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American Society of Neuroimaging 35th Annual Meeting
American Society of Neuroimaging 35th Annual Meeting
Neurosonology Value in the Neuro-
Critical Care Unit (NCCU)
Alex Razumovsky, PhD, FAHA
Director
Sentient NeuroCare Services, Inc.
American Society of Neuroimaging 35th Annual Meeting
American Society of Neuroimaging 35th Annual Meeting
DISCLOSURES
FTE, Private Practice for profit
American Society of Neuroimaging 35th Annual Meeting
Daily TCD
Continuous EEG
ICP monitoring
Pb02
CBF
American Society of Neuroimaging 35th Annual Meeting
Multimodal Monitoring:
Vasospasm/Ischemia/high ICP Detection
• MAP
• SaO2
• ECG
• Et-CO2
• CVP
• Urine output
• ICP
• CBFV/TCD PbO2
cEEG
CT/MR Perfusion
The primary goal of
management for
TBI is the
prevention of
secondary damage
due to neuronal
hypoxia and
hypoperfusion
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American Society of Neuroimaging 35th Annual Meeting
Specific TCD Applications for NCCU
• Vasospasm diagnosis after SAH
• Vasospasm monitoring after SAH
• Vasospasm treatment effect after SAH
• Vasospasm diagnosis and monitoring after tumor resection
• Acute stroke diagnosis/monitoring
• PFO screening in acute stroke patients
• Evaluation of patients after CEA
• Neuroradiology test-occlusion (pre, during and post)
• Neuroradiology stenting (pre, during and post)
• Pre- and Post-treatment AVM evaluation
• Intracranial Hypertension and Brain Death
American Society of Neuroimaging 35th Annual Meeting
Multimodality Monitoring
• Clinical (Neurological)
• Anatomical (Angiography, MRI/MRA,
CT/CTA)
• Neurophysiological (EEG, EP, BAER)
• Hemodynamic Neuromonitoring (MAP,
ICP, CPP, CBF/CBFV)
• Metabolic (EtCO2, PaCO2, SaO2, SjO2)
American Society of Neuroimaging 35th Annual Meeting
Multimodality Monitoring
Classical parameters
• MAP
• ICP
• CPP
• SjvO2
• PtiO2
• PaCO2
• CBF/CBFV
New exp. parameters
• Parenchymal glucose,
lactate, glycerol, and
glutamate
• Brain temperature
• S-100B protein and NSE
• CtiBF (Thermodilution)
• Local CBF (LDF)
• rSO2 (NIRS)
• Interstitial local pH&pCO2
American Society of Neuroimaging 35th Annual Meeting
TCD AND VASOSPASM AFTER SAH
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American Society of Neuroimaging 35th Annual Meeting
Pathophysiological Alterations
following Aneurysmal SAH
• Intracerebral & Intraventricular Hemorrhage
• Hydrocephalus
• Cerebral edema
• Seizures & Seizure-like Activity
• Alteration in Respiratory Function
• Effect on the Heart
• Fluid and Electrolyte Disturbance
• Cerebral ischemia
American Society of Neuroimaging 35th Annual Meeting
Vasospasm and Cerebral Ischemia
• Although there are medical therapies for
vasospasm after SAH, early detection of
vasospasm and initiation of aggressive medical
therapy is of utmost importance to avoid
delayed neurological ischemia, morbidity, and
mortality
American Society of Neuroimaging 35th Annual Meeting
CEREBRAL VASOSPASM AND
ITS CLINICAL SIGNIFICANCE
American Society of Neuroimaging 35th Annual Meeting
Cerebral Vasospasm
• Some substances (numerous neurotransmitters, blood constituents or breakdown products, and autocoids) released at the time of SAH acts on smooth muscle wall to cause vasoconstriction
• Morphological changes of the arterial wall consistent with vasonecrosis or vasculopathy
• Mechanical compression may also result in vessels constriction
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American Society of Neuroimaging 35th Annual Meeting
Vasospasm mechanisms Leung, Stroke, 2002
Macdonald, NeurosurgRev, 2006
Blood breakdown products:
• ApolipoproteinE genotype
Immunomodulatory, neurotoxic, oxidative effects
APOE4 less effective than APOE3 in suppressing neurotoxicity
• Endothelin1 release from CSF leukocytes
Potent vasoconsrictor
Synergistic effect in vasoconstriction between
• APOE and Endothelin1
American Society of Neuroimaging 35th Annual Meeting
Double-hit model of delayed ischemic neurological deficits after SAH
based on Dreier et al. The two hits on the brain parenchyma consist of
acutely triggered microvascular spasm in response to spreading
