Intensive Care Medicine

, Volume 31, Issue 6, pp 785–790 | Cite as

Transcranial Doppler to detect on admission patients at risk for neurological deterioration following mild and moderate brain trauma

  • Paul Jaffres
  • Julien Brun
  • Philippe Declety
  • Jean-Luc Bosson
  • Bertrand Fauvage
  • Almuth Schleiermacher
  • Affif Kaddour
  • Daniel Anglade
  • Claude Jacquot
  • Jean-Francois Payen



To investigate the contribution of transcranial Doppler measurements obtained in the emergency room for detecting patients with secondary neurological deterioration after mild or moderate brain trauma.

Design and setting

Prospective cohort study in the emergency room in a university teaching hospital.


Seventy-eight adult patients admitted to the emergency room after a traumatic brain injury (TBI), including 42 patients with Glasgow Coma Score 14–15 and 36 with 9–13.

Measurements and results

All patients had transcranial Doppler measurements on both middle cerebral arteries and computed tomography on admission. Neurological outcome was assessed 7 days after trauma. Of the patients included 7 and 10 had secondary neurological deterioration after mild and moderate TBI, respectively. On admission these groups of patients had significantly more injuries on computed tomography using the Trauma Coma Data Bank classification and higher pulsatility index using transcranial Doppler than the patients having no subsequent neurological worsening.


Increased pulsatility index after mild or moderate TBI is a reason for concern about the possibility of further neurological deterioration. Computed tomography and Doppler measurements could be combined to detect on admission patients at risk for secondary neurological deterioration in order to improve their initial disposition.


Traumatic brain injury Mild head injury Moderate head injury Transcranial Doppler 



The authors thank Dr. Marek Czosnyka for his helpful comments on the manuscript.


