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Zhu MX, Li JY, Cai ZX, Wang Y, Wang WC, Guo YT, Gao GB, Guo QD, Shi XT, Li WC. A novel method for detecting intracranial pressure changes by monitoring cerebral perfusion via electrical impedance tomography. Fluids Barriers CNS 2025; 22:10. [PMID: 39849599 PMCID: PMC11761725 DOI: 10.1186/s12987-025-00619-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 01/12/2025] [Indexed: 01/25/2025] Open
Abstract
BACKGROUND Acute and critical neurological diseases are often accompanied with elevated intracranial pressure (ICP), leading to insufficient cerebral perfusion, which may cause severe secondary lesion. Existing ICP monitoring techniques often fail to effectively meet the demand for real-time noninvasive ICP monitoring and warning. This study aimed to explore the use of electrical impedance tomography (EIT) to provide real-time early warning of elevated ICP by observing cerebral perfusion. METHODS An intracranial hypertension model was prepared by injecting autologous un-anticoagulated blood into the brain parenchyma of twelve Landrace swine. Invasive ICP monitoring was used as a control method, and a high-precision EIT system was used to acquire and analyze the changing patterns of cerebral perfusion EIT image parameters with respect to ICP. Four EIT parameters related to cerebral perfusion were extracted from the images, and their potential application in detecting ICP elevation was analyzed. RESULTS When ICP increased, all EIT perfusion parameters decreased significantly (P < 0.05). When the subjects were in a state of intracranial hypertension (ICP > 22 mmHg), the correlation between EIT perfusion parameters and ICP was more significant (P < 0.01), with correlation coefficients ranging from -0.72 to -0.83. We tested the objects when they were in baseline ICP and in ICP of 15-40 mmHg. Under both circumstances, ROC curve analysis showed that the comprehensive model of perfusion parameters based on the random forest algorithm had a sensitivity and specificity of more than 90% and an area under the curve (AUC) of more than 0.9 for detecting ICP increments of both 5 and 10 mmHg. CONCLUSION This study demonstrates the feasibility of using perfusion EIT to detect ICP increases in real time, which may provide a new method for real-time non-invasive monitoring of patients with increased ICP.
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Affiliation(s)
- Ming-Xu Zhu
- Department of Biomedical Engineering, Air Force Medical University, Xi'an, China
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Air Force Medical University, Xi'an, China
| | - Jun-Yao Li
- Department of Biomedical Engineering, Air Force Medical University, Xi'an, China
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Air Force Medical University, Xi'an, China
| | - Zhan-Xiu Cai
- College of Life Science and Technology, Shandong Second Medical University, Weifang, China
| | - Yu Wang
- Institute of Medical Research, Northwestern Polytechnical University, Xi'an, China
| | - Wei-Ce Wang
- Department of Biomedical Engineering, Air Force Medical University, Xi'an, China
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Air Force Medical University, Xi'an, China
| | - Yi-Tong Guo
- Department of Biomedical Engineering, Air Force Medical University, Xi'an, China
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Air Force Medical University, Xi'an, China
| | - Guo-Bin Gao
- Faculty of Electrical and Control Engineering, Liaoning Technical University, Huludao, China
| | - Qing-Dong Guo
- Department of Neurosurgery, Xijing Hospital, Air Force Medical University, Xi'an, China.
| | - Xue-Tao Shi
- Department of Biomedical Engineering, Air Force Medical University, Xi'an, China.
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Air Force Medical University, Xi'an, China.
| | - Wei-Chen Li
- Department of Biomedical Engineering, Air Force Medical University, Xi'an, China.
- Department of Radiology, Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Air Force Medical University, Xi'an, China.
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Catena E, Volontè A, Fossali T, Ballone E, Bergomi P, Locatelli M, Borghi B, Ottolina D, Rech R, Castelli A, Colombo R. Echocardiographic clues of the "atrial pump mechanism" during cardiopulmonary resuscitation. Intern Emerg Med 2024:10.1007/s11739-024-03762-w. [PMID: 39242469 DOI: 10.1007/s11739-024-03762-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 08/28/2024] [Indexed: 09/09/2024]
Abstract
Instead of the ventricles, atria may be the cardiac structures mainly compressed during cardiopulmonary resuscitation (CPR). This study aimed to assess the prevalence and the mechanical characteristics of atrial compression, named the "atrial pump mechanism", in patients undergoing CPR. A retrospective cohort study was conducted on patients with witnessed refractory out-of-hospital cardiac arrest who were admitted to a tertiary referral center for extracorporeal CPR. The area of maximal compression (AMC) by chest compressions was assessed by transesophageal echocardiography. Right atrial wall excursion (RAWE), left atrial fractional shortening (LAFS), right ventricular fractional area change (RVFAC), and left ventricular fractional shortening (LVFS) were measured. Common carotid and middle cerebral artery peak velocities were assessed using color-Doppler imaging as markers of cardiac outflow and cerebral perfusion. Forty patients were included in the study. Five (12.5%) had AMC over the atria. The atrial pump pattern was characterized by marked atrial compression with higher RAWE and LAFS values compared to the other patients (p < 0.001). Common carotid Doppler and transcranial Doppler-velocity patterns were detectable in all patients with open left ventricular outflow tract, without differences between patients. CPR was successful in four patients (80%) with atrial pump compared to 14 (40%) with no atrial pump mechanism (p = 0.155). In this series of selected patients with witnessed cardiac arrest, the prevalence of the atrial pump mechanism was not negligible. It may contribute to forward blood flow and the maintenance of cerebral perfusion during prolonged cardiopulmonary resuscitation.
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Affiliation(s)
- Emanuele Catena
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital - Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Alessandra Volontè
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital - Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Tommaso Fossali
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital - Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Elisa Ballone
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital - Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Paola Bergomi
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital - Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Martina Locatelli
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital - Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Beatrice Borghi
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital - Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Davide Ottolina
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital - Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Roberto Rech
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital - Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Antonio Castelli
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital - Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Riccardo Colombo
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital - Polo Universitario, University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy.
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Bidkar PU, Kannabiran N, Chatterjee P. Clinical applications of ultrasound in neurosurgery and neurocritical care: A narrative review. Med J Armed Forces India 2024; 80:16-28. [PMID: 38239602 PMCID: PMC10793236 DOI: 10.1016/j.mjafi.2023.06.007] [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: 03/01/2023] [Accepted: 06/17/2023] [Indexed: 01/22/2024] Open
Abstract
Ultrasonography (USG) has become an invaluable tool in the assessment of neurocritical patients in the operating theaters and critical care units. Due to its easy availability, reliability, safety, and repeatability, neuro-intensivists and neuro-anesthesiologists utilize USG to make a diagnosis, assess prognosis, and decide upon treatment. In neurocritical care units, USG has myriad indications for use, both systemic and neurologic. The neurological indications include the assessment of stroke, vasospasm, traumatic brain injury, brain death, acute brain damage, optic nerve sheath diameter, and pupillary reflexes to name a few. The systemic indications range from assessment of cardio-pulmonary function and intravascular volume status to detection of deep venous thromboses, vocal cord assessment in intubated patients, placement of central venous catheters, and percutaneous tracheostomy. In this narrative review, we iterate the clinical applications of USG in neuroanesthesia and neurocritical care, which we penned after searching relevant databases in PubMed, Medline, Ovid, and Google Scholar by using terms such as ‘applications of transcranial Doppler’, ‘optic nerve sheath diameter’, ‘USG applications in the critical care unit’, and so on. Our search database includes several research papers, neurocritical care books, review articles, and scientific databases. This article reviews various applications of USG in neuroanesthesia, neurosurgery, and neurocritical care.
