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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5783_Библиотеки_им_академика_М_И_Перельмана.pdf
264
C. N. Rodríguez and D. Pugin
a
Fig. 14.10 (a) Transforaminal (Transnuchal) acoustic window by TCCS (B-Mode). (1) foramen
magnum. (b) Transforaminal acoustic window by TCCS (duplex): (1) vertebral artery (blue color),
(2) basilar artery (blue color)
a
b
b
Fig. 14.11 (a) Scheme of the anatomy of the vertebro-basilar system by TCCS through transforaminal acoustic window: (1) basilar artery; (2) right vertebral artery– V4 segment; (3) left vertebral artery– V4 segment; (4) foramen magnum, (Arrow) It highlights that the ow moves away
from the transducer (Blue color). (b) Vertebro-basilar system insonation by TCCS through transforaminal acoustic window: (1) V4 segment of vertebral artery (blue), (2) basilar artery (blue).
Arterial ow moves away from the transduce
(a) Transducer:
• Cardiac (array) low-frequency probe (1.75–3.5MHz)
(b) Patient positioning:
• Lateral position on the bed with the head slightly tilted forward
• (Sometimes impossible in the ICU)
14 Neurosonology in ICU: Transcranial Color-Coded Duplex Sonography (TCCS…
(c) Depth: 7–8cm
Visualize the Foramen magnum in the center of the image (Hypoechoic
structure)
(d) Insonation window: Transforaminal acoustic window:
• Probe marker looking cephalad.
• The transducer is positioned suboccipitally in the midline and pointed toward
the nasion.
(e) B-Mode:
• Locate the echoreective osseous border of the hypoechoic foramen magnum (Fig.14.10a).
(f) Color Doppler: Location of vertebro-basilar vessels: (Figs.14.10 and 14.11)
• Possible to visualize the ¨Y¨ conguration of the converging vessels
• Vertebral Arteries (VA): V4 segments (blue color)
• Basilar Artery (BA) (blue color) [33–35]
• Sometimes: Possible to visualize Postero-inferior Cerebellar Artery (PICA).
Origin in V4 segment of VA with the blood ow toward the probe (red Color)
(g) Arterial Blood ow Velocities (PW Doppler): Doppler spectrum analysis:
• Place the pulsed Doppler (PW) on the V4 segment of VA and BA.
• The PW Doppler allows to obtain the spectral Doppler wave and the ow
velocities (MFV / PSV / EDV) of each insonated vessel.
265
Occasionally, during the examination through the transforaminal window and
the study of the vertebro-basilar arterial system, the operator can image one of the
two V4 segments of the vertebral arteries with their ow directed toward the transducer (red color), because sometimes these segments present some tortuosity. From
time to time, due to kinking of the vertebral arteries, a red color-coded signal can be
identied, as the ow in the loop is moving toward the probe.
14.7.4 Submandibular Acoustic Window Examination
This window allows to insonate the extracranial carotid system: Common Carotid
Artery (CCA), External Carotid Artery (ECA), and Internal Carotid Artery (ICA).
In intubated patients (ICU), it also allows to visualize the vertebro-basilar system,
because sometimes transoccipital approach (requires neck exion) is not always
available [36] (Fig.14.12).
We suggest the following order for the insonation and the arterial carotid system
(CCA-ICA-ECA) (Fig.14.12):
(a) Transducer:
• Cardiac (array) low-frequency transducer (1.75–3.5MHz)
266
C. N. Rodríguez and D. Pugin
a
Fig. 14.12 (a) Submandibular acoustic window by TCCS: (1) external carotid artery (blue color),
(2) internal carotid artery (blue color), and (3) common carotid artery (blue color) (primitive). (b)
Scheme of carotid system insonation by TCCS: (3) external carotid artery (blue color), (2) internal
carotid artery (blue color) and (1) primitive carotid artery (blue color). (Arrow): It highlights the
ow away from transducer
b
• Linear (High frequency): Axial and longitudinal insonation to assess the
arterial carotid system with most detail. Useful in the carotid ultrasound
approach
(b) Patient and examiner positioning:
• Patient: Supine position with the head aligned with the body and slightly (if
possible) tilted toward the opposite side (Head of the bed at 30°)
• (It is difcult in prone position)
• Examiner: In comfortable position at the patient’s side or behind the head
(c) Insonation window: Anatomical location: (Fig.14.13)
• Location: Anterior triangle of the neck [6]
• The transducer position: Cephalic and posterior angle insonation
• The probe marker: To cephalic
(d) B-Mode:
• Mapping: Cross-sectional insonation plane, beginning caudally in the neck.
