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Evaluation of hemodynamic responses in head injury patients with transcranial doppler monitoring


Transcranial Doppler (TCD) can monitor middle cerebral artery (MCA) velocity which can be recorded simultaneously with other physiologic parameters such as end tidal (Et) CO2, arterial blood pressure and intracranial pressure (ICP), in head injured patients. Relative changes in MCA velocity can be used to reflect relative MCA blood flow changes during ICP waves, and also to evaluate cerebral autoregulation, CO2 reactivity and hemodynamic responses to mannitol and barbiturates. The utility and practicality of short intervals of TCD monitoring to evaluate hemodynamic resposnes, was evaluated in a group of 22 head injured patients (average Glasgow coma score 6). During ICP A waves, MCA velocity always decreased during the peak of the wave, and during ICP B waves, fluctuated synchronously with the ICP. Dynamic cerebral autoregulation, and reactivity to CO2, were reduced within 48 hours of admission. Impaired cerebral autoregulation within 48 hours of admission did not correlate with outcome at 1 month. Mannitol infusion caused an increase in MCA velocity (15.4 ± 7.9%) which was significantly correlated to the impairment of dynamic autoregulation (r=0.54, p < 0.0001). The MCA velocity response to a test dose of barbiturates was significantly correlated to the ICP (r=0.61, p < 0.01) response as well as to the CO2 reactivity (r=0.37, p < 0.05).

Continuous MCA velocity monitoring using TCD may be useful in evaluating a variety of hemodynamic responses in head injury patients and may replace more cumbersome cerebral blood flow techniques which have been used in the past for these purposes.


  1. 1.

    Aaslid R, Markwalder T-M, Nornes H (1982) Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 57: 769–777

    PubMed  Google Scholar 

  2. 2.

    Aaslid R (1986) Transcranial Doppler examination techniques. In: Aaslid R (ed) Transcranial Doppler sonography. Raven, New York, pp 39–59

    Google Scholar 

  3. 3.

    Aaslid R (1989) Visually evoked dynamic blood flow response of the human cerebral circulation. Stroke 20: 1005–1011

    PubMed  Google Scholar 

  4. 4.

    Aaslid R, Lindegaard K-F, Sorteberg W, Nornes H (1989) Cerebral autoregulation dynamics in humans. Stroke 20: 45–52

    PubMed  Google Scholar 

  5. 5.

    Aaslid R, Newell DW, Stooss R, Sorteberg W, Lindegaard KF (1991) Assessment of cerebral autoregulation dynamics from simultaneous arterial and venous transcranial Doppler recordings in humans. Stroke 22: 1148–1154

    PubMed  Google Scholar 

  6. 6.

    Aaslid R, Newell DW (1990) Pressure flow relationships in the cerebral circulation. J Cardiovasc Technol 9(1): 57

    Google Scholar 

  7. 7.

    Aaslid R (1992) Developments and principles of transcranial Doppler. In: Newell DW, Aaslid R (eds) Transcranial Doppler. Raven, New York, pp 1–8

    Google Scholar 

  8. 8.

    Aaslid R (1992) Cerebral hemodynamics. In: Newell DW, Aaslid R (eds) Transcranial Doppler. Raven, New York, pp 49–55

    Google Scholar 

  9. 9.

    Abdel-Dayem HM, Sadek SA, Kouris K, Bahar RH, Higaz I, Eriksson S, Englesson SH, Berntman L, Sigurdsson GH, Foad M (1987) Changes in cerebral perfusion after acute head injury: comparison of CT with Tc-99m HM-PAO SPECT. Radiology 165: 221–226

    PubMed  Google Scholar 

  10. 10.

    Auer LM, Sayama I (1983) Intracranial pressure oscillations (B-waves) caused by oscillations in cerebrovascular volume. Acta Neurochir (Wien) 68: 93–100

    Google Scholar 

  11. 11.

