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Deana C, Biasucci DG, Aspide R, Brasil S, Vergano M, Leonardis F, Rica E, Cammarota G, Dauri M, Vetrugno G, Longhini F, Maggiore SM, Rasulo F, Vetrugno L. Transcranial Doppler and Color-Coded Doppler Use for Brain Death Determination in Adult Patients: A Pictorial Essay. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:979-992. [PMID: 38279568 DOI: 10.1002/jum.16421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 01/28/2024]
Abstract
Transcranial Doppler (TCD) is a repeatable, at-the-bedside, helpful tool for confirming cerebral circulatory arrest (CCA). Despite its variable accuracy, TCD is increasingly used during brain death determination, and it is considered among the optional ancillary tests in several countries. Among its limitations, the need for skilled operators with appropriate knowledge of typical CCA patterns and the lack of adequate acoustic bone windows for intracranial arteries assessment are critical. The purpose of this review is to describe how to evaluate cerebral circulatory arrest in the intensive care unit with TCD and transcranial duplex color-coded doppler (TCCD).
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Affiliation(s)
- Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Daniele G Biasucci
- Department of Clinical Science and Translational Medicine, "Tor Vergata" University, Rome, Italy
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
- Catholic University of the Sacred Heart (UCSC), Rome, Italy
| | - Raffaele Aspide
- Anesthesia and Neurointensive Care Unit, Istituto delle Scienze Neurologiche IRCCS, Bologna, Italy
| | - Sergio Brasil
- Neurosurgical Division, Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Francesca Leonardis
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
- Department of Surgical Science, "Tor Vergata" University, Rome, Italy
| | - Ermal Rica
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Gianmaria Cammarota
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, "Tor Vergata" University, Rome, Italy
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
| | - Giuseppe Vetrugno
- Catholic University of the Sacred Heart (UCSC), Rome, Italy
- Risk Management, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Salvatore Maurizio Maggiore
- Department of Innovative Technologies in Medicine & Dentistry, Section of Anesthesia and Intensive Care, "G. D'Annunzio" University, "SS. Annunziata" Hospital, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, "SS. Annunziata" Hospital, Chieti, Italy
| | - Frank Rasulo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency, "SS. Annunziata" Hospital, Chieti, Italy
- Department of Medical, Oral and Biotechnological Science, "G. d'Annunzio" Chieti-Pescara University, Chieti, Italy
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Llompart-Pou JA, Galarza L, Amaya-Villar R, Godoy DA. Transcranial sonography in the critical patient. Med Intensiva 2024; 48:165-173. [PMID: 38431382 DOI: 10.1016/j.medine.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/09/2023] [Indexed: 03/05/2024]
Abstract
Transcranial ultrasonography is a non-invasive, bedside technique that has become a widely implemented tool in the evaluation and management of neurocritically ill patients. It constitutes a technique in continuous growth whose fundamentals (and limitations) must be known by the intensivist. This review provides a practical approach for the intensivist, including the different sonographic windows and planes of insonation and its role in different conditions of the neurocritical patients and in critical care patients of other etiologies.
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Affiliation(s)
- Juan Antonio Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain.
| | - Laura Galarza
- Servicio de Medicina Intensiva, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - Rosario Amaya-Villar
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Daniel Agustín Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina
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Sigman EJ, Laghari FJ, Sarwal A. Neuro Point-of-Care Ultrasound. Semin Ultrasound CT MR 2024; 45:29-45. [PMID: 38070756 DOI: 10.1053/j.sult.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
As the scope of point-of-care ultrasound (POCUS) expands in clinical medicine, its application in neurological applications offers a non-invasive, bedside diagnostic tool. With historical insights, detailed techniques and clinical applications, the chapter provides a comprehensive overview of neurology-based POCUS. It examines the applications, emphasizing its role when traditional neuroimaging is inaccessible or unsafe as well advocating for its use as an adjunctive tool, rather than a replacement of advanced imaging. The chapter covers a range of uses of neuro POCUS including assessment of midline shift, intracranial hemorrhage, hydrocephalus, vasospasm, intracranial pressure, cerebral circulatory arrest, and ultrasound-guided lumbar puncture.
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Affiliation(s)
- Erika J Sigman
- Neurocritical Care, Department of Neurology, Emory University School of Medicine, Atlanta, GA.
| | - Fahad J Laghari
- Neuroendovascular Surgery, Department of Neurosurgery, Carondelet Neurological Institute, Tucson, AZ
| | - Aarti Sarwal
- Neurocritical Care, Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC
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Ganjeifar B, Mehrad-Majd H, Barforooshi AG, Baharvahdat H, Zabihyan S, Moradi A. Diagnostic Value of Computed Tomography Angiography in Confirmation of Brain Death. World Neurosurg 2023; 178:e275-e281. [PMID: 37467952 DOI: 10.1016/j.wneu.2023.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Accurate and on-time confirmation of brain death (BD) is necessary to prevent unnecessary treatment and allow for well-timed organ harvest for transplantation. Although the clinical criteria for BD are legally reliable in some countries, others might prefer complementary ancillary tests to assess the brain's electrical activity and/or blood circulation. The present study aims to define the sensitivity and specificity of computed tomography angiography using 4-, 7-, and 10-point tests compared with the clinical criteria and electroencephalographic findings in patients with BD. METHODS A total of 32 patients with a confirmed diagnosis of BD according to their clinical criteria (cases) and 18 patients with a Glasgow coma scale score of 3 and absent brain stem and papillary reflexes who had spontaneous respiration (controls) were included in the present study. All the patients had blood pressure >90 mm Hg, diuresis >100 mL/hour, and central venous pressure >6-8 mm Hg, and undergone computed tomography angiography (CTA). The 4-, 6-, and 10-point criteria were used to determine the opacity and lack of opacity of the brain vessels in the CTA evaluation scales for the diagnosis of BD. RESULTS The 2 groups were homogeneous in terms of age, gender distribution, and coma etiology. All 18 patients in the control group received a score of 0 in the 4-, 7-, and 10-point scores. In contrast, the average values for the 4-, 7-, and 10-point scores for the patients with confirmed BD were 3.75 ± 0.67, 6.4 ± 1.36, and 9.06 ± 2.2, respectively. Of the patients with BD, 28 (87.5%), 26 (81.25%), and 25 (78.12%) received the full score for the 4-point, 7-point, and 10-point tests. The sensitivity, specificity, and negative and positive predictive values for all 3 scores were 100%. Also, the sensitivity for the various cerebral vessels were as follows: internal cerebral vein, 100%; great cerebral vein, 96.9%; posterior 2, 90.6%, middle 4, 87.5%; basilar artery, 84.4%; and anterior 3, 84.4%. Finally, the specificity for the lack of opacification in all these vessels for the diagnosis of BD was 100%. CONCLUSIONS According to our findings, the CTA-based 4-point scoring system with 100% specificity can be used with the clinical examination findings to confirm BD.
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Affiliation(s)
- Babak Ganjeifar
- Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hassan Mehrad-Majd
- Clinical Research Development Unit, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Humain Baharvahdat
- Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Samira Zabihyan
- Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Moradi
- Clinical Research Development Unit, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran; Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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Abstract
OBJECTIVES Critically ill patients are at high risk of acute brain injury. Bedside multimodality neuromonitoring techniques can provide a direct assessment of physiologic interactions between systemic derangements and intracranial processes and offer the potential for early detection of neurologic deterioration before clinically manifest signs occur. Neuromonitoring provides measurable parameters of new or evolving brain injury that can be used as a target for investigating various therapeutic interventions, monitoring treatment responses, and testing clinical paradigms that could reduce secondary brain injury and improve clinical outcomes. Further investigations may also reveal neuromonitoring markers that can assist in neuroprognostication. We provide an up-to-date summary of clinical applications, risks, benefits, and challenges of various invasive and noninvasive neuromonitoring modalities. DATA SOURCES English articles were retrieved using pertinent search terms related to invasive and noninvasive neuromonitoring techniques in PubMed and CINAHL. STUDY SELECTION Original research, review articles, commentaries, and guidelines. DATA EXTRACTION Syntheses of data retrieved from relevant publications are summarized into a narrative review. DATA SYNTHESIS A cascade of cerebral and systemic pathophysiological processes can compound neuronal damage in critically ill patients. Numerous neuromonitoring modalities and their clinical applications have been investigated in critically ill patients that monitor a range of neurologic physiologic processes, including clinical neurologic assessments, electrophysiology tests, cerebral blood flow, substrate delivery, substrate utilization, and cellular metabolism. Most studies in neuromonitoring have focused on traumatic brain injury, with a paucity of data on other clinical types of acute brain injury. We provide a concise summary of the most commonly used invasive and noninvasive neuromonitoring techniques, their associated risks, their bedside clinical application, and the implications of common findings to guide evaluation and management of critically ill patients. CONCLUSIONS Neuromonitoring techniques provide an essential tool to facilitate early detection and treatment of acute brain injury in critical care. Awareness of the nuances of their use and clinical applications can empower the intensive care team with tools to potentially reduce the burden of neurologic morbidity in critically ill patients.
