Transcranial grey-scale sonography of subdural haematoma in adults

Neuro Point-of-Care Ultrasound

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.

Usefulness of intraoperative transcranial sonography in patients with traumatic brain injuries: a comparison with postoperative computed tomography

Purpose

The aim of this study was to assess the agreement between intraoperative transcranial sonography (TCS) and postoperative computed tomography (CT) in patients with traumatic brain injuries.

Methods

We performed a retrospective cross-sectional study of 35 patients who underwent TCS during surgery, among those who presented to a regional trauma center and underwent decompressive craniectomy between January 1, 2017 and April 30, 2020.

Results

The mean difference between TCS and CT in measuring the midline shift was -1.33 mm (95% confidence interval, -2.00 to -0.65; intraclass correlation coefficient [ICC], 0.96; P<0.001). An excellent correlation was found between TCS and CT in assessing contralateral subdural hematomas (ICC, 0.96; P<0.001) and focal hematoma lesions (ICC, 0.99; P<0.001). A very good correlation between TCS and CT was found for measurements of ventricle width (ICC, 0.92; P<0.001).

Conclusions

TCS during surgery is considered an effective diagnostic tool for the detection of intraoperative parenchymal changes in patients with traumatic brain injuries.

Transcranial ultrasonography to detect intracranial pathology: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Transcranial ultrasonography (TCU) can be a useful diagnostic tool in evaluating intracranial pathology in patients with limited or delayed access to routine neuroimaging in critical care or austere settings. We reviewed available literature investigating the diagnostic utility of TCU for detecting pediatric and adult patient's intracranial pathology in patients with intact skulls and reported diagnostic accuracy measures.

METHODS

We performed a systematic review of PubMed^® , Cochrane Library, Embase^® , Scopus^® , Web of Science™, and Cumulative Index to Nursing and Allied Health Literature databases to identify articles evaluating ultrasound-based detection of intracranial pathology in comparison to routine imaging using broad Medical Subject Heading sets. Two independent reviewers reviewed the retrieved articles for bias using the Quality Assessment of Diagnostic Accuracy Studies tools and extracted measures of diagnostic accuracy and ultrasound parameters. Data were pooled using meta-analysis implementing a random-effects approach to examine the sensitivity, specificity, and accuracy of ultrasound-based diagnosis.

RESULTS

A total of 44 studies out of the 3432 articles screened met the eligibility criteria, totaling 2426 patients (Mean age: 60.1 ± 14.52 years). We found tumors, intracranial hemorrhage (ICH), and neurodegenerative diseases in the eligible studies. Sensitivity, specificity, and accuracy of TCU and their 95% confidence intervals were 0.80 (0.72, 0.89), 0.71 (0.59, 0.82), and 0.76 (0.71, 0.82) for neurodegenerative diseases; 0.88 (0.74, 1.02), 0.81 (0.50, 1.12), and 0.94 (0.92, 0.96) for ICH; and 0.97 (0.92, 1.03), 0.99 (0.96, 1.01), and 0.99 (0.97, 1.01) for intracranial masses. No studies reported ultrasound presets.

CONCLUSIONS

TCU has a reasonable sensitivity and specificity for detecting intracranial pathology involving ICH and tumors with clinical applications in remote locations or where standard imaging is unavailable. Future studies should investigate ultrasound parameters to enhance diagnostic accuracy in diagnosing intracranial pathology.

Brain topography on adult ultrasound images: Techniques, interpretation, and image library

BACKGROUND AND PURPOSE

Many studies have explored the possibility of using cranial ultrasound for discerning intracranial pathologies like tumors, hemorrhagic stroke, or subdural hemorrhage in clinical scenarios where computer tomography may not be accessible or feasible. The visualization of intracranial anatomy on B-mode ultrasound is challenging due to the presence of the skull that limits insonation to a few segments on the temporal bone that are thin enough to allow transcranial transmission of sound. Several artifacts are produced by hyperechoic signals inherent in brain and skull anatomy when images are created using temporal windows.

METHODS

While the literature has investigated the accuracy of diagnosis of intracranial pathology with ultrasound, we lack a reference source for images acquired on cranial topography on B-mode ultrasound to illustrate the appearance of normal and abnormal structures of the brain and skull. Two investigators underwent hands-on training in Cranial point-of-care ultrasound (c-POCUS) and acquired multiple images from each patient to obtain the most in-depth images of brain to investigate all visible anatomical structures and pathology within 24 hours of any CT/MRI imaging done.

