas loop and of the foramen magnum. illustrated in Figure 4.

In normal operation. This proved to be an insuperable problem when two transducer probes were positioned across from each other over the two temporal windows and caused significant interference even for the temporal and suboccipital combination. we relied on our previous experience developing multiple 3D intra-cardiac echo (3D-ICE) catheters wherein we had modified the 3D scanner to switch between two 3D-ICE catheters in one second at the push of a button [17]. 7265 726503-4 Downloaded From: http://proceedings. Schematic of ultrasound brain helmet including simultaneous temporal matrix arrays (T1. In this project. C D 0 Fig. Ti Fig. We simulated matrix array Proc.spiedigitallibrary. Offline 3D renderings of transcranial Doppler data showing (C) contralateral skull and color Doppler of the cerebrovascular tree including MCA from temporal window and (D) 3D color Doppler rendering of the cerebrovascular tree from sub-occipital window including vertebral arteries (VA) joining to form basilar artery (BA). 3. Images from real time 3D transcranial scan including: (A) Axial plane showing the circle of Willis ( CW). (B) Simultaneous coronal plane showing the same ipsilateral . of SPIE Vol.T2) and sub-occipital matrix array (T3).We were concerned that the two transducers would acoustically interfere with each other. the scanner includes 512 transmitters and 256 receive channels with 16:1 receivemode parallel processing to generate 4096 B-mode image lines in the pyramidal scan. ipsilateral Middle Cerebral Artery (MCA) and contralateral skull (CS). T2 Thus. we were convinced of the necessity to modify our 3D scanner for synchronous operation of multiple matrix arrays. on 12/04/2014 Terms of Use: http://spiedl.

-4 mm 2 A C B Fig. shown in Fig. -6 dB beamwidth = 3. In the end. 0°) using the Field II ultrasound simulation software [18].. resulting in the associated C-scan image of the cyst.7 dB relative to that of Fig. -4 0 4 -4 8 4 0 -4 8 8 8 4 4 E 0 mm 4 8 0 4 8 E0 -4 -4 -4 8 E E0 -4 4 4 E r-. -6 dB beamwidth = 3. we calculated the relative peak pressure (a surrogate of image sensitivity). as described by Light et al. 7265 726503-5 Downloaded From: http://proceedings. (1998). of SPIE Vol.35 mm) and 256 receive (Rx) elements (spacing = 0. but an increased grating lobe amplitude of –24 dB.6 mm) was configured in a sparse periodic vernier pattern shown in Figure 5A with 256 transmit (Tx) elements (spacing = 0. as a measure of image quality. 5A. As a demonstration of image quality. For a brain helmet configuration of two simultaneous 3D transducers. The simulations yielded a pulse-echo sensitivity which we assign to 0 dB. flA E0 0 8 -4 048 mm t . A comparison of the C-scans shows the enlarged speckle size associated with increased beam width but good cyst contrast for the brain helmet design.t. This design was used in the transcranial human study of Ivancevich et al. In a later design. and resulting real-time C-scan for: (A) original VMI design. we allocated 256 transmitters and 128 receivers to each matrix array in the pattern shown in Fig. (B) increased SNR. -6 dB beamwidth = 5. Beam plots associated with given arrangements of transmit elements (Tx). For each design. a grating lobe amplitude of -60 dB and associated C-scan image of the cyst.4 mm at a depth of 70 mm. we analyzed the image quality trade-offs of a number of matrix array designs including the use of multiplexers to switch between transducers. every available element in the array was used in transmit mode resulting in 440 transmit elements and 256 receive elements yielding a sensitivity improvement of +4. 5. the 2. 5B. and the grating lobe amplitude (a surrogate of image clutter). (C) matrix array from prototype brain helmet.9 mm at a depth of 70 mm. C 7 degrees ix degrbes - degrées 8 8 8 4 4 4 -4 -4 o -4 . for each design. based on criteria of cost.5 mm at a depth of 70 mm. the – 6 dB beam width (equivalent to transducer lateral resolution). and a grating lobe amplitude = –45 dB resulting in the associated C-scan image.5 MHz Volumetrics matrix array ( λ H2O = 0. producing the axisymmetric beam plots shown in Figure 5. simplicity and sensitivity. Proc.7 mm).designs for multiple simultaneous transducers for a steering angle of (0°. In its original . receive elements (Rx). we also show the experimental C-scan images of a 12 mm cyst phantom (contrast = –40 dB).org/ on 12/04/2014 Terms of Use: http://spiedl. (2008)[11]. 5C yielding a relative sensitivity of -6 dB.

