2004 Mihara Prize Awardee’s SummaryULTRASOUND IMAGING IN STROKE
Michael G. Hennerici,
Chairman of the Department of Neurology,
Universitätsklinikum Mannheim,
Medical Director of the Universitätsklinikum Mannheim
and former Vice-Dean of the Medical Faculty Mannheim
Atherosclerosis is still a major course of morbidity and mortality worldwide and inparticular in industrialized countries and although extensive research in atherosclerosis
has been performed for more than a century, many mechanisms causing and supporting
atherogenesis are still not understood.

In particularexperimental models fail tomirror the discontinuous natural course of human disease, with longstanding
asymptomatic stages until all-of-a-sudden symptoms due to local thrombosis or distal
embolism occur. Only since the last quarter of the 20th century imaging modalities
became available to investigate the complex history of atherosclerosis prospectively inhumans.

From its infancy in Japan (Satomura and Kaneko 1958), Doppler sonography

has been used for non-invasive vascular analysis and expanded our diagnostic repertoire(Hennerici et al. 1976)1-2.Later duplex ultrasound both applied extra- and intracraniallyhave been used (Hennerici et al. 1982)3. Today high resolution vessel online studies ofwall morphology (Hennerici et al. 1984)4, plaque development (Hennerici et al. 1985)5and vascular remodeling (Hennerici et al. 1991)6 can all be performed in individual
patients as well as in large clinical trials.
At the other end of the spectrum, compensatory hemodynamic mechanisms have been
identified in patients with few or no symptoms but extensive cerebrovascular disease.
This led to the new concept that these patients do not need any surgical or interventional
therapy because of the natural high capacity of complex networks from large and smallarteries (Hennerici et al. 1987)7 and was recently confirmed by careful re-analysis of
NASCET and ECST). Regression of atherosclerosis, long assumed not to exist, could
be observed both naturally and during appropriate treatment (e.g. statins) or preventiverisk factor modulation (Hennerici et al. 1985)5.
For the acute stage ultrasound is used in addition to other brain and vascular imaging
modalities (CT, CTA, MRI and MRA) and in particular to predict outcome andprognosis if combined herewith (Hennerici et al. 2000)8. More recent developments
facilitate perfusion imaging of brain tissue (Hennerici et al. 2004)9 and hence allow
short step monitoring of critical conditions after severe strokes in patients treated on
stroke units.

Echo-contrast enhanced ultrasound studies are used and have been

modified in our days to identify in more detail progressive vascular inflammation (oneof the leading mechanisms causing atherosclerosis) and different stages of oligemia inearly stroke (Hennerici et al. 2004)10.

Ultrasound mediated gene therapy and variousspecial modifications of ultrasound characteristics used for thrombolysis of large andsmall vessel strokes are future weapons against stroke and illustrate the change from apurely diagnostic technology for its innovative treatment potential (Hennerici et al.
2004)11.
References
1) H.J. Büdingen, M. Hennerici, K. Voigt, K. Kendel, H.-J. Freund (1976)
Die Diagnostik von Stenosen oder Verschlüssen der A. carotis interna mit derdirektionellen Ultraschall-Doppler-Sonographie der A. supratrochlearis. Dtsch medWschr 101:269-275
2) G.M. v. Reutern, H.J. Büdingen, M. Hennerici, H.-J. Freund (1976) Diagnose undDifferenzierung von Stenosen und Verschlüssen der Arteria carotis mit derDoppler-Sonographie. Arch Psychiat Nervenkr 222:191-207
3) M. Hennerici, W. Rautenberg, S. Mohr (1982) Stroke risk from symptomlessextracranial arterial disease. Lancet II, 1180-1183 / 14764) M. Hennerici, H.-J. Freund (1984) Efficacy of CW-Doppler and duplex-system
examinations for the evaluation of extracranial carotid disease. J Clin Ultrasound
12:155-1615) M. Hennerici, W. Rautenberg, U. Trockel, R.G. Kladetzky (1985) Spontaneousprogression and regression of small carotid atheroma. Lancet I:1415-1419
6) M. Hennerici, W. Steinke (1991) Carotid plaque developments--aspects ofhemodynamic and vessel wall platelet interaction. Cerebrovasc Dis 1:142-148
7) M. Hennerici, H.B. Hülsbömer, H. Hefter, D. Lammerts, W. Rautenberg (1987)
Natural history of asymptomatic extracranial arterial disease. Results of a long-term
prospective study. Brain 110:777-791
8) M. Hennerici and S. Meairs (2000) Imaging arterial wall disease. Cerebrovasc Dis 10(Suppl 5):9-20
9) R Kern, K Szabo, M Hennerici, and S Meairs(2004) Characterization of Carotid
Artery Plaques Using Real-time Compound B-mode Ultrasound Stroke 35:870-875
10) M.G. Hennerici (2004) The unstable plaque Cerebrovasc Dis 17 Suppl 3. 17-22.
Review
11) R. Kern, F. Perren, K. Schoenberger, A. Gass, M. Hennerici, S. Meairs (2004)
Ultrasound microbubble destruction imaging in acute middle cerebral artery stroke.
Stroke 35:1665-1670