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Affiliation(s)
- Swarna Rajagopalan
- Department of Neurology, Cooper Medical School of Rowan University, Camden, NJ
| | - Aarti Sarwal
- Department of Neurology, Atrium Wake Forest School of Medicine, Winston-Salem, NC
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Tamagnone FM, Cheong I, Luna E, Previgliano I, Otero Castro V. Ultrasound-guided cerebral resuscitation in patients with severe traumatic brain Injury. J Clin Monit Comput 2023; 37:359-363. [PMID: 36454340 DOI: 10.1007/s10877-022-00954-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 11/24/2022] [Indexed: 12/04/2022]
Abstract
Traumatic brain injury (TBI) is a worldwide public health concern given its significant morbidity and mortality, years of potential life lost, reduced quality of life and elevated healthcare costs. The primary injury occurs at the moment of impact, but secondary injuries might develop as a result of brain hemodynamic abnormalities, hypoxia, and hypotension. The cerebral edema and hemorrhage of the injured tissues causes a decrease in cerebral perfusion pressure (CPP), which leads to higher risk of cerebral ischemia, herniation and death. In this setting, our role as physicians is to minimize damage by the optimization of the CPP and therefore to reduce mortality and improve neurological outcomes. Performing a transcranial doppler ultrasound (TCD) allows to estimate cerebral blood flow velocities and identify states of low flow and high resistance. We propose to include TCD as an initial assessment and further monitoring tool for resuscitation guidance in patients with severe TBI. We present an Ultrasound-Guided Cardio-cerebral Resuscitation (UGCeR) protocol in Patients with Severe TBI.
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Affiliation(s)
| | - Issac Cheong
- Argentinian Critical Care Ultrasonography Association (ASARUC), Buenos Aires, Argentina.
- Department of critical care medicine, Sanatorio De los Arcos, Buenos Aires, Argentina.
- Department of critical care medicine, Sanatorio De los Arcos, Juan B. Justo 909, Buenos Aires, Argentina.
| | - Ezequiel Luna
- Department of critical care medicine, Sanatorio Guemes, Buenos Aires, Argentina
| | - Ignacio Previgliano
- Maimonides University, Buenos aires, Argentina
- Hospital General de Agudos J. A. Fernández, Buenos Aires, Argentina
| | - Victoria Otero Castro
- Department of critical care medicine, Sanatorio De los Arcos, Buenos Aires, Argentina
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Azevedo E. Diagnostic Ultrasonography in Neurology. Continuum (Minneap Minn) 2023; 29:324-363. [PMID: 36795882 DOI: 10.1212/con.0000000000001241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE Ultrasonography allows neurologists to complement clinical information with additional useful, easily acquired, real-time data. This article highlights its clinical applications in neurology. LATEST DEVELOPMENTS Diagnostic ultrasonography is expanding its applications with smaller and better devices. Most indications in neurology relate to cerebrovascular evaluations. Ultrasonography contributes to the etiologic evaluation and is helpful for hemodynamic diagnosis of brain or eye ischemia. It can accurately characterize cervical vascular atherosclerosis, dissection, vasculitis, or other rarer disorders. Ultrasonography can aid in the diagnosis of intracranial large vessel stenosis or occlusion and evaluation of collateral pathways and indirect hemodynamic signs of more proximal and distal pathology. Transcranial Doppler (TCD) is the most sensitive method for detecting paradoxical emboli from a systemic right-left shunt such as a patent foramen ovale. TCD is mandatory for sickle cell disease surveillance, guiding the timing for preventive transfusion. In subarachnoid hemorrhage, TCD is useful in monitoring vasospasm and adapting treatment. Some arteriovenous shunts can be detected by ultrasonography. Cerebral vasoregulation studies are another developing field of interest. TCD enables monitoring of hemodynamic changes related to intracranial hypertension and can diagnose cerebral circulatory arrest. Optic nerve sheath measurement and brain midline deviation are ultrasonography-detectable signs of intracranial hypertension. Most importantly, ultrasonography allows for easily repeated monitoring of evolving clinical conditions or during and after interventions. ESSENTIAL POINTS Diagnostic ultrasonography is an invaluable tool in neurology, used as an extension of the clinical examination. It helps diagnose and monitor many conditions, allowing for more data-driven and rapid treatment interventions.
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Sharma K, Sheikh A, Maertens P. Use of duplex echoencephalography to evaluate brain death in children: A novel approach to the diagnosis. J Neuroimaging 2023; 33:167-173. [PMID: 36097395 DOI: 10.1111/jon.13048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Brain death is defined as the irreversible cessation of brain function with a known etiology. This study aims to establish the value of duplex echoencephalography (DEG) in children fulfilling clinical brain death diagnostic criteria. METHODS DEG must show intracranial brain structures. Power Doppler is used to assess venous flow when feasible. Color Doppler patterns in all major arteries are assessed. Spectral analysis of arterial flow is divided into four grades: grade 1: inverted flow during entire diastole with time average peak velocity (TAPV) less or equal to zero; grade 2: disappearance of the inverted diastolic flow at the end of diastole; grade 3: oscillating pattern in early diastole; and grade 4: no diastolic flow with systolic blip. To fulfill diagnosis of brain death, brain perfusion must be lost for 30 minutes. RESULTS DEG is performed in 41 pediatric patients. In infants, loss of venous flow occurs regardless of the etiology. Grade 1 is the most common arterial color flow pattern and TAPV is always below zero. A pulsatile color flow is associated with three other types of flow patterns (grades 2-4). TAPV is not calculated, when there is loss of diastolic flow. Diagnosis of brain death is validated using nuclear brain scan in 4 patients. Two have a grade 1 flow pattern, while the other two have a grade 4 flow pattern. CONCLUSIONS In children, DEG following a strict protocol can be used to confirm diagnosis of brain death in the appropriate clinical setting.
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Affiliation(s)
- Kamal Sharma
- Department of Pediatrics, Pediatric Critical Care Division, University of South Alabama, Mobile, Alabama, USA
| | - Ameera Sheikh
- Department of Pediatrics, Pediatric Critical Care Division, University of South Alabama, Mobile, Alabama, USA
| | - Paul Maertens
- Department of Neurology, Child Neurology Division, University of South Alabama, Mobile, Alabama, USA
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Morelli N, Colombi D, Spallazzi M, Rota E, Michieletti E. Systolic spike on transcranial Doppler ultrasound in brain death determination: a matter of numbers. Radiol Bras 2023; 56:50-51. [PMID: 36926357 PMCID: PMC10013189 DOI: 10.1590/0100-3984.2022.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 03/16/2023] Open
Affiliation(s)
- Nicola Morelli
- Neurology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
- Radiology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Davide Colombi
- Radiology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | - Eugenia Rota
- Neurology Unit, San Giacomo Hospital, Novi Ligure, Alessandria,
Italy
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Slak P, Pušnik L, Plut D. Contrast-Enhanced Ultrasound (CEUS) as an Ancillary Imaging Test for Confirmation of Brain Death in an Infant: A Case Report. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101525. [PMID: 36291460 PMCID: PMC9600316 DOI: 10.3390/children9101525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022]
Abstract
The practices for determining brain death are based on clinical criteria and vary immensely across countries. Cerebral angiography and perfusion scintigraphy are the most commonly used ancillary imaging tests for brain death confirmation in children; however, they both share similar shortcomings. Hence, contrast-enhanced ultrasound (CEUS) as a relatively inexpensive, easily accessible, and easy-to-perform technique has been proposed as an ancillary imaging test for brain death confirmation. CEUS has established itself as a favourable and widely used diagnostic imaging method in many different areas, but its application in delineating brain pathologies still necessities further validation. Herein, we present a case report of a 1-year-old polytraumatised patient in whom CEUS was applied as an ancillary imaging test for confirmation of brain death. As CEUS has not been validated as an ancillary test for brain death confirmation, the diagnosis was additionally confirmed with cerebral perfusion scintigraphy.
