Transcranial color coded duplex sonography in the intensive care unit
© Springer-Verlag 2011
Received: 19 October 2010
Accepted: 3 February 2011
Published: 2 March 2011
A case of a 43-year-old male with severe pancreatitis complicated with neurological deterioration is presented.
Methods and result
Different neurosonological examinations using transcranial color coded duplex sonography (TCCS) were combined to obtain a certain diagnosis.
This case illustrates some of the applications of TCCS at bedside in ICU patients. These sonographic explorations are useful in the monitoring of ICU patients, and may avoid hazardous transfers to the radiology department for the patient.
KeywordsTranscranial color coded duplex sonography Critically ill patients Intensive care unit
Transcranial color coded duplex sonography (TCCS) constitutes an established tool in the management of neurological patients. However, its use in the intensive care unit (ICU) is less common, although it can be used bedside and avoiding complicated transportation of the patients .
TCCS has been shown to be useful in monitoring different disorders in the ICU : cerebral hemodynamics, midline shift, vascular stenoses, cerebrovascular disease, intracranial hematomas, vascular malformations and aneurysms, posttraumatic carotid-cavernous fistulas, cerebral vasospasm, and cerebral circulatory arrest. In addition, the use of ultrasound contrast agents (UCAs) allows the increase in the quality and the number of conclusive studies in cases of poor acoustic window  and the minimally invasive study of cerebral perfusion [3, 4].
We would like to present an interesting case which illustrates some of the potential applications of TCCS in the ICU.
A male patient of 43 years was admitted in the ICU with the diagnosis of severe pancreatitis which rapidly worsened and developed multiorgan failure. He was treated with sedatives, muscle relaxation, high dose of norepinephrine, mechanical ventilation with FiO2 100%, and continuous renal replacement therapy. On day 3 after ICU admission, left fixed mydriasis was detected, and TCCS was solicited. TCCS was performed using a Vivid 7 (GE Medical Systems) equipped with a 2- to 4-MHz phased array transducer for cerebral studies and 7.5–10 MHz linear array for carotid duplex ultrasound studies.
With the presumptive diagnosis of left extracranial carotid artery thrombosis, we performed a carotid duplex ultrasound study which confirmed the existence of an occlusive thrombi in the left common carotid artery (Fig. 1b). Finally, the study was completed by performing a perfusion study following the technique described by Eyding et al. . This exploration showed an absence of progression in the time-intensity curves (TIC) in the left hemisphere (flat curves), compared with a normal pattern in the right circulation (Fig. 1c), suggesting an absence of tissue perfusion. Subsequent cranial computed tomography confirmed the sonographic diagnosis (Fig. 1d). Limitation of the therapeutic effort was instituted and the patient died.
TCCS constitutes a diagnostic tool commonly used in the neurological patients. However, its use in the neurocritically ill patients within the ICU is less common although it represents clear advantages over transcranial Doppler (TCD) .
TCCS allows the non-invasive morphological study of the brain parenchyma using the B-mode. It is especially useful in the study of midline shift in patients with brain injury  and cerebrovascular disease , as evidenced in our patient. Measurement was performed as described earlier [5, 7] by placing the transducer in the temporal window and the axial plane, locating the mesencephalon with its classic butterfly-wing structure. Later, the transducer was moved 10° cephalad, locating the third ventricle (diencephalic plane), which is identified by a double hyperecogenic image in the center of the sonogram. The measurement was taken from the center of the third ventricle to the source of the ultrasound wave, which corresponds to the external side of the skull (distance A). The identical maneuver was repeated on the contralateral side (distance B). The following mathematical formula was then applied: Midline shift = (A − B)/2. Other commonly used applications using the B-mode are the evaluation of the ventricular system size  and the study of intraparenchymal hematomas .
Using color-mode, the main advantage over conventional TCD is based on the identification of the basal arteries of the Circle of Willis. This identification allows the examiner to perform angle-corrected and sample volume-adjusted determinations, resulting in an increase in the number  and quality of the vessels studied .