depolarizations, superimposed on chronic vasospasm
American Society of Neuroimaging 35th Annual Meeting
Early Brain Injury Sehba F, 2011
American Society of Neuroimaging 35th Annual Meeting
Early Brain Injury and Potential Therapy Sehba F, 2011
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American Society of Neuroimaging 35th Annual Meeting
Clinical Features of Symptomatic
Vasospasm
• Variable clinical course
• Usually peaks at 7-10 days following SAH
• Usually gradually evolves with waxing and
waning symptoms
• New HA, seizures, or decreased alertness
• New focal neurological signs -
MCA/ACA/border zone
American Society of Neuroimaging 35th Annual Meeting
Cerebral Vasospasm and Delayed Ischemic Deficit
Dorsch et al., 1994
• Literature review of more than 30 000 cases
• Angiographic vasospasm occurred in 43.3% (range
19% - 97%)
• DID occurred in 32.3% (range 5%-90%)
• Outcome of DID:
- Death in 30.3%
- Permanent deficit in 34%
- Good outcome in 35.7%
American Society of Neuroimaging 35th Annual Meeting
A clinical review of cerebral vasospasm and delayed
ischaemia following aneurysm rupture Dorsch N, 2011
• Online and physical searches have been made of the relevant literature.
• The incidence of delayed ischemic deficit (DID) or symptomatic vasospasm
reported in 1994 was 32.5% in over 30,000 reported cases. In recent years, 1994-
2009, it was 6,775/23,806, or 28.5%.
• Many of the recent reports did not specify whether a calcium antagonist was used
routinely, and when this was stated (usually nimodipine or nicardipine), DID was
noted in 22.0% of 10,739 reported patients.
• The outcome of DID in the earlier survey was a death rate of 31.6%, with
favorable outcomes in 36.2%. In recent reports, though with fewer than 1,000
patients, the outcome is possibly better, with death in 25.6% and good outcome in
54.1%.
• It thus appears likely that delayed vasospasm is still common but less so, and that
the overall outcome has improved. This may be due to the more widespread use of
calcium antagonists and more effective fluid management.
American Society of Neuroimaging 35th Annual Meeting
TCD DIAGNOSIS OF
VASOSPASM
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American Society of Neuroimaging 35th Annual Meeting
CBF vs. CBFV
• 133Xe
• Stable xenon-enhanced CT
• MRI/MRA
• CT/CTA
• PET
• SPECT
• The time, expense, and complexity of these
techniques still limits its use in routine clinical
practice American Society of Neuroimaging 35th Annual Meeting
TCD Diagnosis of Vasospasm
Newell et al., 1993
American Society of Neuroimaging 35th Annual Meeting
Diagnosis and Monitoring of
Vasospasm: ANGIOGRAPHY
• Degree of angiographic vasospasm does not
always correlate with the clinical condition.
Some patients remain asymptomatic with
severe vasospasm demonstrated by
angiography
• Incidence of angiographic vasospasm is nearly
twice that of DID
American Society of Neuroimaging 35th Annual Meeting
Diagnosis and Monitoring of
Vasospasm: TCD
• High CBFV can identify patients at higher risk
for developing DID, but also may occur in
asymptomatic patients
• Neurologist/Neurointensivist must determine
whether the severity and location of the vessel
narrowing/high CBFV are appropriate to cause
the clinical deficit
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American Society of Neuroimaging 35th Annual Meeting
Transcranial Doppler in cerebral vasospasm Newell et al., 1990
MCA CBFV ≥ 120 cm/s 25% narrowing
MCA CBFV ≥ 140 cm/s 25-50% narrowing
MCA CBFV ≥ 200 cm/s 50% narrowing
TCD DSA
American Society of Neuroimaging 35th Annual Meeting
TCD Criteria for diagnosis of vasospasm
Mean CBFV MCA/ICA ratio Interpretation
(cm/s) (Lindegaard Ratio)
<100 < 3 Nonspecific
100-139 3-6 Mild
140-199 3-6 Moderate
>200 >6 Severe
American Society of Neuroimaging 35th Annual Meeting
TCD and vasospasm after SAH
• Currently, the gold standard for VSP diagnosis is cerebral angiography, replaceable by CTA, only when angiography is not available. Obviously, it is not feasible to perform such investigation as frequently as bedside clinical assessment.
