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Echography and
Doppler of the Brain
Chiara Robba
Giuseppe Citerio
Editors
123
Echography and Doppler of the Brain
Chiara Robba • Giuseppe Citerio
Editors
Echography and
Doppler of the Brain
Editors
Chiara Robba
Anesthesia and Intensive Care
Policlinico San Martino
IRCCS for Oncology and Neuroscience
Genoa
Italy
Giuseppe Citerio
Anesthesia Neurosurgical Intensive Care
ASST Monza School of Medicine
University of Milano
Bicocca
Milano
Italy
ISBN 978-3-030-48201-5 ISBN 978-3-030-48202-2 (eBook)
https://doi.org/10.1007/978-3-030-48202-2
© Springer Nature Switzerland AG 2021
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microlms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword
The care of critically ill patients with neurological diseases is challenging,
and often involves compromises to select a least-worst rather than a best
option. This is particularly true in the case of neuromonitoring. Clinical monitoring of brain function in our patients is often confounded by sedative drugs,
and we have to rely to a greater extent on neuroimaging and bedside monitoring devices.
Imaging essentially provide snapshots of disease, rather than representing
an approach to ongoing patient monitoring. As a consequence, many neuroICUs have had to primarily rely on multimodality physiological monitoring
(intracranial pressure monitoring, often combined with brain oximetry and
cerebral microdialysis) to understand evolving pathophysiology, select
appropriate therapies, and assess their impact. However, the risks involved
make their use inappropriate in patients with less severe disease, in the prehospital phase, when patients are being screened before ICU admission, and
after patients have left the ICU.Finally, substantial cost of disposable equipment limits their use in resource-limited contexts. There is a clear need for
noninvasive monitoring with limited consumable costs, which can be used
through the entire disease narrative.
While neurophysiological monitoring does full some of these requirements, it tends to be cumbersome to initiate and often requires specialist
expertise for interpretation. Further, while it can detect seizures and may aid
in the titration of sedative, it does not provide information about many of the
physiological parameters we can inuence with ICU interventions.
The case for ultrasound-based investigation of cerebral and cerebrovascular physiology is compelling. These techniques provide key data in several
areas where we have potential therapies, including intracranial pressure, cranial compliance, cerebral blood ow, cerebral autoregulation, and vasospasm.
The noninvasive nature of the technique allows extension of its application
from the prehospital phase to late follow-up, and also to extracranial diseases
where secondary neurological compromise is suspected. Finally, the negligible consumable costs facilitate use in resource-limited environments.
Given these clear benets of ultrasound-based diagnosis and monitoring,
this book, edited by Dr. Robba and Professor Citerio, is a welcome contribution. Written by experienced clinicians who have wide knowledge of the literature and use these techniques regularly, the chapters cover all aspects of
brain ultrasound and echography—including anatomy and physiology, methodology, clinical evidence, and practical application and interpretation. The
v
vi
information that it provides will support the use of ultrasound in both clinical
care and research—either on its own or as a complement to neuroimaging,
invasive monitoring, and neurophysiology.
Ultrasound-based diagnosis and monitoring of brain dysfunction have a
growing role in the care of patients with brain dysfunction and disease—and
this book will contribute to that growth.
Cambridge, UK DavidMenon
Foreword
Foreword
“Learning never exhausts the mind”—Leonardo da Vinci
For decades, clinicians have attempted to use monitoring techniques to try
to understand the pathophysiology of brain disease. In the early 1980s, Aaslid
and colleagues rst demonstrated that cerebral arterial ow velocities could
be measured by pulsed Doppler ultrasound, heralding a new era of noninvasive monitoring of cerebral hemodynamics.
As technology continued to evolve over recent years, a variety of invasive
and noninvasive monitors were developed which introduced the concept of
multimodal neuromonitoring. Whilst this has been supplemented by complex
imaging methodologies, giving us increasingly detailed information about
brain pathophysiology, the principle of bedside monitoring remains the ultimate goal of neuroscientists around the world.
The use of ultrasound moves a long way in achieving this goal, and its
application for the brain and other organ systems continues to expand. Whilst
clinicians continue to push the boundaries of the use of ultrasound, dissemination of their expertise to the next generation of scientists and clinicians is a
responsibility that must not be ignored.
