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How Transcranial Doppler can assess the effect of hyperosmolar therapy and the degree of circulatory compromise in acute brain herniation

How Transcranial Doppler can assess the effect of hyperosmolar therapy and the degree of... Patients in acute neurological extremes secondary to refractory intracranial hypertension are challenging because of the complex management options available to them, especially when compounded with signs of brainstem compromise. Objective evidence of cerebral circulatory compromise is often lacking. We present a case in which an objective evaluation of a cerebral circulatory compromise was documented using transcranial Doppler as well as its resolution with hyperosmolar therapy. Keywords: Transcranial doppler; Cerebral circulatory arrest Background resulting in administration of hyperosmolar therapy in the Mannitol is a widely accepted in therapy for the treatment ambulance (Tazarourte et al. 2011). Moreover, only patients of intracranial hypertension (ICHT), as it has positive effect with abnormal TCD examination required emergency sur- on cerebral perfusion pressure (CPP) and cerebral blood gery and interestingly those patients in whom the TCD par- flow (CBF) more so in those patients with focal injury (vs. ameter where not improved after the administration of diffuse), those with lesions on the brain imaging, and those such therapy died within 48 hours (Tazarourte et al. 2011). in whom the CPP is at or below the auto regulation thresh- The case presented in this article illustrates the usefulness old (Brown et al. 1979; Mendelow et al. 1985; Rosner & of TCD in the monitoring of ICHT leading to herniation Coley 1987; Bratton et al. 2007; Wakai et al. 2007). The and its ability to assess response to therapy. mannitol doses reported in these studies ranged from 0.25 to 0.5 gm/kg bolus of 20% mannitol given intravenously Case report over 10 to 15 minutes. In acute herniation, high doses A 49-year-old right-handed male presented to a local (1.5 g/kg) have been shown to improve patient outcome community hospital with headache and progressive right- (Cruz et al. 2001; Cruz et al. 2002; Cruz et al. 2004). sided weakness. His past medical history included renal Transcranial Doppler (TCD) has been widely used for cell carcinoma, in remission for the past 3 years, treated the assessment of cerebral blood flow in several clinical by surgical resection and chemotherapy. The computer- conditions (Topcuoglu 2012) including intracranial hyper- ized tomography (CT) scan of the head performed on the tension. TCD is gaining acceptance as a rapid, portable day of presentation revealed a large hemorrhagic lesion in and reliable method for assessing intracranial hypertension the left central region of the brain highly suspicious of a and cerebral blood flow compromise. In their recent study, tumoral bleed, as well as significant peri-lesional edema, Tazarourte et al., reported that 50% of TCD’s performed severe midline shift and uncal herniation (Figure 1). prior to the arrival to the trauma center were abnormal, Within 2 hours of his arrival, the patient deteriorated, with a drop in Glasgow Coma Scale (GCS) from 15 to * Correspondence: hosam.aljehani@gmail.com 12 prompting urgent intubation prior to transfer to our Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, 3801 University St., Suite 109, Montreal, QC H3A 2B4, hospital. Upon arrival in our emergency room, the pa- Canada tient’s neurological examination revealed non-reactive Neurocritical Care Unit, Montreal Neurological Institute and Hospital, pupils, absent corneal reflexes and extremely abnormal Montreal, QC, Canada Full list of author information is available at the end of the article eye movements on oculo-cephalic reflex testing. The © 2013 Al-Jehani et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Al-Jehani et al. SpringerPlus 2013, 2:319 Page 2 of 4 http://www.springerplus.com/content/2/1/319 patient was hyperventilated and given a 200 mL bolus of 20% mannitol (0.58 g/kg). A repeat CT scan to rule out fur- ther hemorrhage showed no change from the previous in terms of hemorrhage, swelling or brain stem compression. A neurologic exam performed immediately after the CT scan, 30 minutes after the