BACKGROUND AND PURPOSE: Knock-type Doppler signals (KTDS) are detectable by transcranial Doppler, and it has been hypothesized that they are related to an occlusion of a small perforating artery and microvascular ischemia. However, the nature of KTDS has not been prospectively defined. We aimed at describing the spectral and power motion Doppler characteristics of KTDS and ultrasound exposure conditions that lead to their appearance.METHODS: Consecutive patients referred with symptoms of stroke or transient ischemic attacks to our cerebrovascular ultrasound laboratory were screened for the presence of KTDS. The presence of microvascular ischemia was assessed using brain MRI.RESULTS: Among 327 patients with cerebrovascular symptoms, 46 (14%) had KTDS. KTDS were found more frequently in posterior circulation vessels (55% vertebral artery, 21.5% basilar artery, and 6% posterior cerebral artery). There was no association between ultrasound identification of KTDS and the presence of brain ischemia in the distribution of any vessel (OR, 0.37; 95% CI, 0.09-1.53; P=0.171) on univariate logistic regression analyses. KTDS was not related to the presence of microvascular ischemia on brain MRI (OR, 1.12; 95% CI, 0.55-2.29; P=0.761). We described the range of spectral and power motion Doppler appearances of KTDS and experimentally demonstrated the most likely underlying mechanism being a large vessel wall movement artifact.CONCLUSIONS: Although KTDS can be distinguished from other spectral flow signals, they can be found in normal vessels, they do not seem to be associated with the vessel affected by ischemia, and they should not be overinterpreted.