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Bardakci O, Akdur G, Akdur O, Das M. Accidental Hypothermia and Transcranial Doppler Sonography: Case Report. Ther Hypothermia Temp Manag 2021; 11:192-195. [PMID: 34028287 DOI: 10.1089/ther.2020.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We present a patient who was diagnosed with hypothermia in the emergency department and the changes in bedside transcranial Doppler (TCD) measurements during and immediately after the diagnoses were recorded. To the best of our knowledge, this is the first case report in the literature in which TCD data were shared in an accidental hypothermia patient in the emergency department. A 78-year-old male patient was brought to the emergency department with the complaint of speech impairment. The respiratory rate was 24 bpm, pulse rate 40 bpm, body temperature 25.6°C, blood pressure 80/50 mmHg, and glasgow coma scale 11. On electrocardiography, sinus bradycardia (40 bpm) and a small deflection (J wave) at the end of the QRS complex were observed. Immediately after the patient's admission, right middle cerebral artery end diastolic velocity (EDV) was 13.42 cm/s, peak systolic velocity (PSV) was 40.25 cm/s, and pulsatile index (PI) was 1.26 cm/s. After 1 hour, her body temperature was 34.5°C. Measurements with TCD were repeated 1 hour later at the same point and EDV was found to be 26.12 cm/s, PSV 84.02 cm/s, and PI 1.33. At the fourth hour, the patient's body temperature was 36.4°C, he was normothermic, and his mental status completely normalized. The patient was hospitalized for follow-up and treatment. This case supports that it can be used in the evaluation of cerebral perfusion and improvement during treatment in patients with accidental hypothermia in their admission to the emergency department.
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Affiliation(s)
- Okan Bardakci
- Department of Emergency Medicine, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkey
| | - Gökhan Akdur
- Department of Emergency Medicine, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkey
| | - Okhan Akdur
- Department of Emergency Medicine, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkey
| | - Murat Das
- Department of Emergency Medicine, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkey
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Banahan C, Rogerson Z, Rousseau C, Ramnarine KV, Evans DH, Chung EML. An in vitro comparison of embolus differentiation techniques for clinically significant macroemboli: dual-frequency technique versus frequency modulation method. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:2642-2654. [PMID: 25218455 PMCID: PMC4195753 DOI: 10.1016/j.ultrasmedbio.2014.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 05/12/2014] [Accepted: 06/03/2014] [Indexed: 06/03/2023]
Abstract
The ability to distinguish harmful solid cerebral emboli from gas bubbles intra-operatively has potential to direct interventions to reduce the risk of brain injury. In this in vitro study, two embolus discrimination techniques, dual-frequency (DF) and frequency modulation (FM) methods, are simultaneously compared to assess discrimination of potentially harmful large pieces of carotid plaque debris (0.5-1.55 mm) and thrombus-mimicking material (0.5-2 mm) from gas bubbles (0.01-2.5 mm). Detection of plaque and thrombus-mimic using the DF technique yielded disappointing results, with four out of five particles being misclassified (sensitivity: 18%; specificity: 89%). Although the FM method offered improved sensitivity, a higher number of false positives were observed (sensitivity: 72%; specificity: 50%). Optimum differentiation was achieved using the difference between peak embolus/blood ratio and mean embolus/blood ratio (sensitivity: 77%; specificity: 81%). We conclude that existing DF and FM techniques are unable to confidently distinguish large solid emboli from small gas bubbles (<50 μm).