mannitol bolus, the patient had deteriorated with absent pupillary response, absent corneal reflexes and a total lack of eye movement on oculocephalic reflex testing, no spontaneous breathing and extensor pos- turing in the extremities to painful stimuli. It was felt that the patient was not salvageable. Before calling in the family and withdrawing active care, a transcranial Doppler (TCD) was performed in the emergency department to assess cerebral flow. The TCD was performed by the first author (a neurosurgeon and a neuro-intensivest), using a P4-1c Phased Array probe (ZONARE Medical Systems, Inc., Mountain View,CA, USA),operatedat2–3mHz to insonate the temporal windows bilaterally. There was re- verberating flow in the left middle cerebral artery (MCA) compatible with cerebral circulatory arrest on that side, Figure 1 Non-contrast axial CT scan showing large frontal but a high resistance pattern of flow in the right MCA hemorrhage with peri-lesional edema and evidence of (Bellner et al. 2004). Optic nerve ultrasonography was also mass effect. performed and showed bilateral dilatation of the optic Figure 2 The upper panel shows the transcranial Doppler of the left middle cerebral artery with a prominent systolic spike with a diastolic descent in the Doppler tracing suggestive of reverberating flow seen in circulatory arrest. The lower panel shows the transcranial Doppler of the right middle cerebral artery with high resistance circulatory pattern with a high systolic peak and low diastolic velocity suggestive of malignant intracranial hypertension, with a pulsatility index (PI = peak systolic-end diastolic velocities/mean flow velocity) of 2.5. The optic nerve ultrasonography seen on the right side of the figure are corresponding to the side of the middle cerebral artery insonation and were measuring 7.2 mm and 6.4 mm in the left and right optic nerve sheaths, respectively. Al-Jehani et al. SpringerPlus 2013, 2:319 Page 3 of 4 http://www.springerplus.com/content/2/1/319 nerve sheath compatible with intracranial hypertension left posterior cerebral artery ischemic stroke likely from (Soldatos et al. 2009) (Figure 2). the herniation syndrome the patient sustained at the be- Because of the presence of flow demonstrated in the ginning of his hospital course. right MCA, the patient was given another 500 mL of 20% mannitol (1.53 g/kg) over five minutes with close monitor- Discussion ing of his blood pressure. Within a few minutes the TCD This case shows the potential utility of TCD examination examination showed the return of circulation in both in acute neurological deterioration to assess the extent of hemispheres along with a reduction in the diameter of the cerebral circulation compromise, the potential for reversal optic nerve sheaths bilaterally (Figure 3). Immediately of circulatory arrest and the efficacy of the chosen dose of after the TCD the patient was examined and had reactive hyperosmolar therapy. In this case, the patient had no signs pupils. Several minutes later he was localizing to pain with of brain stem function. This would have placed him on a his left side. Based on this favorable response, the patient conservative palliative approach given the poor neuro- was rushed to the operating room for a decompressive logical prognosis associated with such condition. The TCD craniectomy and expansive duraplasty along with evacu- on the other hand showed severely compromised yet per- ation of the hematoma and tissue sampling of the sistent cerebral flow in a patient who was otherwise con- hemorrhagic mass. The patient was observed in the inten- sidered unsalvageable. This finding promted the use of an sive care unit for a few days and then transferred to the additional large dose of mannitol to objectively assess any neurosurgical ward awaiting further treatment for his le- changes in the cerebral blood flow dynamics. The TCD sion (biopsy revealed a glioblastoma). Upon transfer to a done after the mannitol dose demonstrated a tangible ef- rehabilitation center, he still had significant right-sided fect of hyperosmolar therapy on the cerebral circulation weakness and dysphasia. He had no residual brain stem that was later responsible for a reversal of the herniation dysfunction and repeat imaging showed resolving and the return