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Affiliation(s)
- Prasanna Udupi Bidkar
- Professor & Unit Head (Neuroanesthesiology), Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | | | - Protiti Chatterjee
- Resident (Anesthesiology & Critical Care), Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
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Cruz Navarro J, Ponce Mejia LL, Robertson C. A Precision Medicine Agenda in Traumatic Brain Injury. Front Pharmacol 2022; 13:713100. [PMID: 35370671 PMCID: PMC8966615 DOI: 10.3389/fphar.2022.713100] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 02/25/2022] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury remains a leading cause of death and disability across the globe. Substantial uncertainty in outcome prediction continues to be the rule notwithstanding the existing prediction models. Additionally, despite very promising preclinical data, randomized clinical trials (RCTs) of neuroprotective strategies in moderate and severe TBI have failed to demonstrate significant treatment effects. Better predictive models are needed, as the existing validated ones are more useful in prognosticating poor outcome and do not include biomarkers, genomics, proteonomics, metabolomics, etc. Invasive neuromonitoring long believed to be a "game changer" in the care of TBI patients have shown mixed results, and the level of evidence to support its widespread use remains insufficient. This is due in part to the extremely heterogenous nature of the disease regarding its etiology, pathology and severity. Currently, the diagnosis of traumatic brain injury (TBI) in the acute setting is centered on neurological examination and neuroimaging tools such as CT scanning and MRI, and its treatment has been largely confronted using a "one-size-fits-all" approach, that has left us with many unanswered questions. Precision medicine is an innovative approach for TBI treatment that considers individual variability in genes, environment, and lifestyle and has expanded across the medical fields. In this article, we briefly explore the field of precision medicine in TBI including biomarkers for therapeutic decision-making, multimodal neuromonitoring, and genomics.
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Affiliation(s)
- Jovany Cruz Navarro
- Departments of Anesthesiology and Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Lucido L. Ponce Mejia
- Departments of Neurosurgery and Neurology, LSU Health Science Center, New Orleans, LA, United States
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
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Sentenac P, Charbit J, Maury C, Bory P, Dagod G, Greco F, Capdevila X, Perrigault PF. The Frontal Bone Window for Transcranial Doppler Ultrasonography in Critically Ill Patients: Validation of a New Approach in the ICU. Neurocrit Care 2021; 33:115-123. [PMID: 31664626 PMCID: PMC7392931 DOI: 10.1007/s12028-019-00869-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVE The temporal bone window (TBW) for transcranial Doppler (TCD) often fails to insonate the anterior cerebral artery (ACA). The frontal bone window (FBW) has never been evaluated in intensive care units (ICU). The main objective was to determine the ability of the FBW to assess ACA velocities in critically ill patients. METHODS A prospective study was conducted in two ICUs of the Montpellier University Hospital (France), between November 2014 and September 2016. Adult patients admitted to ICU for brain injury, with a Glasgow Coma Scale score ≤ 13, were enrolled within 3 days after admission. A first TCD examination was carried out bilaterally through the TBW and FBW by an intensivist expert in TCD, repeated by the same examiner, and 15 min later by an intensivist certified in TCD, designated as non-expert, blinded. The success of the FBW examinations was defined by the ability to measure the ACA velocities. Intra- and interobserver agreements were analyzed according to the Bland and Altman method. RESULTS A total of 147 patients were analyzed. The FBW succeeded in insonating the ACA in 66 patients [45%, CI (37-53)], 45 bilaterally and 21 unilaterally. For 16 patients (11%), the FBW was the only way to measure ACA velocities. By combining the two techniques, the ACA success rate increased from 62% CI (54-70) to 73% CI (65-79) (P = 0.05). Intra- and interobserver mean biases and 95% limits of agreement for ACA systolic velocity measurements through the FBW were 1 (- 33 to 35) and 2 (- 34 to 38) cm s-1, respectively. For paired TBW and FBW measures of ACA velocities, mean biases (± SD) for ACA systolic, and mean and diastolic velocities were relatively close to zero, but negatives (- 7 ± 33, - 2 ± 19, - 1 ± 15 cm s-1, respectively), highlighting that ACA velocities were lower with the FBW (A2 segment) than TBW (A1 segment). The correlation coefficient for ACA systolic velocities measured by the FBW and TBW was R = 0.47, CI (0.28-0.62). No risk factors for failure of the FBW were identified. CONCLUSIONS In ICU, the FBW was able to insonate the ACA in 45% of patients admitted for brain injury, without the use of contrast agents. The FBW could improve the detection of ACA vasospasms.
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Affiliation(s)
- Pierre Sentenac
- Anesthesia and Critical Care Medicine Department, Trauma ICU, Level 1 Regional Trauma Center, Lapeyronie Teaching Hospital, Montpellier University School of Medicine, 34295, Montpellier, France.
- Anesthesia and Critical Care Medicine Department, Neurological ICU, Gui de Chauliac Teaching Hospital, Montpellier University School of Medicine, 34295, Montpellier, France.
- PhyMedExp, Unité 1046, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, University of Montpellier, 34295, Montpellier, France.
- Anesthesia and Critical Care Medicine Department, Heart and Lung center, Arnaud de Villeneuve Teaching Hospital, Montpellier University School of Medicine, 371 avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Jonathan Charbit
- Anesthesia and Critical Care Medicine Department, Trauma ICU, Level 1 Regional Trauma Center, Lapeyronie Teaching Hospital, Montpellier University School of Medicine, 34295, Montpellier, France
| | - Camille Maury
- Anesthesia and Critical Care Medicine Department, Trauma ICU, Level 1 Regional Trauma Center, Lapeyronie Teaching Hospital, Montpellier University School of Medicine, 34295, Montpellier, France
| | - Paul Bory
- Anesthesia and Critical Care Medicine Department, Neurological ICU, Gui de Chauliac Teaching Hospital, Montpellier University School of Medicine, 34295, Montpellier, France
| | - Geoffrey Dagod
- Anesthesia and Critical Care Medicine Department, Trauma ICU, Level 1 Regional Trauma Center, Lapeyronie Teaching Hospital, Montpellier University School of Medicine, 34295, Montpellier, France
| | - Frédéric Greco
- Anesthesia and Critical Care Medicine Department, Neurological ICU, Gui de Chauliac Teaching Hospital, Montpellier University School of Medicine, 34295, Montpellier, France
| | - Xavier Capdevila
- Anesthesia and Critical Care Medicine Department, Trauma ICU, Level 1 Regional Trauma Center, Lapeyronie Teaching Hospital, Montpellier University School of Medicine, 34295, Montpellier, France
- Institut des Neurosciences de Montpellier (INM), Unité 1051, Institut National de la Santé et de la Recherche Médicale, University of Montpellier, 34091, Montpellier, France
| | - Pierre-François Perrigault
- Anesthesia and Critical Care Medicine Department, Neurological ICU, Gui de Chauliac Teaching Hospital, Montpellier University School of Medicine, 34295, Montpellier, France
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Zakharchenko S, Hansen A, Ibikunle A, Devasagayaraj R, Charles P. Intracranial hemorrhage detected through a craniotomy site with point of care ultrasound. J Am Coll Emerg Physicians Open 2021; 2:e12419. [PMID: 34179872 PMCID: PMC8212560 DOI: 10.1002/emp2.12419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Svetlana Zakharchenko
- Hackensack University Medical CenterHackensack Meridian HealthHackensackNew JerseyUSA
| | | | - Aminat Ibikunle
- Hackensack University Medical CenterHackensack Meridian HealthHackensackNew JerseyUSA
| | - Richard Devasagayaraj
- Hackensack University Medical CenterHackensack Meridian HealthHackensackNew JerseyUSA
| | - Patrick Charles
- Hackensack University Medical CenterHackensack Meridian HealthHackensackNew JerseyUSA
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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: 25] [Impact Index Per Article: 6.3] [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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Kienzler JC, Zakelis R, Bäbler S, Remonda E, Ragauskas A, Fandino J. Validation of Noninvasive Absolute Intracranial Pressure Measurements in Traumatic Brain Injury and Intracranial Hemorrhage. Oper Neurosurg (Hagerstown) 2020; 16:186-196. [PMID: 29726988 DOI: 10.1093/ons/opy088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 03/22/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Increased intracranial pressure (ICP) causes secondary damage in traumatic brain injury (TBI), and intracranial hemorrhage (ICH). Current methods of ICP monitoring require surgery and carry risks of complications. OBJECTIVE To validate a new instrument for noninvasive ICP measurement by comparing values obtained from noninvasive measurements to those from commercial implantable devices through this pilot study. METHODS The ophthalmic artery (OA) served as a natural ICP sensor. ICP measurements obtained using noninvasive, self-calibrating device utilizing Doppler ultrasound to evaluate OA flow were compared to standard implantable ICP measurement probes. RESULTS A total of 78 simultaneous, paired, invasive, and noninvasive ICP measurements were obtained in 11 ICU patients over a 17-mo period with the diagnosis of TBI, SAH, or ICH. A total of 24 paired data points were initially excluded because of questions about data independence. Analysis of variance was performed first on the 54 remaining data points and then on the entire set of 78 data points. There was no difference between the 2 groups nor was there any correlation between type of sensor and the patient (F[10, 43] = 1.516, P = .167), or the accuracy and precision of noninvasive ICP measurements (F[1, 43] = 0.511, P = .479). Accuracy was [-1.130; 0.539] mm Hg (CL = 95%). Patient-specific calibration was not needed. Standard deviation (precision) was [1.632; 2.396] mm Hg (CL = 95%). No adverse events were encountered. CONCLUSION This pilot study revealed no significant differences between invasive and noninvasive ICP measurements (P < .05), suggesting that noninvasive ICP measurements obtained by this method are comparable and reliable.
