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Review
. 2021 Aug 15;38(16):2206-2220.
doi: 10.1089/neu.2020.7523. Epub 2021 Mar 1.

Utility of Transcranial Doppler in Moderate and Severe Traumatic Brain Injury: A Narrative Review of Cerebral Physiologic Metrics

Alwyn Gomez  1   2 , Carleen Batson  2 , Logan Froese  3 , Amanjyot Singh Sainbhi  3 , Frederick Adam Zeiler  1   2   3   4   5
Affiliations
Review

Utility of Transcranial Doppler in Moderate and Severe Traumatic Brain Injury: A Narrative Review of Cerebral Physiologic Metrics

Alwyn Gomez et al. J Neurotrauma. .

Abstract

Since its creation in the 1980s, transcranial Doppler (TCD) has provided a method of non-invasively monitoring cerebral physiology and has become an invaluable tool in neurocritical care. In this narrative review, we examine the role TCD has in the management of the moderate and severe traumatic brain injury (TBI) patient. We examine the principles of TCD and the ways in which it has been applied to gain insight into cerebral physiology following TBI, as well as explore the clinical evidence supporting these applications. Its usefulness as a tool to non-invasively determine intracranial pressure, detect post-traumatic vasospasm, predict patient outcome, and assess the state of cerebral autoregulation are all explored.

Keywords: cerebral autoregulation; multi-modal monitoring; transcranial doppler; traumatic brain injury.

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Conflict of interest statement

The authors have no disclosures or conflicts of interest.

Figures

FIG. 1.
FIG. 1.
Typical transcranial Doppler ultrasound windows and the vessels of interest. An overview of the windows can be seen in (A). The transorbital window is seen in (B), with the anterior cerebral artery (ACA), ophthalmic artery (OpA), and the internal carotid artery (ICA) labeled. The transforaminal window is seen in (C), with the vertebral artery (VA) and basilar artery (BA) labeled. Final the transtemporal window is seen in (D), with the ACA, ICA, and middle cerebral artery (MCA) labeled.
FIG. 2.
FIG. 2.
The typical output of a transcranial Doppler (TCD) as recorded on a Delica EMS 9D robotic TCD device (Delica EMS 9D System, Shenzen Delica Medical Equipment Co. Ltd, China). Note that the peak of the waveform is the systolic flow velocity (FVs) and is approximately 55 cm/sec. The trough of the waveform is the diastolic flow velocity (FVd) and is approximately 25 cm/sec. The mean flow velocity (FVm) would then be expected to be around 35 cm/sec.
FIG. 3.
FIG. 3.
A schematic representation of the derivation of critical closing pressure (CrCP). Flow velocity (FV) is plotted against arterial blood pressure (ABP) and the x intercept, which the ABP at which FV is zero, represents the CrCP.
FIG. 4.
FIG. 4.
An example of continuous arterial blood pressure (ABP), intracranial pressure (ICP), and flow velocity (FV) data for a single patient. Also presented are the associated pressure reactivity (PRx) and mean flow velocity index (Mx) versus cerebral perfusion pressure (CPP) graphs that demonstrate a parabolic relationship. A concordant optimal CPP, where cerebrovascular reactivity is most intact, can be identified at approximately 61.25 mm Hg. Modified from an open access 2018 article by Zeiler and colleagues and used with permission from the corresponding author.
FIG. 5.
FIG. 5.
Robotic transcranial Doppler (TCD) setup using a Delica EMS 9D robotic TCD device (Delica EMS 9D System, Shenzen Delica Medical Equipment Co. Ltd, China).
See this image and copyright information in PMC

References

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