• Repeated clinical assessments of a patient's neurological status carry the problem of detecting the clinical signs and symptoms of VSP, which occur only after VSP has already manifested its deleterious effects on the cerebral parenchyma.
• TCD is a non-invasive, non-expensive and sensitive modality allowing for bedside monitoring to determine CBFV’s indicative of changes in vascular diameter
American Society of Neuroimaging 35th Annual Meeting
TCD and vasospasm after SAH
• TCD can be useful pre-, intra- and post-operatively, while helping to recognize the development of cerebral VSP before the onset of its clinical effects
• VSP following SAH is a very important source of morbidity and mortality. Too often, the first sign is a neurologic deficit, which may be too late to reverse
• TCD assists in the clinical decision-making regarding further diagnostic evaluation and therapeutic interventions.
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Guidelines for the Management of
Aneurysmal SAH Stroke Council, AHA, 1994
• Summary and Recommendations: 1. SAH is a medical emergency…
2. CT scanning for suspected SAH is strongly
recommended…
3. Selective cerebral angiography to document...
4. TCD is recommended for the diagnosis and
monitoring of VSP, although the cerebral
angiography may be required for definitive
diagnosis
American Society of Neuroimaging 35th Annual Meeting
Prediction of symptomatic VSP after
SAH with TCD
• An early CBFV increase
(Seiler et al., 1988)
• A rapid CBFV increase in
the first 6 days (Grote et
al., 1988)
• A CBFV increase of at
least 50 cm/sec during 24
hours (Grosset et al.,
1993)
• A CBFV increase of 50 cm/sec during 48 hours (Wardlow et al., 1998)
• Relative changes in CBFV’s (two or threefold CBFV increase) in patients with aneurysmal SAH correlated better with clinically significant VSP than absolute CBFV’s (Naval et al,
2005)
American Society of Neuroimaging 35th Annual Meeting
SAH Pt 1
Day 1
Rt MCA (M1 segm); 60 cm/s Lt MCA (M1 segm); 64 cm/s
Day 3
Rt MCA; 100 cm/s Lt MCA; 110 cm/s
American Society of Neuroimaging 35th Annual Meeting
SAH Pt 1
Day 8
Rt MCA (M1 segm); 212 cm/s Lt MCA (M1 segm); 230 cm/s
Day 15
Rt MCA; 308 cm/s Lt MCA; 121 cm/s
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SAH. Pt 2
Day 5
Lt MCA; 126 cm/s Rt MCA; 88 cm/s
Day 6
Lt MCA; 118 cm/s Rt MCA; 28 cm/s
American Society of Neuroimaging 35th Annual Meeting
SAH. Pt 2
Day 7
Lt MCA; 139 cm/s Rt MCA; 148 cm/s
American Society of Neuroimaging 35th Annual Meeting
SAH. Pt. 3
Day 3
Rt MCA; 126 cm/s Lt MCA; 88 cm/s
Day 4
Rt MCA; 38 cm/s Lt MCA; 43 cm/s
American Society of Neuroimaging 35th Annual Meeting
SAH. Pt 3
Day 5
Rt MCA; 131 cm/s Lt MCA; 158 cm/s
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Role of TCD: VSP Diagnosis
• Elevated CBFV’s in asymptomatic patients warrant
meticulous observation in some closely supervised
setting until CBFV’s begin trend downward
• Elevated CBFV’s in a particular vascular territory can
focus subsequent neurologic examinations to detect
subtle changes earlier in their clinical course
American Society of Neuroimaging 35th Annual Meeting
Role of TCD: VSP Diagnosis
• In symptomatic patients, elevated CBFV’s most
likely represent significant vessel narrowing and
may obviate the need for cerebral angiography. At
this point, triple-H therapy can be initiated or
advanced
• Asymptomatic patients without elevated CBFV’s
probably can avoid additional angiography.
However, we need to consider patient’s age
because elderly patient’s could develop VSP in
normal or slightly abnormal CBFV range
American Society of Neuroimaging 35th Annual Meeting
2011 AHA/ASA Metrics for Measuring
Quality of Care in Comprehensive Stroke
Centers
• Among different measures for Comprehensive
Stroke Centers is:
Median frequency of noninvasive monitoring
for surveillance for vasospasm in patients with
aneurysmal SAH during the period between
three and 14 days after SAH
American Society of Neuroimaging 35th Annual Meeting
TCD AND VASOSPASM AFTER TBI
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American Society of Neuroimaging 35th Annual Meeting
TBI
• Every 21 seconds, one person
in the US sustains traumatic
brain injury (TBI)
• An estimated 5.3 million
Americans – little more than
2% of the US population –
currently live with disabilities
resulting from brain injury
• Each year, 80,000 Americans
experience the onset of long-
term disability following TBI
• Okie, NEJM, 2005: Among
surviving soldiers wounded in
combat in Iraq and Afghanistan,
TBI appears to account for a
larger proportion of casualties
than it has in other recent U.S.
wars. According to the Joint
Theater Trauma Registry, 22%
had injuries to the head, face, or
neck.