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Affiliation(s)
- Peter Slak
- Clinical Radiology Institute, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana 1000, Slovenia
| | - Luka Pušnik
- Faculty of Medicine, University of Ljubljana, Ljubljana 1000, Slovenia
| | - Domen Plut
- Clinical Radiology Institute, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana 1000, Slovenia
- Correspondence:
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Lin JJ, Kuo HC, Hsia SH, Lin YJ, Wang HS, Hsu MH, Chiang MC, Chan OW, Lee EP, Lin KL. The Utility of a Point-of-Care Transcranial Doppler Ultrasound Management Algorithm on Outcomes in Pediatric Asphyxial Out-of-Hospital Cardiac Arrest – An Exploratory Investigation. Front Med (Lausanne) 2022; 8:690405. [PMID: 35155456 PMCID: PMC8832099 DOI: 10.3389/fmed.2021.690405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background Transcranial Doppler ultrasound is a sensitive, real time tool used for monitoring cerebral blood flow; it could provide additional information for cerebral perfusion in cerebral resuscitation during post cardiac arrest care. The aim of the current study was to evaluate the utility of a point-of-care transcranial Doppler ultrasound management algorithm on outcomes in pediatric asphyxial out-of-hospital cardiac arrest. Methods This retrospective cohort study was conducted in two tertiary pediatric intensive care units between January 2013 and June 2018. All children between 1 month and 18 years of age with asphyxial out-of-hospital cardiac arrest and a history of at least 3 min of chest compressions, who were treated with therapeutic hypothermia and survived for 12 h or more after the return of circulation were eligible for inclusion. Results Twenty-one patients met the eligibility criteria for the study. Sixteen (76.2%) of the 21 children were male, and the mean age was 2.8 ± 4.1 years. Seven (33.3%) of the children had underlying disorders. The overall 1-month survival rate was 52.4%. Twelve (57.1%) of the children received point-of-care transcranial Doppler ultrasound. The 1-month survival rate was significantly higher (p = 0.03) in the point-of-care transcranial Doppler ultrasound group (9/12, 75%) than in the non-point-of-care transcranial Doppler ultrasound group (2/9, 22.2%). Conclusions Point-of-care transcranial Doppler ultrasound group was associated with a significantly better 1-month survival rate compared with no point-of-care transcranial Doppler ultrasound group in pediatric asphyxial out-of-hospital cardiac arrest.
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Affiliation(s)
- Jainn-Jim Lin
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Respiratory Therapy, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hsuan-Chang Kuo
- Division of Cardiology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ying-Jui Lin
- Division of Cardiology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Mei-Hsin Hsu
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Neurology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ming-Chou Chiang
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Respiratory Therapy, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Division of Neonatology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - En-Pei Lee
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- *Correspondence: Kuang-Lin Lin
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Carotid Artery Ultrasound in the (peri-) Arrest Setting—A Prospective Pilot Study. J Clin Med 2022; 11:jcm11020469. [PMID: 35054163 PMCID: PMC8780199 DOI: 10.3390/jcm11020469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/13/2022] [Accepted: 01/16/2022] [Indexed: 01/25/2023] Open
Abstract
Point-of-care ultrasounds (US) are used during cardiopulmonary resuscitation (CPR) and after return of spontaneous circulation (ROSC). Carotid ultrasounds are a potential non-invasive monitoring tool for chest compressions, but their general value and feasibility during CPR are not fully determined. In this prospective observational study, we performed carotid US during conventional- and extracorporeal CPR and after ROSC with at least one transverse and coronal image, corresponding loops with and without color doppler, and pulsed-wave doppler loops. The feasibility of carotid US during (peri-)arrest and type and frequency of diagnostic findings were examined. We recruited 16 patients and recorded utilizable US images in 14 cases (88%; complete imaging protocols in 11 patients [69%]). In three of all patients (19%) and in 60% (3/5) of cases during CPR plus a full imaging protocol, we observed: (i) in one patient a collapse of the common carotid artery linked to hypovolemia, and (ii) in two patients a biphasic flow during CPR linked to prolonged low-flow time prior to admission and adverse outcome. Carotid artery morphology and carotid blood flow characteristics may serve as therapeutic target and prognostic parameters. However, future studies with larger sample sizes are needed.
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13
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Castro AMC. Evaluation of Cerebral Circulatory Arrest. NEUROVASCULAR SONOGRAPHY 2022:133-144. [DOI: 10.1007/978-3-030-96893-9_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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14
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Robles-Caballero A, Henríquez-Recine MA, Juárez-Vela R, García-Olmos L, Yus-Teruel S, Quintana-Díaz M. Usefulness of the optic nerve sheath ultrasound in patients with cessation of cerebral flow. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:9-14. [PMID: 34998492 DOI: 10.1016/j.neucie.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 11/03/2020] [Indexed: 06/14/2023]
Abstract
UNLABELLED Optic nerve sheath diameter (ONSD) ultrasound has proven to be a useful tool for the detection of intracranial hypertension (IH). The DVNO values, in patients with cessation of cerebral blood flow (CCBF), has not been clarified yet. OBJECTIVE Establish an association between DVNO and CFSC in neurocritical patients admitted to an ICU. PATIENTS AND METHODS Cross-sectional study of patients admitted in a third level ICU, between April 2017 and April 2018, with neurological pathology. ONSD ultrasound was performed in the first 24 h and as the patient was diagnosed of CCBF. The ONSD values of patients with and without diagnosis of CCBF were compared. RESULTS 99 patients were included, 29 of whom showed CCBF in transcranial Doppler. The ONSD measurement did not demonstrate significant differences between both groups, 65.94 ± 7.55 in the group with CCBF and 63.88 ± 5.56 in the group without CCBF, p = 0.14. CONCLUSION In our study, ONSD values capable of recognizing CCBF were not identified.
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Affiliation(s)
- Alejandro Robles-Caballero
- Servicio de Medicina Intensiva, Hospital Universitario La Paz, Madrid, Spain; Grupo BMP, Instituto de Investigación-IdiPaz, Madrid, Spain
| | - María Angélica Henríquez-Recine
- Servicio de Medicina Intensiva, Hospital Universitario La Paz, Madrid, Spain; Grupo BMP, Instituto de Investigación-IdiPaz, Madrid, Spain
| | - Raúl Juárez-Vela
- Grupo BMP, Instituto de Investigación-IdiPaz, Madrid, Spain; Universidad de la Rioja, Logroño, Spain.
| | - Luís García-Olmos
- Unidad Docente Multiprofesional de Atención Familiar y Comunitaria Sureste, Madrid, Spain
| | - Santiago Yus-Teruel
- Servicio de Medicina Intensiva, Hospital Universitario La Paz, Madrid, Spain; Grupo BMP, Instituto de Investigación-IdiPaz, Madrid, Spain
| | - Manuel Quintana-Díaz
- Servicio de Medicina Intensiva, Hospital Universitario La Paz, Madrid, Spain; Grupo BMP, Instituto de Investigación-IdiPaz, Madrid, Spain
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15
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O'Brien NF, Reuter-Rice K, Wainwright MS, Kaplan SL, Appavu B, Erklauer JC, Ghosh S, Kirschen M, Kozak B, Lidsky K, Lovett ME, Mehollin-Ray AR, Miles DK, Press CA, Simon DW, Tasker RC, LaRovere KL. Practice Recommendations for Transcranial Doppler Ultrasonography in Critically Ill Children in the Pediatric Intensive Care Unit: A Multidisciplinary Expert Consensus Statement. J Pediatr Intensive Care 2021; 10:133-142. [PMID: 33884214 PMCID: PMC8052112 DOI: 10.1055/s-0040-1715128] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/12/2020] [Indexed: 12/16/2022] Open
Abstract
Transcranial Doppler ultrasonography (TCD) is being used in many pediatric intensive care units (PICUs) to aid in the diagnosis and monitoring of children with known or suspected pathophysiological changes to cerebral hemodynamics. Standardized approaches to scanning protocols, interpretation, and documentation of TCD examinations in this setting are lacking. A panel of multidisciplinary clinicians with expertise in the use of TCD in the PICU undertook a three-round modified Delphi process to reach unanimous agreement on 34 statements and then create practice recommendations for TCD use in the PICU. Use of these recommendations will help to ensure that high quality TCD images are captured, interpreted, and reported using standard nomenclature. Furthermore, use will aid in ensuring reproducible and meaningful study results between TCD practitioners and across PICUs.
