# Establishing a Sex-Specific Cut-Off for Temporal Bone Thickness in Transcranial Color-Coded Duplex Sonography

## TL;DR

This study identifies sex-specific thresholds for temporal bone thickness on CT scans to predict the success of transcranial ultrasound exams, improving efficiency in neurosonography.

## Contribution

The study introduces sex-specific cut-off values for temporal bone thickness to predict temporal window failure in TCCS, enabling more efficient patient pre-selection.

## Key findings

- Temporal bone thickness is the strongest predictor of temporal window failure in TCCS.
- Sex-specific cut-off values of 3.8 mm in men and 3.3 mm in women reliably identify patients with inadequate acoustic windows.
- CT-based pre-selection using these thresholds can improve workflow efficiency and reduce operator dependency.

## Abstract

What are the main findings?
Temporal bone thickness measured on routine cranial computed tomography (CT) is the strongest predictor of temporal window failure in transcranial color-coded duplex sonography (TCCS).Sex-specific CT-based cut-off values (3.8 mm in men and 3.3 mm in women) reliably identify patients with a high probability of inadequate acoustic windows.

Temporal bone thickness measured on routine cranial computed tomography (CT) is the strongest predictor of temporal window failure in transcranial color-coded duplex sonography (TCCS).

Sex-specific CT-based cut-off values (3.8 mm in men and 3.3 mm in women) reliably identify patients with a high probability of inadequate acoustic windows.

What are the implications of the main findings?
CT-based pre-selection enables more efficient use of transcranial ultrasound by avoiding examinations with a high likelihood of failure.Implementation of sex-adapted thresholds may reduce operator dependency and improve workflow efficiency.

CT-based pre-selection enables more efficient use of transcranial ultrasound by avoiding examinations with a high likelihood of failure.

Implementation of sex-adapted thresholds may reduce operator dependency and improve workflow efficiency.

Background/Objectives: The aim of this study was to identify predictors of temporal window failure (TWF) in transcranial color-coded duplex sonography (TCCS) based on demographical and computed tomography (CT)-based parameters such as temporal bone thickness (TBT), and to define sex-specific thresholds for predicting TWF. Methods: We retrospectively analyzed a series of adult patients who underwent cranial CT and TCCS. Bitemporal TBT was measured in nine standardized regions on CT, and mean TBT per side was calculated. Temporal bone window (TBW) quality was graded with two semiquantitative TCCS scores assessing the visibility of the middle cerebral artery (MCA), contralateral temporal bone, mesencephalon, and ipsilateral sphenoid bone. Associations between TBT, sex, age, and TBW visibility were analyzed by correlation, chi-square tests, and logistic regression. Results: 200 patients (102 men, 98 women; mean age 68 ± 16 years) were enrolled. Mean TBT was 3.1 ± 0.7 mm (right) and 3.2 ± 0.7 mm (left). TBT correlated weakly with age (r = 0.15–0.18, p < 0.05) and was higher in women (p < 0.05). Age and sex influenced TBW visibility (p < 0.05) with small effect sizes. Increased TBT strongly predicted poor TBW (β ≈ –1.7, p < 0.001). Optimal TBT cut-offs predicting adequate TBW were 3.8 mm (men) and 3.3 mm (women), maximizing specificity (men: 0.95, women: 0.85) and negative predictive value (men: 0.87, women: 0.66). Conclusions: Advanced age and female sex were both associated with TWF. CT-assessed TBT represents a robust predictor of TCCS feasibility. Implementation of sex-specific TBT threshold values may facilitate patient pre-selection and improve procedural efficiency in neurosonographic diagnostics.