    Barzo P, Doczi T, Csete K, Buza Z, Bodosi M (1991) Measurements of regional cerebral blood flow and blood flow velocity in experimental intracranial hypertension: infusion via the cisterna magna in rabbits. Neurosurgery 28: 821–825

    PubMed  Google Scholar 

  12. 12.

    Bishop CC, Powell S, Rutt D, Browse NL (1986) Transcranial Doppler measurement of middle cerebral artery blood flow velocity: a validation study. Stroke 17: 913–915

    PubMed  Google Scholar 

  13. 13.

    Bouma GJ, Muizelaar JP, Stringer WA, Choi SC, Fatouros P, Young HF (1992) Ultra-early evaluation of regional cerebral blood flow in severely head-injured patients using xenonenhanced computerized tomography. J Neurosurg 77: 360–368

    PubMed  Google Scholar 

  14. 14.

    Cold GE (1989) Measurements of CO2 reactivity and barbiturate reactivity in patients with severe head injury. Acta Neurochir (Wien) 98: 153–163

    Google Scholar 

  15. 15.

    Cold GE, Jensen FT, Malmros R (1977) The cerebrovascular CO2 reactivity during the acute phase of brain injury. Acta Anaesth Scand 21: 222–231

    PubMed  Google Scholar 

  16. 16.

    Cold GE (1986) The relationship between cerebral metabolic rate of oxygen and cerebral blood flow in the acute phase of head injury. Acta Anaesth Scand 30: 453–457

    PubMed  Google Scholar 

  17. 17.

    Early CB, Dewey RC, Pieper HP, Hunt WE (1974) Dynamic pressure-flow relationships of brain blood flow in the monkey. J Neurosurg 41: 590–596

    PubMed  Google Scholar 

  18. 18.

    Eisenberg HM, Frankowski RF, Contant CF, Marshall LF, Walker MD, Comprehensive Central Nervous System Trauma Centers (1988) High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg 69: 15–23

    PubMed  Google Scholar 

  19. 19.

    Envoldsen EM, Jensen FT (1978) Autoregulation and CO2 responses of cerebral blood flow in patients with acute severe head injury. J Neurosurg 48: 689–703

    PubMed  Google Scholar 

  20. 20.

    Enevoldsen E (1986) CBF in head injury. Acta Neurochir (Wien) [Suppl] 36: 133–136

    Google Scholar 

  21. 21.

    Giller CA, Bowman G, Dyer H, Mootz L, Krippner W (1993) Cerebral artery diameters during changes in blood pressure and carbon dioxide during craniotomy. Neurosurgery 32(5): 737–742

    PubMed  Google Scholar 

  22. 22.

    Hashimoto T, Nakamura N, Kanki T, Abe S, Akachi K (1991) Monitoring of hemodynamics in subarachnoid hemorrhage with transcranial Doppler and laser Doppler. Arteries et Veines 10 (1): 29–34

    Google Scholar 

  23. 23.

    Huber P, Haneda J (1967) Effect of contrast material, hypercapnia, hyperventilation, hypertonic glucose and papaverine on the diameter of the cerebral arteries — angiographic determination in man. Invest Radiol 2: 17–32

    PubMed  Google Scholar 

  24. 24.

    Kontos HA (1989) Validity of cerebral arterial blood flow calculations from velocity measurements. Stroke 20: 1–3

    PubMed  Google Scholar 

  25. 25.

    Koshu K, Hirota S, Sonobe M, Takahashi S, Takaku A, Saito T, Ushijima T (1987) Continuous recording of cerebral blood flow by means of a thermal diffusion method using a peltier stack. Neurosurgery 21: 693–698

    PubMed  Google Scholar 

  26. 26.

    Langfitt TW, Kassell NF (1963) Cerebral blood flow with intracranial hypertension. Neurology: 761–773

  27. 27.

    Lassen NA (1959) Cerebral blood flow and oxygen consumption in man. Physiol Rev 39: 183–237

    PubMed  Google Scholar 

  28. 28.

    Lewelt W, Jenkins LW, Miller JD (1980) Autoregulation of cerebral blood flow after experimental fluid percussion injury of the brain. J Neurosurg 53: 500–511

    PubMed  Google Scholar 

  29. 29.