RESULTS

Most reproducible structures visible on c-POCUS included bony parts and parenchymal structures. Transcranial and abdominal presets were equivalent in elucidating anatomical structures. Brain pathology like parenchymal hemorrhage, cerebral edema, and hydrocephalus were also visualized.

CONCLUSIONS

We present an illustrated anatomical atlas of cranial ultrasound B-mode images acquired in various pathologies in a critical care environment and compare our findings with published literature by performing a scoping review of literature on the subject.

Intracranial hemorrhage detected through a craniotomy site with point of care ultrasound

A 60-year-old male presented to the emergency department with acute change in mental status while recovering from a recent hemicraniectomy. During evaluation by the emergency physician, a point-of-care ultrasound (POCUS) was performed using the patient's existing craniectomy site as a sonographic window. Multiple areas of intracranial hemorrhage were visualized on POCUS and head computed tomography scan ultimately requiring urgent neurosurgical intervention. Our case report demonstrates an innovative application of POCUS in the emergency department- setting that has potential to expedite diagnosis and management of life-threatening neurosurgical etiologies, such as hemorrhage and midline shift, in a unique patient population.

Bedsided Transcranial Sonographic Monitoring for Expansion and Progression of Subdural Hematoma Compared to Computed Tomography

Introduction

Transcranial high-resolution ultrasonography reliably allows diagnosis and monitoring of intracerebral hemorrhage in adults. Sonographic monitoring of subdural hematoma (SDH) has not been evaluated in adults so far. This study investigates the reliability of transcranial gray-scale sonography (TGS) in monitoring acute and chronic SDH in adults.

Methods

TGS was performed in 47 consecutive patients with either acute or chronic SDH confirmed by cerebral CT. Four patients were excluded due to insufficient bone window. After identification of SDH in TGS extent was measured and correlated with extent of SDH on cerebral computer tomography (CCT). If possible measurement was performed at least on 2 days to evaluate the possibility to monitor SDH with TGS.

Results

In 43 patients with SDH, 76 examinations were performed with 2 examinations in 23 patients and 3 examinations in 10 patients. Overall extent of SDH correlated significantly between TGS and CCT (r = 0.962). Accordingly correlation was high during each single examination time point. In patients in need for surgical evacuation sonographic measurement yielded a sensitivity of 90.9% and specificity of 93.8% in predicting surgical evacuation (p < 0.001).

Discussion

Imaging of SDH with TGS is possible in patients with SDH and extent of SDH correlates significantly between TGS and CCT during initial as well as during follow-up examination. Thus monitoring of SDH with TGS at patients’ bedside is possible.

Intraoperative Transcranial Sonography for Detection of Contralateral Hematoma Volume Change in Patients with Traumatic Brain Injury

The authors present two clinical cases, in which intraoperative transcranial sonography (TCS) was used to detect a change in contralateral hematoma volume. A 51-year-old female and a 5-year-old male underwent osteoplastic craniotomy for epidural hematoma removal. Scant contralateral hematoma was evident by preoperative computed tomography in both patients. Intraoperative TCS was used to detect changes in contralateral hematomas. After observing a volume change in one case, a second operation was performed immediately. Based in this experience, the authors recommend intraoperative TCS for the detection of contralateral hematoma volume changes.

Applications of Transcranial Color-Coded Sonography in the Emergency Department

Transcranial color-coded Doppler sonography is a noninvasive bedside ultrasound application that combines both imaging of parenchymal structures and Doppler assessment of intracranial vessels. It may aid in rapid diagnoses and treatment decision making of patients with intracranial emergencies in point-of-care settings. This pictorial essay illustrates the technical aspects and emergency department applications of transcranial color-coded Doppler sonography, and provides some rationale for implementation of this technique into the emergency department practice.

Echography in brain imaging in intensive care unit: State of the art

Transcranial sonography (TCS) is an ultrasound-based imaging technique, which allows the identification of several structures within the brain parenchyma. In the past it has been applied for bedside assessment of different intracranial pathologies in children. Presently, TCS is also used on adult patients to diagnose intracranial space occupying lesions of various origins, intracranial hemorrhage, hydrocephalus, midline shift and neurodegenerative movement disorders, in both acute and chronic clinical settings. In comparison with conventional neuroimaging methods (such as computed tomography or magnetic resonance), TCS has the advantages of low costs, short investigation times, repeatability, and bedside availability. These noninvasive characteristics, together with the possibility of offering a continuous patient neuro-monitoring system, determine its applicability in the monitoring of multiple emergency and non-emergency settings. Currently, TCS is a still underestimated imaging modality that requires a wider diffusion and a qualified training process. In this review we focused on the main indications of TCS for the assessment of acute neurologic disorders in intensive care unit.