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Affiliation(s)
- Nicole Fortier O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Ohio, United States
| | - Karin Reuter-Rice
- Department of Pediatrics, Division of Pediatric Critical Care, School of Medicine, School of Nursing, Duke University, Duke Institute for Brain Sciences, North Carolina, United States
| | - Mark S. Wainwright
- Department of Neurology, University of Washington, Seattle Children's Hospital, Washington, United States
| | - Summer L. Kaplan
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Brian Appavu
- Department of Pediatrics, Division of Critical Care Medicine, Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine—Phoenix, Arizona, United States
| | - Jennifer C. Erklauer
- Department of Pediatrics, Division of Critical Care Medicine and Neurology, Baylor College of Medicine, Texas Children's Hospital, Texas, United States
| | - Suman Ghosh
- Department of Pediatrics, Division of Pediatric Neurology, University of Florida, College of Medicine, Florida, United States
| | - Matthew Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Brandi Kozak
- Department of Radiology, Ultrasound Division, Center for Pediatric Contrast Ultrasound, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Karen Lidsky
- Department of Pediatrics, Division of Pediatric Critical Care, Wolfson Children's Hospital, University of Florida, Florida, United States
| | - Marlina Elizabeth Lovett
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Ohio, United States
| | - Amy R. Mehollin-Ray
- Department of Radiology, Baylor College of Medicine, E.B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Texas, United States
| | - Darryl K. Miles
- Department of Pediatrics/Division of Critical Care, UT Southwestern Medical Center, Texas, United States
| | - Craig A. Press
- Department of Pediatrics, Section of Child Neurology, University of Colorado, Children's Hospital Colorado, Colorado, United States
| | - Dennis W. Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pennsylvania, United States
| | - Robert C. Tasker
- Departments of Neurology & Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Massachusetts, United States
| | - Kerri Lynn LaRovere
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Massachusetts, United States
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16
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Transcranial Doppler: A Useful Tool to Predict Brain Death Still Not Confirmed by Clinical Assessment. Transplant Proc 2021; 53:1803-1807. [PMID: 33962775 DOI: 10.1016/j.transproceed.2021.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/10/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Diagnosing brain death (BD) with accuracy and urgency is of great importance because an early diagnosis may guide the clinical management, optimize hospital beds, and facilitate organ transplantation. The clinical diagnosis of nonreactive and irreversible coma can be confirmed with additional tests. Among the complimentary exams that may testify brain circulatory arrest, transcranial Doppler (TCD) can be an option. It is a real-time, bedside, inexpensive, noninvasive method that assesses cerebral blood flow. In patients with suspected BD, especially those who are under sedative drugs, early diagnosis is imperative. The aim of the present study was to evaluate the role of TCD in predicting BD. METHODS One hundred consecutive comatose patients with a Glasgow Coma Scale score of less than 5, owing to different etiologies, were included. TCD was performed in all patients. The TCD operator was blinded for clinical and neurologic data. This study is in compliance with the Declaration of Helsinki. RESULTS Sixty-nine patients with TCD-brain circulatory collapse were diagnosed later with BD. Of the 31 patients with brain circulatory activity, 8 (25.8%) were clinically brain dead and 23 (74.2%) were alive. TCD showing brain circulatory collapse had a sensitivity of 89.6%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 74.2%. CONCLUSION TCD is highly specific (100%) and sensitive (89.6%) as a method to confirm the clinical diagnosis of BD, even in patients under sedation. The possibility of patients presenting with cerebral circulatory activity and clinical diagnosis of BD was demonstrated to occur.
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17
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Robles-Caballero A, Henríquez-Recine MA, Juárez-Vela R, García-Olmos L, Yus-Teruel S, Quintana-Díaz M. Usefulness of the optic nerve sheath ultrasound in patients with cessation of cerebral flow. Neurocirugia (Astur) 2020; 33:S1130-1473(20)30134-2. [PMID: 33384224 DOI: 10.1016/j.neucir.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 10/09/2020] [Accepted: 11/03/2020] [Indexed: 10/22/2022]
Abstract
Optic nerve sheath diameter (ONSD) ultrasound has proven to be a useful tool for the detection of intracranial hypertension (IH). The ONSD values, in patients with cessation of cerebral blood flow (CCBF), has not been clarified yet. OBJECTIVE Establish an association between ONSD and CCBF in neurocritical patients admitted to an ICU. PATIENTS AND METHODS Cross-sectional study of patients admitted in a third level ICU, between April 2017 and April 2018, with neurological pathology. ONSD ultrasound was performed in the first 24 hours and as the patient was diagnosed of CCBF. The ONSD values of patients with and without diagnosis of CCBF were compared. RESULTS 99 patients were included, 29 of whom showed CCBF in transcranial Doppler. The ONSD measurement did not demonstrate significant differences between both groups, 6,59 ± 0,75 in the group with CCBF and 6,39 ± 0,56 in the group without CCBF p=0.141. CONCLUSION In our study, ONSD values capable of recognizing CCBF were not identified.
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Affiliation(s)
- Alejandro Robles-Caballero
- Servicio de Medicina Intensiva, Hospital Universitario La Paz, Madrid, España; Grupo BMP, Instituto de Investigación-IdiPaz, Madrid, España
| | - María Angélica Henríquez-Recine
- Servicio de Medicina Intensiva, Hospital Universitario La Paz, Madrid, España; Grupo BMP, Instituto de Investigación-IdiPaz, Madrid, España
| | - Raúl Juárez-Vela
- Grupo BMP, Instituto de Investigación-IdiPaz, Madrid, España; Universidad de la Rioja , Logroño, España.
| | - Luís García-Olmos
- Unidad Docente Multiprofesional de Atención Familiar y Comunitaria Sureste, Madrid, España
| | - Santiago Yus-Teruel
- Servicio de Medicina Intensiva, Hospital Universitario La Paz, Madrid, España; Grupo BMP, Instituto de Investigación-IdiPaz, Madrid, España
| | - Manuel Quintana-Díaz
- Servicio de Medicina Intensiva, Hospital Universitario La Paz, Madrid, España; Grupo BMP, Instituto de Investigación-IdiPaz, Madrid, España
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18
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Bonow RH, Young CC, Bass DI, Moore A, Levitt MR. Transcranial Doppler ultrasonography in neurological surgery and neurocritical care. Neurosurg Focus 2020; 47:E2. [PMID: 31786564 DOI: 10.3171/2019.9.focus19611] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 09/04/2019] [Indexed: 11/06/2022]
Abstract
Transcranial Doppler (TCD) ultrasonography is an inexpensive, noninvasive means of measuring blood flow within the arteries of the brain. In this review, the authors outline the technology underlying TCD ultrasonography and describe its uses in patients with neurosurgical diseases. One of the most common uses of TCD ultrasonography is monitoring for vasospasm following subarachnoid hemorrhage. In this setting, elevated blood flow velocities serve as a proxy for vasospasm and can herald the onset of ischemia. TCD ultrasonography is also useful in the evaluation and management of occlusive cerebrovascular disease. Monitoring for microembolic signals enables stratification of stroke risk due to carotid stenosis and can also be used to clarify stroke etiology. TCD ultrasonography can identify patients with exhausted cerebrovascular reserve, and after extracranial-intracranial bypass procedures it can be used to assess adequacy of flow through the graft. Finally, assessment of cerebral autoregulation can be performed using TCD ultrasonography, providing data important to the management of patients with severe traumatic brain injury. As the clinical applications of TCD ultrasonography have expanded over time, so has their importance in the management of neurosurgical patients. Familiarity with this diagnostic tool is crucial for the modern neurological surgeon.
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Affiliation(s)
| | | | | | | | - Michael R Levitt
- Departments of1Neurological Surgery.,2Radiology.,3Mechanical Engineering, and.,4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
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19
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Singh Y, Tissot C, Fraga MV, Yousef N, Cortes RG, Lopez J, Sanchez-de-Toledo J, Brierley J, Colunga JM, Raffaj D, Da Cruz E, Durand P, Kenderessy P, Lang HJ, Nishisaki A, Kneyber MC, Tissieres P, Conlon TW, De Luca D. International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Crit Care 2020; 24:65. [PMID: 32093763 PMCID: PMC7041196 DOI: 10.1186/s13054-020-2787-9] [Citation(s) in RCA: 291] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. METHODS Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. RESULTS Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). CONCLUSIONS Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.