In normal operation. opposing transducers. were unchanged. so we split this pyramidal scan between the two matrix arrays by enabling only the elements of array #1 during the first 2048 image lines and enabling only the elements of array #2 during the second 2048 image lines. To complete our hardware developments. Under software control. Previously we have developed 90° and 120° pyramidal scans for our 3D intracardiac catheters [19] and 3D endoscopes [20]. As of yet. On the left side. We also modified the scanner software to produce dual pyramidal scans. In subsequent studies. which normally are connected to two ITT Cannon connectors (Model DLM6-360).spiedigitallibrary. Positive and negative isosurfaces are displayed for each transducer.5 MHz transducers in opposing temporal windows of a human subject. At the time of our first human trial. Seattle. While initial coupling prototypes were hand-wired. A quick trackball adjustment moves this cursor to select which axial scan is displayed. As with our previous renderings. equivalent to selecting the Doppler gain on the scanner. This study was conducted per IRB-approved protocol on normal volunteers. this image can be rotated to provide clinical personnel with any desired point of view. presented here. WA). Proc. which consisted of adjacent parasagittal planes from the dual transducers. We are also able to display two C-scans simultaneously. this time for the two independent. 2) C-scan planes of adjustable orientation and depth. we can enable or disable individual array elements on each image line. ability to detect the path of this vessel in normal subjects is encouraging for our goal of detecting abnormal perfusion in patients [21]. the current model utilizes a custom multi-layer printed circuit board to limit interference across channels as well as ensure proper grounding to decrease pick-up from external sources. Note that the scan line spacing was doubled in the elevation direction. RESULTS Figure 6 shows the results of a real-time 3D scan with color Doppler of one human subject with dual simultaneous matrix array transducers positioned on the temporal acoustic windows after a contrast agent injection of Definity. still having 64 x 64 = 4096 image lines. In addition to the scanner’s real-time . providing parasagittal planes cutting across both transducers. including Doppler capabilities. of SPIE Vol. The slice orientation in Figure 6C is indicated by the white cursor in Figure 6A. which is conventionally used for 1D spectral Doppler. the arrangement of transducers and the success of this offline merged rendering suggest the possibility of achieving actual registration of the volumes. 3) a 64º azimuth sector scan selected from one of the dual transducers. while that of Figure 6D is indicated by the white cursor in Figure 6B. In this case we developed a 64° x 128º pyramidal scan. the simultaneous display planes included: 1) a 128º elevation (coronal plane) sector scan which consisted of adjacent 64º elevation planes from the dual transducers. Figures 6A and 6B—the so-called 128 º elevation sector—show blood flow simultaneously imaged in the elevation (coronal) plane from transducers on the right and left sides of the skull.Having chosen the transducer design. to mount two simultaneous matrix array probes in the temporal windows. Thus we created two independent pyramidal scans each of roughly 64º x 64 º. The two resulting volumes of Doppler data were merged by simply placing the identically-sized pyramids adjacent to one another (Figure 7). 7265 726503-6 Downloaded From: http://proceedings. Note that the color-flow reject required adjustment between capturing these two images due to differences in the noise floors of the two sides of the system. we again performed offline rendering of Doppler data. we adapted a Transcranial Doppler Fixation System (Spencer Technologies. Identified structures include the middle cerebral and internal carotid arteries on both sides of the image. we believe we have identified sections of the carotid siphon. we have not customized the display features of the 3D scanner for the brain helmet. Additionally. were rewired into four of these connectors for the two matrix arrays. the transducer fixation system was used to simultaneously position the two 2. where signal to noise ratio is higher. Because the path of the carotid siphon tends to vary between individuals and with age. Early testing of the system was conducted using a phantom constructed in-house to mimic the skull and its soft tissue and vascular contents. we fabricated a new transducer coupling system wherein the circuitry of 512 transmitters and 256 receivers. All other features of the 3D scanner. a 64° pyramidal scan includes 64 x 64 = 4096 image lines. the tortuous windings of the internal carotid artery as it ascends before bifurcating into anterior and middle cerebral on 12/04/2014 Terms of Use: http://spiedl. Figures 6C and 6D show the simultaneous azimuth (axial) plane images from the right and left transducers. that of either the right or left transducer. 3.

Coronal plane images with color Doppler information from simultaneous transcranial scans through the right (A) and left (B) temporal windows. as well as the corresponding axial plane images from the left (C) and right (D) sides. (A) Anterior and slightly superior view of offline 3D Doppler renderings from both temporal windows of a human subject provides an example of the utility of this scan for simultaneous visualization of cerebral vasculature on both sides of the brain.spiedigitallibrary. Images are shown as they appear on the display of the modified Volumetrics 3D scanner.Fig. of SPIE Vol. 7265 726503-7 Downloaded From: on 12/04/2014 Terms of Use: http://spiedl. Back of head transducer 2 S MCA ICA (06) a ICA (Carotid siphon) p MCA transducer 1 S ICA (Carotid siphon) Ophthalmic artery Anterior (patient nose) Fig . (B) Schematic of vessels shown in (A) for both hemispheres of the brain. 6. Proc.