In cases with a poor acoustic window or in incomplete studies with the color-mode, some authors support the use of UCA. Based on their biochemical properties , the UCA generates an increase of the acoustic signal which results in quantitative and qualitative improvements in TCCS examinations . In addition, the use of UCAs permits the minimally invasive study of the cerebral perfusion using ultrasound perfusion imaging techniques in patients with neurological disorders, especially those with ischemic cerebrovascular disease . In our patient, we used the bolus kinetic approach, evaluating different regions of interest (ROIs) in which we studied the TICs. Different derived parameters after infusion of UCAs have been studied . The peak intensity, peak width, and time to peak intensity have been correlated with cerebral perfusion. A delay in the time to peak intensity has been suggested to constitute the most accurate parameter for studying cerebral perfusion in cerebrovascular disease because its value shows low intraindividual variability and is not influenced by the depth of the insonation plane [6, 12]. A delay of close to 4 s compared with the unaffected hemisphere may identify hypoperfused areas . In our patient, we obtained a flat TIC in the left hemisphere, suggesting an absence of perfusion in this hemisphere.
In conclusion, this case illustrates some of the applications of TCCS at bedside in ICU patients. These sonographic explorations are useful in the monitoring of ICU patients, and may avoid hazardous transfers to the radiology department for the patient.
Conflict of interest
- Abadal JM, Llompart-Pou JA, Homar J, Pérez-Bárcena J, Ibáñez J (2007) Applications of transcranial color-coded duplex sonography in monitoring neurocritical patients. Med Intensiva 31:510–517PubMedView ArticleGoogle Scholar
- Droste DW, Boehm T, Ritter MA, Dittrich R, Rigelstein EB (2005) Benefit of echocontrast-enhanced transcranial arterial color-coded duplex ultrasound. Cerebrovasc Dis 20:332–336PubMedView ArticleGoogle Scholar
- Seidel G, Meyer-Wiethe K (2006) Acute stroke: perfusion imaging. Front Neurol Neurosci 21:127–139PubMedView ArticleGoogle Scholar
- Abadal JM, Llompart-Pou JA, Homar J, Velasco J, Ibáñez J, Pérez-Bárcena J (2008) Ultrasonographic cerebral perfusion in assessment of brain death: a preliminary study. J Ultrasound Med 27:791–794PubMedGoogle Scholar
- Llompart Pou JA, Abadal Centellas JM, Palmer Sans M, Pérez-Bárcena J, Casaes Vivas M, Homar Ramírez J, Ibáñez Juvé J (2004) Monitoring midline shift by transcranial color-coded sonography in traumatic brain injury. A comparison with cranial computerized tomography. Intensive Care Med 30:1672–16755PubMedView ArticleGoogle Scholar
- Eyding J, Krogias C, Schollhammer M, Eyding D, Wilkening W, Meves S, Schröder A, Przuntek H, Postert T (2006) Contrast-enhanced ultrasonic parametric perfusion imaging detects dysfunctional tissue at risk in acute MCA stroke. J Cereb Blood Flow Metab 26:576–582PubMedView ArticleGoogle Scholar
- Seidel G, Gerriets T, Kaps M, Missler U (1996) Dislocation of the third ventricle due to space-occupying stroke evaluated by transcranial duplex sonography. J Neuroimaging 6:227–230PubMedGoogle Scholar
- Seidel G, Kaps M, Gerriets T, Hutzelmann A (1995) Evaluation of the ventricular system in adults by transcranial duplex sonography. J Neuroimaging 5:105–108PubMedGoogle Scholar
- Seidel G, Kaps M, Dorndorf W (1993) Transcranial color-coded duplex sonography of intracerebral hematomas in adults. Stroke 24:1519–1527PubMedView ArticleGoogle Scholar
- Homar J, Abadal JM, Llompart Pou JA, Pérez Bárcena J, Ibáñez J (2007) Cerebral hemodynamics in patients with traumatic brain injury evaluated by transcranial Doppler and transcranial color coded sonography. A comparison study. Neurocirugía (Astur) 18:221–226View ArticleGoogle Scholar
- Schoning M, Buchholz R, Walter J (1993) Comparative study of transcranial color duplex sonography and transcranial doppler sonography in adults. J Neurosurg 78:776–784PubMedView ArticleGoogle Scholar
- Della Martina A, Meyer-Wiethe K, Allémann E, Seidel G (2005) Ultrasound contrast agents for brain perfusion imaging and ischemic stroke therapy. J Neuroimaging 15:217–232PubMedView ArticleGoogle Scholar