Armonda et al, 2006: 47.4% had
traumatic cerebral vasospasm.
Majority were blast related injury
Civilian
Battlefield
American Society of Neuroimaging 35th Annual Meeting
Blast TBI
• Blast injuries historically
seen by providers as
limited to military concern
Peacetime terrorism over
the last decade has
reminded us otherwise
•
American Society of Neuroimaging 35th Annual Meeting
Why we need talk about blast TBI?
• Mortality:
– Oklahoma City 167
– US Embassy 223
– World Trade Center 2,801
– Madrid train bombings 191
– London 56
– Domodedovo 37
– Minsk metro 12
Large number of injured…
American Society of Neuroimaging 35th Annual Meeting
TBI PATHOPHYSIOLOGY
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Balancing Multisystem Interactions
TBI
American Society of Neuroimaging 35th Annual Meeting
TBI: Pathophysiology
Primary Injury:
- Contusions/Hemorrhages
- Diffuse Axonal Injury (DAI)
Secondary Injury (Intracranial) occurs hours to weeks after injury:
- Blood Flow and Metabolic Changes
- Traumatic Hematomas
- Cerebral Edema
- Hydrocephalus
- Increased Intracranial Pressure - PTSD?!
American Society of Neuroimaging 35th Annual Meeting
Decrease in CBF
BRAIN
EDEMA
More Brain Ischemic Blood Vessels
Edema brain cells Dilate
Increased ICP
Cell Injury
American Society of Neuroimaging 35th Annual Meeting
TBI and vasospasm
• Cerebral posttraumatic VSP (PTV) was first described by Lorn in 1936
• The incidence of CT documented traumatic SAH has been identified in 4% to 63% of pts after TBI
• Study from the University of Mississippi Medical Center indicated that traumatic SAH complicate course of TBI in 69% of the patients due to the presence of PTV
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WARTIME TRAUMATIC CEREBRAL VASOSPASM:
RECENT REVIEW OF COMBAT CASUALTIES
Armonda et al., Neurosurgery, 2006
• The first study to analyze the effects of
blast-related injury on the cerebral
vasculature
• This study showed that TCV occurred in a
substantial number of patients with severe
neurotrauma, and clinical outcomes were
worse for those with this condition
American Society of Neuroimaging 35th Annual Meeting
25 yo, severe concussion (IED)
no hemorrhage (Courtesy of Dr. Armonda)
CBFV
(cm/sec)
Calendar
TLA
TLA TLA
American Society of Neuroimaging 35th Annual Meeting
Mild TBI
American Society of Neuroimaging 35th Annual Meeting
Transcranial Doppler to screen on admission patients with
mild to moderate traumatic brain injury.
Bouzat et a, Neurosurgery, 2011
• In patients with no severe brain lesions on
CT following mild to moderate TBI, TCD
on admission, in complement with brain CT
scan, could accurately screen patients at risk
for secondary neurological deterioration
(edema, herniation, hydrocephalus) within
first week after TBI
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Patient with GSW. The CBFV and PI asymmetry
Right MCA
Left MCA
American Society of Neuroimaging 35th Annual Meeting
Role of TCD: Traumatic Brain Injury
• CBFV’s often increased in patients with TBI due to the vasospasm
• TCD waveform changes can signal significant ICP changes
• Sudden onset of the asymmetric pattern of the CBFV’s and PI’s could indicate midline shift
• TCD ultrasonography is valid in predicting the patient’s outcome
American Society of Neuroimaging 35th Annual Meeting
TCD AND VASOSPASM AFTER
TUMOR RESECTION
American Society of Neuroimaging 35th Annual Meeting
Tumor Resection and Vasospasm
• The occurrence of vasospasm and delayed
cerebral ischemia after resection of
intracranial tumor has not received
extensive attention clinically, and is often
misdiagnosed and improperly treated as
surgical brain damage or brain swelling
• However, DID from vasospasm after tumor
resection is a complication that is being
reported in increasing numbers
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Tumor Resection and Vasospasm: Literature
review
• Reports are sparse and mainly case series
• Vasospasm was found in 2% to 49% patients. No
significant difference among age, sex, surgical
approaches, pathological diagnosis, duration of
surgery, amount of blood loss and transfusion
during surgery were found, but significant
difference was seen in cisternal hemorrhage on CT
scan and the amount of blood in cerebrospinal
fluid
American Society of Neuroimaging 35th Annual Meeting
Tumor Resection and Vasospasm: Probable
Mechanism
• It is suggested that accumulation of blood in the basal cisterns may have been responsible for this unusual condition, and it is therefore important to consider vasospasm as a probable etiological cause of clinical deterioration in patients undergoing the surgical removal of a cerebral tumor.
