Background/objectives Stroke remains a leading cause of disability and death worldwide, with rapid diagnosis critical for effective treatment. Transcranial ultrasonography offers a potentially valuable diagnostic tool, particularly in resource-limited settings. This study aimed to evaluate the diagnostic accuracy of transcranial Doppler (TCD) and transcranial color-coded duplex sonography (TCCS) for detecting ischemic and hemorrhagic stroke. Methods We conducted a systematic review and bivariate random-effects meta-analysis following PRISMA guidelines (PROSPERO CRD42023471425). Three databases (Scopus, PubMed, Web of Science) were searched from inception to November 20, 2022. We included studies assessing adult (≥18 years) stroke patients using TCD or TCCS compared to reference standards (MRI, CT, or angiography). Exclusion criteria included pediatric populations, animal studies, vasospasm assessments, and studies with 10 participants. Four reviewers independently screened studies, extracted data, and assessed risk of bias using NIH tools. Primary outcomes were pooled sensitivity and specificity analyzed using bivariate random-effects models; this technique was chosen as it jointly analyses sensitivity and specificity using a random-effects model that accounts for their correlation and between-study variability. Results From 16,397 records, 26 studies met inclusion criteria, with 13 studies ( n = 802 ultrasound examinations) included in meta-analysis. Overall diagnostic accuracy showed sensitivity of 81.1% (95% CI 73.1–87.2%) and specificity of 85.5% (95% CI 71.4–93.3%), with an AUC of 0.874. TCCS demonstrated higher sensitivity for hemorrhagic stroke (87.8%) than for ischemic stroke (77.2%). TCCS showed sensitivity of 74.8% (95% CI 66.4–81.6%) and specificity of 85.2% (95% CI 63.0–95.1%), with an AUC of 0.796. Risk of bias was low in 30.6% of studies, moderate in 50%, and high in 19.4%. Heterogeneity was low to moderate ( I 2 = 6.2–23.1%). Conclusion Transcranial ultrasonography demonstrates good diagnostic accuracy for stroke detection. While operator-dependent and limited by acoustic window availability, these techniques, after thorough training and validation, may be prioritized in low-resource setting were computed tomography is not readily available through the means of formal capacitation and feasibility studies. The moderate risk of bias in half of included studies suggests a lack of higher-quality research. Systematic review registration CRD42023471425.
Pinto-Villalba et al. (2026) studied this question.