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Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review

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Abstract

Brain ultrasonography can be used to evaluate cerebral anatomy and pathology, as well as cerebral circulation through analysis of blood flow velocities. Transcranial colour-coded duplex sonography is a generally safe, repeatable, non-invasive, bedside technique that has a strong potential in neurocritical care patients in many clinical scenarios, including traumatic brain injury, aneurysmal subarachnoid haemorrhage, hydrocephalus, and the diagnosis of cerebral circulatory arrest. Furthermore, the clinical applications of this technique may extend to different settings, including the general intensive care unit and the emergency department. Its increasing use reflects a growing interest in non-invasive cerebral and systemic assessment. The aim of this manuscript is to provide an overview of the basic and advanced principles underlying brain ultrasonography, and to review the different techniques and different clinical applications of this approach in the monitoring and treatment of critically ill patients.

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Acknowledgements

We would like to thank Mazen Elwishi, Andrea Petropolis, Carolina B. Gomez, Andrea Rigamonti and Simon Abrahamson for generously sharing their educational material.

Funding

None.

Author information

Author notes

  1. Frank Rasulo and Giuseppe Citerio contributed equally to this article

Authors and Affiliations

  1. Department of Anaesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy

    Chiara Robba

  2. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

    Alberto Goffi

  3. Department of Anaesthesia and Intensive Care, University Hospital of Toulouse, Toulouse NeuroImaging Center (ToNIC), Inserm-UPS, University Toulouse 3-Paul Sabatier, Toulouse, France

    Thomas Geeraerts

  4. Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada

    Danilo Cardim

  5. Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland

    Gabriele Via

  6. Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK

    Marek Czosnyka

  7. Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University, New York, USA

    Soojin Park

  8. Department of Neurology, Wake Forest Baptist Medical Center, Winston Salem, NC, USA

    Aarti Sarwal

  9. Department of Neurosurgery, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa

    Llewellyn Padayachy

  10. Department of Anaesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy

    Frank Rasulo

  11. School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy

    Giuseppe Citerio

Authors
  1. Chiara Robba
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  2. Alberto Goffi
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  3. Thomas Geeraerts
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  4. Danilo Cardim
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  5. Gabriele Via
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  6. Marek Czosnyka
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  7. Soojin Park
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  8. Aarti Sarwal
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  9. Llewellyn Padayachy
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  10. Frank Rasulo
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  11. Giuseppe Citerio
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Corresponding author

Correspondence to Chiara Robba.

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GC is Editor-in-Chief of Intensive Care Medicine. CR is Junior Editor of Intensive Care Medicine. The other authors have nothing to declare.

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Probes/Technology, TCCD anatomy (DOC 42 kb)

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TCCD-basic technique. Basic steps for the insonation of the MCA. Using two-dimensional B-mode imaging, midbrain is identified in the transtemporal window (step 1), and subsequently pulsations of the cerebral arteries at the level of the circle of Willis are identified anterior and lateral to the midbrain. Colour Doppler is then used to better identify each artery by its depth and direction of flow in relation to the probe and other visualised arteries (step 2). Once the target vessel is identified, spectral Doppler waveforms can be obtained through pulsed-wave (PW) Doppler with a sample volume of 3–6-mm gate for the anterior circulation and up to 10-mm gate for posterior circulation (step 3) (JPEG 1745 kb)

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1c–d Summary of identification criteria for arteries of the circle of Willis. MCA, middle cerebral artery; ACA, anterior cerebral artery; PCA, posterior cerebral artery (JPEG 2159 kb)

Supplementary material 4 (JPEG 1521 kb)

Video demonstrating TCCD examination and vessels insonation (MP4 18745 kb)

Basic and advanced TCD-derived parameters (DOC 356 kb)

Video demonstrating how to perform ONSD examination (MP4 17572 kb)

TCD for the diagnosis of vasospasm (DOCX 737 kb)

