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Dr. Frank Rasulo

LA NEUROSONOLOGIA NELL’AMBITO DELLE NEUROSCIENZE: Primo Corso teorico pratico BRESCIA 12-13 NOVEMBRE 2010 U.O. Neurorianimazione Spedali Civili di Brescia. I. Dr. Frank Rasulo. U.O. Neurorianimazione Università di Brescia. pertensione Intracranica:. V. alutazione con TCD.

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Dr. Frank Rasulo

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  1. LA NEUROSONOLOGIA NELL’AMBITO DELLE NEUROSCIENZE: Primo Corso teorico pratico BRESCIA 12-13 NOVEMBRE 2010 U.O. Neurorianimazione Spedali Civili di Brescia I Dr. Frank Rasulo U.O. Neurorianimazione Università di Brescia pertensione Intracranica: V alutazione con TCD

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

  3. d 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,

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

  5. n 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,

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

  7. TCD -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,

  8. TCD -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,

  9. TCD -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,

  10. TCD -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,

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

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

  13. TCD -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,

  14. T 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,

  15. TCD -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,

  16. T 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,

  17. T CD for ICP EVALUATION The pulsatility of blood flow through conductance vessels reflects distal vascular resistance. Gosling et al. 1969 N Σ 1 A2 PI = A2n n=1 TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA Dr. FRANK RASULO SSVD Neurorianimazione ,Spedali Civili, Brescia,

  18. 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,

  19. T 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,

  20. T CD for non invasive ICP EVALUATION PI Ratio – therefore not infuenced by the angle of insonation Reduced with the reduction of upstream blood supply (stenosis, CO, hypotension) influenced by certain factors that influences flow velocity Increased with the increase of downstream resistance (vasocostriction, ICP) Upstream - Downstream Hemodynamic Respiratory Hematologic Tissue compliance Parameters 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,

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

  22. I 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,

  23. O rigins of non invasive assessment 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

  24. slid and the Fourier analysis A 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

  25. C ambridge proposal 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,

  26. C 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,

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

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

  29. T 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,

  30. T 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,

  31. T 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,

  32. T 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,

  33. T 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,

  34. T 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 + PI CBF TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA Dr. FRANK RASULO SSVD Neurorianimazione ,Spedali Civili, Brescia,

  35. T 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,

  36. T 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,

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

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

  39. Maximum Vasoconstriction R = Rmax Maximum Vasodilation R = Rmin 5 Critical Closing Pressure TCD identification of changing autoregulatory thresholds after autoregulatory impairment. Lewis SB et al. Neurosurgery 2001:49(6);1484-85 CBF PI 50 mmHg 160 mmHg ABP CBF = CPP/R TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA Dr. FRANK RASULO SSVD Neurorianimazione ,Spedali Civili, Brescia,

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

  41. T 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,

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

  43. T 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,

  44. 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 ICP ? TCD PER LA DIAGNOSI DI IPERTENSIONE INTRACRANICA Dr. FRANK RASULO SSVD Neurorianimazione ,Spedali Civili, Brescia,

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

  46. TCD and CCP 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,

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

  48. D T C

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