LA NEUROSONOLOGIA
NELL’AMBITO DELLE
NEUROSCIENZE:
pertensione Intracranica:
Primo Corso teorico pratico
BRESCIA
12-13 NOVEMBRE 2010
U.O. Neurorianimazione
Spedali Civili di Brescia
alutazione con TCD
Dr. Frank Rasulo
U.O. Neurorianimazione
Università di Brescia
TCD in the ICU
 VASOSPASM
 INTRACRANIAL
HYPERTENSION
 CEREBRAL
CIRCULATORY ARREST
 AUTOREGULATION
 STENOSIS
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
SUBARACHNOID
HEMORRHAGE
 HEAD TRAUMA
 STROKE
 BRAIN DEATH
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
iagnosing high ICP
The gold standard for
the measurement of
ICP is its invasive
measurement.
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
ypes of Devices
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
on invasive evaluation of high ICP
However there are various situations where a
non invasive measurement may be useful…
-mild and moderate head injury
-Ischemic & hemorrhagic stroke, vasospasm
-meningo-encephalytis
-faulty ICP cathters
-outside the ICU (ER, OR, etc.)
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD waveform analysis for the
evaluation of intracranial pressure
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
-derived parameters
Mean flow velocity
partial information regarding cerebral hemodynamics,
not optimal to assess biophysical properties of the brain.
Systolic flow velocity
FV systolic is predominantly dependant on the cardiac output
systemic hemodynamics, rather than depicting cerebral hemodynamics.
Diastolic flow velocity
Pulsatility index
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
-derived parameters
Mean flow velocity
partial information regarding cerebral hemodynamics,
not optimal to assess biophysical properties of the brain.
Systolic flow velocity
FV systolic is predominantly dependant on the cardiac output
systemic hemodynamics, rather than depicting cerebral hemodynamics.
Diastolic flow velocity
Pulsatility index
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
-derived parameters
Mean flow velocity
partial information regarding cerebral hemodynamics,
not optimal to assess biophysical properties of the brain.
Systolic flow velocity
FV systolic is predominantly dependant on the cardiac output
systemic hemodynamics, rather than depicting cerebral hemodynamics.
Diastolic flow velocity
Pulsatility index
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
-derived parameters
Mean flow velocity
partial information regarding cerebral hemodynamics,
not optimal to assess biophysical properties of the brain.
Systolic flow velocity
FV systolic is predominantly dependant on the cardiac output
systemic hemodynamics, rather than depicting cerebral hemodynamics.
Diastolic flow velocity
Pulsatility index
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
-derived parameters
Diastolic flow velocity
Chan KH. The effect of changes in cerebral perfusion pressure upon
middle cerebral artery blood flow velocity and jugular bulb venous
oxygen saturation after severe brain injury.
J Neurosurg. 1992 Jul;77(1):55-61.
“a reduction of CPP by rising ICP or by falling BP in head injured
patients, resulted in a greater fall in diastolic flow velocity than
other flow parameters”
Trabold F. The prognostic value of transcranial Doppler studies in
children with moderate and severe head injury.
Intensive Care Med. 2004;30(1):108-12
Pediatric head trauma study, an end-diastolic velocity less
than 25 cm/s was associated with a poor prognosis
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
Monitorare il ritardo di crescita: la flussimetria dell'arteria ombelicale
Il flusso diastolico normale in un feto
Il flusso diastolico assente richiede invece la valutazione di altri distretti fetali quali l'arteria
cerebrale media ed il dotto venoso, due vasi che danno informazioni sul benessere fetale,
Il flusso diastolico invertito rappresenta una condizione particolarmente a rischio e come tale
deve essere gestita.
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
-derived parameters
Mean flow velocity
partial information regarding cerebral hemodynamics,
not optimal to assess biophysical properties of the brain.
Systolic flow velocity
FV systolic is predominantly dependant on the cardiac output
systemic hemodynamics, rather than depicting cerebral hemodynamics.
Diastolic flow velocity
Pulsatility index
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
PI 
FVs  FVd
FVm
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD waveform analysis for the
evaluation of intracranial pressure
PULSATILITY INDEX
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for ICP EVALUATION
The pulsatility of blood flow through conductance vessels reflects distal vascular
resistance.