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Affiliation(s)
- Yogen Singh
- Department of Paediatrics - Neonatology and Paediatric Cardiology, Cambridge University Hospitals and University of Cambridge School of Clinical Medicine, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
- Addenbrooke's Hospital, Box 402, Cambridge, UK.
| | - Cecile Tissot
- Paediatric Cardiology, Centre de Pédiatrie, Clinique des Grangettes, Geneva, Switzerland
| | - María V Fraga
- Department of Paediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Nadya Yousef
- Division of Paediatrics and Neonatal Critical Care, APHP - Paris Saclay University Hospitals, "A. Béclère" Medical centre, Paris, France
| | - Rafael Gonzalez Cortes
- Department of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Jorge Lopez
- Department of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | | | - Joe Brierley
- Department of Paediatric Intensive Care, Great Ormond Street Hospital, London, UK
| | - Juan Mayordomo Colunga
- Department of Paediatric Intensive Care, Hospital Universitario Central de Asturias, Oviedo. CIBER-Enfermedades Respiratorias. Instituto de Salud Carlos III, Madrid. Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Dusan Raffaj
- Department of Paediatric Intensive Care, Nottingham University Hospitals, Nottingham, UK
| | - Eduardo Da Cruz
- Department of Paediatric and Cardiac Intensive Care, Children's Hospital Colorado, Aurora, USA
| | - Philippe Durand
- Division of Paediatric Critical Care, APHP - Paris Saclay University Hospitals, "Kremlin Bicetre" Medical Centre, Paris, France
| | - Peter Kenderessy
- Department of Paediatric Anaesthesia and Intensive Care, Children's Hospital Banska Bystrica, Banska Bystrica, Slovakia
| | - Hans-Joerg Lang
- Department of Paediatrics, Medicins Sans Frontieres (Suisse), Geneva, Switzerland
| | - Akira Nishisaki
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Martin C Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Pierre Tissieres
- Division of Paediatric Critical Care, APHP - Paris Saclay University Hospitals, "Kremlin Bicetre" Medical Centre, Paris, France
| | - Thomas W Conlon
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, APHP - Paris Saclay University Hospitals, "A. Béclère" Medical centre, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM Unit U999, South Paris Medical School, Paris Saclay University, Paris, France
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20
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Moya Sánchez J, Royo-Villanova Reparaz M, Andreu Ruiz A, Ros Argente del Castillo T, Sánchez Cámara S, de Gea García J, Andreu Soler E, Pérez Martínez D, Olmo Sánchez M, Llamas Lázaro C, Reyes Marlés R, Jara Rubio R. Minigammacámara portátil para el diagnóstico de muerte encefálica. Med Intensiva 2020; 44:1-8. [DOI: 10.1016/j.medin.2018.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/24/2018] [Accepted: 07/28/2018] [Indexed: 10/28/2022]
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21
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Gastala J, Fattal D, Kirby PA, Capizzano AA, Sato Y, Moritani T. Brain death: Radiologic signs of a non-radiologic diagnosis. Clin Neurol Neurosurg 2019; 185:105465. [DOI: 10.1016/j.clineuro.2019.105465] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/30/2019] [Accepted: 08/06/2019] [Indexed: 11/13/2022]
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22
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Kasapoğlu US, Haliloğlu M, Bilgili B, Cinel İ. The Role of Transcranial Doppler Ultrasonography in the Diagnosis of Brain Death. Turk J Anaesthesiol Reanim 2019; 47:367-374. [PMID: 31572986 DOI: 10.5152/tjar.2019.82258] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/22/2019] [Indexed: 12/30/2022] Open
Abstract
Ancillary tests can be used for the diagnosis of brain death in cases wherein uncertainty exists regarding the neurological examination and apnoea test cannot be performed. Transcranial Doppler ultrasonography (TCD) is a useful, valid, non-invasive, portable, and repeatable ancillary test for the confirmation of brain death. Despite its varying sensitivity and specificity rates with regard to the diagnosis of the brain death, its clinical use has steadily increased in the intensive care unit because of its numerous superior properties. The use of TCD as an ancillary test for the diagnosis of brain death and cerebral circulatory arrest is discussed in the current review.
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Affiliation(s)
- Umut Sabri Kasapoğlu
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Marmara University School of Medicine, İstanbul, Turkey
| | - Murat Haliloğlu
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Marmara University School of Medicine, İstanbul, Turkey
| | - Beliz Bilgili
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Marmara University School of Medicine, İstanbul, Turkey
| | - İsmail Cinel
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Marmara University School of Medicine, İstanbul, Turkey
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23
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Brain Death in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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24
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Walter U, Fernández-Torre JL, Kirschstein T, Laureys S. When is “brainstem death” brain death? The case for ancillary testing in primary infratentorial brain lesion. Clin Neurophysiol 2018; 129:2451-2465. [DOI: 10.1016/j.clinph.2018.08.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/20/2018] [Accepted: 08/25/2018] [Indexed: 12/19/2022]
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25
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The role of cervical color Doppler ultrasound in the diagnosis of brain death. Neuroradiology 2018; 61:137-145. [DOI: 10.1007/s00234-018-2111-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/04/2018] [Indexed: 10/28/2022]
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26
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Cacciatori A, Godino M, Mizraji R. Does Traumatic Brain Injury by Firearm Injury Accelerates the Brain Death Cascade? Preliminary Results. Transplant Proc 2018; 50:400-404. [PMID: 29579813 DOI: 10.1016/j.transproceed.2018.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/20/2017] [Accepted: 01/17/2018] [Indexed: 11/25/2022]
Abstract
Brain death (BD) triggers a series of pathophysiological events similar to multiple-organ dysfunction. Traumatic brain injury (TBI) due to firearm injury (FAI) causes lesions that could lead to BD. Patients admitted to the ICU due to severe TBI that evolved to BD were studied, including those caused by FAI; the 2 groups were compared with the objective of demonstrating that the support of the deceased donor by TBI due to FAI is more unstable and of shorter duration than the one related to TBI by another cause. Preliminary results demonstrated that the individuals with TBI by FAI died in BD in a higher percentage than the individuals with TBI caused by accidents (83% vs 41%). The donor treatment period was lower in individuals who presented TBI by FAI. These individuals needed higher doses of noradrenaline as vasopressor support for their treatment, without showing a statistically significant difference (P = .15), compared with individuals whose BD cause was TBI caused by accident.
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Affiliation(s)
- A Cacciatori
- National Institute of Donations and Transplants (INDT), Montevideo, Uruguay.
| | - M Godino
- National Institute of Donations and Transplants (INDT), Montevideo, Uruguay
| | - R Mizraji
- National Institute of Donations and Transplants (INDT), Montevideo, Uruguay
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27
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Cacciatori A, Godino M, Mizraji R. Systodiastolic Separation Expresses Cerebral Circulatory Arrest? Transplant Proc 2018; 50:412-415. [PMID: 29579816 DOI: 10.1016/j.transproceed.2018.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/20/2017] [Accepted: 01/17/2018] [Indexed: 10/17/2022]
Abstract
There is a situation before the cerebral circulatory cessation phase, the systodiastolic separation in transcranial Doppler (TCD), which may raise doubts to the operator technician who performs it. A total of 266 studies were performed in 188 neurocritical patients over a 9-year period: 88 cases (77%) corresponded to cerebral circulatory arrest (CCA) which accompanies brain death (BD); 9 (5%) presented the systodiastolic separation pattern. In 1 of those 9 there was persistence of cough reflex and spontaneous breathing; in 5, CCA was not reached; only 3 evolved to CCA. The finding of a minimal persistent neurologic semiology is a categoric fact that would rule out the clinical correlation between this pattern and BD diagnosis.
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Affiliation(s)
- A Cacciatori
- National Institute of Donations and Transplants, Montevideo, Uruguay.
| | - M Godino
- National Institute of Donations and Transplants, Montevideo, Uruguay
| | - R Mizraji
- National Institute of Donations and Transplants, Montevideo, Uruguay
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28
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Blanco P, Abdo-Cuza A. Transcranial Doppler ultrasound in neurocritical care. J Ultrasound 2018; 21:1-16. [PMID: 29429015 DOI: 10.1007/s40477-018-0282-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/09/2018] [Indexed: 12/27/2022] Open
Abstract
Multimodality monitoring is a common practice in caring for neurocritically ill patients, and consists mainly in clinical assessment, intracranial pressure monitoring and using several imaging methods. Of these imaging methods, transcranial Doppler (TCD) is an interesting tool that provides a non-invasive, portable and radiation-free way to assess cerebral circulation and diagnose and follow-up (duplex method) intracranial mass-occupying lesions, such as hematomas and midline shift. This article reviews the basics of TCD applied to neurocritical care patients, offering a rationale for its use as well as tips for practitioners.
