Transcranial Doppler
POCUS Seminars
King’s College Hospital
October 2023
Masumi Tanaka Gutiez
Content
• Case
• Technique for insonation
• Use of TCD
• Use of cranial ultrasound
• Case
• Conclusion
Case
• 70 yo male transfer from other hospital
• Polytrauma
• Bilateral pneumothoraces with ICD
• BP unstable MAP 50-70
• Suddenly BP to 220/70, HR 38
• PEARLA
• Etiology?
Technique
Technique
• Low-frequency (2.0–
3.5 MHz) sector
probes (to penetrate
the skull), B mode
• 4 windows
• transtemporal most
common in ICU in
the UK
• Middle cerebral
artery
Transtemporal window
• Above the arcus zygomaticus, between the
external auditory canal and the orbital area.
• 3 areas; Anterior, middle, posterior
• MCA, ACA, PCA, terminal ICA
• Start at 50mm depth (M1)
How to identify your vessels: checklist
❑Direction of probe within acoustic window
❑Direction of blood flow in relation to probe
❑Depth of insonation
❑Blood flow response to carotid compression if to distinguish anterior
and posterior circulation
Transtemporal window
• Lesser wing of sphenoid bone
• Cerebral peduncles
• Interpeducular and supracellar cisterns
[Link]
Transtemporal- Axial view
[Link]
ultrasound-what-are-its-clinical-applications/
Transtemporal window
Ventricular plane
Horizontal planes: 3 • Frontal horns
• Thalami
Diencephalic plane
• Third ventricle
• Midline shift
Double hyperechoic line
Mesencephalic plane
• Cerebral peduncles
• “butterfly”
• Basal cisterns
Insonation depths
MCA:35-55mm
ACA: 60-70mm
ICA bifurification: 55-65mm
PCA: 60-70mm
Transtemporal- Axial view:
90° rotation
Carotid siphon and segments of the MCA
Transorbital window
• Opthalmic Artery (40 - 50mm)
• Carotid Siphon (55 - 70mm)
Submandibular window
• Angle of the jaw
• Distal ICA (40-60mm)
Suboccipital window
• Vertebral arteries (80-115mm)
• Basilar artery (60-70mm)
• Upper plane
• Point to frontal eminence
• Distal V4, prox-mid BA
• Lower plane
• Point to root of nose
• V3, V4, prox BA
TCD Basic principles
• 80% of blood flow to the brain from MCA
• Mean velocities <90cm/s
• Velocities raised in
• Vasospasm
• Stenosis
• Hyperdynamic flow
• Collateral flow
Vasospasm
Vasospasm
• As diameter of the vessel decreases, velocity increases
• Mean flow velocity = PSV + (EDV · 2)/3
• Physiological states make MFV unreliable
• Hyperaemia
• Autoregulation
• Hypertension
• Hypervolaemia
Vasospasm • Lindegaard ratio:
11.5
• MCA: Lindegaard ratio: MFV
(MCA)/MFV (ICA)
• ACA: Sloan ratio: MFV (ACA)/MFV
(ICA)
Intracranial hypertension
• Pulsatility index = PI = (PSV −
EDV)/MFV
Confounding factors
• Factors affecting PI:
• CO2
• AVM
• Blood pressure
• Cerebral vascular resistance
IMPRESSIT-1
• prospective, international, multicenter study
• 266 patients
• Diagnostic accuracy
• Good as a screening test to rule out raised intracranial pressure.
• measured ICPtcd threshold: 20.5 mmHg, sensitivity of 0.70 (0.41–
0.93) specificity of 0.76 (0.70–0.81) with an AUC of 0.76 (95% CI
0.66–0.85)
• High NPV
• ICP > 20 mmHg = 91.3%, > 22 mmHg = 95.6%, > 25 mmHg = 98.6
• ABP derived
• MAP*FVd /FVm+14
• ICP = MAP–CPP
Raised ICP… different methods
• PI
• PI = (PSV − EDV)/MFV
• PI and EDV if <20cm/s
• ABP derived
• MAP*FVd /FVm+14
• ICP = MAP–CPP
Raised intracranial pressure
• Phase 1: normal
• Phase 2: flowrate at the end of diastole starts to drop
• Phase 3: When ICP is higher than diastolic BP, systolic peaks are seen
Brain Death
Brain Death confirmation
• Overall sensitivity: 0.90 (95% CI, 0.87–0.92
• Overall specificity: 0.98 (95% CI, 0.96 –0.99
Raised intracranial pressure
• Phase 1: normal
• Phase 2: flowrate at the end of diastole starts to drop
• Phase 3: When ICP is higher than diastolic BP, systolic peaks are seen
Cerebral Circulatory Arrest: Oscillating flow
• Systolic flow becomes shorter in duration:
• Systolic forward and Diastolic backward flow
• ICP> CPP
• Confirm circulation stopped:
• currents above and below zero equalised, net forward current zero
Cerebral Circulatory Arrest: Systolic Spikes
• ICP approaches systolic blood pressure
• Diastolic reverse current disappears
• Confirm: systolic spikes
• flows <200ms, slower than 50cms/s
Cerebral Circulatory Arrest: no signal
• No blood flow in basal arteries, thus no signal
• Consider repeating againg in 30 minutes
Cautions: Brain death
• Flow continues despite clinical BS death
• In decompressive craniectomies
• HBI
• Poor acoustic window in 10-20%
• 50% variation in Circle of Willis
• In patients with sudden spikes in ICP may mimic TCDs of those with
brain death. Repeat TCD in a time interval advised.
