The Neurosonology Research Group of the World Federation of Neurology
As accepted by the general meeting of NSRG during 12th meeting in Osaka, July 2005
Guidelines for Neurosonology Laboratories

Introduction: This document represents a guideline for international guidelines of neurosonology laboratory proposed by a task force of the NSRG. It is meant to help organizing and controlling a quality guideline for neurosonologic examinations, necessary to obtain reproducible and clinical meaningful results. The guidelines shall allow self-control of neurosonology laboratories in those countries where no specific elaborated national guidelines exist.
1. Personal and responsibilities

1.1. Responsible physician: A board certified neurologist (or physician experienced in cerebrovascular disease) has to be responsible for all diagnostic services provided by the neurosonology laboratory, as well concerning the appropriateness and technical aspects of testing as the practical performance, documentation and correct interpretation.
1.1.1 Qualification of the responsible physician: The physician is specifically qualified by
a. National certification process for neurosonology. This can be a part of the process of specialisation for neurology and theoretical formation.
b. If there is no national certification, this can be replaced by a formal and specific certification of neurosonology established by a national or international scientific medical society (ultrasound, neurology or other societies in the field of neuroscience)
c. If there is no legal national certification or certification by a scientific society, qualification can be obtained through a practical training of at least 6 month full-time activity in a neurovascular laboratory under the supervision of the responsible physician of this laboratory. During this time at least 300 extra- and 300 intracranial vascular ultrasound studies should be performed and interpreted by the physician in formation himself, including about 20% pathologic cases. The examinations during the training have to be documented for the certification process. The responsible physician of the laboratory in which the training takes place has to certify the successful training.
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1.1.2 Continuous education: The responsible physician has to maintain his level of knowledge in the field of neurovascular ultrasound by participating in CME courses concerning vascular ultrasound or in equivalent training courses.
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1.2. The medical staff: working in the neurovascular lab under the supervision of the responsible physician take part and the practical examination, documentation and reporting but need supervision from the responsible physician so long as they do not have the same qualification.
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1.3. The technical staff: The technical staff is not an essential requirement but technical staff in general improves quality of service. Technical staff can provide secretary work or take part in the examination. However this should be under the supervision of the responsible physician. If the technical staffs take part in the examination of patients the responsible physician stands also responsible for the correct application and reporting of the test. The medical staff can qualify by an established training program (as for vascular technicians in the US) or by a training of at least 12 month full-time in a certified neurosonology laboratory. Precondition for such a training program is a prior formation in a health profession i.e. nurse, medical or radiologic technical assistant. The responsible physician is responsible for the training of technical staff as well as for an adequate continuous education.

2. Guidelines of examination
2.1. The extracranial examinations (continuous wave Doppler sonography, pulse wave Duplex sonography) contains the following arteries always on both sides:
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¢w branches of the ophthalmic artery;
¢w common carotid artery (CCA);
¢w external carotid artery (ECA);
¢w internal carotid artery (ICA);
¢w vertebral artery (VA) and
¢w subclavian artery (SC).
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¡@¡@The ICA has to be examined close to the origin and to be followed as far as distal possible. The vertebral artery has to be examined at least in two segments, always as close as possible at the origin and in the V2 or V3 segment in addition.
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2.2. The intracranial examinations (transcranial Doppler sonography, transcranial Duplex sonography) encompasses the M1 segment of the middle cerebral artery (MCA), the A1 segment of the anterior cerebral arteries (ACA), the P1 and P2 segments of the posterior cerebral artery (PCA) and the VA through the occipital approach as well as the basilar artery (BA) followed as deep as possible by the occipital approach. (other relevant procedures, e.g. PFO detection, emboli detection, and CO2 reactivity, can be included as needed).
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3. Guidelines of documentation, reports and interpretation
3.1. Format: Reports have to be given in a standard format. Identification of the technologist or physician performing the vascular examination must appear on the record. The final results and related report has to be signed by the responsible physician or another member of the medical staff with similar reporting experience as described for the responsible physician in section 1.

3.2. Content: The contents of the report must include:
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  1. The clinical indication leading to the performance of the examinations.
  2. A detailed description of the techniques used and of the result of the examination of each examined artery or vein.¡@
  3. The final conclusion (interpretation of results)
3.3. Documentation: Documentation in the report has to be provided for each examined arterial segment. If it is not possible to examine a specific segment, the most probable reason for that has to be indicated. In case of abnormal findings results have to be quantified for example the maximum systolic velocity (frequency) or the maximum wall thickness and length of a plaque. Pathologic findings should be visualized and documented in two planes if possible.

3.4. Interpretation: Each laboratory should have written criteria of interpretation. The type of measurement of degree of stenosis (NASCET- or ECST-criteria) have to be listed as well as criteria for the recognition of an occlusion of different sites or the ultrasound criteria for determining the degree of stenosis.
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4. Patient Safety

Procedures and policies must exist with respect to control of infectious diseases, transducer cleaning and protection of laboratory personnel from the transmission of infectious diseases and blood borne pathogens.
Appropriate equipment, supplies, and trained personnel must be available to deal with medical emergencies and critically ill patients.
A policy must exist regarding routine inspection and testing for electrical safety of all existing equipment.
The laboratory must meet the standards set forth by the local authorities.

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5. Internal quality controls

Any available additional vascular testing as digital subtraction angiography (DSA) or magnetic resonance angiography (MRA) or report from the vascular operation should be compared with the results of the ultrasound examination. These comparisons should be communicated with all of the medical and technical staff and prospectively evaluated.
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Toshiyuki Shiogai, M.D. Secretary NSRG
Tel/Fax: +81-75-325-2295¡@E-mail: nsrg@mail.hato.com.tw
Shan-Jin Ryu, M.D.¡@Webmaster NSRG