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Affiliation(s)
- Pablo Blanco
- Ecodiagnóstico-Centro de Diagnóstico por Imágenes, 3272, 50 St., 7630, Necochea, Argentina.
| | - Anselmo Abdo-Cuza
- Centro de Investigaciones Médico-Quirúrgicas, 11-13 and 216 St., Siboney, 12100, Havana, Cuba
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29
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Blanco P, Abdo-Cuza A. Transcranial Doppler ultrasound in the ICU: it is not all sunshine and rainbows. Crit Ultrasound J 2018; 10:2. [PMID: 29340797 PMCID: PMC5770348 DOI: 10.1186/s13089-018-0085-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/09/2018] [Indexed: 01/04/2023] Open
Affiliation(s)
- Pablo Blanco
- Ecodiagnóstico-Centro de Diagnóstico por Imágenes, 3272, 50 St., Necochea, 7630 Argentina
| | - Anselmo Abdo-Cuza
- Centro de Investigaciones Médico-Quirúrgicas, 11-13 and 216 St., Siboney, La Habana, 12100 Cuba
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30
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Abstract
OBJECTIVE The purpose of this observational study is to explore if bedside Doppler ultrasonography of the central retinal vessels has the potential to become an ancillary study to support the timely diagnosis of brain death in children. DESIGN Seventeen-month prospective observational cohort. SETTING Forty-four bed pediatric medical and surgical ICU in an academic teaching hospital. PATIENTS All children 0-18 years old who were clinically evaluated for brain death at Children's National Health Systems were enrolled and followed until discharge or death. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All patients had at least one ophthalmic ultrasound within 30 minutes of each brain death examination. The central retinal artery peak systolic blood flow velocity, resistive index, pulsatility index, and Doppler waveforms were evaluated in each patient. Thirty-five ophthalmic ultrasounds were obtained on 13 patients, 3 months to 15 years old, who each had two clinical examinations consistent with brain death. The average systolic blood pressure during the ultrasound examinations was 102 mm Hg (± 28), diastolic blood pressure 65 mm Hg (± 24), mean arterial pressure 79 mm Hg (± 23), heart rate 133 beats/min (± 27), temperature 36°C (± 0.96), arterial CO2 35 mm Hg (± 9), and end-tidal CO2 23 mm Hg (± 6). For all examinations, the average peak systolic velocity of the central retinal artery was significantly decreased at 4.66 cm/s (± 3.2). Twelve of 13 patients had both resistive indexes greater than or equal to 1, average pulsatility indexes of 3.6 (± 3.5) with transcranial Doppler waveforms consistent with brain death. Waveform analysis of the 35 ultrasound examinations revealed 11% with tall systolic peaks without diastolic flow, 17% with oscillatory flow, 29% showed short systolic spikes, and 23% had no Doppler movement detected. A rippling "tardus-parvus" waveform was present in 20% of examinations. CONCLUSION This study supports that the combination of qualitative waveform analysis and quantitative blood flow variables of the central retinal vessels may have the potential to be developed as an ancillary study for supporting the diagnosis of brain death in children.
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Llompart-Pou JA, Pérez-Bárcena J, Homar J, Abadal JM. Holistic ultrasound in trauma. Injury 2016; 47:2381. [PMID: 27575373 DOI: 10.1016/j.injury.2016.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/24/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Juan Antonio Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Carretera Valldemossa, 79 07010, Spain.
| | - Jon Pérez-Bárcena
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Carretera Valldemossa, 79 07010, Spain
| | - Javier Homar
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Carretera Valldemossa, 79 07010, Spain
| | - Josep Maria Abadal
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Carretera Valldemossa, 79 07010, Spain
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D’Andrea A, Conte M, Cavallaro M, Scarafile R, Riegler L, Cocchia R, Pezzullo E, Carbone A, Natale F, Santoro G, Caso P, Russo MG, Bossone E, Calabrò R. Transcranial Doppler ultrasonography: From methodology to major clinical applications. World J Cardiol 2016; 8:383-400. [PMID: 27468332 PMCID: PMC4958690 DOI: 10.4330/wjc.v8.i7.383] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/22/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023] Open
Abstract
Non-invasive Doppler ultrasonographic study of cerebral arteries [transcranial Doppler (TCD)] has been extensively applied on both outpatient and inpatient settings. It is performed placing a low-frequency (≤ 2 MHz) transducer on the scalp of the patient over specific acoustic windows, in order to visualize the intracranial arterial vessels and to evaluate the cerebral blood flow velocity and its alteration in many different conditions. Nowadays the most widespread indication for TCD in outpatient setting is the research of right to left shunting, responsable of so called “paradoxical embolism”, most often due to patency of foramen ovale which is responsable of the majority of cryptogenic strokes occuring in patients younger than 55 years old. TCD also allows to classify the grade of severity of such shunts using the so called “microembolic signal grading score”. In addition TCD has found many useful applications in neurocritical care practice. It is useful on both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoidal haemorrhage (caused by aneurysm rupture or traumatic injury), traumatic brain injury, brain stem death. It is used also to evaluate cerebral hemodynamic changes after stroke. It also allows to investigate cerebral pressure autoregulation and for the clinical evaluation of cerebral autoregulatory reserve.
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Abstract
PURPOSE OF REVIEW Maintenance of adequate blood flow and oxygen to the brain is one of the principal endpoints of all surgery and anesthesia. During operations in general anesthesia, however, the brain is at particular risk for silent ischemia. Despite this risk, the brain still remains one of the last monitored organs in clincial anesthesiology. RECENT FINDINGS Transcranial Doppler (TCD) sonography and near-infrared spectroscopy (NIRS) experience a revival as these noninvasive technologies help to detect silent cerebral ischemia. TCD allows for quantification of blood flow velocities in basal intracranial arteries. TCD-derived variables such as the pulsatility index might hint toward diminished cognitive reserve or raised intracranial pressure. NIRS allows for assessment of regional cerebral oxygenation. Monitoring should be performed during high-risk surgery for silent cerebral ischemia and special circumstances during critical care medicine. Both techniques allow for the assessment of cerebrovascular autoregulation and individualized management of cerebral hemodynamics. SUMMARY TCD and NIRS are noninvasive monitors that anesthesiologists apply to tailor cerebral oxygen delivery, aiming to safeguard brain function in the perioperative period.
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Wojczal J, Tomczyk T, Luchowski P, Kozera G, Kaźmierski R, Stelmasiak Z. Standards in neurosonology. Part II. J Ultrason 2016; 16:44-54. [PMID: 27104002 PMCID: PMC4834370 DOI: 10.15557/jou.2016.0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 10/09/2015] [Accepted: 10/16/2015] [Indexed: 11/22/2022] Open
Abstract
The paper presents standards related to ultrasound imaging of the cerebral vasculature and structures. The aim of this paper is to standardize both the performance and description of ultrasound imaging of the extracranial and intracranial cerebral arteries as well as a study of a specific brain structure, i.e. substantia nigra hyperechogenicity. The following aspects are included in the description of standards for each ultrasonographic method: equipment requirements, patient preparation, study technique and documentation as well as the required elements of ultrasound description. Practical criteria for the diagnosis of certain pathologies in accordance with the latest literature were also presented. Furthermore, additional comments were included in some of the sections. Part I discusses standards for the performance, documentation and description of different ultrasound methods (Duplex, Doppler). Part II and III are devoted to standards for specific clinical situations (vasospasm, monitoring after the acute stage of stroke, detection of a right-to-left shunts, confirmation of the arrest of the cerebral circulation, an assessment of the functional efficiency of circle of Willis, an assessment of the cerebrovascular vasomotor reserve as well as the measurement of substantia nigra hyperechogenicity).