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Affiliation(s)
- Caroline Banahan
- Medical Physics Department, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - Zach Rogerson
- Department of Physics, University of Leicester, Leicester, UK
| | - Clément Rousseau
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - David H Evans
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Emma M L Chung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Sloan MA. Prevention of Ischemic Neurologic Injury With Intraoperative Monitoring of Selected Cardiovascular and Cerebrovascular Procedures: Roles of Electroencephalography, Somatosensory Evoked Potentials, Transcranial Doppler, and Near-Infrared Spectroscopy. Neurol Clin 2006; 24:631-45. [PMID: 16935192 DOI: 10.1016/j.ncl.2006.05.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
All neuromonitoring techniques, although imperfect, provide useful information for monitoring cardiothoracic and carotid vascular operations. They may be viewed as providing complementary information, which may help surgical technique and, as a result, possibly improve clinical outcomes. As of this writing, the efficacy of TCD and NIRS monitoring during cardiothoracic and vascular surgery cannot be considered established. Well designed, prospective, adequately powered, double-blind, and randomized outcome studies are needed to determine the optimal neurologic monitoring modality (or modalities), in specific surgical settings.
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Affiliation(s)
- Michael A Sloan
- Division of Neurology, Neuroscience and Spine Institute, Carolinas Medical Center, Charlotte, NC 28207, USA.
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Abstract
Cardiac surgery (CS) with cardiopulmonary bypass (CPB) is currently the most common surgery in the United States. Understanding, avoiding, and preventing postoperative complications, including neurologic deficits following CS, represents a great public and economic benefit for society, especially considering our aging population. There is a critical need to identify new strategies that will prevent harmful events during and after CS. At present, experience with neurophysiologic techniques includes the ability to measure cerebral blood flow velocity/emboli and regional cerebral venous oxygen saturation by transcranial Doppler ultrasound, and by near-infrared spectroscopy, respectively. Continuous monitoring of these variables along with systemic hemodynamics will provide a better understanding of mechanisms of brain and other organ injury during CPB. Neuroprotective interventions based on multimodality neurologic monitoring would ideally eliminate postoperative complications and improve patient outcomes.
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Affiliation(s)
- Alexander Y Razumovsky
- Sentient Medical Systems, Inc., 10151 York Road, Suite 120, Cockeysville, MD 21030, USA.
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Mahmood MA, Voorhees ME, Parnell M, Zweifler RM. Transcranial Doppler Ultrasonographic Evaluation of Middle Cerebral Artery Hemodynamics During Mild Hypothermia. J Neuroimaging 2005. [DOI: 10.1111/j.1552-6569.2005.tb00333.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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NAKANE M, NEMOTO C, MARU H, MURAKAWA M. Clinical Monitoring of Cerebral Blood Flow Velocity with Transcranial Doppler Sonography. ACTA ACUST UNITED AC 2005. [DOI: 10.2199/jjsca.25.25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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7
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Razumovsky AY, Tseng EE, Hanley DF, Baumgartner WA. Cerebral hemodynamics changes during retrograde brain perfusion in dogs. J Neuroimaging 2001; 11:171-8. [PMID: 11296588 DOI: 10.1111/j.1552-6569.2001.tb00029.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The objective of this study was to examine cerebral hemodynamics changes during hypothermic circulatory arrest (HCA) with and without retrograde cerebral perfusion (RCP). Thirteen colony-bred hound dogs were placed on cardiopulmonary bypass (CPB) and cooled to 18 degrees C. Five dogs underwent 2 hours of HCA without RCP and 8 with RCP. The animals were then rewarmed on CPB until normothermic and weaned. Cerebral blood flow velocity (CBFV) and Gosling Pulsatility Index (PI) in the middle cerebral artery (MCA) were studied using trans-cranial Doppler ultrasound (TCD). At baseline and during pre- and postarrest CPB, there was anterograde direction of blood flow in the MCA. During HCA with RCP, there was retrograde direction of blood flow in the MCA. There was no difference in CBFV between pre-, during, and postarrest CPB in the group with RCP; however, there was significantly increased CBFV during postarrest CPB in the group without RCP compared to the dogs with RCP. Later, at 3 hours after postarrest CPB, there was decreased CBFV in all animals accompanied by increased PI (2.4 +/- 0.4 and 2.2 +/- 0.6 for animals with RCP and without RCP, respectively) and abnormal TCD waveform changes including decreased diastolic compartment and sharp systolic peak. During hypothermic circulatory arrest, RCP provides CBFV in the MCA comparable to MCA CBFV during CPB. HCA dogs without RCP showed immediate hyperemia on reperfusion. The decreased CBFV and increased PI at 1 hour after postarrest CPB could be an indicator of progressive ischemic injury due to the increased intracranial pressure despite the implementation of RCP.