of brain function. The patient care shifted hemorrhage and residual tumor as expected, as well as a from a consideration of a palliative approach to aggressive Figure 3 This is the post mannitol and hyperventilation transcranial Doppler showing normal tracing in both middle cerebral arteries (Left upper and lower panels) with PI of 2.9 bilaterally. In addition, there was a reduction of the diameter of the optic nerve sheath with the left and right side measuring 6.2 mm and 5.4 mm, respectively. Al-Jehani et al. SpringerPlus 2013, 2:319 Page 4 of 4 http://www.springerplus.com/content/2/1/319 surgical and medical therapy with good outcome of the Canada. Neurocritical Care Unit, Montreal Neurological Institute and Hospital, Montreal, QC, Canada. Department of Neurosurgery, King Fahad acute care of this patient, not achievable otherwise, had University Hospital, Dammam University, Al-Khobar, Saudi Arabia. the TCD examination not been performed. This tech- nique may also be useful in gauging whether the chosen Received: 14 May 2013 Accepted: 9 July 2013 Published: 15 July 2013 dose of hyperosmotic agent is actually the appropriate one. In a pilot study by Tazarourte et al., TCD examin- References ation was carried out in a pre-hospital setting, or upon Bellner J, et al. (2004) Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP). Surg Neurol 62(1):45–51. discussion 51 arrival, and patients were treated according to the TCD Bratton SL, et al. (2007) Guidelines for the management of severe traumatic brain results of improved blood flow (Tazarourte et al. 2011). injury. II. Hyperosmolar therapy. J Neurotrauma 24(Suppl 1):S14–S20 TCD was used to assess the efficacy of the maneuvers, Brown FD, et al. (1979) Detailed monitoring of the effects of mannitol following experimental head injury. J Neurosurg 50:423–432 and those patients for whom the cerebral perfusion Cruz J, Minoja G, Okuchi K (2001) Improving clinical outcomes from acute could be corrected according to the pulsatility index subdural hematomas with the emergency preoperative administration of fared better (Bellner et al. 2004). high doses of mannitol: a randomized trial. Neurosurgery 49(4):864–871 Cruz J, Minoja G, Okuchi K (2002) Major clinical and physiological benefits of Both TCD and optic nerve ultrasonography can be done early high doses of mannitol for intraparenchymal temporal lobe with portable machines in the emergency department, in- hemorrhages with abnormal pupillary widening: a randomized trial. tensive care unit and even in the operating room if neces- Neurosurgery 51(3):628–637. discussion 637–8 Cruz J, et al. (2004) Successful use of the new high-dose mannitol treatment in sary (Soldatos et al. 2009; Raboel et al. 2012). Performance patients with Glasgow Coma Scale scores of 3 and bilateral abnormal of TCD examination by a trained technician or a physician pupillary widening: a randomized trial. J Neurosurg 100(3):376–383 is not time consuming. Most TCD units are easily Mendelow AD, et al. (1985) Effect of mannitol on cerebral blood flow and cerebral perfusion pressure in human head injury. J Neurosurg 63:43–48 transported to the point of care where the patient is (e.g. Raboel PH, et al. (2012) Intracranial pressure monitoring: invasive versus Non- The emergency department or the operating room) and invasive methods-a review. Crit Care Res Pract 2012:14 newer models even offer portable hand held forms of the Rosner MJ, Coley I (1987) Cerebral perfusion pressure: a hemodynamic mechanism of mannitol and the post-mannitol hemogram. Neurosurgery device. The learning curve is not discouragingly steep. 21:147–156 The major limitation is the logistic constrains of having a Soldatos T, et al. (2009) Optic nerve sonography: a new window for the non- trained TCD performer available to capture such patients invasive evaluation of intracranial pressure in brain injury. Emerg Med J 26 (9):630–634 at these extreme conditions. In conclusion, the use of Tazarourte K, et al. (2011) Pre-hospital transcranial Doppler in severe traumatic TCD and optic nerve ultrasonography at the point of care brain injury: a pilot study. Acta Anaesthesiol Scand 55(4):422–428 on patients with acute neurological deterioration could be Topcuoglu MA (2012) Transcranial Doppler ultrasound in