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Affiliation(s)
- Joanna Wojczal
- Department of Neurology, Medical University of Lublin, Poland
| | | | - Piotr Luchowski
- Department of Neurology, Medical University of Lublin, Poland
| | - Grzegorz Kozera
- Department of Neurology of Adults, Medical University of Gdańsk, Poland
| | - Radosław Kaźmierski
- Department of Neurology and Vascular Diseases of the Nervous System, Poznań University of Medical Sciences, Poland
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Latin American consensus on the use of transcranial Doppler in the diagnosis of brain death. Rev Bras Ter Intensiva 2016; 26:240-52. [PMID: 25295818 PMCID: PMC4188460 DOI: 10.5935/0103-507x.20140035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 03/17/2014] [Indexed: 12/13/2022] Open
Abstract
Transcranial Doppler evaluates cerebral hemodynamics in patients with brain injury and is a useful technical tool in diagnosing cerebral circulatory arrest, usually present in the brain-dead patient. This Latin American Consensus was formed by a group of 26 physicians experienced in the use of transcranial Doppler in the context of brain death. The purpose of this agreement was to make recommendations regarding the indications, technique, and interpretation of the study of transcranial ultrasonography in patients with a clinical diagnosis of brain death or in the patient whose clinical diagnosis presents difficulties; a working group was formed to enable further knowledge and to strengthen ties between Latin American physicians working on the same topic. A review of the literature, concepts,and experiences were exchanged in two meetings and via the Internet. Questions about pathophysiology, equipment, techniques, findings, common problems, and the interpretation of transcranial Doppler in the context of brain death were answered. The basic consensus statements are the following: cerebral circulatory arrest is the final stage in the evolution of progressive intracranial hypertension, which is visualized with transcranial Doppler as a "pattern of cerebral circulatory arrest". The following are accepted as the standard of cerebral circulatory arrest: reverberant pattern, systolic spikes, and absence of previously demonstrated flow. Ultrasonography should be used - in acceptable hemodynamic conditions - in the anterior circulation bilaterally (middle cerebral artery) and in the posterior (basilar artery) territory. If no ultrasonographic images are found in any or all of these vessels, their proximal arteries are acceptable to be studied to look for a a pattern of cerebral circulatory arrest.
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36
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D'Andrea A, Conte M, Scarafile R, Riegler L, Cocchia R, Pezzullo E, Cavallaro M, Carbone A, Natale F, Russo MG, Gregorio G, Calabrò R. Transcranial Doppler Ultrasound: Physical Principles and Principal Applications in Neurocritical Care Unit. J Cardiovasc Echogr 2016; 26:28-41. [PMID: 28465958 PMCID: PMC5224659 DOI: 10.4103/2211-4122.183746] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Transcranial Doppler (TCD) ultrasonography is a noninvasive ultrasound study, which has been extensively applied on both outpatient and inpatient settings. It involves the use of a low-frequency (≤2 MHz) transducer, placed on the scalp, to insonate the basal cerebral arteries through relatively thin bone windows and to measure the cerebral blood flow velocity and its alteration in many different conditions. In neurointensive care setting, TCD is useful for both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, and brain stem death. It also allows to investigate the cerebrovascular autoregulation in setting of carotid disease and syncope. In this review, we will describe physical principles underlying TCD, flow indices most frequently used in clinical practice and critical care applications in Neurocritical Unit care.
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Affiliation(s)
- Antonello D'Andrea
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Marianna Conte
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Raffaella Scarafile
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Lucia Riegler
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Rosangela Cocchia
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Enrica Pezzullo
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Massimo Cavallaro
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Andreina Carbone
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Francesco Natale
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Maria Giovanna Russo
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Giovanni Gregorio
- Department of Cardiology, San Luca Hospital, Vallo della Lucania, Salerno, Italy
| | - Raffaele Calabrò
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
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LaRovere KL, O'Brien NF. Transcranial Doppler Sonography in Pediatric Neurocritical Care: A Review of Clinical Applications and Case Illustrations in the Pediatric Intensive Care Unit. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:2121-32. [PMID: 26573100 DOI: 10.7863/ultra.15.02016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 03/31/2015] [Indexed: 05/25/2023]
Abstract
Transcranial Doppler sonography is a noninvasive, real-time physiologic monitor that can detect altered cerebral hemodynamics during catastrophic brain injury. Recent data suggest that transcranial Doppler sonography may provide important information about cerebrovascular hemodynamics in children with traumatic brain injury, intracranial hypertension, vasospasm, stroke, cerebrovascular disorders, central nervous system infections, and brain death. Information derived from transcranial Doppler sonography in these disorders may elucidate underlying pathophysiologic characteristics, predict outcomes, monitor responses to treatment, and prompt a change in management. We review emerging applications for transcranial Doppler sonography in the pediatric intensive care unit with case illustrations from our own experience.
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Affiliation(s)
- Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts USA (K.L.L.); and Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital and Ohio State University, Columbus, Ohio USA (N.F.O.).
| | - Nicole F O'Brien
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts USA (K.L.L.); and Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital and Ohio State University, Columbus, Ohio USA (N.F.O.)
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38
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Amyot F, Arciniegas DB, Brazaitis MP, Curley KC, Diaz-Arrastia R, Gandjbakhche A, Herscovitch P, Hinds SR, Manley GT, Pacifico A, Razumovsky A, Riley J, Salzer W, Shih R, Smirniotopoulos JG, Stocker D. A Review of the Effectiveness of Neuroimaging Modalities for the Detection of Traumatic Brain Injury. J Neurotrauma 2015; 32:1693-721. [PMID: 26176603 PMCID: PMC4651019 DOI: 10.1089/neu.2013.3306] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The incidence of traumatic brain injury (TBI) in the United States was 3.5 million cases in 2009, according to the Centers for Disease Control and Prevention. It is a contributing factor in 30.5% of injury-related deaths among civilians. Additionally, since 2000, more than 260,000 service members were diagnosed with TBI, with the vast majority classified as mild or concussive (76%). The objective assessment of TBI via imaging is a critical research gap, both in the military and civilian communities. In 2011, the Department of Defense (DoD) prepared a congressional report summarizing the effectiveness of seven neuroimaging modalities (computed tomography [CT], magnetic resonance imaging [MRI], transcranial Doppler [TCD], positron emission tomography, single photon emission computed tomography, electrophysiologic techniques [magnetoencephalography and electroencephalography], and functional near-infrared spectroscopy) to assess the spectrum of TBI from concussion to coma. For this report, neuroimaging experts identified the most relevant peer-reviewed publications and assessed the quality of the literature for each of these imaging technique in the clinical and research settings. Although CT, MRI, and TCD were determined to be the most useful modalities in the clinical setting, no single imaging modality proved sufficient for all patients due to the heterogeneity of TBI. All imaging modalities reviewed demonstrated the potential to emerge as part of future clinical care. This paper describes and updates the results of the DoD report and also expands on the use of angiography in patients with TBI.
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Affiliation(s)
- Franck Amyot
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - David B. Arciniegas
- Beth K. and Stuart C. Yudofsky Division of Neuropsychiatry, Baylor College of Medicine, Houston, Texas
- Brain Injury Research, TIRR Memorial Hermann, Houston, Texas
| | | | - Kenneth C. Curley
- Combat Casualty Care Directorate (RAD2), U.S. Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Ramon Diaz-Arrastia
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Amir Gandjbakhche
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Peter Herscovitch
- Positron Emission Tomography Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Sidney R. Hinds
- Defense and Veterans Brain Injury Center, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Silver Spring, Maryland
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Anthony Pacifico
- Congressionally Directed Medical Research Programs, Fort Detrick, Maryland
| | | | - Jason Riley
- Queens University, Kingston, Ontario, Canada
- ArcheOptix Inc., Picton, Ontario, Canada
| | - Wanda Salzer
- Congressionally Directed Medical Research Programs, Fort Detrick, Maryland
| | - Robert Shih
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - James G. Smirniotopoulos
- Department of Radiology, Neurology, and Biomedical Informatics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Derek Stocker
- Walter Reed National Military Medical Center, Bethesda, Maryland
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Thompson BB, Wendell LC, Potter NS, Fehnel C, Wilterdink J, Silver B, Furie K. The use of transcranial Doppler ultrasound in confirming brain death in the setting of skull defects and extraventricular drains. Neurocrit Care 2015; 21:534-8. [PMID: 24718963 DOI: 10.1007/s12028-014-9979-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Transcranial Doppler ultrasound (TCD) has been used as a confirmatory test for the diagnosis of brain death (BD), but may be inaccurate in patients with a skull defect or extraventricular drain (EVD). METHODS AND RESULTS We report three cases of patients with a skull defect or EVD in whom TCD supported a diagnosis of BD but in which the clinical examination later refuted the diagnosis. CONCLUSION We caution against the use of TCD to confirm the diagnosis of BD in the presence of a skull defect or EVD.