Follow the vessel as high as possible to the angle of mandible
• (Most common during Carotid approach than TCCS approach)
(e) Color Doppler: Location of Carotid system vessels:
• Identication: Common Carotid Artery (CCA) (Blue color)
• Identication: Internal Carotid Artery (ICA) (Blue color)
• Identication: External Carotid Artery (ECA) (Blue color)
• Remember: The carotid blood ow away from the probe (Fig.14.12)
(f) Arterial blood ow velocities (PW Doppler): Doppler spectrum analysis:
• Internal Carotid Artery (ICA): Low resistance spectral waveform velocity
prole. High diastolic component (Figs.14.14 and 14.15)
14 Neurosonology in ICU: Transcranial Color-Coded Duplex Sonography (TCCS…
Fig. 14.13 Scheme:
Supercial anatomy of
neck: (1) angle of the
mandible, (2)
sternocleidomastoid
muscle, (3) thyroid
cartilage, and (4) anterior
(carotid) triangle of neck
a
267
b
c
Fig. 14.14 Spectral Doppler waveform of carotid vessels: (a) common carotid artery (CCA); (b)
external carotid artery (ECA); (c) internal carotid artery (ICA); (PSV) peak systolic velocity,
(MFV) mean velocity, (EDV) end-diastolic velocity
268
C. N. Rodríguez and D. Pugin
a
Fig. 14.15 Doppler spectral waveform by TCCS approach through submandibular acoustic window: (a) internal carotid artery (ICA), peak systolic velocity, (PSV) and end-diastolic velocity
(EDV) (low resistance); (b) external carotid artery (ECA), peak systolic velocity (PSV), and enddiastolic velocity(EDV) (high resistance)
Table 14.1 Ultrasound criteria to differentiate between ICA and ECA [38] (Fig.14.12)
ICA ECA
No ramication Ramication
Low pulsatility High pulsatility
No changes in the pulsed Doppler waveforn
morphology (¨Tapping¨)
(Blue color) (Blue color)
Pulsed Doppler (low resistance)
High diastolic component
Low systolic component
a
Maneuver that facilitates the identication of the ICA: internal carotid artery and ECA: external
carotid artery
a
b
Changes in the pulsed Doppler waveform
morphology (¨Tapping¨)
Pulsed Doppler (high resistance)
Low diastolic component
High systolic component
a
• External Carotid Artery (ECA): High resistance spectral waveform velocity
prole. Low diastolic component (Figs.14.14 and 14.15)
• Common Carotid Artery (CCA): Mixed spectral waveform velocity prole
(Fig.14.14)
It is essential to record the ICA velocities as the mean ow velocity is requested
to calculate the Lindegaard ratio; this must be an essential part of a complete and
comparative examination. Remember that when calculating the Lindegaard index,
you should take the MFV (also called TAMAX) of the Internal Carotid Artery
(ICA), in order to obtain a more reliable hemodynamic value (Table14.1) [37, 52].
We suggest the following order for the insonation of the vertebro-basilar arterial
system through this window:
(a) Transducer:
• Cardiac (array) low-frequency transducer (1.75–3.5MHz)
14 Neurosonology in ICU: Transcranial Color-Coded Duplex Sonography (TCCS…
• Linear (High frequency): Axial and longitudinal insonations to assess the
arterial carotid system with most detail. Useful in the carotid ultrasound
approach
(b) Depth: 8–12cm
Locate the echoreective osseous border of the hypoechoic foramen magnum
(c) Patient and examiner positioning:
• Patient: Supine position with the head aligned with the body and slightly (if
possible) tilted toward the opposite side (Head of the bed at 30°)
• Examiner: In comfortable position at the patient’s side or behind the head
(d) Insonation window: Anatomical location: (Fig.14.13)
• Location: Anterior triangle of the neck [6]
• The transducer position: Cephalic and posterior angle insonations
• The probe marker: To cephalic
(e) B-Mode:
• Locate: Foramen Magnum
(f) Color Doppler: Location of vertebro-basilar system:
• Possible to visualize the ¨Y¨ conguration of the converging vessels
• Vertebral Arteries (VA): V4 segments (blue color)
• Basilar Artery (BA) (blue color)
269
(g) Arterial blood ow velocities (PW Doppler): Doppler spectrum analysis:
• Place the pulsed Doppler (PW) on the V4 segment of VA and BA.