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Affiliation(s)
- A Y Razumovsky
- Department of Anesthesiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Babikian VL, Feldmann E, Wechsler LR, Newell DW, Gomez CR, Bogdahn U, Caplan LR, Spencer MP, Tegeler C, Ringelstein EB, Alexandrov AV. Transcranial Doppler ultrasonography: year 2000 update. J Neuroimaging 2000; 10:101-15. [PMID: 10800264 DOI: 10.1111/jon2000102101] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
In this update, the main clinical applications of transcranial Doppler ultrasonography are reassessed. A specific format for technology assessment, personal experience, and an extensive review of the literature form the basis of the evaluation. The document is approved by the American Society of Neuroimaging and the Neurosonology Research Group of the World Federation of Neurology.
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Affiliation(s)
- V L Babikian
- Department of Neurology of Boston University, MA, USA
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Grocott HP, Amory DW, Lowry E, Croughwell ND, Newman MF. Transcranial Doppler blood flow velocity versus 133Xe clearance cerebral blood flow during mild hypothermic cardiopulmonary bypass. J Clin Monit Comput 1998; 14:35-9. [PMID: 9641854 DOI: 10.1023/a:1007493422230] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Transcranial doppler (TCD) is used during cardiopulmonary bypass (CPB) to assess cerebral emboli and to estimate cerebral perfusion. We sought to compare TCD middle cerebral artery blood flow velocity (Vmca) to 133Xe clearance cerebral blood flow (CBF) measurements during mild hypothermic CPB thus determining its utility in cerebral perfusion assessment. METHODS Thirty-four patients undergoing mild hypothermic CPB (35 degrees C) were studied and had comparisons of Vmca and 133Xe CBF at three time intervals, 10, 30 and 60 min after the institution of CPB. Linear regression analysis was performed on data from each of the 3 intervals as well as for pooled data from all 3 periods. RESULTS The correlation coefficients for the 3 time periods were, r = 0.32 (p = 0.12), r = 0.32 (p = 0.11), r = 0.48 (p = (0.02), respectively. The pooled data correlation had a coefficient of 0.34 (p = 0.003). CONCLUSION These findings suggest that TCD Vmca is a relatively poor correlate of CBF during mild hypothermic CPB.
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Affiliation(s)
- H P Grocott
- Department of Anesthesiology, Duke Heart Center, Duke University Medical Center, Durham, NC 27710, USA
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Taormina MA, Nichols FT. Use of Transcranial Doppler Sonography to Evaluate Patients With Cerebrovascular Disease. Neurosurg Clin N Am 1996. [DOI: 10.1016/s1042-3680(18)30348-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Nuttall GA, Cook DJ, Fulgham JR, Oliver WC, Proper JA. The Relationship Between Cerebral Blood Flow and Transcranial Doppler Blood Flow Velocity During Hypothermic Cardiopulmonary Bypass in Adults. Anesth Analg 1996. [DOI: 10.1213/00000539-199606000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nuttall GA, Cook DJ, Fulgham JR, Oliver WC, Proper JA. The relationship between cerebral blood flow and transcranial Doppler blood flow velocity during hypothermic cardiopulmonary bypass in adults. Anesth Analg 1996; 82:1146-51. [PMID: 8638782 DOI: 10.1097/00000539-199606000-00008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A noninvasive, simple, and continuous method to assess cerebral perfusion during cardiopulmonary bypass (CPB) could help prevent cerebral ischemia. Transcranial Doppler sonography (TCD) allows a noninvasive, on-line measurement of blood flow velocity in cerebral arteries. The correlation of TCD-estimated and actual cerebral blood flow (CBF) has not been well studied during CPB. We determined the correlation of middle cerebral artery (MCA) mean velocity and CBF determined by the Kety-Schmidt method during nonbypass and two hypothermic bypass flow conditions. Sixteen