18. transcranial doppler (tcd) ultrasonography. vasospasm ... · 18. transcranial doppler (tcd)...
TRANSCRIPT
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18. Transcranial Doppler (TCD) Ultrasonography.
Vasospasm . Transcranial Doppler Pulsatility Index and
other useful measures of blood transport in great
cerebral vessels. Is Pulsatility Index related to ICP? Is
it a measure of cerebrovascular resistance?
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Spasm: Left: FV= 250 cm/s, LR=5 Right FV=150 cm/s, LR=3.5 Left CBF= 25 ml/min/100g Right CBF= 37 ml/min/100g
Confounding picture: Left FV=155 cm/s, LR= 5 Right FV = 45 cm/s , LR=1.5 Left CBF=56 ml/min/100g Right CBF=41 ml/min/100g
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Pulsatility index and resistance index
gPI (Gosling Pulsatility index)= (Fvsys-Fvdia)/Fvmean RI (Purcelot Resistance Index)= (Fvsys-Fvdia)/Fvsys PI (spectral)= F1/FVmean
All indices theoretically independent of the angle of insonation What they measure- many thought that higher PI means higher CVR
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Gosling Pulsatility Index and Resistance Index are linearly related
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Gosling Pulsatility index and ‘spectral’ PI are also linearly related
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Plateau wave of ICP: Widening of CBFv peak-to-peak amplitude, mean CBFv decreases
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CBFv during ICP plateau waves:
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Czosnyka et al. Neurosurgery 1994: 35(2) Thanks to Mr.K.Budohoski
With lowering ABP, FV systolic and diastolic react differently –
experimental data
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Clinical data:
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Change in the shape of CBFv waveform during intracranial hypertension
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PI is a useful index of decreasing CPP
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Decrease in Doppler Pulsatilty during arterial hypertension
FV
ABP
mmHg
cm/s
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PI increases during arterial hypotension. What happens to ICP ?
FV
ABP
mmHg
cm/s
mmHg
ICP
PI
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Infusion test. Pressure monitoring interrupted at the end. TCD pulsatility indicated plateau wave!
FV
ABP
mmHg
cm/s
mmHg
ICP
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The same study: PI increases faster during plateau than during infusion
FV
ABP
mmHg
cm/s
mmHg
ICP
PI
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Rise in PI does not indicate lower limit of autoregulation
Richards HK, Czosnyka M, Whitehouse H, Pickard JD. Increase in transcranial Doppler pulsatility index does not indicate the lower limit of cerebral autoregulation. Acta Neurochir (Suppl) 1998;
71:229-232
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Pulsatility Index does not describe CVR under all circumstances
Hypercapnia
Decrease in CPP
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Hypocapnia Hypotension
Study in volunteers (Student’s project 1997)
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Plateau wave changes
Thanks to Dr. Nico de Riva
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Hypocapnia changes
Thanks to Dr. Nico de Riva
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‘Analytical’ presentation of PI:
Thanks to Dr. Nico de Riva
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R=0.95
PI ‘calculated’ versus ‘model’ in plateau+hypocapnia group
Thanks to Dr. Nico de Riva
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Vasodilation after Diamox- PI decreases
FV
ABP
mmHg
cm/s
PI
cm/s
F1
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Statistics:
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R=-0.719 R=-0.573
Pulsatility and ABP, PaCO2 and ICP- experimental study
Thanks to Raj
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R=0.114 R=0.131
Pulsatility indices versus experimental rise in ICP
Thanks to Raj
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R=-0.247 R=-0.304
Pulsatility index versus experimental change in PaCO2
Thanks to Raj
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Means and 95.0 Percent LSD Intervals
cabp
spi
0 1
0.32
0.52
0.72
0.92
1.12
1.32
Arterial hypotension normotension
Hypocapnia Normocapnia Hypercapnia Baseline ICP high ICP
Thanks to Raj
Summary of experimental results
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R=0.764
R=0.614
Pulsatility and CPP
Thanks to Raj
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Pulsatility and CPP- clinical (TBI)
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95% confidence limit for predictors 5 mm Hg
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Things are not so optimistic in our own material (95% confidence limit= +/- 20 mm Hg )
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Pulsatility index and outcome after TBI
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Symmetry of gPI in unilateral spasm
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Carotid artery stenotic disease
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Asymmetry of PI in unilateral ICA stenotic disease
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TCD Pulsatility index What it is: Useful indicator of cerebral hemodynamic asymmetry Indicator of low Cerebral Perfusion Pressure What it isn’t: Descriptor of Cerebrovascular Resistance Reliable predictor of raised ICP* Indicator of autoregulation limit
* However, if at a bedside I see PI>2; and I am sure MAP is normal and PaCO2>30; I am cautious that ICP may be elevated