• For this reason, whenever any neurological deterioration occurs in such patients, it is advisable to perform TCD in order to verify the presence of any vasospasm and promptly commence suitable treatment.
American Society of Neuroimaging 35th Annual Meeting
Suprasellar tumor resection.
The CBFV's and Trends of the Systemic
Hemodynamic
RIGHT LEFT
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10/3010/3111/111/211/311/411/511/611/711/811/911/10 10/3010/3111/111/211/311/411/511/611/711/811/911/10
Calendar
CB
FV
's a
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MCA M1
MCA M2
ACA
ICA C1
VA
BA
MAP
ICP
Hct
PaCO2
Temp
American Society of Neuroimaging 35th Annual Meeting
Factors influencing TCD data
interpretation
• Patient age
• The presence of moderate to severe anemia
(Hct <27)
• Impaired CBF autoregulation (passive CBFV
variation with MAP changes)
• Hyperemia induced by triple-H therapy
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Role of TCD: Vasospasm Monitoring
• It is useful to perform TCD test on admission (or
ASAP after surgery) and perform daily TCD
studies when patient is in the ICU
• The frequency with which TCD should be
performed may be guided by patient clinical
presentation, knowledge of risk factors for VSP,
early clinical course
• TCD studies should be performed after
endovascular treatment to identify patients with
recurrent VSP American Society of Neuroimaging 35th Annual Meeting
Role of TCD: Vasospasm Monitoring
• The presence and temporal profile of CBFV’s in all available vessels must be detected and serially monitored
• The pattern of CBFV’s elevation may indicate the need to follow patient carefully for evidence of deficits related to specific vascular territory
• Waveform appearance either regionally, or globally may be clinically significant
American Society of Neuroimaging 35th Annual Meeting
CEA/STENTING EFFECT
EVALUATION
American Society of Neuroimaging 35th Annual Meeting
Role of TCD: CEA/Stenting
• TCD evaluation of CVR (CO2 induced response)
allows selection and quantification of patients with
true cerebrovascular insufficiency
• TCD can directly insonate the intracranial arteries
to evaluate collateral circulation around the circle
of Willis and to select those patients who most and
least likely to benefit from i/o shunt insertion
during CEA
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Role of TCD: CEA/Stenting
• TCD provides continuous noninvasive
monitoring of the right and left MCA CBFV’s
and immediately detects changes in cerebral
perfusion during CEA manipulation (cross-
clamping)/stenting
• Malfunction of the shunt (twisting or
compression) can be promptly detected by
TCD and corrected
American Society of Neuroimaging 35th Annual Meeting
Role of TCD: CEA/Stenting
• TCD monitoring provides the opportunity to
assess the rate of microemboli to the brain in
patients before, during or after CEA/stenting to
verify whether these phenomena have ceased after
procedure. If not, the pharmacological
intervention can be instituted
• If CBFV is markedly decreased from the baseline
level after CEA/stenting, intraluminal
complications can be suspected and exploration of
the arteriotomy can be immediately carried out
American Society of Neuroimaging 35th Annual Meeting
Role of TCD: CEA/Stenting
• Patients with a relative hyperemia after shunt
insertion/CEA/stenting (100% or greater
increase in CBFV MCA) can be identified and
pharmacological intervention can be instituted
if necessary
American Society of Neuroimaging 35th Annual Meeting
TCD AND NEURORADIOLOGY
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Neuroradiology (Test-Occlusion)
• Patients with giant intracranial aneurysms
(not accessible with direct surgery/coiling)
and vascular tumors (cervical cancer) may
undergo temporary/permanent occlusion of
the internal carotid artery, to determine
brain tolerance to exclusion of that vessel if
it must be sacrificed
American Society of Neuroimaging 35th Annual Meeting
Neuroradiology: Test-Occlusion
Arteriogram of a giant
aneurysm of the ICA
MCA CBFV during test-occlusion
American Society of Neuroimaging 35th Annual Meeting
Predicting cerebral ischemia…
Eckert et al, AJNR, 1998
American Society of Neuroimaging 35th Annual Meeting
Role of TCD: Neuroradiology (Test-Occlusion)