Changes in the middle cerebral artery waveform morphology during progressive increase of ICP and decrease in CPP. When ICP equalizes to diastolic blood pressure, cerebral blood flow is only detected during systole. If ICP reaches values greater than diastolic blood pressure, an oscillatory movement of blood with reversal of diastolic flow appears. When ICP reaches the systolic blood pressure, only sharp systolic spikes are evident (reverberating flow), indicating the absence of any net forward flow (i.e., absence of cerebral blood supply) compatible with cerebral circulatory arrest (MP4 24921 kb)

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B-mode and colour Doppler video of middle cerebral artery showing only Doppler signals during the systolic phase of the cardiac cycle. This pattern is concerning for high ICPs and progression to cerebral circulatory arrest (DOC 58 kb)

Brain ultrasonography in the context of stroke management (JPEG 1691 kb)

Figure demonstrating the use of point-of-care ultrasound in the context of cardiac arrest. Brain ultrasonography can be implemented as part of the whole-body sonographic assessment of patients suffering cardiac arrest for resuscitation guidance or for monitoring in the post-cardiac arrest management (MOV 4015 kb)

The use of brain ultrasonography in the context of cardiac arrest and post-resuscitation syndrome (JPEG 890 kb)

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Table 2a. Summary of studies exploring ultrasonography-TCCD prognostic performance in cardiac arrest. CPC: cerebral performance category; CVR: cerebrovascular resistance; Dia: diastolic; SD: standard deviations from previously published normative values for children of similar age and gender; EDV: end-diastolic velocity; EFV: extreme flow velocity (= a value greater than or less than two standard deviations from normative); GOS-E: Extended Glasgow Outcome Scale, dFV: diastolic flow velocity; MFVMCA: mean flow velocity middle of cerebral artery; NR: not reported; NS: non-survivors; PI: pulsatility index; PSV: peak systolic velocity; RI: resistivity index; Sys: systolic (JPEG 2352 kb)

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Table 2b. Summary of studies exploring ultrasonography-ONSD prognostic performance. Adm: admission; AUC: area under the curve; CI: confidence interval; CPC: cerebral performance category; d: day; GOS: Glasgow Outcome Scale; IQR: inter-quartile range; SD: standard deviation; Se: sensitivity; Sp: specificity; TTM: targeted temperature management (DOCX 231 kb)

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Special considerations: the use of brain ultrasonography in the paediatric population and in pregnant patients (DOCX 70 kb)

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Paediatric case 1. Video clip in axial plane demonstrating hyperechogenic tumour with a hypoechogenic cystic component and compression of surrounding cerebellar tissue (DOCX 30 kb)

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Paediatric case 2. Video demonstrating large arterial supply and venous drainage of an intraventricular choroid plexus tumour (DOCX 153 kb)

Supplementary material 19 (MOV 8283 kb)

Supplementary material 20 (MOV 7436 kb)

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Different case scenarios in the paediatric population. Image A. Coronal image demonstrating marked ventriculomegaly, involving both lateral ventricles, frontal and occipital horns, as well the third ventricle. Image B. Coronal image demonstrating a large intraventricular cyst displacing the midline and causing contralateral entrapment hydrocephalus. Image C. Sagittal image demonstrating ventriculomegaly, with hyperdense choroid plexus in the posterior aspect of the lateral ventricle. Image D. Coronal image demonstrating hydrocephalus due to a tectal arachnoid cyst, with catheter insertion demonstrated in the inferior aspect of the cyst. Image E. Coronal image demonstrating marked ventriculomegaly and a cavum septum pellucidum. Image F. Axial image demonstrating large hyperechogenic tumour with hypoechogenic cystic component compressing the cerebellum. Image G. Coronal image demonstrating intraparenchymal hypoechogenic cystic lesion with surrounding superolateral hyperechogenic oedematous tissue. Image H. Sagittal image demonstrating a large, bilobar, hyperechogenic mass within the lateral ventricle, arising from the choroid plexus. Image I. Duplex Doppler imaging demonstrating the large vasculature which are the arterial supply and venous drainage of the tumour. (TIFF 1521 kb)

Pitfalls, artefacts and limitations of brain ultrasonography (DOCX 41 kb)

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Robba, C., Goffi, A., Geeraerts, T. et al. Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review. Intensive Care Med 45, 913–927 (2019). https://doi.org/10.1007/s00134-019-05610-4

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