Neurosurgical Applications of Transcranial Doppler Sonography


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About this book During the Procedure

Distance A is measured from the ipsilateral side, whereas distance B is from the contralateral side. One should also measure the full length from the ipsilateral to the contralateral temporal bone. Then use the following equation to calculate the midline shift deviation:. For an expedited investigation, the other method see Fig. Our recommendation is to utilize the first method for midline shift quantification. With 2 independent measurements from each side to assess midline shift and an internal check for correct measurements the sum of distance A and B should equal the full distance from the ipsilateral to contralateral temporal bones , it is the least vulnerable to operator error.

Clinical utilization of TCD or TCDI for midline shift also incorporates comparisons of measured cerebral blood flow velocities and pulsatility indexes between right and left anterior circulation. MLS measurement relies heavily on finding a proper trans-temporal window. There are no data correlating angle of insonation and accuracy of transcranial US midline shift measurements.

The presence of hydrocephalus of the third ventricle does not have much bearing on the MLS measurement, as the measurements are done to the center of the third ventricle, not to its outer walls. Kiphuth et al. In patients with external ventricular drainage EVD , they estimated that a cut-off value of an increase of 5.


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They suggested that an increase in ventricular width lower than the cut-off was an indication for a safe removal of EVD [ 27 ]. Transcranial Doppler has been studied extensively as a validated screening tool for diagnosing vasospasm [ 6 , 7 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ], aiding in the management of subarachnoid hemorrhage SAH patients. Using the inverse relationship between cerebral blood vessel diameter and TCD mean velocities, we are able to quantify and subcategorize vasospasm [ 25 , 35 , 36 ].

Assessment of the MCA requires pulse wave spectral Doppler. These cutoffs have been derived using non-imaging traditional TCD probes as are commonly used in complete, diagnostic TCD [ 6 , 9 , 28 , 36 , 42 ]. Progressive increase of mean velocities during the early stages of SAH to predictive of vasospasm.

The broad range of clinical applications with the Transcranial Doppler Sonography

Another method of grading vasospasm severity would be the formula known as the Lindegaard ratio [ 36 ]:. As entities other than vasospasm e. The diagnostic value of TCD clinical utilization to detect vasospasm is not in question. However, the trans-orbital and trans-foraminal windows are less reliably insonated compared to the trans-temporal window [ 47 ], and the ACA and PCA are less sensitive and specific for vasospasm compared to the MCA.

The same applies to the basilar artery and vertebral artery with lower sensitivity and specificity in the trans-foraminal window [ 30 , 31 ]. Exhaustive exclusion of vasospasm calls for all cerebral vessels to be insonated. Thus, the technique as we have described it represents a screening test of the highest yield arterial territory MCA —of greatest value if vasospasm is identified and insufficient to exclude the possibility [ 6 , 42 ].

Several factors make the diagnosis of vasospasm challenging. The clinician must be mindful that cerebral blood flow maybe influenced by many factors PaO 2 , PaCO 2 , blood viscosity, collateral flow. Furthermore, operator experience is required for accurate assessment, as improper vessel identification, proximal lesions and aberrant vessel course can confound even experienced sonographers [ 9 ]. For Doppler interrogation, diagnostic TCD utilizes non-imaging probes set for measurement of spectral Doppler signs at specific distances to insonate various vessels in question.

However, most radiology departments now use color-coded duplex sonography CDDS imaging probes with pulse wave Doppler and angle correction [ 48 ]. The advantage to using CDDS imaging probes is that insonation no longer needs a perfectly on-axis due to anatomic variations between different segments of cerebral arteries, as machines are able to solve for off-axis measurements using angle correction. The caveat is that normal velocities reported for TCD are validated for non-imaging probes and not for color-coded duplex sonography [ 48 ].

Neurosurgical Applications of Transcranial Doppler Sonography

As ICP increases, flow in intra-cranial vessels changes. Initially, systolic velocity increases i. Raised ICP can also exceed normal forward flow during diastole, leading to diastolic flow reversal Fig. Progression of intra-cranial circulatory arrest via transcranial Doppler of middle cerebral artery flows. The red box denotes states d , e , f in which cerebral circulatory arrest can be diagnosed. Bellner et al. Generally, high ICPs result in high pulsatility indices PIs in high-resistance vascular beds, where systolic velocity is increased relative to decreased end-diastolic velocity.

The main advantage of PI is that it is not affected by the angle of insonation [ 18 ].

Some suggest using TCD as a binary assessment for the absence of intra-cranial hypertension [ 12 ]. Lack of pulsatile flow, such as with venous—arterial V—A extracorporeal membrane oxygenation ECMO or left ventricular assist devices LVADs , as systolic and diastolic ratios for pulsatility index would be uninterpretable for ICP and brain death. Disadvantage to transcranial Doppler when interpreting MCA flows for patient with non-pulsatile flow states i. Predictable, step-wise changes in cerebral blood flow may be observed as part of progression to cerebral circulatory arrest Fig.

