1

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
ABSTRACT
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
1. INTRODUCTION
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: bdl14@duke.edu
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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strong candidate for use in the pre-hospital and emergency room settings, speeding diagnosis for this time-critical
disease. For example, 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]. 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.
Since the 1980s, the transcranial ultrasound examination, in which a sonographer examines the major cerebral
arteries through the temporal and suboccipital acoustic windows of the skull, has been a valuable tool for the diagnosis
and evaluation of stroke [4]. 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. This is combined with
the administration of microbubble contrast agent to improve visual assessment of cerebrovascular disease using color
and spectral Doppler. All transcranial ultrasound is real-time, portable, non-invasive, and low cost. It is a bedside
technology ideal for the restless or uncooperative patient and retains widespread use for acute and intensive care
applications, as well as for therapy monitoring and perioperative management.
In recently published findings, 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, the diagnosis of vascular anatomy, and lesion vascularity for tumors [5] and the analysis of intracranial
aneurysms[6, 7]. In our laboratories we have concentrated on real-time 3D ultrasound scanning, originally developed at
Duke University [8, 9] and commercialized by Volumetrics Medical Imaging, Inc. (VMI, Durham, NC). In 2004 we
described real-time 3D scans of the brain [10]. In 2008, in the first human trial of real-time 3D transcranial ultrasound, we
used our scanner from the temporal and suboccipital acoustic windows with Definity contrast agent enhancement
(Lantheus Medical Imaging, Billerica, MA), to produce simultaneous transcranial images in the axial, coronal, 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]. In a single subject, we showed human in vivo correction of the phase
aberration of the skull. 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, the corrected images yielded an increase in detected cerebral vessels as determined
by blinded observations of two neurosonologists (Figure 1). In addition, the number of voxels above the Doppler signal
reject threshold increased by 38.6%, 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.
P1
7,
P1
Al
EDT
Li
w
Al
Al
Ml
Fig. 1. Anterior (A1) and posterior (P1) cerebral arteries contributing to the Circle of Willis (black ring) for
pre-correction (A) and post-correction (B) scans. Middle cerebral arteries (M1) are also indicated.

Mi
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.
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. 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.
2-0
- array
N
Axial
ParaSag ittal
Coronal
Fig. 2A. Schematic of 2D matrix array scanning a pyramid and displaying simultaneous axial, coronal, and
parasagittal scans, as well as steerable spectral Doppler (blue), B) Photograph of 2.5 MHz matrix array.
2. METHODS
Our 3D ultrasound system scans a full 64 pyramid using a matrix (checkerboard) array transducer at up to 30
volumes per second. Figure 2A shows a schematic of the matrix phased array transducer producing such a pyramidal
scan and displaying two simultaneous orthogonal B-mode images, corresponding to axial and coronal image planes, as
well as two C-mode planes, corresponding to parasagittal image planes. Real-time display options in our 3D scanner
also include 3D volume rendering, 3D color flow imaging, and a steerable 3D ultrasound beam, shown in blue, to be
used for spectral Doppler measurements of cerebral blood flow or therapeutic applications such as ultrasound-enhanced
thrombolysis [16]. 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.
In Figure 3A, we show an illustrative axial image of the Circle of Willis (CW), the ipsilateral middle cerebral
artery (MCA) and contralateral skull (CS) from a normal subject. By manipulating the thickness and orientation of the
simultaneous coronal slice from the real-time 3D scan, we show, in Figure 3B, a coronal view of that same MCA
demonstrating patency as the vessel makes its tortuous path toward the outer surface of the brain. Figure 3C shows the
offline 3D-rendered view of the contralateral skull and cerebral vasculature from the same subject, a 3D ultrasound
angiogram. This view can be tilted and rotated to examine the vasculature from any perspective. In like manner, for
another subject scanned from the suboccipital window, Figure 3D shows the color Doppler 3D rendering of the vertebral
arteries (VA) joining to form the basilar artery (BA).
From these images, the concept of the brain helmet, illustrated in Figure 4, 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 the first experiment of our feasibility study, we simply scanned
the brain of a human subject, who had given informed consent per the IRB-approved protocol [11], using two
simultaneous Volumetrics 3D scanners running asynchronously. The video output of the two displays was fed into a
video screen splitter (MicroImage, Boyertown, PA) so that the image planes from two simultaneous 3D scans could be
viewed on a single television monitor. After a Definity contrast injection, 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, middle, and posterior cerebral arteries. Simultaneously, a second matrix
array on the suboccipital window produced the coronal and parasagittal image planes, yielding views of a vertebral artery
and the atlas loop and of the foramen magnum.