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Affiliation(s)
- Bradford B Thompson
- Department of Neurology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy Street, APC-712, Providence, RI, 02903, USA,
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Doppler transcraneal en el diagnóstico de la muerte encefálica. ¿Es útil o retrasa el diagnóstico? Med Intensiva 2015; 39:244-50. [DOI: 10.1016/j.medin.2014.11.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 11/07/2014] [Accepted: 11/11/2014] [Indexed: 11/21/2022]
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Lin JJ, Hsia SH, Wang HS, Chiang MC, Lin KL. Transcranial Doppler ultrasound in therapeutic hypothermia for children after resuscitation. Resuscitation 2015; 89:182-7. [PMID: 25659371 DOI: 10.1016/j.resuscitation.2015.01.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/11/2015] [Accepted: 01/23/2015] [Indexed: 10/24/2022]
Abstract
AIM OF THE STUDY The aim of the present study was to assess the cerebral flow in children receiving therapeutic hypothermia after resuscitation. The prognostic value of transcranial Doppler findings was correlated with the clinical outcomes in these children. METHODS A retrospective cohort study was conducted at the paediatric intensive care unit of Chang Gung Children's Hospital between January 2011 and December 2012. All children from 1 month to 18 years of age who received therapeutic hypothermia after resuscitation were eligible. Serial transcranial Doppler examinations were performed and the findings were reviewed. RESULTS Seventeen children met the eligibility criteria for this study. Fourteen patients (82.3%) were asphyxial in aetiology, and 12 (70.5%) of these cases occurred outside of the hospital. Eight patients (47.1%) had a Paediatric Cerebral Performance Score of 1 or 2 at 3 months after the events. Reversal diastolic or undetectable flow patterns during therapeutic hypothermia were associated with unfavourable prognosis. Normal mean flow velocity in the rewarming phase and normal pulsatility index in the hypothermia and rewarming phases were associated with favourable outcome. CONCLUSION The transcranial Doppler examinations provided additional information for cerebral perfusion during therapeutic hypothermia, which may in the future be used to guide changes to hypothermia management. Mean cerebral blood flow velocity and pulsatility index by transcranial Doppler sonography can serve as a prognostic factor for children who receive therapeutic hypothermia after resuscitation.
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Affiliation(s)
- Jainn-Jim Lin
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, Chang Gung University, College of Medicine, Taoyuan, Taiwan; Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, College of Medicine, Taoyuan, Taiwan; Division of Neonatology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Affiliation(s)
| | - Marilyn H. Burkman
- Neurodiagnostic Laboratory Duke University Hospital Durham, North Carolina
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43
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Transcranial Doppler in the Diagnosis of Cerebral Circulatory Arrest: Cases of the National Institute of Donation and Transplantation of Uruguay. Transplant Proc 2014; 46:2947-9. [DOI: 10.1016/j.transproceed.2014.06.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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44
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Shutter L. Pathophysiology of brain death: what does the brain do and what is lost in brain death? J Crit Care 2014; 29:683-6. [PMID: 24930369 DOI: 10.1016/j.jcrc.2014.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 04/20/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Lori Shutter
- Critical Care Medicine, Departments of Critical Care Medicine, Neurology & Neurosurgery, University of Pittsburgh School of Medicine.
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45
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Huang H, Sejdić E. Assessment of resting-state blood flow through anterior cerebral arteries using trans-cranial doppler recordings. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:2285-2294. [PMID: 24120413 DOI: 10.1016/j.ultrasmedbio.2013.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 04/05/2013] [Accepted: 06/28/2013] [Indexed: 06/02/2023]
Abstract
Trans-cranial Doppler (TCD) recordings are used to monitor cerebral blood flow in the main cerebral arteries. The resting state is usually characterized by the mean velocity or the maximum Doppler shift frequency (an envelope signal) by insonating the middle cerebral arteries. In this study, we characterized cerebral blood flow in the anterior cerebral arteries. We analyzed both envelope signals and raw signals obtained from bilateral insonation. We recruited 20 healthy patients and conducted the data acquisition for 15 min. Features were extracted from the time domain, the frequency domain and the time-frequency domain. The results indicate that a gender-based statistical difference exists in the frequency and time-frequency domains. However, no handedness effect was found. In the time domain, information-theoretic features indicated that mutual dependence is higher in raw signals than in envelope signals. Finally, we concluded that insonation of the anterior cerebral arteries serves as a complement to middle cerebral artery studies. Additionally, investigation of the raw signals provided us with additional information that is not otherwise available from envelope signals. Use of direct trans-cranial Doppler raw data is therefore validated as a valuable method for characterizing the resting state.
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Affiliation(s)
- Hanrui Huang
- Department of Electrical and Computer Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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46
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Llompart-Pou JA, Abadal JM, Güenther A, Rayo L, Martín-del Rincón JP, Homar J, Pérez-Bárcena J. Transcranial Sonography and Cerebral Circulatory Arrest in Adults: A Comprehensive Review. ACTA ACUST UNITED AC 2013. [DOI: 10.5402/2013/167468] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The diagnosis of brain death remains a clinical challenge for intensive care unit physicians. Worldwide regulations in its diagnosis may differ, and the need of ancillary tests after a clinical examination is not uniform. Transcranial sonography is a noninvasive, bedside, and widely available technique that can be used in the diagnosis of the cerebral circulatory arrest that preceeds brain death. In this paper we review the general concepts, the technical requisites, the patterns of Doppler signal confirming cerebral circulatory arrest, the vessels to insonate, and the options in cases with poor acoustic window. Future research perspectives in the field of transcranial sonography are discussed as well.
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Affiliation(s)
- Juan Antonio Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Carretera Valldemossa 79, 07010 Palma, Spain
| | - Josep Maria Abadal
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Carretera Valldemossa 79, 07010 Palma, Spain
| | - Albrecht Güenther
- Hans Berger Clinic for Neurology, University Hospital Jena, 07743 Jena, Germany
| | - Luis Rayo
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Carretera Valldemossa 79, 07010 Palma, Spain
| | | | - Javier Homar
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Carretera Valldemossa 79, 07010 Palma, Spain
| | - Jon Pérez-Bárcena
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Carretera Valldemossa 79, 07010 Palma, Spain
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Welschehold S, Geisel F, Beyer C, Reuland A, Kerz T. Contrast-enhanced transcranial Doppler ultrasonography in the diagnosis of brain death. J Neurol Neurosurg Psychiatry 2013; 84:939-40. [PMID: 23584493 DOI: 10.1136/jnnp-2012-304129] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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48
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Topcuoglu MA, Unal A, Arsava EM. Advances in transcranial Doppler clinical applications. ACTA ACUST UNITED AC 2013; 4:343-58. [PMID: 23496150 DOI: 10.1517/17530059.2010.495749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Diagnostic neurosonology techniques including transcranial Doppler (TCD), transcranial color Doppler imaging (TCDI) and power motion-mode (PMD) TCD provide information about various aspects of cerebrovascular status such as microemboli detection, dynamic autoregulation and long-duration real-time monitoring of flow characteristics. Although most of the information provided cannot be obtained by any other imaging methodology, and is critical in clinical decision-making in the care of various neurovascular diseases, these modalities are widely underutilized. Increasing the familiarity to neurosonological techniques is of crucial importance. AREAS COVERED IN THIS REVIEW After briefly reviewing TCD, TCDI and PMD techniques, classical features are summarized and recent developments in the clinical neurosonology applications with specific interest in the neurovascular disorders. WHAT THE READER WILL GAIN Practical perspectives of ultrasound evaluation of intracranial arterial status in various neurovascular diseases including sickle cell vasculopathy and vasospasm are reviewed in detail. Pearls on the neurosonological monitoring of acute ischemic stroke and increased intracranial pressure increase is provided. Standards of cerebral microembolism detection, right to left shunts diagnosis and cerebral autoregulation assessment are discussed methodologically. Future perspectives of therapeutic neurosonology including sonothrombolysis, microbubble-ultrasound-mediated gene and drug delivery into the brain, and alteration of the brain-blood barrier permeability are summarized. TAKE HOME MESSAGE Suitable with future medicine, neurosonology brings imaging to the bedside, which enables the treating physician to monitor a given intervention in real time. A non-invasive neurosonology-guided treatment of various diseases could be possible in the near future. The first and foremost step in gaining mastery in this very fruitful field is beginning to use it.
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Affiliation(s)
- Mehmet Akif Topcuoglu
- Hacettepe University Hospitals, Department of Neurology, Neurological Intensive Care Unit, 06100, Sihhiye, Ankara, Turkey +90 312 3051806 ; +90 312 3093451 ;
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Computed tomographic angiography as a useful adjunct in the diagnosis of brain death. J Trauma Acute Care Surg 2013; 74:1279-85. [DOI: 10.1097/ta.0b013e31828c46ba] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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