neurovascular diseases: diagnostic and therapeutic aspects. J Neurochem 123(Suppl 2):39–51 a useful and objective adjunct to help gauge ICP and guide Wakai A, Roberts I, Schierhout G (2007) Mannitol for acute traumatic brain injury. therapy outside of the Intensive Care environment and Cochrane Database Syst Rev(1):CD001049 without the potential delays associated with the installa- doi:10.1186/2193-1801-2-319 tion of invasive monitoring techniques. Cite this article as: Al-Jehani et al.: How Transcranial Doppler can assess the effect of hyperosmolar therapy and the degree of circulatory compromise in acute brain herniation. SpringerPlus 2013 2:319. Conclusion The use of transcranial Doppler in patients presenting with acute neurological deterioration could be a valuable tool to objectively and non-invasively assesses the intracranial pressure dynamics and guide effective course of treatment. Consent Written informed consent was obtained from the pa- tient for the publication of this report and any accom- panying images. Submit your manuscript to a Competing interests journal and benefi t from: There is no competing interest for the material presented from any of the authors. 7 Convenient online submission 7 Rigorous peer review Authors’ contributions HA-J Clinical care and writing of the manuscript; MA Participated in the 7 Immediate publication on acceptance preparation of the Manuscript; MM Clinical care and review of the manuscript; 7 Open access: articles freely available online JM Clinical care and review of the manuscript; JT Clinical care and review of the 7 High visibility within the fi eld manuscript. All authors read and approved the final manuscript. 7 Retaining the copyright to your article Author details Department of Neurology and Neurosurgery, Montreal Neurological Submit your next manuscript at 7 springeropen.com Institute and Hospital, 3801 University St., Suite 109, Montreal, QC H3A 2B4, http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png SpringerPlus Springer Journals

How Transcranial Doppler can assess the effect of hyperosmolar therapy and the degree of circulatory compromise in acute brain herniation

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Publisher
Springer Journals
Copyright
Copyright © 2013 by Al-Jehani et al.; licensee Springer.
Subject
Science; Science, general
eISSN
2193-1801
DOI
10.1186/2193-1801-2-319
pmid
23961393
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See Article on Publisher Site

Abstract

Patients in acute neurological extremes secondary to refractory intracranial hypertension are challenging because of the complex management options available to them, especially when compounded with signs of brainstem compromise. Objective evidence of cerebral circulatory compromise is often lacking. We present a case in which an objective evaluation of a cerebral circulatory compromise was documented using transcranial Doppler as well as its resolution with hyperosmolar therapy. Keywords: Transcranial doppler; Cerebral circulatory arrest Background resulting in administration of hyperosmolar therapy in the Mannitol is a widely accepted in therapy for the treatment ambulance (Tazarourte et al. 2011). Moreover, only patients of intracranial hypertension (ICHT), as it has positive effect with abnormal TCD examination required emergency sur- on cerebral perfusion pressure (CPP) and cerebral blood gery and interestingly those patients in whom the TCD par- flow (CBF) more so in those patients with focal injury (vs. ameter where not improved after the administration of diffuse), those with lesions on the brain imaging, and those such therapy died within 48 hours (Tazarourte et al. 2011). in whom the CPP is at or below the auto regulation thresh- The case presented in this article illustrates the usefulness old (Brown et al. 1979; Mendelow et al. 1985; Rosner & of TCD in the monitoring of ICHT leading to herniation Coley 1987; Bratton et al. 2007; Wakai et al. 2007). The and its ability to assess response to therapy. mannitol doses reported in these studies ranged from 0.25 to 0.5 gm/kg bolus of 20% mannitol given intravenously Case report over 10 to 15 minutes. In acute herniation, high doses A 49-year-old right-handed male presented to a local (1.5 g/kg) have been shown to improve patient