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Affiliation(s)
- Jenny C Kienzler
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Rolandas Zakelis
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.,Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Sabrina Bäbler
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Elke Remonda
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Arminas Ragauskas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
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McHugh JA, D'Antona L, Toma AK, Bremner FD. Spontaneous Venous Pulsations Detected With Infrared Videography. J Neuroophthalmol 2020; 40:174-177. [PMID: 31464805 DOI: 10.1097/wno.0000000000000815] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Assessment of spontaneous venous pulsation (SVP) is commonly undertaken to help determine whether intracranial pressure (ICP) is elevated. Previous studies using direct ophthalmoscopy or slit-lamp assessments have found that SVP is not observed in 67%-81% of subjects with normal ICP, and that interobserver agreement when grading SVP is poor. METHODS Patients (n = 105) undergoing clinically indicated retinal OCT scans, who were all believed to have normal ICP, had 10-second infrared video recordings performed with the Heidelberg Spectralis OCT system (Heidelberg Engineering GmbH, Heidelberg, Germany). The presence and amplitude of SVP in each video was independently graded by 2 neuro-ophthalmologists. RESULTS The 2 observers found SVP present in 97% and 98% of right eyes and in one or both eyes in 99% and 100% of subjects. Interobserver agreement was high (Cohen's kappa 0.82 for right eyes). Optic discs with a smaller cup had a significantly lower SVP amplitude (Spearman's rho = 0.22, P = 0.02). CONCLUSIONS Infrared video is widely available in eye clinics by the use of OCT imaging systems and is substantially more sensitive in detecting SVP than traditional assessments using ophthalmoscopy. SVP is absent in as few as 1% of people with presumed normal ICP.
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Affiliation(s)
- James A McHugh
- Department of Neuro-Ophthalmology (JAM, FDB), National Hospital for Neurology and Neurosurgery, London, United Kingdom; Department of Ophthalmology (JAM), King's College Hospital London, United Kingdom; and Department of Neurosurgery (LD, AKT), National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Bendella H, Spreer J, Hartmann A, Igressa A, Maegele M, Lefering R, Nakamura M. Bedside Sonographic Duplex Technique as a Monitoring Tool in Patients after Decompressive Craniectomy: A Single Centre Experience. ACTA ACUST UNITED AC 2020; 56:medicina56020085. [PMID: 32093047 PMCID: PMC7074068 DOI: 10.3390/medicina56020085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/23/2020] [Accepted: 02/13/2020] [Indexed: 11/16/2022]
Abstract
Background and objectives: Bedside sonographic duplex technique (SDT) may be used as an adjunct to cranial computed tomography (CCT) to monitor brain-injured patients after decompressive craniectomy (DC). The present study aimed to assess the value of SDT in repeated measurements of ventricle dimensions in patients after DC by comparing both techniques. Materials and Methods: Retrospective assessment of 20 consecutive patients after DC for refractory intracranial pressure (ICP) increase following subarachnoid hemorrhage (SAH), bleeding and trauma which were examined by SDT and CCT in the context of routine clinical practice. Whenever a repeated CCT was clinically indicated SDT examinations were performed within 24 hours and correlated via measurement of the dimensions of all four cerebral ventricles. Basal cerebral arteries including pathologies such as vasospasms were also evaluated in comparison to selected digital subtraction angiography (DSA). Results: Repeated measurements of all four ventricle diameters showed high correlation between CCT and SDT (right lateral r = 0.997, p < 0.001; left lateral r = 0.997, p < 0.001; third r = 0.991, p < 0.001, fourth ventricle r = 0.977, p < 0.001). SDT performed well in visualizing basal cerebral arteries including pathologies (e.g., vasospasms) as compared to DSA. Conclusions: Repeated SDT measurements of the dimensions of all four ventricles in patients after DC for refractory ICP increase delivered reproducible results comparable to CCT. SDT may be considered as a valuable bedside monitoring tool in patients after DC.
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Affiliation(s)
- Habib Bendella
- Department of Neurosurgery, University of Witten/Herdecke, Cologne Merheim Medical Center (CMMC), 51109 Cologne, Germany; (A.H.); (A.I.); (M.N.)
- Correspondence: ; Tel.: +49-221-8907-13085
| | - Joachim Spreer
- Division of Neuroradiology, Department of Radiology, University of Witten/Herdecke, Cologne Merheim Medical Center (CMMC), 51109 Cologne, Germany;
| | - Alexander Hartmann
- Department of Neurosurgery, University of Witten/Herdecke, Cologne Merheim Medical Center (CMMC), 51109 Cologne, Germany; (A.H.); (A.I.); (M.N.)
| | - Alhadi Igressa
- Department of Neurosurgery, University of Witten/Herdecke, Cologne Merheim Medical Center (CMMC), 51109 Cologne, Germany; (A.H.); (A.I.); (M.N.)
| | - Marc Maegele
- Department of Traumatology, Orthopedic Surgery and Sportsmedicine, University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), 51109 Cologne, Germany;
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim, 51109 Cologne, Germany;
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim, 51109 Cologne, Germany;
| | - Makoto Nakamura
- Department of Neurosurgery, University of Witten/Herdecke, Cologne Merheim Medical Center (CMMC), 51109 Cologne, Germany; (A.H.); (A.I.); (M.N.)
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Hamdy S, Aref HMA, Reda R, ElSadek A. Comparison between intracranial collaterals and cerebral hemodynamics in patients with extracranial carotid stenosis versus combined extra- and intracranial stenosis using transcranial duplex. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0061-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Lau VI, Jaidka A, Wiskar K, Packer N, Tang JE, Koenig S, Millington SJ, Arntfield RT. Better With Ultrasound: Transcranial Doppler. Chest 2019; 157:142-150. [PMID: 31580841 DOI: 10.1016/j.chest.2019.08.2204] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/15/2019] [Accepted: 08/31/2019] [Indexed: 02/02/2023] Open
Abstract
Transcranial Doppler (TCD) ultrasound is a noninvasive method of obtaining bedside neurologic information that can supplement the physical examination. In critical care, this can be of particular value in patients who are unconscious with an equivocal neurologic examination because TCD findings can help the physician in decisions related to more definitive imaging studies and potential clinical interventions. Although TCD is traditionally the domain of sonographers and radiologists, there is increasing adoption of goal-directed TCD at the bedside in the critical care environment. The value of this approach includes round-the-clock availability and a goal-directed approach allowing for repeatability, immediate interpretation, and quick clinical integration. This paper presents a systematic approach to incorporating the highest yield TCD techniques into critical care bedside practice, and includes a series of illustrative figures and narrated video presentations to demonstrate the techniques described.
