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Dr. Frank Rasulo U.O. Neurorianimazione Università di Brescia pertensione Intracranica: alutazione con TCD LA NEUROSONOLOGIA NELLAMBITO DELLE NEUROSCIENZE:

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Presentation on theme: "Dr. Frank Rasulo U.O. Neurorianimazione Università di Brescia pertensione Intracranica: alutazione con TCD LA NEUROSONOLOGIA NELLAMBITO DELLE NEUROSCIENZE:"— Presentation transcript:

1 Dr. Frank Rasulo U.O. Neurorianimazione Università di Brescia pertensione Intracranica: alutazione con TCD LA NEUROSONOLOGIA NELLAMBITO DELLE NEUROSCIENZE: Primo Corso teorico pratico BRESCIA NOVEMBRE 2010 U.O. Neurorianimazione Spedali Civili di Brescia

2 VASOSPASM VASOSPASM INTRACRANIAL INTRACRANIAL HYPERTENSION HYPERTENSION CEREBRAL CEREBRAL CIRCULATORY ARREST CIRCULATORY ARREST AUTOREGULATION AUTOREGULATION STENOSIS STENOSIS SUBARACHNOID HEMORRHAGE HEAD TRAUMA STROKE BRAIN DEATH TCD in the ICU SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

3 iagnosing high ICP The gold standard for the measurement of ICP is its invasive measurement. SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

4 ypes of Devices SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

5 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.) on invasive evaluation of high ICP SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

6 CD waveform analysis for the evaluation of intracranial pressure SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

7 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 -derived parameters SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

8 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 -derived parameters SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

9 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 -derived parameters SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

10 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 -derived parameters SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

11 CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

12 CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

13 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 Jul;77(1): 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 Pediatric head trauma study, an end-diastolic velocity less than 25 cm/s was associated with a poor prognosis Trabold F. The prognostic value of transcranial Doppler studies in children with moderate and severe head injury. Intensive Care Med. 2004;30(1): derived parameters SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

14 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. Monitorare il ritardo di crescita: la flussimetria dell'arteria ombelicale CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

15 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 -derived parameters SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

16 CD waveform analysis for the evaluation of intracranial pressure PULSATILITY INDEX SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

17 CD for ICP EVALUATION The pulsatility of blood flow through conductance vessels reflects distal vascular resistance. Gosling et al Σ N A2nA2n 1A21A2 n=1 PI = SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

18 Gosling RG, King DH. Arterial assessment by Doppler Shift ultrasound. ProcRsoc Med 1974;67:447–9. Peak to peak amplitude of the Doppler shift recording Mean value PI = INDICA LANDAMENTO DELLA CURVA DI VELOCITA DURANTE UN CICLO CARDIACO SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

19 The earliest sign of increased ICP is increased pulsatility. ICP CD for non invasive ICP EVALUATION PI Normal value < 1 SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

20 influenced by certain factors that influences flow velocity Hemodynamic Respiratory Hematologic Tissue compliance Parameters Ratio – therefore not infuenced by the angle of insonation The arterioles are greater influenced than in the larger vessels Increased with the increase of downstream resistance (vasocostriction, ICP) Reduced with the reduction of upstream blood supply (stenosis, CO, hypotension) Upstream - Downstream CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

21 ICP- 20ICP- 60 aveform analysis of high ICP SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

22 Can we be satisfied with a qualitative measurment ? s a waveform enough? SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

23 Houmburg AM. et al. Transcranial Doppler recording in raised intracranial pressure Acta Neurol Scand 1993:87: Chan KM et all. Transcranial Doppler waveform differences in hyperemic and non hyperemics patients after severe injury- Sur Neurol 1992;87: Klingelhofer J. et all Evaluation of intracranial pressure from transcranial Doppler studies in cerebral desease. J Neurosonol 1988;235: rigins of non invasive assessment

24 slid and the Fourier analysis PA1= ampiezza della prima armonica dellonda che descrive la pressione arteriosa FV1 = ampiezza della prima armonica dellonda che descrive la velocità di flusso 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 pp pazienti < 27 mmHg 95% delle stime < 10 mmHg 52% delle stime

25 PAM = pressione arteriosa media FVd = Velocità di flusso diastolica FVm = Velocità di flusso media ambridge proposal SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

26 25 pazienti 5 mmHg 49% 10 mmHg 81% 15 mm Hg 94% Schmidt EA et all. Preliminary experience of the estimation of cerebral perfusion pressure using transcranial Doppler ultrasonography J Neurol Neurosurg and Psycjiatry 2001;170: ambridge proposal 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 SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

27 Aaslid et al < 27 mmHg 95% < 10 mmHg 52% < 21 mmHg 95% dellestime < 10 mmHg 81% dellestime Czosnykaet al. CPP CD for CPP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

28 OUR RESULTS 21 pazienti 21 pazienti 530 stime 530 stime 21 pazienti 21 pazienti 530 stime 530 stime SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

29 CD for non invasive ICP EVALUATION Head Trauma Brain Infarct Menengtis /Encephalytis Decompressive Craniectomy SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

30 Bellner J et al. Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP). Surg Neurol 2004;62:45,51. Ract C et al. Transcranial Doppler ultrasound goal-directed therapy for the early management of severe traumatic brain injury. Inten Care Med 2007;33: Splavski B et al. Transcranial Doppler ultrasonography as an early outcome forecaster following severe brain injury. Br J Neurosurg 2006; 20: Literature suggests that the PI is useful as a non invasive estimate of ICP and CPP in adult TBI and SAH CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

31 et al. prospective First prospective study to investigate the relationship between ICP and TCD derived PI. ICP higher than 20 mm Hg could be detected with sensitivityspecificity a sensitivity of 0.89 and specificity of CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

32 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. CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

33 TALIP ASIL et al. - Increased PI correlated with midline shifts on CT scans. - Early outcomes of pts who had increased PI were poorer. CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

34 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 + PI CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

35 INTERHEMISPHERIC PRESSURE GRADIENTS TRANSMANTLE PRESSURE GRADIENTS PRESSURE GRADIENTS BETWEEN THE SUPRA AND INFRATENTORIAL SPACES PRESSURE GRADIENTS WITHIN THE CEREBROSPINAL AXIS CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

36 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. CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

37 CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

38 CD for non invasive ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

39 CBF ABP 160 mmHg 50 mmHg CBF = CPP/R PI Maximum Vasodilation R = R min Maximum Vasoconstriction R = R max Critical Closing Pressure 5 TCD identification of changing autoregulatory thresholds after autoregulatory impairment. Lewis SB et al. Neurosurgery 2001:49(6); SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

40 CD for Emergency ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

41 Admission Admission velocities, FVm< 30 cm/s, were related to GCS, and correctly predicted early outcome. Chan KH et al. Admission Admission FVd 1.3 is associated with a poor outcome Trabold et al. CD for Emergency ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

42 CD for Emergency ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

43 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. CD for Emergency ICP EVALUATION SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

44 Comparison of TCD and Ultrasound for non-invasive estimation of intracranial hypertension and its prediction during the early phase following severe head trauma. SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA ? TCDECO

45 2° STARLING RESISTOR bridging Veins 1° STARLING RESISTOR Arteriolar resistance vessels = MAP - CCP CPP TCD & Critical Closing Pressure = MAP - ICP CPP P = T/r P = pressione transmurale T = tensione di parete r = raggio del vaso P < T/r MAP ICP Tono vasomostore MABP CVP SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

46 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: TCD and CCP SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

47 flusso SSVD Neurorianimazione,Spedali Civili, Brescia, Dr. FRANK RASULO TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA

48 T C D

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