We were concerned that the two transducers would acoustically interfere with each other. 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.
Fig. 3. Images from real time 3D transcranial scan including: (A) Axial plane showing the circle
of Willis ( CW), ipsilateral Middle Cerebral Artery (MCA) and contralateral skull (CS). (B) Simultaneous
coronal plane showing the same ipsilateral MCA. 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).
Ti
Fig. 4. Schematic of ultrasound brain helmet including simultaneous
temporal matrix arrays (T1,T2) and sub-occipital matrix array (T3).
T2
Thus, we were convinced of the necessity to modify our 3D scanner for synchronous operation of multiple
matrix arrays. In this project, 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]. In normal operation, 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. We simulated matrix array

designs for multiple simultaneous transducers for a steering angle of (0, 0) using the Field II ultrasound simulation
software [18], producing the axisymmetric beam plots shown in Figure 5. For each design, as a measure of image quality,
we calculated the relative peak pressure (a surrogate of image sensitivity), the 6 dB beam width (equivalent to
transducer lateral resolution), and the grating lobe amplitude (a surrogate of image clutter). As a demonstration of image
quality, for each design, we also show the experimental C-scan images of a 12 mm cyst phantom (contrast = 40 dB).
C
degrees
ix
degrbes -
degres
-4
-4
o
-4
-4
-4
-4
4
E
0
mm
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-4
-4
-4
E0
-4
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flA E0
-4 048
mm
t .t.
-4
mm
A
C
B
Fig. 5. Beam plots associated with given arrangements of transmit elements (Tx), receive elements (Rx), and
resulting real-time C-scan for: (A) original VMI design, (B) increased SNR, (C) matrix array from prototype
brain helmet.
In its original configuration, as described by Light et al. (1998), the 2.5 MHz Volumetrics matrix array ( H2O =
0.6 mm) was configured in a sparse periodic vernier pattern shown in Figure 5A with 256 transmit (Tx) elements
(spacing = 0.35 mm) and 256 receive (Rx) elements (spacing = 0.7 mm). The simulations yielded a pulse-echo
sensitivity which we assign to 0 dB, -6 dB beamwidth = 3.9 mm at a depth of 70 mm, and a grating lobe amplitude = 45
dB resulting in the associated C-scan image.
In a later design, shown in Fig. 5B, 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 +4.7 dB relative to that of Fig. 5A, -6
dB beamwidth = 3.4 mm at a depth of 70 mm, but an increased grating lobe amplitude of 24 dB, resulting in the
associated C-scan image of the cyst. This design was used in the transcranial human study of Ivancevich et al. (2008)[11].
For a brain helmet configuration of two simultaneous 3D transducers, we analyzed the image quality trade-offs
of a number of matrix array designs including the use of multiplexers to switch between transducers. In the end, based
on criteria of cost, simplicity and sensitivity, we allocated 256 transmitters and 128 receivers to each matrix array in the
pattern shown in Fig. 5C yielding a relative sensitivity of -6 dB, -6 dB beamwidth = 5.5 mm at a depth of 70 mm, a
grating lobe amplitude of -60 dB and associated C-scan image of the cyst. 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.

Having chosen the transducer design, we fabricated a new transducer coupling system wherein the circuitry of
512 transmitters and 256 receivers, which normally are connected to two ITT Cannon connectors (Model DLM6-360),
were rewired into four of these connectors for the two matrix arrays. While initial coupling prototypes were hand-wired,
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. To complete our hardware developments, we
adapted a Transcranial Doppler Fixation System (Spencer Technologies, Seattle, WA), which is conventionally used for
1D spectral Doppler, to mount two simultaneous matrix array probes in the temporal windows. Early testing of the
system was conducted using a phantom constructed in-house to mimic the skull and its soft tissue and vascular contents.
In subsequent studies, presented here, the transducer fixation system was used to simultaneously position the two 2.5
MHz transducers in opposing temporal windows of a human subject. This study was conducted per IRB-approved
protocol on normal volunteers.
We also modified the scanner software to produce dual pyramidal scans. In normal operation, a 64 pyramidal
scan includes 64 x 64 = 4096 image lines. Previously we have developed 90 and 120 pyramidal scans for our 3D intracardiac catheters [19] and 3D endoscopes [20]. In this case we developed a 64 x 128 pyramidal scan, still having 64 x 64
= 4096 image lines. Under software control, we can enable or disable individual array elements on each image line, 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. Thus we created two
independent pyramidal scans each of roughly 64 x 64 . Note that the scan line spacing was doubled in the elevation
direction. All other features of the 3D scanner, including Doppler capabilities, were unchanged.
As of yet, we have not customized the display features of the 3D scanner for the brain helmet. At the time of
our first human trial, the simultaneous display planes included: 1) a 128 elevation (coronal plane) sector scan which
consisted of adjacent 64 elevation planes from the dual transducers; 2) C-scan planes of adjustable orientation and
depth, which consisted of adjacent parasagittal planes from the dual transducers; 3) a 64 azimuth sector scan selected
from one of the dual transducers.
3. 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. Figures 6A and 6Bthe so-called 128 elevation sectorshow blood flow simultaneously imaged in the
elevation (coronal) plane from transducers on the right and left sides of the skull. 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.
Figures 6C and 6D show the simultaneous azimuth (axial) plane images from the right and left transducers. The slice
orientation in Figure 6C is indicated by the white cursor in Figure 6A, while that of Figure 6D is indicated by the white
cursor in Figure 6B. A quick trackball adjustment moves this cursor to select which axial scan is displayed, that of either
the right or left transducer. We are also able to display two C-scans simultaneously, providing parasagittal planes cutting
across both transducers.
In addition to the scanners real-time display, we again performed offline rendering of Doppler data, this time
for the two independent, opposing transducers. The two resulting volumes of Doppler data were merged by simply
placing the identically-sized pyramids adjacent to one another (Figure 7). Positive and negative isosurfaces are
displayed for each transducer, equivalent to selecting the Doppler gain on the scanner. As with our previous renderings,
this image can be rotated to provide clinical personnel with any desired point of view. Identified structures include the
middle cerebral and internal carotid arteries on both sides of the image. On the left side, where signal to noise ratio is
higher, we believe we have identified sections of the carotid siphon, the tortuous windings of the internal carotid artery
as it ascends before bifurcating into anterior and middle cerebral arteries. Because the path of the carotid siphon tends to
vary between individuals and with age, ability to detect the path of this vessel in normal subjects is encouraging for our
goal of detecting abnormal perfusion in patients [21]. Additionally, the arrangement of transducers and the success of this
offline merged rendering suggest the possibility of achieving actual registration of the volumes.