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Affiliation(s)
| | | | - Katie Wiskar
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Seth Koenig
- Hofstra North Shore - Long-Island Jewish School of Medicine, Hempstead, NY
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Kondrashova T, Makar M, Proctor C, Bridgmon KA, Pazdernik V. Dynamic assessment of cerebral blood flow and intracranial pressure during inversion table tilt using ultrasonography. J Neurol Sci 2019; 404:150-156. [PMID: 31398694 DOI: 10.1016/j.jns.2019.07.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/11/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Inversion tables are used as treatment for back pain, but there is a lack of agreement on systemic effects of inversion. OBJECTIVE To assess intracranial pressure (ICP) and cerebral blood flow using ultrasonography during inversion table tilt. METHODS Optic nerve sheath diameter (ONSD), heart rate (HR), blood pressure, internal carotid artery (ICA) and middle cerebral artery (MCA) blood flow of participants were measured in 3 positions: supine before inversion, during inversion with head down, and supine post-inversion. ONSD was evaluated with ocular ultrasonography and blood flow (ICA and MCA) with Doppler ultrasonography. RESULTS The ONSD changed significantly between the supine position, at 3 min of inversion, and after returning to supine position (all P < .001). The post-inversion HR was less than pre-inversion (P = .03) and 3-min inversion HR (P = .003). There were significant changes in ICA and MCA flow caused by inversion, which affected blood flow velocity, resistance, and pulsatility index (all P ≤ .005). CONCLUSION Inversion caused significant changes in ICP and blood flow. Thus, increased chance of complications may exist when using inversion as a therapeutic tool or during surgical procedures in patients with previous history of elevated ICP. These results demonstrate that inversion therapy should be used with caution.
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Affiliation(s)
- Tatyana Kondrashova
- Department of Family Medicine, Preventive Medicine, and Community Health, Kirksville College of Osteopathic Medicine, A.T. Still University, 800 W. Jefferson St., Kirksville, MO 63501, USA.
| | - Monica Makar
- Kirksville College of Osteopathic Medicine, A.T. Still University, 800 W. Jefferson St., Kirksville, MO 63501, USA.
| | - Carlie Proctor
- Kirksville College of Osteopathic Medicine, A.T. Still University, 800 W. Jefferson St., Kirksville, MO 63501, USA.
| | - Kenneth A Bridgmon
- Kirksville College of Osteopathic Medicine, A.T. Still University, 800 W. Jefferson St., Kirksville, MO 63501, USA.
| | - Vanessa Pazdernik
- Department of Research Support, A.T. Still University, 800 W. Jefferson St., Kirksville, MO 63501, USA.
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Rafi S, Tadie JM, Gacouin A, Leurent G, Bedossa M, Le Tulzo Y, Maamar A. Doppler sonography of cerebral blood flow for early prognostication after out-of-hospital cardiac arrest: DOTAC study. Resuscitation 2019; 141:188-194. [DOI: 10.1016/j.resuscitation.2019.05.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/11/2019] [Accepted: 05/17/2019] [Indexed: 10/26/2022]
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15
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Abecasis F, Oliveira V, Robba C, Czosnyka M. Transcranial Doppler in pediatric emergency and intensive care unit: a case series and literature review. Childs Nerv Syst 2018; 34:1465-1470. [PMID: 29955941 DOI: 10.1007/s00381-018-3877-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/21/2018] [Indexed: 02/03/2023]
Abstract
PURPOSE Transcranial Doppler (TCD) has been used for more than 30 years in clinical practice. Although adult intensive care is relatively well covered, pediatric cases are still underrepresented. We intend to review a series of pediatric cases where TCD was determinant in clinical decisions and a literature review on this topic. METHODS We describe cases with different pathologies where TCD had an important role in clinical management of the patients. We discuss TCD utility and potential role both in the emergency department and the intensive care unit. RESULTS Five patients with different neurologic insults are presented. TCD was useful in the identification of intracranial hypertension in traumatic brain injury, hydrocephalus and central nervous system infection; identification of decreased cerebral perfusion pressure in hypovolemic shock and the diagnosis of impending cerebral circulatory arrest in a child with meningococcal septicemia. We discuss how TCD can be used in emergency and intensive care settings, reviewing relevant literature and our own experience. CONCLUSIONS Non-invasive testing using TCD can aid clinical decisions. More widespread use of this technique will allow for better care of children with neurologic insults.
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Affiliation(s)
- Francisco Abecasis
- Pediatric Intensive Care Unit, Centro Hospitalar Lisboa Norte, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
| | - Vitor Oliveira
- Department of Neurology, Centro Hospitalar Lisboa Norte, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Chiara Robba
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRSSS for Oncology, Genoa, Italy
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, UK.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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Lovett ME, Maa T, Chung MG, O'Brien NF. Cerebral blood flow velocity and autoregulation in paediatric patients following a global hypoxic-ischaemic insult. Resuscitation 2018; 126:191-196. [PMID: 29452150 DOI: 10.1016/j.resuscitation.2018.02.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 10/27/2017] [Accepted: 02/05/2018] [Indexed: 12/17/2022]
Abstract
AIM To describe the cerebral blood flow velocity pattern and investigate cerebral autoregulation using transcranial Doppler ultrasonography (TCD) following a global hypoxic-ischaemic (HI) event in children. METHODS This was a prospective, observational study in a quaternary-level paediatric intensive care unit. Intubated children, newborn to 17 years admitted to the PICU following HI injury (asphyxia, drowning, cardiac arrest) were eligible for inclusion. TCD was performed daily until post-injury day 8, discharge, or death, whichever occurred earliest. RESULTS Twenty-six patients were enrolled. Median age was 3 years (0.33, 11.75), initial pH 6.95, and initial lactate 5.4. Median post-resuscitation Glasgow Coma Score was 3T. Across the entire cohort, cerebral blood flow velocity (CBFV) was near normal on day 1. Flow velocity increased to a maximum median value of 1.4 standard deviations above normal on day 3 and slowly downtrended back to baseline by the end of the study period. Median Paediatric Extended Version of the Glasgow Outcome Score was 4 at three months. No patient in the favourable outcome group had extreme CBFV on day one, and only one patient in the favourable group had extreme CBFV on PID 2. In contrast, 38% of patients in the unfavourable group had extreme CBFV on PID 1 (p=.039 compared to frequency in favourable group), and 55% had extreme CBFV on PID 2 (p = .023 compared to frequency in favourable group). No patient had consistently intact cerebral autoregulation throughout the study period. CONCLUSIONS Following a HI event, patients with favourable neurologic outcomes had flow velocity near normal whereas unfavourable outcomes had more extreme flow velocity. Intermittently intact cerebral autoregulation was more frequently seen in those with favourable neurologic outcomes though return to the autoregulatory baseline appears delayed.
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Affiliation(s)
- Marlina E Lovett
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States.
| | - Tensing Maa
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States; Department of Paediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Melissa G Chung
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States; Department of Paediatrics, The Ohio State University College of Medicine, Columbus, OH, United States; Division of Neurology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Nicole F O'Brien
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States; Department of Paediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
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Lau VI, Arntfield RT. Point-of-care transcranial Doppler by intensivists. Crit Ultrasound J 2017; 9:21. [PMID: 29030715 PMCID: PMC5640565 DOI: 10.1186/s13089-017-0077-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/06/2017] [Indexed: 11/10/2022] Open
Abstract
In the unconscious patient, there is a diagnostic void between the neurologic physical exam, and more invasive, costly and potentially harmful investigations. Transcranial color-coded sonography and two-dimensional transcranial Doppler imaging of the brain have the potential to be a middle ground to bridge this gap for certain diagnoses. With the increasing availability of point-of-care ultrasound devices, coupled with the need for rapid diagnosis of deteriorating neurologic patients, intensivists may be trained to perform point-of-care transcranial Doppler at the bedside. The feasibility and value of this technique in the intensive care unit to help rule-in specific intra-cranial pathologies will form the focus of this article. The proposed scope for point-of-care transcranial Doppler for the intensivist will be put forth and illustrated using four representative cases: presence of midline shift, vasospasm, raised intra-cranial pressure, and progression of cerebral circulatory arrest. We will review the technical details, including methods of image acquisition and interpretation. Common pitfalls and limitations of point-of-care transcranial Doppler will also be reviewed, as they must be understood for accurate diagnoses during interpretation, as well as the drawbacks and inadequacies of the modality in general.