Serial interrogations are often required for TCD diagnosis of cerebral circulatory arrest and brain death, including a scan preceding the onset of cerebral circulatory arrest to demonstrate the presence of prior intra-cranial flow [ 15 , 65 , 66 , 67 ]. Cerebral circulatory arrest may be identified on TCD red box of Fig. Determination of brain death is typically a clinical diagnosis with parameters like brainstem reflex testing and an apnea test.

Certain situations i. If TCD rules in cerebral circulatory arrest by non-reassuring MCA flows, ancillary testing 4-vessel cerebral angiography, nuclear medicine radionuclide brain perfusion scan, CT or MR cerebral blood flow angiography could be sought to formally confirm the diagnosis.

However, if TCD shows reassuring cerebral blood flows not meeting aforementioned criteria, this would possibly save premature, unnecessary serial ancillary tests, until the diagnosis can be first confirmed on TCD. This helps optimizing the ideal time to obtain ancillary testing when clinical determination of brain death has confounders [ 65 , 66 , 67 , 68 , 69 , 70 ].


  1. The Cranial Nerves: Anatomy Imaging Vascularisation.
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  6. Nonnos: Dionysiaca, Volume III, Books 36-48 (Loeb Classical Library No. 356).
  7. In addition to previously discussed limitations in other sections, there are specific limitations to TCD diagnosis of brain death. Despite the presence of reassuring spectral Doppler waveforms, a patient can still qualify as brain dead by other clinical means brainstem and apnea testing in the absence of confounders. This means cerebral blood flow maybe inadequate to sustain life despite reassuring waveforms. The opposite is also true, as the absence of reassuring spectral Doppler waveforms meeting above criteria does not automatically mean brain death, as TCD evaluates cerebral circulatory arrest, not brainstem function.

    Furthermore, most medical jurisdictions will not accept a TCD as its own ancillary test to confirm brain death [ 67 ]. The advent of intensivist-performed ultrasound and availability of ultrasound machines now provides a unique climate where point-of-care TCD is a reality. Barriers to training do still exist, but despite these pitfalls and limitations, intensivists performing limited point-of-care TCD as a screening tool to rule-in certain indications is feasible.

    Reaching competence is attainable, without extensive formal radiology training for diagnostic TCD. Much like many other POC modalities, to rule in various pathologies where prompt bedside diagnosis could be invaluable to the expedition of patient care. Lancet — J Trauma Acute Care Surg 56 3 — Lieben MA Indications for intracranial pressure monitoring. J Neurotrauma [Internet].

    Neurosurgical Applications of Transcranial Doppler Ultrasoun : Contemporary Neurosurgery

    Cited 16 Jan Savers S Guidelines for cerebral perfusion pressure. J Neurotrauma 17 6—7 — J Neurosurg 47 4 — J Neurosurg 57 6 — Radiology AC of, others AIUM practice guideline for the performance of a transcranial Doppler ultrasound examination for adults and children. Lancet [Internet]. In: Cerebral vasospasm: neurovascular events after subarachnoid hemorrhage [Internet].

    Surg Neurol 62 1 — Eur J Anaesthesiol 25 S42 — Crit Care 21 1 Normal Values. Natural Time Course of Vasospasm. Vasospasm and Delayed Aneurysm Surgery. Intra-aneurysmal Flow Pattern. Extracranial-intracranial Bypass. Arteriovenous Malformations. Vascular Hemodynamic Response to Meningitis. Back Matter Pages About this book Introduction In , the Norwegian physiologist and cyberneticist, Rune Aaslid, developed a device which made it possible to apply the transcranial Doppler sonographic technique in man.

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    Tell us if something is incorrect. Book Format: Choose an option. Product Highlights In , the Norwegian physiologist and cyberneticist, Rune Aaslid, developed a device which made it possible to apply the transcranial Doppler sonographic technique in man. Albrecht Harders took on the project of working out a clinically practicable method that would allow atraumatic m. About This Item We aim to show you accurate product information. Manufacturers, suppliers and others provide what you see here, and we have not verified it. See our disclaimer. Customer Reviews. Write a review.

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    Neurosurgical Applications of Transcranial Doppler Sonography Neurosurgical Applications of Transcranial Doppler Sonography
    Neurosurgical Applications of Transcranial Doppler Sonography Neurosurgical Applications of Transcranial Doppler Sonography
    Neurosurgical Applications of Transcranial Doppler Sonography Neurosurgical Applications of Transcranial Doppler Sonography
    Neurosurgical Applications of Transcranial Doppler Sonography Neurosurgical Applications of Transcranial Doppler Sonography
    Neurosurgical Applications of Transcranial Doppler Sonography Neurosurgical Applications of Transcranial Doppler Sonography
    Neurosurgical Applications of Transcranial Doppler Sonography Neurosurgical Applications of Transcranial Doppler Sonography
    Neurosurgical Applications of Transcranial Doppler Sonography Neurosurgical Applications of Transcranial Doppler Sonography
    Neurosurgical Applications of Transcranial Doppler Sonography Neurosurgical Applications of Transcranial Doppler Sonography

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