  1. 1.
    Stein SC, Ross SE (1992) Moderate head injury: a guide to initial management. J Neurosurg 77:562–564Google Scholar
  2. 2.
    Cushman JG, Agarwal N, Fabian TC, Garcia V, Nagy KK, Pasquale MD, Salotto AG (2001) Practice management guidelines for the management of mild traumatic brain injury: the EAST practice management guidelines work group. J Trauma 51:1016–1026Google Scholar
  3. 3.
    Jagoda AS, Cantrill SV, Wears RL, Valadka A, Gallagher EJ, Gottesfeld SH, Pietrzak MP, Bolden J, Bruns JJ Jr, Zimmerman R (2002) Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 40:231–249Google Scholar
  4. 4.
    Fabbri A, Servadei F, Marchesini G, Morselli-Labate AM, Dente M, Iervese T, Spada M, Vandelli A (2004) Prospective validation of a proposal for diagnosis and management of patients attending the emergency department for mild head injury. J Neurol Neurosurg Psychiatry 75:410–416Google Scholar
  5. 5.
    Marshall LF, Toole BM, Bowers SA (1983) The National Traumatic Coma Data Bank. II. Patients who talk and deteriorate: implications for treatment. J Neurosurg 59:285–288Google Scholar
  6. 6.
    Lobato RD, Rivas JJ, Gomez PA, Castaneda M, Canizal JM, Sarabia R, Cabrera A, Munoz MJ (1991) Head-injured patients who talk and deteriorate into coma. Analysis of 211 cases studied with computerized tomography. J Neurosurg 75:256–261Google Scholar
  7. 7.
    Lee ST, Liu TN, Wong CW, Yeh YS, Tzaan WC (1995) Relative risk of deterioration after mild closed head injury. Acta Neurochir (Wien) 135:136–140Google Scholar
  8. 8.
    Marshall LF, Marshall SB, Klauber MR, van Berkum Clark M, Eisenberg HM, Jane JA, Luerssen TG, Marmarou A, Foulkes MA (1991) A new classification of head injury based on computerized tomography. J Neurosurg 75:S14–S20Google Scholar
  9. 9.
    Lobato RD, Gomez PA, Alday R, Rivas JJ, Dominguez J, Cabrera A, Turanzas FS, Benitez A, Rivero B (1997) Sequential computerized tomography changes and related final outcome in severe head injury patients. Acta Neurochir (Wien) 139:385–391Google Scholar
  10. 10.
    Signorini DF, Andrews PJ, Jones PA, Wardlaw JM, Miller JD (1999) Predicting survival using simple clinical variables: a case study in traumatic brain injury. J Neurol Neurosurg Psychiatry 66:20–25Google Scholar
  11. 11.
    Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA (1993) The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34:216–222Google Scholar
  12. 12.
    Ingebrigtsen T, Romner B (2002) Biochemical serum markers of traumatic brain injury. J Trauma 52:798–808Google Scholar
  13. 13.
    Aaslid R, Markwalder TM, Nornes H (1982) Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 57:769–774Google Scholar
  14. 14.
    Moppett IK, Mahajan RP (2004) Transcranial Doppler ultrasonography in anaesthesia and intensive care. Br J Anaesth 93:710–724Google Scholar
  15. 15.
    Martin NA, Patwardhan RV, Alexander MJ, Africk CZ, Lee JH, Shalmon E, Hovda DA, Becker DP (1997) Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm. J Neurosurg 87:9–19Google Scholar
  16. 16.
    Santbrink H van, Schouten JW, Steyerberg EW, Avezaat CJ, Maas AI (2002) Serial transcranial Doppler measurements in traumatic brain injury with special focus on the early posttraumatic period. Acta Neurochir (Wien) 144:1141–1149Google Scholar
  17. 17.
    Junger EC, Newell DW, Grant GA, Avellino AM, Ghatan S, Douville CM, Lam AM, Aaslid R, Winn HR (1997) Cerebral autoregulation following minor head injury. J Neurosurg 86:425–432Google Scholar
  18. 18.
    Lee JH, Kelly DF, Oertel M, McArthur DL, Glenn TC, Vespa P, Boscardin WJ, Martin NA (2001) Carbon dioxide reactivity, pressure autoregulation, and metabolic suppression reactivity after head injury: a transcranial Doppler study. J Neurosurg 95:222–232Google Scholar
  19. 19.
    Newell DW, Aaslid R, Stooss R, Seiler RW, Reulen HJ (1997) Evaluation of hemodynamic responses in head injury patients with transcranial Doppler monitoring. Acta Neurochir (Wien) 139:804–817Google Scholar
  20. 20.
    Steiner LA, Czosnyka M, Piechnik SK, Smielewski P, Chatfield D, Menon DK, Pickard JD (2002) Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med 30:733–738Google Scholar
  21. 21.
    McQuire JC, Sutcliffe JC, Coats TJ (1998) Early changes in middle cerebral artery blood flow velocity after head injury. J Neurosurg 89:526–532Google Scholar
  22. 22.
    Trabold F, Meyer PG, Blanot S, Carli PA, Orliaguet GA (2004) The prognostic value of transcranial Doppler studies in children with moderate and severe head injury. Intensive Care Med 30:108–112Google Scholar
  23. 23.
    Anonymous (1990) The Abbreviated Injury Scale, 1990 revision. American Association for the Advancement for Automotive Medicine, Des PlainesGoogle Scholar
  24. 24.
    Shackford SR, Wald SL, Ross SE, Cogbill TH, Hoyt DB, Morris JA, Mucha PA, Pachter HL, Sugerman HJ, O’Malley K et al (1992) The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma 33:385–394Google Scholar
  25. 25.
    Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM (2000) Indications for computed tomography in patients with minor head injury. N Engl J Med 343:100–105Google Scholar
  26. 26.
    Af Geijerstam JL, Britton M, Marke LA (2004) Mild head injury: observation or computed tomography? Economic aspects by literature review and decision analysis. Emerg Med J 21:54–58Google Scholar
  27. 27.
    Servadei F, Teasdale G, Merry G (2001) Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management. J Neurotrauma 18:657–664Google Scholar
  28. 28.
    Wardlaw JM, Easton VJ, Statham P (2002) Which CT features help predict outcome after head injury? J Neurol Neurosurg Psychiatry 72:188–192Google Scholar
  29. 29.
    Bouma GJ, Muizelaar JP, Choi SC, Newlon PG, Young HF (1991) Cerebral circulation and metabolism after severe traumatic brain injury: the elusive role of ischemia. J Neurosurg 75:685–693Google Scholar
  30. 30.
    Shafe M, Blaivas M, Hooker E, Straus L (2004) Noninvasive intracranial cerebral flow velocity evaluation in the emergency department by emergency physicians. Acad Emerg Med 11:774–777Google Scholar
  31. 31.
    Chan KH, Miller JD, Dearden NM (1992) Intracranial blood flow velocity after head injury: relationship to severity of injury, time, neurological status and outcome. J Neurol Neurosurg Psychiatry 55:787–791Google Scholar
  32. 32.
    Klingelhofer J, Conrad B, Benecke R, Sander D, Markakis E (1988) Evaluation of intracranial pressure from transcranial Doppler studies in cerebral disease. J Neurol 235:159–162Google Scholar
  33. 33.
    Bellner J, Romner B, Reinstrup P, Kristiansson KA, Ryding E, Brandt L (2004) Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP). Surg Neurol 62:45–51Google Scholar
  34. 34.
    Kidwell CS, el-Saden S, Livshits Z, Martin NA, Glenn TC, Saver JL (2001) Transcranial Doppler pulsatility indices as a measure of diffuse small-vessel disease. J Neuroimaging 11:229–235Google Scholar
  35. 35.
    Richards HK, Czosnyka M, Whitehouse H, Pickard JD (1998) Increase in transcranial Doppler pulsatility index does not indicate the lower limit of cerebral autoregulation. Acta Neurochir Suppl 71:229–232Google Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Paul Jaffres
    • 1
  • Julien Brun
    • 1
  • Philippe Declety
    • 1
  • Jean-Luc Bosson
    • 2
  • Bertrand Fauvage
    • 1
  • Almuth Schleiermacher
    • 3
  • Affif Kaddour
    • 3
  • Daniel Anglade
    • 1
  • Claude Jacquot
    • 1
  • Jean-Francois Payen
    • 1
  1. 1.Department of Anaesthesiology and Critical Care MedicineAlbert Michallon HospitalGrenobleFrance
  2. 2.Division of BiostatisticsAlbert Michallon HospitalGrenobleFrance
  3. 3.Department of Emergency MedicineAlbert Michallon HospitalGrenobleFrance

Personalised recommendations