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Affiliation(s)
- Vincent Issac Lau
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
- London Health Sciences Centre, Victoria Hospital Rm, D2-528, 800 Commissioners Road East, London, ON N6A 5W9 Canada
| | - Robert Thomas Arntfield
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
- London Health Sciences Centre, Victoria Hospital Rm, D2-528, 800 Commissioners Road East, London, ON N6A 5W9 Canada
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Blanco P, Blaivas M. Applications of Transcranial Color-Coded Sonography in the Emergency Department. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1251-1266. [PMID: 28240783 DOI: 10.7863/ultra.16.04050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/19/2016] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Pablo Blanco
- Intensive Care Unit, Hospital "Dr. Emilio Ferreyra,", Necochea, Argentina
| | - Michael Blaivas
- Department of Emergency Medicine, University of South Carolina School of Medicine, Piedmont Hospital, Newnan, Georgia, USA
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González Cortés R, Renter Valdovinos L, Coca Pérez A, Vázquez Martínez JL. Point-of-care ultrasound in Spanish paediatric intensive care units. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.anpede.2016.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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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: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/29/2016] [Accepted: 05/17/2016] [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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Affiliation(s)
- Antonello D'Andrea
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Marianna Conte
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Massimo Cavallaro
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Raffaella Scarafile
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Lucia Riegler
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Rosangela Cocchia
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Enrica Pezzullo
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Andreina Carbone
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Francesco Natale
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Giuseppe Santoro
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Pio Caso
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Maria Giovanna Russo
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Eduardo Bossone
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Raffaele Calabrò
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
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González Cortés R, Renter Valdovinos L, Coca Pérez A, Vázquez Martínez JL. [Point-of-care ultrasound in Spanish paediatric intensive care units]. An Pediatr (Barc) 2016; 86:344-349. [PMID: 27436571 DOI: 10.1016/j.anpedi.2016.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 06/15/2016] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Point-of-care (bedside) ultrasound is being increasingly used by paediatricians who treat critically ill children. The aim of this study is to describe its availability, use, and specific training in Paediatric Intensive Care Units in Spain. MATERIAL AND METHODS A descriptive, cross-sectional, multicentre study was performed using an online survey. RESULTS Of a total of 51 PICUs identified in our country, 64.7% responded to the survey. Just over half (53.1%) have their own ultrasound machine, 25% share it, with other units with the usual location in the PICU, and 21.9% share it, but it is usually located outside the PICU. Ultrasound machine availability was not related to size, care complexity, or number PICU admissions. The ultrasound was used daily in 35% of the units, and was associated with location of the machine in the PICU (P=.026), the existence of a transplant program (P=.009), availability of ECMO (P=.006), and number of admissions (P=.015). 45.5% of PICUs has less than 50% of the medical staff specifically trained in bedside ultrasound, and 18.2% have all their medical staff trained. The presence of more than 50% of medical staff trained was associated with a higher rate of daily use (P=.033), and with specific use to evaluate cardiac function (P=.033), intravascular volume estimation (P=.004), or the presence of intra-abdominal collections (P=.021). CONCLUSIONS Bedside ultrasound is frequently available in Spanish PICUs. Specific training is still variable, but it should serve to enhance its implementation.
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Affiliation(s)
- Rafael González Cortés
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de investigación Sanitaria Gregorio Marañón, RETICS financiada por el PN I+D+I 2008-2011, ISCIII - Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER), ref. RD12/0026; Red de Salud Materno Infantil y Desarrollo, Madrid, España.
| | - Luis Renter Valdovinos
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Parc Taulí, Sabadell, Barcelona, España
| | - Ana Coca Pérez
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Ramón y Cajal, Madrid, España
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Noninvasive Vascular Methods for Detection of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. J Clin Neurophysiol 2016; 33:260-7. [DOI: 10.1097/wnp.0000000000000271] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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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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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: 62] [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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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: 121] [Impact Index Per Article: 12.1] [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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Nogueira AB, Nogueira AB, Esteves Veiga JC, Teixeira MJ. Multimodality monitoring, inflammation, and neuroregeneration in subarachnoid hemorrhage. Neurosurgery 2015; 75:678-89. [PMID: 25050583 PMCID: PMC4224571 DOI: 10.1227/neu.0000000000000512] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Stroke, including subarachnoid hemorrhage (SAH), is one of the leading causes of morbidity and mortality worldwide. The mortality rate of poor-grade SAH ranges from 34% to 52%. In an attempt to improve SAH outcomes, clinical research on multimodality monitoring has been performed, as has basic science research on inflammation and neuroregeneration (which can occur due to injury-induced neurogenesis). Nevertheless, the current literature does not focus on the integrated study of these fields. Multimodality monitoring corresponds to physiological data obtained during clinical management by both noninvasive and invasive methods. Regarding inflammation and neuroregeneration, evidence suggests that, in all types of stroke, a proinflammatory phase and an anti-inflammatory phase occur consecutively; these phases affect neurogenesis, which is also influenced by other pathophysiological features of stroke, such as ischemia, seizures, and spreading depression. OBJECTIVE To assess whether injury-induced neurogenesis is a prognostic factor in poor-grade SAH that can be monitored and modulated. METHODS We propose a protocol for multimodality monitoring-guided hypothermia in poor-grade SAH in which cellular and molecular markers of inflammation and neuroregeneration can be monitored in parallel with clinical and multimodal data. EXPECTED OUTCOMES This study may reveal correlations between markers of inflammation and neurogenesis in blood and cerebrospinal fluid, based on clinical and multimodality monitoring parameters. DISCUSSION This protocol has the potential to lead to new therapies for acute, diffuse, and severe brain diseases.
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Affiliation(s)
- Adriano B Nogueira
- *Division of Neurosurgery Clinics, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil; ‡Institute of Radiology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil; and §Santa Casa Faculty of Medical Sciences, São Paulo, Brazil
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Early Mobilization in Aneurysmal Subarachnoid Hemorrhage Accelerates Recovery and Reduces Length of Stay. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2015. [DOI: 10.1097/jat.0000000000000008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.
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Affiliation(s)
- Stanlies D'Souza
- Department of Neuroanesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
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29
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Abstract
PURPOSE OF REVIEW To present the practical aspects of transcranial Doppler (TCD) and provide evidence supporting its use for the management of traumatic brain injury (TBI) patients. RECENT FINDINGS TCD measures systolic, mean, and diastolic cerebral blood flow (CBF) velocities and calculates the pulsatility index from basal intracranial arteries. These variables reflect the brain circulation, provided there is control of potential confounding factors. TCD can be useful in patients with severe TBI to detect low CBF, for example, during intracranial hypertension, and to assess cerebral autoregulation. In the emergency room, TCD might complement brain computed tomography (CT) scan and clinical examination to screen patients at risk for further neurological deterioration after mild-to-moderate TBI. SUMMARY The diagnostic value of TCD should be incorporated into other findings from multimodal brain monitoring and CT scan to optimize the bedside management of patients with TBI and help guide the choice of appropriate therapies.
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30
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Frevert U, Nacer A. Fatal cerebral malaria: a venous efflux problem. Front Cell Infect Microbiol 2014; 4:155. [PMID: 25414834 PMCID: PMC4222339 DOI: 10.3389/fcimb.2014.00155] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 10/13/2014] [Indexed: 12/20/2022] Open
Abstract
Most Plasmodium falciparum-infected children with cerebral malaria (CM) die from respiratory arrest, but the underlying pathology is unclear. Here we present a model in which the ultimate cause of death from CM is severe intracranial hypertension. Dynamic imaging of mice infected with P. berghei ANKA, an accepted model for experimental CM, revealed that leukocyte adhesion impairs the venous blood flow by reducing the functional lumen of postcapillary venules (PCV). The resulting increase in intracranial pressure (ICP) exacerbates cerebral edema formation, a hallmark of both murine and pediatric CM. We propose that two entirely different pathogenetic mechanisms-cytoadherence of P. falciparum-infected erythrocytes in pediatric CM and leukocyte arrest in murine CM-result in the same pathological outcome: a severe increase in ICP leading to brainstem herniation and death from respiratory arrest. The intracranial hypertension (IH) model unifies previous hypotheses, applies to human and experimental CM alike, eliminates the need to explain any selective recognition mechanism Plasmodium might use to target multiple sensitive sites in the brain, and explains how an intravascular parasite can cause so much neuronal dysfunction.