Gosling et al. 1969
1
PI = 2
A
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
N
Σ
A2n
n=1
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
INDICA L’ANDAMENTO DELLA CURVA DI VELOCITA’ DURANTE UN CICLO CARDIACO
Gosling RG, King DH. Arterial assessment by Doppler
Shift ultrasound. ProcRsoc Med 1974;67:447–9.
PI =
Peak to peak amplitude of the Doppler shift recording
Mean value
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
ICP
The earliest sign of increased ICP is increased pulsatility.
PI Normal value < 1
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
Ratio – therefore not infuenced by the angle of insonation
influenced by certain factors that influences flow velocity
Upstream - Downstream
Hemodynamic
Respiratory
Parameters
Hematologic
Reduced with the reduction
Increased with the increase
of upstream blood supply
of downstream resistance
Tissue
compliance
(stenosis, CO, hypotension)
(vasocostriction, ICP)
The arterioles are greater influenced than in the larger vessels
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
aveform analysis of high ICP
ICP- 20
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
ICP- 60
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
s a waveform enough?
Can we be satisfied
with a qualitative
measurment ?
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
rigins of non invasive assessment
FVs  FVd
RI 
FVs
FVs  FVd
PI 
FVm
RI
PIC  PAM 
FVm
Houmburg AM. et al. Transcranial Doppler recording in raised intracranial
pressure Acta Neurol Scand 1993:87:488-493
Chan KM et all. Transcranial Doppler waveform differences in hyperemic and non
hyperemics patients after severe injury- Sur Neurol 1992;87:488-93
Klingelhofer J. et all Evaluation of intracranial pressure from transcranial
Doppler studies in cerebral desease. J Neurosonol 1988;235:159-62
slid and the Fourier analysis
FVm
ePPC  PA1
 15
FV 1
PA1= ampiezza della prima
armonica dell’onda che descrive la
pressione arteriosa
FV1 = ampiezza della prima
armonica dell’onda che descrive la
velocità di flusso
10 pazienti
< 27 mmHg  95% delle stime
< 10 mmHg  52% delle stime
Aaslid R. et all Estimation of cerebral perfusion pressure from arterial blood pressure and
transcranial Doppler recordings in Intracranial pressur IV Berlin Spnger-Verlag 1986 pp226-29
ambridge proposal
FVd
nPPC  PAM 
 14
FVm
PAM = pressione arteriosa media
FVd = Velocità di flusso diastolica
FVm = Velocità di flusso media
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
ambridge proposal
25 pazienti
≤ 5 mmHg  49%
≤ 10 mmHg  81%
≤ 15 mm Hg  94%
Czosnyka M, et al. Cerebral perfusion pressure in head injured patients: a non invasive assessment using transcranial
doppler ultrasonography. J Neurosurg 1998; 88:802-8
Schmidt EA et all. Preliminary experience of the estimation of cerebral perfusion pressure using transcranial Doppler
ultrasonography J Neurol Neurosurg and Psycjiatry 2001;170:198204
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for CPP EVALUATION
Aaslid et al
FVm
eCPP  AP1
 15
FV 1
Czosnykaet al.
nCPP  MAP 
FVd
 14
FVm
< 27 mmHg  95%
< 21 mmHg  95% dellestime
< 10 mmHg  52%
< 10 mmHg  81% dellestime
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
OUR RESULTS
5%
5%
ESA
33%
24%
 21 pazienti
EIP
TC
 530 stime
M ENINGITE
ISCHEM IA
Errore assoluto
(mmHg)
33%
<5 (56,04)
<10 (81,51%)
<15 (89,81%)
<20 (96,79%)
0%
<5 mmHg
20%
5-10 mmHg
40%
5-15 mmHg
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
60%
80%
100%
15-20 mmHg
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
Head Trauma
Brain Infarct
Menengtis /Encephalytis
Decompressive Craniectomy
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
Literature suggests that the PI is useful as a non invasive
estimate of ICP and CPP in adult TBI and SAH
Bellner J et al. Transcranial Doppler sonography pulsatility index (PI)
reflects intracranial pressure (ICP). Surg Neurol 2004;62:45,51.