    Lindegaard K-F, Lundar T, Wiberg J, Sjoberg D, Aaslid R, Nornes H (1987) Variations in middle cerebral artery blood flow investigated with noninvasive transcranial blood velocity measurements. Stroke 18: 1025–1030

    PubMed  Google Scholar 

  30. 30.

    Lundberg N (1960) Continuous recording and control of ventricular fluid pressure in neurosurgical practice. Acta Psychiatr Scand [Suppl] 149: 1–193

    Google Scholar 

  31. 31.

    Lundberg N, Cronqvist S, Kjallquist A (1968) Clinical investigation on interrelations between intracranial pressure and intracranial hemodynamics. Prog Brain Res 30: 70–75

    Google Scholar 

  32. 32.

    Lundar T, Lindegaard KF, Nornes H (1990) Continuous recording of middle cerebral artery blood velocity in clinical neurosurgery. Acta Neurochir (Wien) 102: 85–90

    Google Scholar 

  33. 33.

    Markwalder T-M, Grolimund P, Seiler RW, Roth F, Aaslid R (1984) Dependency of blood flow velocity in the middle cerebral artery on end-tidal carbon dioxide partial pressure. A transcranial Doppler study. J Cereb Blood Flow Metab 4: 368–372

    PubMed  Google Scholar 

  34. 34.

    Mendelow AD, Teasdale GM, Russell T, Flood J, Patterson J, Murray GD (1985) Effect of mannitol on cerebral blood flow and cerebral perfusion pressure in human head injury. J Neurosurg 63: 43–48

    PubMed  Google Scholar 

  35. 35.

    Messeter K, Nordstrom C-H, Sundbarg G, Algotsson L, Ryding E (1986) Cerebral hemodynamics in patients with acute severe head trauma. J Neurosurg 64: 231–237

    PubMed  Google Scholar 

  36. 36.

    Miller JD, Stanek AE, Langfitt TW (1973) Cerebral blood flow regulation during experimental brain compression. J Neurosurg 39: 186–196

    PubMed  Google Scholar 

  37. 37.

    Muizelaar JP, Wei EP, Kontos HA, Becker DP (1983) Mannitol causes compensatory cerebral vasoconstriction and vasodilation in response to blood viscosity changes. J Neurosurg 59: 822–828

    PubMed  Google Scholar 

  38. 38.

    Muizelaar JP (1989) Cerebral blood flow, cerebral blood volume, and cerebral metabolism after severe head injury. In: Becker DP, Gudeman SK (eds) Textbook of head injury. Saunders, Philadelphia, pp 221–240

    Google Scholar 

  39. 39.

    Muizelaar JP, Lutz HA III, Becker DP (1984) Effect of mannitol on ICP and CBF and correlation with pressure autoregulation in severely head-injured patients. J Neurosurg 61: 700–706

    PubMed  Google Scholar 

  40. 40.

    Muizelaar JP, van der Poel HG, Li Z, Kontos HA, Levasseur JE (1988) Pial arteriolar vessel diameter and CO2 reactivity during prolonged hyperventilation in the rabbit. J Neurosurg 69: 923–927

    PubMed  Google Scholar 

  41. 41.

    Newell DW, Aaslid R, Stooss R, Reulen HJ (1992) The relationship of blood flow velocity fluctuations to intracranial pressure B waves. J Neurosurg 76: 415–421

    PubMed  Google Scholar 

  42. 42.

    Newell DW, Eskridge J, Mayberg MR, Grady MS, Lewis D, Winn HR (1992) Endovascular treatment of intracranial aneurysms and cerebral vasospasm. In: Selman W (ed) Clinical neurosurgery. Williams and Wilkins, Baltimore, pp 348–360

    Google Scholar 

  43. 43.

    Newell DW, Aaslid R, Lam A, Mayberg TS, Winn HR (1994) Comparison of flow and velocity during dynamic autoregulation testing in humans. Stroke 25: 793–797

    PubMed  Google Scholar 

  44. 44.