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Affiliation(s)
- Ute Frevert
- Division of Medical Parasitology, Department of Microbiology, New York University School of Medicine New York, NY, USA
| | - Adéla Nacer
- Unité de Biologie des Interactions Hôte-Parasite, Département de Parasitologie et Mycologie, Institut Pasteur Paris, France
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31
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Amin H, Greer DM. Cryptogenic Stroke—The Appropriate Diagnostic Evaluation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 16:280. [DOI: 10.1007/s11936-013-0280-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Naqvi J, Yap KH, Ahmad G, Ghosh J. Transcranial Doppler ultrasound: a review of the physical principles and major applications in critical care. Int J Vasc Med 2013; 2013:629378. [PMID: 24455270 PMCID: PMC3876587 DOI: 10.1155/2013/629378] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 11/10/2013] [Indexed: 12/28/2022] Open
Abstract
Transcranial Doppler (TCD) is a noninvasive ultrasound (US) study used to measure cerebral blood flow velocity (CBF-V) in the major intracranial arteries. It involves use of low-frequency (≤2 MHz) US waves to insonate the basal cerebral arteries through relatively thin bone windows. TCD allows dynamic monitoring of CBF-V and vessel pulsatility, with a high temporal resolution. It is relatively inexpensive, repeatable, and portable. However, the performance of TCD is highly operator dependent and can be difficult, with approximately 10-20% of patients having inadequate transtemporal acoustic windows. Current applications of TCD include vasospasm in sickle cell disease, subarachnoid haemorrhage (SAH), and intra- and extracranial arterial stenosis and occlusion. TCD is also used in brain stem death, head injury, raised intracranial pressure (ICP), intraoperative monitoring, cerebral microembolism, and autoregulatory testing.
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Affiliation(s)
- Jawad Naqvi
- University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Kok Hooi Yap
- Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Gulraiz Ahmad
- Royal Oldham Hospital, Rochdale Road, Manchester OL1 2JH, UK
| | - Jonathan Ghosh
- University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
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Abstract
When brain injury is refractory to aggressive management and is considered nonsurvivable, with loss of consciousness and brain stem reflexes, a brain death protocol may be initiated to determine death according to neurological criteria. Clinical evaluation typically entails 2 consecutive formal neurological examinations to document total loss of consciousness and absence of brain stem reflexes and then apnea testing to evaluate carbon dioxide unresponsiveness within the brain stem. Confounding factors such as use of therapeutic hypothermia, high-dose metabolic suppression, and movements associated with complex spinal reflexes, fasciculations, or cardiogenic ventilator autotriggering may delay initiation or completion of brain death protocols. Neurodiagnostic studies such as 4-vessel cerebral angiography can rapidly document absence of blood flow to the brain and decrease intervals between onset of terminal brain stem herniation and formal declaration of death by neurological criteria. Intracranial pathophysiology leading to brain death must be considered along with clinical assessment, patterns of vital signs, and relevant diagnostic studies.
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Affiliation(s)
- Richard B. Arbour
- Richard B. Arbour is a liver transplant coordinator at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania
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Jabbarli R, Gläsker S, Weber J, Taschner C, Olschewski M, Van Velthoven V. Predictors of Severity of Cerebral Vasospasm caused by Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2013; 22:1332-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.01.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Revised: 12/15/2012] [Accepted: 01/07/2013] [Indexed: 10/27/2022] Open
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Krainik A, Villien M, Troprès I, Attyé A, Lamalle L, Bouvier J, Pietras J, Grand S, Le Bas JF, Warnking J. Functional imaging of cerebral perfusion. Diagn Interv Imaging 2013; 94:1259-78. [PMID: 24011870 DOI: 10.1016/j.diii.2013.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The functional imaging of perfusion enables the study of its properties such as the vasoreactivity to circulating gases, the autoregulation and the neurovascular coupling. Downstream from arterial stenosis, this imaging can estimate the vascular reserve and the risk of ischemia in order to adapt the therapeutic strategy. This method reveals the hemodynamic disorders in patients suffering from Alzheimer's disease or with arteriovenous malformations revealed by epilepsy. Functional MRI of the vasoreactivity also helps to better interpret the functional MRI activation in practice and in clinical research.
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Affiliation(s)
- A Krainik
- Clinique universitaire de neuroradiologie et IRM, CHU de Grenoble, CS 10217, 38043 Grenoble cedex, France; Inserm U836, université Joseph-Fourier, site santé, chemin Fortuné-Ferrini, 38706 La Tronche cedex, France; UMS IRMaGe, unité IRM 3T recherche, CHU de Grenoble, CS 10217, 38043 Grenoble cedex 9, France.
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Güresir E, Vasiliadis N, Konczalla J, Raab P, Hattingen E, Seifert V, Vatter H. Erythropoietin prevents delayed hemodynamic dysfunction after subarachnoid hemorrhage in a randomized controlled experimental setting. J Neurol Sci 2013; 332:128-35. [DOI: 10.1016/j.jns.2013.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 06/30/2013] [Accepted: 07/08/2013] [Indexed: 10/26/2022]
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Purvis D, Aldaghlas T, Trickey AW, Rizzo A, Sikdar S. A novel decision tree approach based on transcranial Doppler sonography to screen for blunt cervical vascular injuries. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:1023-1031. [PMID: 23716524 DOI: 10.7863/ultra.32.6.1023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Early detection and treatment of blunt cervical vascular injuries prevent adverse neurologic sequelae. Current screening criteria can miss up to 22% of these injuries. The study objective was to investigate bedside transcranial Doppler sonography for detecting blunt cervical vascular injuries in trauma patients using a novel decision tree approach. METHODS This prospective pilot study was conducted at a level I trauma center. Patients undergoing computed tomographic angiography for suspected blunt cervical vascular injuries were studied with transcranial Doppler sonography. Extracranial and intracranial vasculatures were examined with a portable power M-mode transcranial Doppler unit. The middle cerebral artery mean flow velocity, pulsatility index, and their asymmetries were used to quantify flow patterns and develop an injury decision tree screening protocol. Student t tests validated associations between injuries and transcranial Doppler predictive measures. RESULTS We evaluated 27 trauma patients with 13 injuries. Single vertebral artery injuries were most common (38.5%), followed by single internal carotid artery injuries (30%). Compared to patients without injuries, mean flow velocity asymmetry was higher for single internal carotid artery (P = .003) and single vertebral artery (P = .004) injuries. Similarly, pulsatility index asymmetry was higher in single internal carotid artery (P = .015) and single vertebral artery (P = .042) injuries, whereas the lowest pulsatility index was elevated for bilateral vertebral artery injuries (P = .006). The decision tree yielded 92% specificity, 93% sensitivity, and 93% correct classifications. CONCLUSIONS In this pilot feasibility study, transcranial Doppler measures were significantly associated with the blunt cervical vascular injury status, suggesting that transcranial Doppler sonography might be a viable bedside screening tool for trauma. Patient-specific hemodynamic information from transcranial Doppler assessment has the potential to alter patient care pathways to improve outcomes.
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Affiliation(s)
- Dianna Purvis
- Department of Neuroscience, George Mason University, Fairfax, VA 22030, USA
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38
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Abstract
Transcranial Doppler (TCD) is a portable device that uses a handheld 2-MHz transducer. It is most commonly used in subarachnoid hemorrhage where cerebral blood flow velocities in major intracranial blood vessels are measured to detect vasospasm in the first 2 to 3 weeks. TCD is used to detect vasospasm in traumatic brain injury and post-tumor resection, measurement of cerebral autoregulation and cerebrovascular reactivity, diagnosis of acute arterial occlusions in stroke, screening for patent foramen ovale and monitoring of emboli. It can be used to detect abnormally high intracranial pressure and for confirmation of total cerebral circulatory arrest in brain death.