outcome community hospital with headache and progressive right- (Cruz et al. 2001; Cruz et al. 2002; Cruz et al. 2004). sided weakness. His past medical history included renal Transcranial Doppler (TCD) has been widely used for cell carcinoma, in remission for the past 3 years, treated the assessment of cerebral blood flow in several clinical by surgical resection and chemotherapy. The computer- conditions (Topcuoglu 2012) including intracranial hyper- ized tomography (CT) scan of the head performed on the tension. TCD is gaining acceptance as a rapid, portable day of presentation revealed a large hemorrhagic lesion in and reliable method for assessing intracranial hypertension the left central region of the brain highly suspicious of a and cerebral blood flow compromise. In their recent study, tumoral bleed, as well as significant peri-lesional edema, Tazarourte et al., reported that 50% of TCD’s performed severe midline shift and uncal herniation (Figure 1). prior to the arrival to the trauma center were abnormal, Within 2 hours of his arrival, the patient deteriorated, with a drop in Glasgow Coma Scale (GCS) from 15 to * Correspondence: hosam.aljehani@gmail.com 12 prompting urgent intubation prior to transfer to our Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, 3801 University St., Suite 109, Montreal, QC H3A 2B4, hospital. Upon arrival in our emergency room, the pa- Canada tient’s neurological examination revealed non-reactive Neurocritical Care Unit, Montreal Neurological Institute and Hospital, pupils, absent corneal reflexes and extremely abnormal Montreal, QC, Canada Full list of author information is available at the end of the article eye movements on oculo-cephalic reflex testing. The © 2013 Al-Jehani et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Al-Jehani et al. SpringerPlus 2013, 2:319 Page 2 of 4 http://www.springerplus.com/content/2/1/319 patient was hyperventilated and given a 200 mL bolus of 20% mannitol (0.58 g/kg). A repeat CT scan to rule out fur- ther hemorrhage showed no change from the previous in terms of hemorrhage, swelling or brain stem compression. A neurologic exam performed immediately after the CT scan, 30 minutes after the mannitol bolus, the patient had deteriorated with absent pupillary response, absent corneal reflexes and a total lack of eye movement on oculocephalic reflex testing, no spontaneous breathing and extensor pos- turing in the extremities to painful stimuli. It was felt that the patient was not salvageable. Before calling in the family and withdrawing active care, a transcranial Doppler (TCD) was performed in the emergency department to assess cerebral flow. The TCD was performed by the first author (a neurosurgeon and a neuro-intensivest), using a P4-1c Phased Array probe (ZONARE Medical Systems, Inc., Mountain View,CA, USA),operatedat2–3mHz to insonate the temporal windows bilaterally. There was re- verberating flow in the left middle cerebral artery (MCA) compatible with cerebral circulatory arrest on that side, Figure 1 Non-contrast axial CT scan showing large frontal but a high resistance pattern of flow in the right MCA hemorrhage with peri-lesional edema and evidence of (Bellner et al. 2004). Optic nerve ultrasonography was also mass effect. performed and showed bilateral dilatation of the optic Figure 2 The upper panel shows the transcranial Doppler of the left middle cerebral artery with a prominent systolic spike with a diastolic descent in the Doppler tracing suggestive of reverberating flow seen in circulatory arrest. The lower panel shows the transcranial Doppler of the right middle cerebral artery with high resistance circulatory pattern with a high systolic peak and low diastolic velocity suggestive of malignant intracranial hypertension, with a pulsatility index (PI = peak systolic-end diastolic velocities/mean flow velocity) of 2.5. The optic nerve ultrasonography seen on the right side of the figure are corresponding to the side of the middle cerebral artery insonation and were measuring 7.2 mm and 6.4 mm in the left and right optic nerve sheaths, respectively. Al-Jehani et al. SpringerPlus 2013, 2:319 Page 3 of 4 http://www.springerplus.com/content/2/1/319 nerve sheath compatible with intracranial hypertension left posterior cerebral artery