    Nordstrom C-H, Messeter K, Sundberg G, Schalen W, Werner M, Ryding E (1988) Cerebral blood flow, vasoreactivity, and oxygen consumption during barbiturate therapy in severe traumatic brain lesions. J Neurosurg 68: 424–431

    PubMed  Google Scholar 

  45. 45.

    Nornes H, Magnes B, Aaslid R (1975) Observations of intracranial pressure plateau waves. In: Lundberg N, Ponten U, Brock M (eds) Intracranial pressure 2. Springer, Berlin Heidelberg New York, pp 421–426

    Google Scholar 

  46. 46.

    Obrist WD, Langfitt TW, Jaggi JL, Cruz J, Gennarelli TA (1984) Cerebral blood flow and metabolism in comatose patients with acute head injury. Relationship to intracranial hypertension. J Neurosurg 61: 241–253

    PubMed  Google Scholar 

  47. 47.

    Paulson OB, Strandgaard S, Edvinsson L (1990) Cerebral autoregulation. Cerebrovasc Brain Metab Rev 2: 161–192

    PubMed  Google Scholar 

  48. 48.

    Pierce EC, Lambertsen CJ, Deutsch S, Chase PE, Linde HW, Dripps RD, Price HL (1962) Cerebral circulation and metabolism during theiopental anesthesia and hyperventilation in man. J Clin Invest 41(8): 1664–1671

    PubMed  Google Scholar 

  49. 49.

    Risberg J, Lundberg N, Ingvar DH (1969) Regional cerebral blood volume during acute transient rises of the intracranial pressure (plateau waves). J Neurosurg 31: 303–310

    PubMed  Google Scholar 

  50. 50.

    Robertson CS, Contant CF, Gokaslan ZL, Narayan RK, Grossman RG (1992) Cerebral blood flow, arteriovenous oxygen difference, and outcome in head injured patients. J Neurol Neurosurg Psychiatry 55: 594–603

    PubMed  Google Scholar 

  51. 51.

    Rosner MJ, Becker DP (1984) Origin and evolution of plateau waves: experimental observations and a theoretical model. J Neurosurg 60: 312–324

    PubMed  Google Scholar 

  52. 52.

    Sander D, Klingelhofer J (1990) Correlation between CO2 reactivity, ICP and outcome in severe cerebral disease. J Cardiovasc Tech 9: 261–262(A)

    Google Scholar 

  53. 53.

    Simard JM, Bellefleur M (1989) Systemic arterial hypertension in head trauma. Am J Card 63: 32C-35C

    PubMed  Google Scholar 

  54. 54.

    Smith AL, Wollman H (1972) Cerebral blood flow and metabolism: effects of anesthetic drugs and techniques. Anesthesiology 36(4): 378–400

    PubMed  Google Scholar 

  55. 55.

    Sorteberg W (1992) Cerebral blood velocity and cerebral blood flow. In: Newell DW, Aaslid R (eds) Transcranial Doppler. Raven, New York, pp 57–66

    Google Scholar 

  56. 56.

    Ward JD, Becker DP, Miller J, Choi SC, Marmarou A, Wood C, Newlon PG, Keenan R (1985) Failure of prophylactic barbiturate coma in the treatment of severe head injury. J Neurosurg 62: 383–388

    PubMed  Google Scholar 

  57. 57.

    Werner C, Hoffman WE, Baughman VL, Albrecht RF, Schulte J (1991) Effects of sufentanil on cerebral blood flow, cerebral blood flow velocity, and metabolism in dogs. Anesth Analg 72: 177–181

    PubMed  Google Scholar 

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Correspondence to D. W. Newell.

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Newell, D.W., Aaslid, R., Stooss, R. et al. Evaluation of hemodynamic responses in head injury patients with transcranial doppler monitoring. Acta neurochir 139, 804–817 (1997).

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  • Transcranial Doppler ultrasound
  • head injury
  • autoregulation
  • A-waves