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39
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Ahmad M, Legrand M, Lukaszewicz AC, Charlier P, Mateo J, Payen D. Transcranial Doppler monitoring may be misleading in prediction of elevated ICP in brain-injured patients. Intensive Care Med 2013; 39:1150-1. [PMID: 23512071 DOI: 10.1007/s00134-013-2885-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2013] [Indexed: 10/27/2022]
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40
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Bentzinger P, Mahoudeau G, Alezrah M, Pottecher T. [Learning ultrasonography: where do the anesthesiology residents of the French north-eastern sector currently stand?]. ACTA ACUST UNITED AC 2013; 32:246-50. [PMID: 23453930 DOI: 10.1016/j.annfar.2013.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Accepted: 01/18/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Ultrasonography is in continuing expansion in anesthesiology and critical care medicine (ACCM). It is an operator-dependent tool whose contribution is partly related to the quality of the user's initial and subsequent training. Within the framework of the ACCM residency, the French north-east anesthesiology residents have an initiation to ultrasonography by 24 hours of formal lectures. The evaluation of this teaching has not yet been performed. The objective of this survey is to depict this learning and delineate the expectations of the residents. METHODS An anonymous computerized self-rated survey, published on a specific internet website, was performed between September 2011 and January 2012, and addressed to the ACCM residents of the French north-east anesthesiology residency by the local coordinators. It consisted in several items: current abilities and aims in echography, equipment availability and frequency of use, existence of a potential independent ultrasonography training, desired improvements, evaluation of the teaching and interest of rendering it mandatory, potential interest in creating a form of assessment. RESULTS In total, 105 questionnaires were analyzed (response rate 44%). The distribution of respondents was homogeneous from the 1st to the 5th year of residency. Thirty percent of residents had good knowledge or mastered echocardiography. Ultrasound-guiding during vascular access was the best acquired technique: 73% masterized or had good knowledge of it. The results were more mitigated regarding ultrasound-guided regional anesthesia (UGRA) (60%), trans-cranial echography (46%), FAST-echo (23%), pleuro-pulmonary echography (38%). At the end of the ACCM residency, 69% wished to master echocardiography and 86% UGRA. The echograph was used more than once a week (76%) and of easy access (93%). The teaching was mainly theoretical; 76% of the residents were unsatisfied and nine out of ten had followed an echography training outside the ACCM residency courses or intended to do so. Moreover, 78% wished a mandatory echography learning, with seminars and a strengthened practical training: 94% considered workshops indispensable, and 62% simulation sessions. An assessment of knowledge was found useful, particularly in practical form. The realization of a training rotation with echographic orientation was desired by 78% of respondents. CONCLUSION A clear gap exists between the real capability in echocardiography and the intended one. UGRA and echocardiography raise a particular interest. The practical training in ultrasonography using simulation and workshops is to be favored.
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Affiliation(s)
- P Bentzinger
- Pôle anesthésie-réanimations chirurgicales, Samu-Smur, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France.
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Safety and feasibility of an early mobilization program for patients with aneurysmal subarachnoid hemorrhage. Phys Ther 2013; 93:208-15. [PMID: 22652987 DOI: 10.2522/ptj.20110334] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Survivors of aneurysmal subarachnoid hemorrhage (SAH) are faced with a complicated recovery, which typically includes surgery, prolonged monitoring in the intensive care unit, and treatment focusing on the prevention of complications. OBJECTIVE The purpose of this study was to determine the safety and feasibility of an early mobilization program for patients with aneurysmal SAH. DESIGN This study was a retrospective analysis. METHODS Twenty-five patients received early mobilization by a physical therapist or an occupational therapist, or both, which focused on functional training and therapeutic exercise in more progressively upright positions. Participation criteria focused on neurologic and physiologic stability prior to the initiation of early mobilization program sessions. RESULTS Patients met the criteria for participation in 86.1% of the early mobilization program sessions attempted. Patients did not meet criteria for the following reasons: Lindegaard ratio >3.0 or middle cerebral artery (MCA) mean flow velocity (MFV) >120 cm/s (8.1%), mean arterial pressure (MAP) <80 mm Hg (1.8%), intracranial pressure (ICP) >15 mm Hg (1.8%), unable to open eyes in response to voice (0.9%), respiratory rate >40 breaths/min (0.6%), MAP >110 mm Hg (0.3%), and heart rate <40 bpm (0.3%). Adverse events occurred in 5.9% of early mobilization program sessions for the following reasons: MAP <70 mm Hg (3.1%) or >120 mm Hg (2.4%) and heart rate >130 bpm (0.3%). The 30-day mortality rate for all patients was 0%. Participation in the early mobilization program began a mean of 3.2 days (SD=1.3) after aneurysmal SAH, and patients received an average of 11.4 sessions (SD=4.3). Patients required a mean of 5.4 days (SD=4.2) to participate in out-of-bed activity and a mean of 10.7 days (SD=6.2) to walk ≥15.24 m (50 ft). CONCLUSIONS The results of this study suggest that an early mobilization program for patients with aneurysmal SAH is safe and feasible.
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Abstract
Transcranial Doppler (TCD) ultrasound provides rapid, noninvasive, real-time measures of cerebrovascular function. TCD can be used to measure flow velocity in the basal arteries of the brain to assess relative changes in flow, diagnose focal vascular stenosis, or to detect embolic signals within these arteries. TCD can also be used to assess the physiologic health of a particular vascular territory by measuring blood flow responses to changes in blood pressure (cerebral autoregulation), changes in end-tidal CO2 (cerebral vasoreactivity), or cognitive and motor activation (neurovascular coupling or functional hyperemia). TCD has established utility in the clinical diagnosis of a number of cerebrovascular disorders such as acute ischemic stroke, vasospasm, subarachnoid hemorrhage, sickle cell disease, as well as other conditions such as brain death. Clinical indication and research applications for this mode of imaging continue to expand. In this review, the authors summarize the basic principles and clinical utility of TCD and provide an overview of a few TCD research applications.
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Aleem I, Chau T. Towards a hemodynamic BCI using transcranial Doppler without user-specific training data. J Neural Eng 2012; 10:016005. [PMID: 23234760 DOI: 10.1088/1741-2560/10/1/016005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
UNLABELLED Transcranial Doppler (TCD) was recently introduced as a new brain-computer interface (BCI) modality for detecting task-induced hemispheric lateralization. To date, single-trial discrimination between a lateralized mental activity and a rest state has been demonstrated with long (45 s) activation time periods. However, the possibility of detecting successive activations in a user-independent framework (i.e. without training data from the user) remains an open question. OBJECTIVE The objective of this research was to assess TCD-based detection of lateralized mental activity with a user-independent classifier. In so doing, we also investigated the accuracy of detecting successive lateralizations. Approach. TCD data from 18 participants were collected during verbal fluency, mental rotation tasks and baseline counting tasks. Linear discriminant analysis and a set of four time-domain features were used to classify successive left and right brain activations. MAIN RESULTS In a user-independent framework, accuracies up to 74.6 ± 12.6% were achieved using training data from a single participant, and lateralization task durations of 18 s. SIGNIFICANCE Subject-independent, algorithmic classification of TCD signals corresponding to successive brain lateralization may be a feasible paradigm for TCD-BCI design.
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Affiliation(s)
- Idris Aleem
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
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The effect of formal training on the clinical utility of transcranial Doppler ultrasound monitoring in patients with aneurysmal subarachnoid haemorrhage. J Clin Neurosci 2012; 19:1255-60. [PMID: 22727749 DOI: 10.1016/j.jocn.2012.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 02/04/2012] [Indexed: 11/21/2022]
Abstract
We have previously shown that the clinical utility of transcranial Doppler (TCD) ultrasound monitoring for vasospasm in patients with aneurysmal subarachnoid haemorrhage, as performed by untrained operators in a busy neurosurgical unit, is questionable, despite the recommendations for its use in the literature. We determined if formal training improved the utility of TCD. Twelve untrained operators and one trained operator performed a total of 206 TCD examinations. There was poor agreement of results between trained and untrained operators. For the left middle cerebral artery (MCA), right MCA, left anterior cerebral artery (ACA) and right ACA, the blood flow velocities (BFV) recorded by the trained operator were greater than those recorded by the untrained operators by a mean (95% confidence interval) of 27.7 (25.0-30.4), 24.3 (21.4-27.1), 28.2 (25.6-30.9) and 28.1 (24.9-31.1) cm/s, respectively (p<0.001 for all vessels). Greater sensitivity was observed in TCD measurements from the trained operator (100%) compared to untrained operators (40%). To improve the utility of TCD, operators should be provided with training or a professional sonographer employed.