This book, co-edited by leaders in the eld of neurosciences and neuromonitoring, establishes a rm foundation to promote knowledge and understanding in this area of neurosciences. It is an excellent educational asset for
those interested in the use of ultrasound and Doppler as applied to brain
pathophysiology and clinical management of neurological disease. As well as
covering a breadth of conditions, readers will nd the link to pathology and
clinical applications in each section both stimulating and informative.
Although the basic technique of ultrasound is not complex, this book will
allow readers to rene their understanding of the technique, its application,
and interpretation of information that the technique gives them. As with any
skill however, continued practice is essential!
I look forward in the coming years that I will see more clinicians using the
technique of ultrasound in the management of complex neurological conditions as a result of the learning from this unique book.
I wish you enjoyable and informative reading!
Cambridge, UK ArunGupta
vii
Acknowledgements
The authors would like to thank Dr Alberto Addis for his help in revieweing
the book content.
ix
Contents
Part I Technology, Views and Normal Echo Anatomy
1 Principles of Transcranial Doppler Ultrasonography . . . . . . . . . 3
Danilo Cardim and Chiara Robba
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Transcranial Doppler Ultrasonography . . . . . . . . . . . . . . . . . . 4
1.3 Transcranial Colour-Coded Duplex Ultrasonography . . . . . . . 6
1.4 Final Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2 Basic Anatomy with TCCD and Vessels . . . . . . . . . . . . . . . . . . . . 9
Pierre Bouzat and Thibaud Crespy
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.2 Vascular Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2.1 The Circle of Willis . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2.2 Vascular Anatomy Through the Temporal
Window . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2.3 Vascular Anatomy Through the Transorbital
Window . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2.4 Vascular Anatomy Through the Suboccipital
Window . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.2.5 Vascular Anatomy Through the Submandibular
Window . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.2.6 Sonography of Cerebral Veins and Sinus . . . . . . . . . . . 12
2.3 Brain Anatomy with Ultrasonography . . . . . . . . . . . . . . . . . . . 14
2.3.1 Anatomic Landmarks . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.3.2 Clinical Implications . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3 Windows and the Practical Approach: The MOTOr . . . . . . . . . . 21
Aoife Quinn and Andrea Rigamonti
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2 Anatomy Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.3 Measurements and Basic Calculations . . . . . . . . . . . . . . . . . . . 22
3.4 Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.5 The MOTOr Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.5.1 Mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
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3.5.2 Occipital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.5.3 Transtemporal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.5.4 Orbital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.6 Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.7 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4 Optic Nerve Sheath Diameter . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Thomas Geeraerts, Louis Delamarre,
and Charles-Henri Houze-Cerfon
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.2 Anatomical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.3 Technology and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.3.1 Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.3.2 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.3.3 Normal Views . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.3.4 Feasibility and Reproducibility . . . . . . . . . . . . . . . . . . 36
4.4 Limits and Safety Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.4.1 Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.4.2 Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.5 Recent Innovation and Future Perspectives . . . . . . . . . . . . . . . 37
4.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Contents
5 Limitations and Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Aarti Sarwal
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
5.2 Technical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
5.2.1 Acquisition of Images . . . . . . . . . . . . . . . . . . . . . . . . . 42
5.2.2 Accuracy of Quantitative Measurements . . . . . . . . . . . 44
5.2.3 Ultrasound-Related Artifacts . . . . . . . . . . . . . . . . . . . . 45
5.3 Anatomical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.4 Clinical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.4.1 Harmful Effects of Ultrasound Exposure. . . . . . . . . . . 47
5.4.2 Systemic Factors Related to Patients’
Cardiopulmonary State . . . . . . . . . . . . . . . . . . . . . . . . 47
5.4.3 Waveform Analysis in Acute Cerebrovascular
Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.4.4 Cerebral Circulatory Arrest . . . . . . . . . . . . . . . . . . . . . 48
5.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6 The Minimal, Intermediate, and Advanced Skills:
How to Boost Your Competencies . . . . . . . . . . . . . . . . . . . . . . . . . 51
Frank A. Rasulo and Nicola Zugni
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
6.2 TCD and TCCD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
6.3 Training Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6.4 Learning Through Technological Aid . . . . . . . . . . . . . . . . . . . 59