Intracranial ultrasound
Midline shift
Hydrocephalus
• No established consensus
• Visualised on one side in 87%
Intracerebral haemorrhage
Autoregulation
• Cerebral blood flow remains relatively constant during changes in is
cerebral perfusion pressure
• Currently more appropriate for Continuous monitoring
• Relevant for
• TBI
• CA
• SAH
• ICH
• Stroke
Limitations of TCD
•Inter-operator variability
•Variability of circle of Willis in 50%
•Velocities can be variable with different
metrics including CO2
•For autoregulation, continuous monitoring
is required at present
Summary
Pan Y, Wan W, Xiang M, Guan Y. Transcranial Doppler Ultrasonography as a Diagnostic Tool for Cerebrovascular Disorders. Front Hum
Neurosci. 2022 Apr 29;16:841809. doi: 10.3389/fnhum.2022.841809. PMID: 35572008; PMCID
• Insonation windows
• Transtemporal
(pathology/vessels)
• Transorbital
• Submandibular
• Suboccipital
Summary
Case
OFNS 7.5mm
bilaterally
Hypertonic saline
given→ CTH
Would TCD have
been useful?
Conclusions
• There is a clinical need for transcranial doppler
• B-mode USS uses non-invasive, quick assessment of brain anatomy
and physiology
• Currently used as part of a multimodal assessment in context of its
limitations
• Future: trendsetters
• Can guide management in real-time.
• Prognostication
• ECMO
• Cardiac arrest
References
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Aaslid, R. , Markwalder, T. M. , & Nornes, H. (1982) Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. Journal of
Neurosurgery, 57, 769–774.
Kirsch, J. D., Mathur, M., Johnson, M. H., Gowthaman, G., & Scoutt, L. M. (2013). Advances in Transcranial Doppler US: Imaging Ahead. RadioGraphics, 33(1), E1–E14.
Atul Kalanuria, Paul A. Nyquist, Rocco A. Armonda, Alexander Razumovsky, Use of Transcranial Doppler (TCD) Ultrasound in the Neurocritical Care Unit,
Neurosurgery Clinics of North America, Volume 24, Issue 3, 2013, Pages 441-456,
Blanco, P., Abdo-Cuza, A. Transcranial Doppler ultrasound in neurocritical care. J Ultrasound 21, 1–16 (2018). [Link]
Blanco, P., & Abdo-Cuza, A. (2018). Transcranial Doppler ultrasound in neurocritical care. Journal of Ultrasound, 21(1), 1–16. doi:10.1007/s40477-018-0282-9
Transcranial Color-Coded Sonography Successfully Visualizes All Intracranial Parts of the Internal Carotid Artery Using the Combined Transtemporal Axial and Coronal
Approach
J. Eggers, O. Pade, A. Rogge, S.J. Schreiber, J.M. Valdueza American Journal of Neuroradiology Sep 2009, 30 (8) 1589-1593; DOI: 10.3174/ajnr.A1602
Transcranial Doppler – Sonographic Tendencies
Dupont S, Rabinstein AA. CT evaluation of lateral ventricular dilatation after subarachnoid hemorrhage: baseline bicaudate index values [correction of values]. Neurol Res.
2013;35:103–.
Amedeo Bianchini, Rocco D'Andrea, Berin Lepic, Lorenzo Querci, Cristiana Laici, Antonio Siniscalchi, Intracranial Hemorrhage Diagnosed with Transcranial Ultrasound in a
Comatose, Postliver Transplant Patient, Journal of Stroke and Cerebrovascular Diseases,, Volume 28, Issue 11, 2019, 104357, ISSN 1052-3057,
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