ischemic stroke likely from (Soldatos et al. 2009) (Figure 2). the herniation syndrome the patient sustained at the be- Because of the presence of flow demonstrated in the ginning of his hospital course. right MCA, the patient was given another 500 mL of 20% mannitol (1.53 g/kg) over five minutes with close monitor- Discussion ing of his blood pressure. Within a few minutes the TCD This case shows the potential utility of TCD examination examination showed the return of circulation in both in acute neurological deterioration to assess the extent of hemispheres along with a reduction in the diameter of the cerebral circulation compromise, the potential for reversal optic nerve sheaths bilaterally (Figure 3). Immediately of circulatory arrest and the efficacy of the chosen dose of after the TCD the patient was examined and had reactive hyperosmolar therapy. In this case, the patient had no signs pupils. Several minutes later he was localizing to pain with of brain stem function. This would have placed him on a his left side. Based on this favorable response, the patient conservative palliative approach given the poor neuro- was rushed to the operating room for a decompressive logical prognosis associated with such condition. The TCD craniectomy and expansive duraplasty along with evacu- on the other hand showed severely compromised yet per- ation of the hematoma and tissue sampling of the sistent cerebral flow in a patient who was otherwise con- hemorrhagic mass. The patient was observed in the inten- sidered unsalvageable. This finding promted the use of an sive care unit for a few days and then transferred to the additional large dose of mannitol to objectively assess any neurosurgical ward awaiting further treatment for his le- changes in the cerebral blood flow dynamics. The TCD sion (biopsy revealed a glioblastoma). Upon transfer to a done after the mannitol dose demonstrated a tangible ef- rehabilitation center, he still had significant right-sided fect of hyperosmolar therapy on the cerebral circulation weakness and dysphasia. He had no residual brain stem that was later responsible for a reversal of the herniation dysfunction and repeat imaging showed resolving and the return of brain function. The patient care shifted hemorrhage and residual tumor as expected, as well as a from a consideration of a palliative approach to aggressive Figure 3 This is the post mannitol and hyperventilation transcranial Doppler showing normal tracing in both middle cerebral arteries (Left upper and lower panels) with PI of 2.9 bilaterally. In addition, there was a reduction of the diameter of the optic nerve sheath with the left and right side measuring 6.2 mm and 5.4 mm, respectively. Al-Jehani et al. SpringerPlus 2013, 2:319 Page 4 of 4 http://www.springerplus.com/content/2/1/319 surgical and medical therapy with good outcome of the Canada. Neurocritical Care Unit, Montreal Neurological Institute and Hospital, Montreal, QC, Canada. Department of Neurosurgery, King Fahad acute care of this patient, not achievable otherwise, had University Hospital, Dammam University, Al-Khobar, Saudi Arabia. the TCD examination not been performed. This tech- nique may also be useful in gauging whether the chosen Received: 14 May 2013 Accepted: 9 July 2013 Published: 15 July 2013 dose of hyperosmotic agent is actually the appropriate one. In a pilot study by Tazarourte et al., TCD examin- References ation was carried out in a pre-hospital setting, or upon Bellner J, et al. (2004) Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP). Surg Neurol 62(1):45–51. discussion 51 arrival, and patients were treated according to the TCD Bratton SL, et al. (2007) Guidelines for the management of severe traumatic brain results of improved blood flow (Tazarourte et al. 2011). injury. II. Hyperosmolar therapy. J Neurotrauma 24(Suppl 1):S14–S20 TCD was used to assess the efficacy of the maneuvers, Brown FD, et al. (1979) Detailed monitoring of the effects of mannitol following experimental head injury. J Neurosurg 50:423–432 and those patients for whom the cerebral perfusion Cruz J, Minoja G, Okuchi K (2001) Improving clinical outcomes from acute could be corrected according to the pulsatility index subdural hematomas with the emergency preoperative administration of fared better (Bellner et al. 2004). high doses of mannitol: a randomized trial. Neurosurgery 49(4):864–871 Cruz J, Minoja G, Okuchi K (2002) Major clinical and physiological benefits of Both TCD and optic nerve ultrasonography can be done early high doses of mannitol for intraparenchymal temporal lobe with portable machines in the emergency department, in- hemorrhages with abnormal pupillary widening: a randomized trial. tensive care unit and even in the operating room if neces- Neurosurgery 51(3):628–637. discussion 637–8 Cruz J, et al. (2004) Successful use of the new high-dose mannitol treatment in sary (Soldatos et al. 2009; Raboel et al. 2012). Performance patients with Glasgow Coma Scale scores of 3 and bilateral abnormal of TCD examination by a trained technician or a physician pupillary widening: a randomized trial. J Neurosurg 100(3):376–383 is not time consuming. Most TCD units are easily Mendelow AD, et al. (1985) Effect of mannitol on cerebral blood flow and cerebral perfusion pressure in human head injury. J Neurosurg 63:43–48 transported to the point of care where the patient is (e.g. Raboel PH, et al. (2012) Intracranial pressure monitoring: invasive versus Non- The emergency department or the operating room) and invasive methods-a review. Crit Care Res Pract 2012:14 newer models even offer portable hand held forms of the Rosner MJ, Coley I (1987) Cerebral perfusion pressure: a hemodynamic mechanism of mannitol and the post-mannitol hemogram. Neurosurgery device. The learning curve is not discouragingly steep. 21:147–156 The major limitation is the logistic constrains of having a Soldatos T, et al. (2009) Optic nerve sonography: a new window for the non- trained TCD performer available to capture such patients invasive evaluation of intracranial pressure in brain injury. Emerg Med J 26 (9):630–634 at these extreme conditions. In conclusion, the use of Tazarourte K, et al. (2011) Pre-hospital transcranial Doppler in severe traumatic TCD and optic nerve ultrasonography at the point of care brain injury: a pilot study. Acta Anaesthesiol Scand 55(4):422–428 on patients with acute neurological deterioration could be Topcuoglu MA (2012) Transcranial Doppler ultrasound in neurovascular diseases: diagnostic and therapeutic aspects. J Neurochem 123(Suppl 2):39–51 a useful and objective adjunct to help gauge ICP and guide Wakai A, Roberts I, Schierhout G (2007) Mannitol for acute traumatic brain injury. therapy outside of the Intensive Care environment and Cochrane Database Syst Rev(1):CD001049 without the potential delays associated with the installa- doi:10.1186/2193-1801-2-319 tion of invasive monitoring techniques. Cite this article as: Al-Jehani et al.: How Transcranial Doppler can assess the effect of hyperosmolar therapy and the degree of circulatory compromise in acute brain herniation. SpringerPlus 2013 2:319. Conclusion The use of transcranial Doppler in patients presenting with acute neurological deterioration could be a valuable tool to objectively and non-invasively assesses the intracranial pressure dynamics and guide effective course of treatment. Consent Written informed consent was obtained from the pa- tient for the publication of this report and any accom- panying images. Submit your manuscript to a Competing interests journal and benefi t from: There is no competing interest for the material presented from any of the authors. 7 Convenient online submission 7 Rigorous peer review Authors’ contributions HA-J Clinical care and writing of the manuscript; MA Participated in the 7 Immediate publication on acceptance preparation of the Manuscript; MM Clinical care and review of the manuscript; 7 Open access: articles freely available online JM Clinical care and review of the manuscript; JT Clinical care and review of the 7 High visibility within the fi eld manuscript. All authors read and approved the final manuscript. 7 Retaining the copyright to your article Author details Department of Neurology and Neurosurgery, Montreal Neurological Submit your next manuscript at 7 springeropen.com Institute and Hospital, 3801 University St., Suite 109, Montreal, QC H3A 2B4,

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SpringerPlusSpringer Journals

Published: Jul 15, 2013

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