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Deb S, Gogos AJ, Drummond KJ, Teddy PJ. The role of transcranial Doppler ultrasound monitoring in patients with aneurysmal subarachnoid haemorrhage. J Clin Neurosci 2012; 19:950-5. [PMID: 22281386 DOI: 10.1016/j.jocn.2011.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Revised: 12/08/2011] [Accepted: 12/10/2011] [Indexed: 11/25/2022]
Abstract
The effect of transcranial Doppler (TCD) ultrasound monitoring of vasospasm on patient management following aneurysmal subarachnoid haemorrhage (aSAH) remains unclear. We reviewed our departmental use of TCD by retrospectively analysing 152 medical records. Results of investigations and management changes, including frequency of neurological monitoring and changes in triple H therapy, were examined. TCD monitoring occurred in 87 patients (57%) by untrained neurosurgical registrars. There was high variability in the number of operators for each patient (over 50% of patients had more than two different operators), insonation protocol and monitoring duration (at least 50% of patients were monitored for fewer than seven days). TCD results influenced management in only 18 (12%) patients, while clinical deterioration or improvement dictated more than 80% of changes in triple H therapy and neurological monitoring. Prospective validation in similar neurosurgical settings is needed to justify continued usage of TCD monitoring. Formal training for operators and a standard monitoring protocol should also be considered to increase TCD utility. Prospective evaluation of TCD at our centre has recently been completed.
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Affiliation(s)
- Smita Deb
- Department of Neurosurgery, The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria 3050, Australia.
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Myrden AJB, Kushki A, Sejdić E, Guerguerian AM, Chau T. A brain-computer interface based on bilateral transcranial Doppler ultrasound. PLoS One 2011; 6:e24170. [PMID: 21915292 PMCID: PMC3168473 DOI: 10.1371/journal.pone.0024170] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 08/01/2011] [Indexed: 11/19/2022] Open
Abstract
In this study, we investigate the feasibility of a BCI based on transcranial Doppler ultrasound (TCD), a medical imaging technique used to monitor cerebral blood flow velocity. We classified the cerebral blood flow velocity changes associated with two mental tasks - a word generation task, and a mental rotation task. Cerebral blood flow velocity was measured simultaneously within the left and right middle cerebral arteries while nine able-bodied adults alternated between mental activity (i.e. word generation or mental rotation) and relaxation. Using linear discriminant analysis and a set of time-domain features, word generation and mental rotation were classified with respective average accuracies of 82.9%10.5 and 85.7%10.0 across all participants. Accuracies for all participants significantly exceeded chance. These results indicate that TCD is a promising measurement modality for BCI research.
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Affiliation(s)
- Andrew J B Myrden
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada.
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Abstract
OBJECTIVE To investigate whether hand-carried ultrasound technology may be valuable in the assessment of children with acute malaria. Every year, approximately 800,000 children under the age of 5 yrs die of complications of Plasmodium falciparum malaria infection. The advent of hand-carried ultrasound technology has made diagnostic ultrasonography possible in underresourced settings. DESIGN We performed a pilot observational study collecting clinical data and performing ultrasound examinations on children diagnosed with P. falciparum malaria infection. The targeted ultrasound examination included measurement of optic nerve sheath diameter, color transcranial Doppler insonation of the cerebral vasculature, cardiac ultrasound, and abdominal ultrasound. SETTING Pediatric acute care unit of Mulago Hospital in Kampala, Uganda. PATIENTS Thirty-three hospitalized children between the ages of 6 months and 12 yrs with documented acute P. falciparum infection. INTERVENTION Targeted bedside ultrasound examination. MEASUREMENTS AND MAIN RESULTS Increased optic nerve sheath diameter was observed in one third of all patients with malaria and in 100% of the patients diagnosed with cerebral malaria. Although higher-than-normal cerebral blood flow velocities were demonstrated in three (25%) of 12 patients with severe anemia, most patients demonstrated a normal cerebral blood flow velocity, suggesting a blunted response to anemia. We did not find evidence of pulmonary hypertension by cardiac ultrasound, and cardiac function did not seem depressed, even among patients with severe anemia and lactic acidosis. Finally, spleen size as determined by palpation significantly overestimated the true incidence of splenomegaly as measured by ultrasound (48% and 24%, respectively). CONCLUSIONS A targeted ultrasound examination focusing on optic nerve sheath diameter, color transcranial Doppler, cardiac ultrasound, and spleen size may prove useful for patient classification, risk stratification, research studies, and treatment monitoring in pediatric malaria. More studies should be done.
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Bouhemad B, Brisson H, Le-Guen M, Arbelot C, Lu Q, Rouby JJ. Bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment. Am J Respir Crit Care Med 2010; 183:341-7. [PMID: 20851923 DOI: 10.1164/rccm.201003-0369oc] [Citation(s) in RCA: 481] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE In the critically ill patients, lung ultrasound (LUS) is increasingly being used at the bedside for assessing alveolar-interstitial syndrome, lung consolidation, pneumonia, pneumothorax, and pleural effusion. It could be an easily repeatable noninvasive tool for assessing lung recruitment. OBJECTIVES Our goal was to compare the pressure-volume (PV) curve method with LUS for assessing positive end-expiratory pressure (PEEP)-induced lung recruitment in patients with acute respiratory distress syndrome/acute lung injury (ARDS/ALI). METHODS Thirty patients with ARDS and 10 patients with ALI were prospectively studied. PV curves and LUS were performed in PEEP 0 and PEEP 15 cm H₂O₂. PEEP-induced lung recruitment was measured using the PV curve method. MEASUREMENTS AND MAIN RESULTS Four LUS entities were defined: consolidation; multiple, irregularly spaced B lines; multiple coalescent B lines; and normal aeration. For each of the 12 lung regions examined, PEEP-induced ultrasound changes were measured, and an ultrasound reaeration score was calculated. A highly significant correlation was found between PEEP-induced lung recruitment measured by PV curves and ultrasound reaeration score (Rho = 0.88; P < 0.0001). An ultrasound reaeration score of +8 or higher was associated with a PEEP-induced lung recruitment greater than 600 ml. An ultrasound lung reaeration score of +4 or less was associated with a PEEP-induced lung recruitment ranging from 75 to 450 ml. A statistically significant correlation was found between LUS reaeration score and PEEP-induced increase in Pa(O₂) (Rho = 0.63; P < 0.05). CONCLUSIONS PEEP-induced lung recruitment can be adequately estimated with bedside LUS. Because LUS cannot assess PEEP-induced lung hyperinflation, it should not be the sole method for PEEP titration.
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Affiliation(s)
- Belaïd Bouhemad
- Multidisciplinary Intensive Care Unit Pierre Viars, Assistance Publique Hôpitaux de Paris.
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Abstract
Permanent neurologic injury and death remain common outcomes following aneurysmal subarachnoid hemorrhage. Although many sophisticated techniques are evolving for securing intracranial aneurysms to prevent rebleeding, progress is lagging in the management of posthemorrhagic complications, particularly cerebral vasospasm. Vasospasm can be defined either angiographically, by visible reduction in arterial lumen diameters, or clinically, with signs of focal or regional cerebral ischemia. The relationship between angiographic and clinical vasospasm is not straightforward. The most important known risk factors for developing posthemorrhagic vasospasm include volume and distribution of subarachnoid blood, and no preventive measures have proven effective. Established treatment strategies for vasospasm include hyperdynamic therapy, angioplasty, and selective intra-arterial injection of vasodilators. The vasodilatory approach has been called into question by recent data suggesting that reduction of arterial luminal diameters may be due largely to a proliferative arteriopathy. Novel treatment strategies have focused on protecting the cerebrum, targeting components of the inflammatory cascade, and identifying genetic factors predisposing toward vasospasm, all of which may soon yield new treatment modalities.
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Marshall SA, Nyquist P, Ziai WC. The role of transcranial Doppler ultrasonography in the diagnosis and management of vasospasm after aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am 2010; 21:291-303. [PMID: 20380971 DOI: 10.1016/j.nec.2009.10.010] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Transcranial Doppler ultrasonography (TCD) is a tool employed by the neurosurgeon and neurointensivist in the management of vasospasm in the intensive care unit after aneurysmal subarachnoid hemorrhage. A review of the current indications, monitoring parameters, indices, and relevance of modern TCD technology is provided, as well as algorithms for the use of TCD ultrasonography in the management of patients with subarachnoid hemorrhage. Other current uses of TCD ultrasonography are also discussed in the setting of neurocritical care.
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Affiliation(s)
- Scott A Marshall
- Division of Neurosciences Critical Care, Departments of Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Meyer 8-140, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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