• TCD Monitoring of the ipsilateral MCA CBFV during test-occlusion determines the percent change in CBFV during balloon inflation and documents the collateral pathways patency/absency
• This information compliments the balloon occlusion procedure and can help in identifying the patients who are at risk for hemodynamic stroke following ICA permanent occlusion
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AVM Treatment
PRE-EMBOLIZATION POSTEMBOLIZATION
TCD PRE-EMBOLIZATION TCD POST-EMBOLIZATION
American Society of Neuroimaging 35th Annual Meeting
Role of TCD: AVM
• TCD study can provide two different types of
clinical information: the diagnosis and anatomical
localization of AVM
• TCD can be useful addition to CT-scanning and
for planning the angiography
• TCD offers the prospect of reducing the number of
X-ray exposures required in follow up
American Society of Neuroimaging 35th Annual Meeting
TCD AND INTRACRANIAL
HYPERTENSION
American Society of Neuroimaging 35th Annual Meeting
TCD wave-form changes with
development of intracranial
hypertension
Normal ICP
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Patient with GSW Trend shows almost direct inverse relationship between
CBFV and PI
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CBFV ICP PI
CALENDAR
MCA CBFV
MCA PI
ICP
RIGHT LEFT
American Society of Neuroimaging 35th Annual Meeting
TCD role for intracranial
hypertension evaluation
• TCD wave-form changes indicates abnormally high ICP, especially after 30 to 35 mm Hg
• TCD changes may alarm Neuro-ICU personnel and may indicate malfunctioning of ICP probe
• Sudden onset of asymmetrical CBFV’s and PI’s changes may indicate potential mid-line shift
• TCD quantitative and qualitative analysis must be taken into account for evaluation of intracranial hypertension, however, MAP, PaCO2 and cardiac output must be within the normal limits
American Society of Neuroimaging 35th Annual Meeting
TCD in the management of
TBI/Intracranial Hypertension
Pulsatility Index (PI) measurements permit the early identification of patients with low CPP and high risk of cerebral ischemia. In emergency situations it can be used alone when ICP monitoring is contraindicated or not readily available
TCD is an excellent first-line examination to determine those patients who need urgent aggressive treatment and continuous invasive ICP monitoring
Preliminary study suggests that TCD could be used in pre-hospital care to detect patients whose CPP may be impaired
American Society of Neuroimaging 35th Annual Meeting
Role of TCD: Intracranial Hypertension
• TCD waveform changes can signal significant ICP changes, usually after 30 – 35 mm Hg
• TCD waveform changes can alarm NCCU personnel and indicate malfunctioning of ICP probe
• CBFV’s decreased in patients with suspected intracranial hypertension and decreased brain compliance
• Sudden onset of the asymmetric pattern of the CBFV’s and PI’s could indicate midline shift
• TCD quantitative and qualitative analysis is valid in predicting intracranial hypertension
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TCD AND BRAIN DEATH
American Society of Neuroimaging 35th Annual Meeting
TCD wave form progression from intact
CBFV to circulatory arrest
Hassler et al., 1988
C P P
American Society of Neuroimaging 35th Annual Meeting
TCD pattern in patient with brain
stem stroke
American Society of Neuroimaging 35th Annual Meeting
CPP = 0
TCD pattern in Brain Death
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Role of TCD: Brain Death
• Quickly detects dramatically elevated ICP
• Confirms brain death in comatose patients
• Reliably determines arrest of cerebral
circulation, which can shorten observation
time for organ retrieval in patient with brain
death
American Society of Neuroimaging 35th Annual Meeting
TODAY:
• The value of TCD in clinical practice is well
established, especially to measure and grade
vasospasm following SAH and TBI
• Based on AHA Guidelines and many years of clinical
practice TCD is a tool employed by the
Neurosurgeon, Neurointensivist and Neurologist in
the management with SAH, TBI, acute stroke, etc
TCD is Critical Tool in Critical Care
American Society of Neuroimaging 35th Annual Meeting
TCD as a Modality
• Will be very good, reliable and accurate , if:
• Dedicated Personnel
• Daily Monitoring of the Technical
Performance Quality
• Quality of Interpretation