• The PW Doppler allows to obtain the spectral Doppler wave and the ow
velocities (MFV/PSV/EDV) of each insonated vessel.
14.7.5 Transorbital Acoustic Window Examination
We suggest the following order for insonation of the Optic Nerve (ON) as a part of
TCCS approach:
(a) Transducer:
• High-frequency linear transducer (5–12MHz)
• Low-frequency sector transducer (1.6–3.5MHz)
(b) Patient positioning:
• Patient: Supine position with the head aligned with the body
(Head of the bed at 30°)
• Examiner: In comfortable position at the patient’s side or behind the head
270
C. N. Rodríguez and D. Pugin
(c) Depth: 4cm
It is necessary to record all patients with the same settings to have similar
measures of the optic nerve sheath diameter.
(d) Machine: Set the safety:
• Consider: ALARA
• Safety setting: Mechanical Index: <0.23
• Safety setting: Thermal Index: <0.2
(e) Patient: Safety procedure:
• Occlude the eyelids, before placing the ultrasound gel, preferably with a
disposable and transparent lm (Tegaderm®) to avoid any corneal and/or
conjunctival irritation [39].
(f) B-Mode: Insonate axial and sagittal planes:
• Transducer: Place on the eyeball (on the upper closed eyelid) that you want
to insonate. The thenar eminence, at the time of the study, should be in contact with the ipsilateral superciliary region of the patient as a point of support
for the examining hand and thus minimize the pressure on the eyeball.
• Identication: Eyeball (Hypoechoic structure).
• Identication: Papilla.
• Identication: Optic nerve.
(g) B-Mode: Optic nerve (ON):
• Location: Posterior pole of the eyeball (Hypoechoic structure)
• Study documentation: Optic Nerve Sheath Diameter (ONSD). Measure
bilaterally 3 mm behind the papilla through longitudinal and sagittal
view [41]
• ONSD(cut-off): <5mm
(h) Color Doppler: Location of intra-orbital vessels:
• Ophthalmic Artery (OA): (red color)
• Central Retinal Artery: (red color)
(i) Arterial blood ow velocities (PW Doppler): Doppler spectrum analysis:
• Place the pulsed Doppler (PW) on the Ophthalmic Artery (OA).
• The PW Doppler allows to obtain the spectral Doppler wave and the ow
velocities (MFV/PSV/EDV) of each insonated vessel.
(j) Interpretation:
See chapter of neuro-orbital ultrasound.
A greater number of quality scientic papers is needed to achieve stronger evidence for an individualized and accurate applicability with respect to the best cutoff value of ONSD for each population.
14 Neurosonology in ICU: Transcranial Color-Coded Duplex Sonography (TCCS…
271
14.7.6 Frontal Bone Window Examination
Sometimes, the transtemporal acoustic window (TAW) often fails to measure blood
ow velocities in approximately 10–30% of patients. Besides, the TAW is most
often inadequate approach to insonate the anterior cerebral artery (ACA), especially
A2 segment where the insonate angle is unfavorable. In this scenario, frontal bone
window may have the ability to assess ACA velocities in patients admitted to ICU
[69–71] (Fig.14.16).