Fig. 6. 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. Images are shown as they appear on the display of the modified Volumetrics 3D scanner.
Back of head
transducer 2
MCA
ICA (06)
ICA (Carotid
siphon)
MCA
transducer 1
ICA (Carotid
siphon)
Ophthalmic
artery
Anterior
(patient nose)
Fig 7. (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. (B) Schematic of vessels shown in (A) for both hemispheres of the
brain.

4. 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. In particular, note that the contralateral
MCA is not visible from the temporal scan of Figures 3A-C. This problem is eliminated by the dual simultaneous
temporal 3D scans, since each MCA is scanned from the ipsilateral side in one of the two scans, as seen in the dual
Doppler rendering of Figure 7.
There are, of course, a number of hurdles which we must address and overcome before the ultrasound brain
helmet can become a useful clinical device. First, 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. However, 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,
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. Also, 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. This suggests the need for greater mechanical freedom in the transducer mountings of the helmet to allow an
increased range of transducer orientations.
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 stroke. At the current time it is
unknown if this ultrasound image quality is attainable. 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, 23]. In particular, we note
that for the case of the transducers positioned over the temporal windows, each transducer can act as a phase correction
beacon for the opposing transducer. 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, et al. [24, 25]. Also encouraging is the recent
development of improved transcranial phase inversion harmonic imaging to reduce the blooming artifact of contrast
agents [26].
The real-time 3D scanner must be substantially miniaturized for use in a helmet apparatus. Here we are
encouraged by the ongoing drive to miniaturize all ultrasound systems, which has recently resulted in the Siemens P10, a 2D phased array scanner the size of a personal digital assistant (PDA), and in the GE Voluson i, a real-time
mechanical 3D fetal scanner the size of a laptop computer. These trends should continue and will likely yield the
necessary miniaturization for the brain helmet.
Another challenge is to miniaturize the thickness of the matrix arrays with a low profile to fit within a helmet
configuration. Our past experience with arrays for 3D catheter and endoscope applications gives us confidence in
meeting this challenge, as we have fabricated such arrays on multi-layer flexible circuits of polyimide measuring as
small as two millimeters in total thickness [20]. Development of interface circuits between the scanner and our
transducers will also include minimizing the length of the transducer cables to limit insertion loss, which should also
improve image quality.
To achieve the stated long-term goal, the remote transmission of interactively controlled 3D ultrasound scans
from a battery powered portable unit must be perfected. 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. The stroke team would select the imaging planes within a volume of data, thus enabling interactive 3D
imaging, remote diagnosis and earlier therapeutic intervention. 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, Plano, TX) with no evident loss of image quality. 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. Finally, we note the current commercial availability of ambulance-based ECG telemedicine systems
giving us additional confidence in the feasibility of this approach.

The display features of the scanner need to be modified for convenient analysis by the stroke team. For
example, 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. Additionally, the 3D
rendering color Doppler scan needs to be displayed in real time. Finally, the 3D scans from multiple transducers
should be fully and accurately fused into a single 3D image for easy examination by the neurosonologist, building on
what we demonstrate in Figure 7. This is an area of active research in the image processing community undergoing
rapid advances [27]. 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. 3C obtained from the temporal skull window and the basilar artery of Fig. 3D obtained from the
sub-occipital window.
5. 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. Our long-term goal is to produce real-time 3D ultrasound images of
virtually the entire cerebral vasculature. 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. The team would be capable of
remotely selecting the imaging plane to display, thus enabling interactive 3D imaging.
6. ACKNOWLEDGMENTS
This study was supported by grants RR024128 and HL089507 from the National Institutes of Health.

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