of course. This problem is eliminated by the dual simultaneous temporal 3D scans. The image quality of the 3D ultrasound brain scans must continue to be improved to be able to reliably differentiate normal cerebral vasculature from that of an ischemic or hemorrhagic on 12/04/2014 Terms of Use: http://spiedl. The stroke team would select the imaging planes within a volume of data. This would allow transmission of images via cell phone or internet using webcam technology from a remote hospital or from an ambulance to a neurological team at a stroke center. Finally. each transducer can act as a phase correction beacon for the opposing transducer. At the current time it is unknown if this ultrasound image quality is attainable. Also. a number of hurdles which we must address and overcome before the ultrasound brain helmet can become a useful clinical device. Development of interface circuits between the scanner and our transducers will also include minimizing the length of the transducer cables to limit insertion loss. and display planes may be selected interactively at any desired orientation either in real time or in playback mode by the members of a remote stroke team. The real-time 3D scanner must be substantially miniaturized for use in a helmet apparatus. the remote transmission of interactively controlled 3D ultrasound scans from a battery powered portable unit must be perfected. To achieve the stated long-term goal. a 2D phased array scanner the size of a personal digital assistant (PDA). as seen in the dual Doppler rendering of Figure 7. Yet to be completed is the remote control selection of the image display planes from the real time 3D scan volume analogous to the panning and tilting features of webcam technology. 7265 726503-8 Downloaded From: http://proceedings. we note that for the case of the transducers positioned over the temporal windows. as we have fabricated such arrays on multi-layer flexible circuits of polyimide measuring as small as two millimeters in total thickness [20]. precise positioning and aiming of the matrix array may not be as important in a 3D scan as in conventional 1D and 2D transcranial Doppler since an entire volume of the brain will be scanned and stored.4. the presence of the carotid siphon in our acquired volumes indicates that our transducers were aimed too far inferiorly to acquire complete views of the Circle of Willis for our initial human test subjects. Also encouraging is the recent development of improved transcranial phase inversion harmonic imaging to reduce the blooming artifact of contrast agents [26]. 25]. There are. since each MCA is scanned from the ipsilateral side in one of the two scans. and in the GE Voluson i. We note that with our own 3D scanner we easily transmitted the streaming video output of the display over the internet using a video capture card (ViewCast Osprey 100. In particular. which has recently resulted in the Siemens P10. remote diagnosis and earlier therapeutic intervention. [24. note that the contralateral MCA is not visible from the temporal scan of Figures 3A-C. Here we are encouraged by the ongoing drive to miniaturize all ultrasound systems. Our past experience with arrays for 3D catheter and endoscope applications gives us confidence in meeting this challenge. Proc. However we are encouraged by the recent progress in phase aberration correction of the skull bone both from our own group [11] and other laboratories [22. we note the current commercial availability of ambulance-based ECG telemedicine systems giving us additional confidence in the feasibility of this approach. we must test whether the multiple matrix array probes within a helmet can be positioned over the acoustic windows of the skull by medical personnel of limited training such as in an ambulance environment. thus enabling interactive 3D imaging. a real-time mechanical 3D fetal scanner the size of a laptop computer.spiedigitallibrary. TX) with no evident loss of image quality. However. Plano. et al. Another challenge is to miniaturize the thickness of the matrix arrays with a low profile to fit within a helmet configuration. 23]. DISCUSSION We believe that dual simultaneous in vivo 3D scans from both temporal windows should provide additional diagnostic information compared to the single temporal 3D scan of Figure 3. . The use of an external transducer as a phase correction beacon was pursued in our laboratories by Miller-Jones and more recently by the team of Vignon. These trends should continue and will likely yield the necessary miniaturization for the brain helmet. of SPIE Vol. This suggests the need for greater mechanical freedom in the transducer mountings of the helmet to allow an increased range of transducer orientations. In particular. which should also improve image quality.

ACKNOWLEDGMENTS This study was supported by grants RR024128 and HL089507 from the National Institutes of Health. 7265 726503-9 Downloaded From: http://proceedings. building on what we demonstrate in Figure 7. of SPIE Vol. the simultaneous axial and coronal slices from both transducers are probably the most useful and should be displayed in real time in standard orientations rather than the current display of Figure 6A-D. 6. Finally.spiedigitallibrary. This is an area of active research in the image processing community undergoing rapid advances [27]. SUMMARY We have described early stage in vivo and in vitro experiments to test the feasibility of an ultrasound brain helmet to produce multiple simultaneous real-time 3D scans of the cerebral vasculature from the temporal and suboccipital acoustic windows of the skull. the 3D scans from multiple transducers should be fully and accurately fused into a single 3D image for easy examination by the neurosonologist. Our long-term goal is to produce real-time 3D ultrasound images of virtually the entire cerebral vasculature. 5. Fusing 3D scans from one temporal and one sub-occipital transducer may provide additional useful information and can be envisioned by mentally connecting structures indicated by the double arrow: the posterior cerebral artery of Fig. thus enabling interactive 3D imaging. on 12/04/2014 Terms of Use: http://spiedl. 3D obtained from the sub-occipital . The team would be capable of remotely selecting the imaging plane to display. the 3D rendering color Doppler scan needs to be displayed in real time. Additionally. For example.The display features of the scanner need to be modified for convenient analysis by the stroke team. This scanner would transmit its images from a remote hospital or from an ambulance via cellular networks or internet to a neurological team at a stroke center. 3C obtained from the temporal skull window and the basilar artery of Fig.

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