We suggest the following order for insonation of the Optic Nerve (ON) as a part
of TCCS approach:
(a) Transducer:
• Low-frequency sector transducer (1.6–3.5MHz)
(b) Patient positioning:
• Patient: Supine position with the head aligned with the body and slightly
(Head of the bed at 30°)
• Examiner: In comfortable position at the patient’s side
(c) Depth: 13–16cm
(d) B-Mode: Insonate brain parenchyma: Paramedian zone
• Positioned transducer vertically at the paramedian zone
• (Probe mark at the top)
• Brain Parenchyma Structures:
• Contralateral skull bone
a
Fig. 14.16 Frontal lobe window approach by TCCS: (a) (B-Mode: brain parenchyma) The transducer is positioned vertically at the paramedian frontal zone with probe mark at the top; (b) (Color
Doppler: A2 segment of the ACA) Rotated the probe 90° outward and shifted horizontally with
probe mark laterally to the supraorbital zone at the top of the orbital arcade; (c) Pulsed wave
Doppler: blood ow velocity using pulsed Doppler. From the supraorbital zone slides laterally to
access to the laterofrontal zone. (Modied from Sentenac etal. [69])
b
c
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C. N. Rodríguez and D. Pugin
• Corpus callosum
• Choroid plexus of the third ventricle
• Cerebellar tentorium
(e) Color Doppler: Rotated the probe 90° to insonate supra-orbital zone and
latero-frontal zone
• Positioned probe mark laterally
• Identication: A1 and A2 segments of ACA (red color)
• Identication: Circle of Willis (especially in latero-frontal zone)
(f) Arterial blood ow velocities (PW Doppler): Doppler spectrum analysis:
• Place the pulsed wave Doppler (PW) on the anterior cerebral artery (ACA).
• The PW Doppler allows to obtain the spectral Doppler wave and the ow
velocities (MFV / PSV / EDV) of each insonated vessel.
• Place the pulsed wave Doppler (PW): Circle of Willis.
14.8 TCCS Protocol: Clinical Applications
The clinical applications of transcranial color-coded duplex sonography (TCCS)
include evaluation of the arterial blood ow velocities and their modications, and
evaluation of the parenchymal structures and any abnormalities like hematoma,
bleeding, or midline shift [42] (Table14.2). In the following table, only pathologies
relevant to ICU specialists are listed; there are of course other pathologies which
can be evaluated with TCCS but non-relevant to our practice.
Table 14.2 Clinical applications of TCCS
Trauma brain injury (TBI) Non-invasive estimation of ICP
Subarachnoid hemorrhage (SAH) Non-invasive estimation of ICP
Ischemic stroke Diagnosis.
CPP estimation through index of pulsatility (IP)
Cerebral autoregulation (CA)
Cerebrovascular reactivity
Vasospasm
Middle line shift (MLS)
Estimation of CPP
Cerebral autoregulation (CAR)
Cerebrovascular reactivity
Vasospasm
Middle line shift (MLS)
Estimation of CPP
Non-invasive estimation of ICP
Monitoring of treatment
Monitoring of micro-embolism
Middle line shift (MLS)
Stenosis / occlusion diagnosis
14 Neurosonology in ICU: Transcranial Color-Coded Duplex Sonography (TCCS…
Table 14.2 (continued)
Brain death (BDD) Brain death diagnosis (BDD)
Intracerebral hemorrhage (ICH) Non-invasive estimation of ICP
Size measurement
Middle line shift (MLS)
Preeclampsia Cerebral autoregulation and ow velocities as a
prognosis
Non-invasive estimation of ICP
Sickle cell disease Detection and monitoring
Liver failure Non-invasive estimation of ICP
A-V malformation Diagnosis and monitoring
Hydrocephalus Middle line shift (MLS)
Non-invasive estimation of ICP
Estimation of the size of ventricles
Cerebral autoregulation
Cerebrovascular reactivity
Cerebral tumors Non-invasive estimation of ICP
Vasospasm
Detection of Intracerebral hematoma.
Estimation the size and location of the tumor
Middle line shift (MLS)
Right-left cardiac shunt Evaluation of PFO with microbubbles
Infection of CNS Non-invasive estimation of ICP
Middle line shift (MLS)
Detection of Intra-extra-axial collection
Detection changes of the cerebral hemodynamic (blood
ow velocity)
Carotid surgery Post-surgical evaluation after endarterectomy or stent
placement. (risk of cerebral hypoperfusion or embolism)
ARDS Non-invasive estimation of ICP
Changes in the cerebral perfusion pressure (CPP) and
blood ow velocities
Cerebral autoregulation
VV-ECMO / VA-ECMO Non-invasive estimation of ICP
Middle line shift (MLS)
Cerebral autoregulation
Changes in the cerebral perfusion pressure (CPP) and
blood ow velocities
Detection of Intra-extra-axial collection.
Detection of cerebral circulatory arrest
Renal replacement therapy (RRT) Non-invasive estimation of ICP
Cerebral autoregulation
Changes in the cerebral perfusion Pressure (CPP) and
blood ow velocities
Middle line shift (MLS)
273