patients undergoing hypothermic (27 degrees C) CPB for coronary artery bypass grafting and/or valve replacement surgery were enrolled in the study. We were able to determine MCA velocity in only 12 patients. We determined CBF and MCA velocity in each patient during four 15-min study periods: 1) prebypass after sternotomy before aortic cannulation; 2) hypothermic (27 degrees C) CPB with 1.2 L.min-1.m-2 pump flow; 3) hypothermic CPB with 2.4 L.min-1.m-2 pump flow, and 4) 30 min after weaning from CPB. There was no difference in the mean arterial pressure between the two CPB pump blood flows. The pooled change in MCA velocity and CBF as percentage of baseline (prebypass) for all patients and at all time points had a correlation of 0.33 (r). A decrease or increase in MCA velocity did not necessarily indicate a corresponding decrease or increase in CBF. This technology may be of limited usefulness during the circulatory condition of hypothermic, nonpulsatile CPB.
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Affiliation(s)
- G A Nuttall
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Doblar DD. Cerebrovascular assessment of the high-risk patient: the role of transcranial Doppler ultrasound. J Cardiothorac Vasc Anesth 1996; 10:3-14. [PMID: 8634384 DOI: 10.1016/s1053-0770(96)80173-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
With increased attention to the causes and effects of neurologic injury related to cardiopulmonary bypass anesthesia and surgery, multiple modality examination and monitoring of cerebral function and perfusion in the perioperative period may prove to be advantageous. Transcranial Doppler examination and monitoring is inexpensive, noninvasive, safe, provides unique information about the functional status of the intracranial circulation, and complements the duplex Doppler study of the extracranial carotid vessels of the neck for preoperative evaluation of the surgical patient. The transcranial Doppler examination permits quantitation of blood flow velocity of the intracranial vessels, evaluation of autoregulatory capacity and vasomotor reserve, determination of symmetry of flow velocity in the circle of Willis, assessment of collateral circulatory capacity, examination of vessels not accessible to the duplex Doppler and serves as a baseline for intraoperative monitoring and the postoperative examination. Noninvasive, unilateral or bilateral, continuous monitoring of brain blood flow velocity intraoperatively or postoperatively with trending, storage, and correlation with other physiologic variables provides evidence of cerebral perfusion, occurrence and rate of cerebral embolism, and continuous monitoring of therapeutic interventions. A review of the incidence of stroke and neuropsychologic deficit after bypass surgery is focused on parameters amenable to diagnosis using transcranial Doppler. Patient-specific risk factors for neurologic injury derived from previous studies are discussed as well as risk factors that are related to anesthetic and surgical management and equipment. A description of Doppler technology and the correlation of transcranial Doppler findings with angiography and radionucleotide scans establishes the accuracy of the Doppler examination. The preoperative examination, provocative tests of vasomotor reserve, the evaluation of cerebral collateral circulation, and examples of Doppler applications are discussed.
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Affiliation(s)
- D D Doblar
- Department of Anesthesiology, University of Alabama at Birmingham 35233- 1924, USA
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Kahn RA, Slogoff FB, Reich DL, Konstadt SN. Transcranial Doppler ultrasonography: what is its role in cardiac and vascular surgical patients? J Cardiothorac Vasc Anesth 1995; 9:589-97. [PMID: 8547566 DOI: 10.1016/s1053-0770(05)80148-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- R A Kahn
- Department of Anesthesiology, Mount Sinai Medical Center, New York, NY 10029, USA
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