Splavski B et al. Transcranial Doppler ultrasonography as an early outcome
forecaster following severe brain injury. Br J Neurosurg 2006; 20:386-90.
Ract C et al. Transcranial Doppler ultrasound goal-directed therapy for the early
management of severe traumatic brain injury. Inten Care Med 2007;33:645-51.
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
et al.
First prospective study to investigate the relationship between ICP and TCD derived PI.
ICP higher than 20 mm Hg could be detected with
a sensitivity of 0.89 and specificity of 0.92.
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
There is a strong correlation between PI and ICP
( ICP values > 20 mmHg ), and between PI and CPP
( CPP values < 70 mmHg). Voulgaris et al.
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
TALIP ASIL et al.
- Increased PI correlated with midline shifts on CT scans.
- Early outcomes of pts who had increased PI were poorer.
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
Cerebral hemodynamic changes gauged by transcranial Doppler ultrasonography
in patients with post-traumatic brain swelling treated by surgical decompression
EdsonBor-Seng-Shuet al. J Neurosurg 104:93-100, 2006
CVR = FV +
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
PI
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
INTERHEMISPHERIC PRESSURE GRADIENTS
TRANSMANTLE PRESSURE GRADIENTS
PRESSURE GRADIENTS BETWEEN THE
SUPRA AND INFRATENTORIAL SPACES
PRESSURE GRADIENTS WITHIN
THE CEREBROSPINAL AXIS
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
Cardoso ER, Kupchak JA. Evaluation of intracranial pressure gradients by means of
transcranial Doppler sonography. Acta Neurochir 1992; 55 (Suppl): 1-5.
Intracranial pressure gradients
generated by mass lesions are
responsible for the asymmetry
of TCD readings.
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for non invasive ICP EVALUATION
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
TCD identification of changing autoregulatory thresholds
after autoregulatory impairment.
Lewis SB et al. Neurosurgery 2001:49(6);1484-85
CBF
Maximum
Vasoconstriction
R = Rmax
Maximum
Vasodilation
R = Rmin
PI
5
Critical
Closing
Pressure
50
160
mmHg
mmHg
ABP
CBF = CPP/R
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for Emergency ICP EVALUATION
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for Emergency ICP EVALUATION
Admission FVd< 25 cm/s and PI > 1.3 is associated
with a poor outcome
Trabold et al.
Admission velocities, FVm< 30 cm/s, were related to
GCS, and correctly predicted early outcome.
Chan KH et al.
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for Emergency ICP EVALUATION
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
CD for Emergency ICP EVALUATION
24 TBI pts.
Anormal TCD values (group 1)
Normal TCD values (group 2)
3-month GOS was
significantly poorer in
group 1 than in group 2.
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
Comparison of TCD and Ultrasound for non-invasive estimation of
intracranial hypertension and its prediction during the early phase
following severe head trauma.
TCD
ECO
?
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
TCD & Critical Closing Pressure
MABP
 MAP
 ICP
 Tono vasomostore
P = T/r
CVP
P = pressione transmurale
T = tensione di parete
r = raggio del vaso
P < T/r
2° STARLING RESISTOR
bridging Veins
CPP = MAP - ICP
CPP = MAP - CCP
1° STARLING RESISTOR
Arteriolar resistance vessels
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
TCD and CCP
CCP DX
200
180
160
140
MCA
120
y = 2,189x - 78,71
R² = 0,996
CCP DX
100
Lineare (CCP DX)
80
60
40
20
CCP = 35,96
0
0
20
40
60
80
100
120
140
PRESS
Weyland A. et all
Cerebrovascular tone rather than intracranialpressure
determinesthe effective downstreampressure of the
cerebralcirculation in the absence of intracranial hypertension
J Neurosurg Anesth 2000;12:210-16
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,
flusso
TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA
Dr. FRANK RASULO
SSVD Neurorianimazione ,Spedali Civili, Brescia,