1. SPECIFIC CLINICAL APPLICATIONS OF
TRANSCRANIAL DOPPLER
ULTRASOUND FOR PATIENTS WITH
WARTIME TRAUMATIC BRAIN INJURY
RoccoArmonda, Teodoro Tigno, Sven Hochheimer,
Frederick Stephens, Randy Bell, Alexander Vo, Meryl
Severson, Robert Ecker, Alexander Razumovsky
Presented for National Neurotrauma
Symposium 2011
July 12, 2011

2. Disclosure
 R. Armonda, T. Tigno, S. Hochheimer, F.
Stephens, R. Bell, A. Vo, M. Severson, R.
Ecker – nothing to disclose
 A. Razumovsky is FTE for the private practice
that currently is under contract with AMEDD

3. Disclaimer
The views expressed in this presentation are
those of the authors and do not reflect the
official policy of the Department of the Army,
Department of Defense, or U.S. Government.

4. TBI
Civilian Battlefield
 Every 21 seconds, one person  Okie, NEJM, 2005: Among
in the US sustains traumatic surviving soldiers wounded in
brain injury (TBI) combat in Iraq and Afghanistan,
TBI appears to account for a
larger proportion of casualties
than it has in other recent U.S.
wars. According to the Joint
Theater Trauma Registry, 22%
had injuries to the head, face, or
neck.

5. TBI: Pathophysiology
Primary Injury:
- Contusions/Hemorrhages
- Diffuse Axonal Injury (DAI)
Secondary Injury (Intracranial) occurs hours
to weeks/years after injury:
- Blood Flow and Metabolic Changes
- Cerebral Ischemia
- Traumatic Hematomas
- Cerebral Edema
- Hydrocephalus
- Increased Intracranial Pressure
- PTSD?

6. WARTIME TRAUMATIC CEREBRAL VASOSPASM:
RECENT REVIEW OF COMBAT CASUALTIES
Armonda et al., Neurosurgery, 2006
 The first study to analyze the effects of blast-
related injury on the cerebral vasculature.
 This study showed that TCV occurred in a
substantial number of patients with severe
neurotrauma, and clinical outcomes were
worse for those with this condition.

7. WARTIME TRAUMATIC CEREBRAL VASOSPASM: RECENT
REVIEW OF COMBAT CASUALTIES
Armonda et al., Neurosurgery, 2006
 Based on this study, the authors recommend
that an assessment of the cranial vasculature
be made for all patients experiencing a severe
closed or penetrating head injury from
military-grade weaponry
 TCD used to perform the initial assessment
and subsequent follow-up evaluation.

8. Multimodal Monitoring:
Vasospasm/Ischemia/high ICP Detection
The primary goal of  MAP
 SaO2
management for
 ECG
TBI is the  Et-CO2
prevention of  CVP
 Urine output
secondary damage
 ICP
due to neuronal
 CBFV/TCD
hypoxia and  PbO2
hypoperfusion  cEEG
 CT/MR Perfusion

9. Transcranial Doppler (TCD)
 Today, the use of the TCD to assess and monitor cerebral
vasospasm and other cerebrovascular abnormalities, like
intracranial hypertension, stroke, etc. is considered the
minimum standard of care
 Physicians, including military - mainly neurologists and
neurosurgeons, located at military and civil medical
centers need immediate access to comprehensive TCD
services in order to ensure the highest quality of neurology
and neurosurgery care for civilians/warriors

10. Objectives
 Traumatic brain injury (TBI) is associated with the
severest casualties from Operation Iraqi Freedom (OIF)
and Operation Enduring Freedom (OEF). A consequences
of neurotrauma are cerebral vasospasm and intracranial
hypertension.
 From Oct. 1, 2008 AMEDD TBI program initiated TCD
ultrasound service for TBI patients who were presented
for care at the National Naval Medical Center and at the
Walter Reed Army Medical Center.
 This prospective study evaluated all inpatient TCD studies
related to battle injury from OIF and OEF.

11. MATERIAL &
METHODS

12. Clinical Material
 Ninety patients (2 females) aged 18 to 50
years (mean 25.9 years) who had suffered
wartime TBI injuries (with Glasgow Coma
Scale scores ranging from 3 to 15) were
investigated with daily TCD studies.
 A total of 567 TCD studies (mean 6.4
tests/patient, ranged from 1 to 30) were made
after admission.

13. Clinical material
TBI Number % M F TLA Cranioplasty
Type/Mechanism
CHI 19 21.1 18 1 1 4
CHI/IED 18 20 18 - 1 -
PHI 33 36.6 32 1 2 10
PHI/IED 20 22.2 19 - 1 4
Total 90 88 2 5 18

14. TCD Protocol
 Comprehensive TCD protocol and well
published diagnostic criteria for vasospasm
and abnormally high intracranial pressure
(ICP) applied in all cases

15. TCD Criteria for diagnosis of vasospasm
Mean CBFV MCA/ICA ratio Interpretation
(cm/s) (Lindegaard Ratio)
<100 <3 Nonspecific
100-140 3-6 Mild
140-200 3-6 Moderate
>200 >6 Severe

16. Typical morphology of TCD wave-form
 MCA (M1 and M2 segm)  OA
 ICA (C1, C3 and C4 segm)
 ACA (A1 segm)
 PCA (P1, P2 segm)
 VA’s and BA
 High peripheral
resistance/High PI
 Low peripheral
resistance/Low PI

17. TCD wave-form changes with
development of intracranial hypertension
Normal ICP

18. TCD criteria for abnormally high ICP
 We are judging quantitative and qualitative TCD
wave form morphology changes
 These changes usually will be obvious after ICP will
be more 30 mm Hg
 However, one condition must be full filled if you
would be using TCD wave from changes to predict
intracranial hypertension: MAP, cardiac output and
PaCO2 are normal and not different significantly
compared to the previous day
 PI more than 1.2 in two or more vessels

19. RESULTS:
POSTTRAUMATIC
VASOSPASM

20. Posttraumatic Vasospasm
 57 patients or 63% demonstrated different
degree TCD signs of vasospasm

21. TCD signs of Vasospasm (in %) by
type of TBI
80
75
70 68.4
60
50
40 36.8 Mild (%)
35.7
31.5 Mod (%)
29
30
23.5 Severe (%)
20 17.6
14.3 15.7
10
5.2 5.2
0
PHI PHI/IED CHI CHI/IED

22. TCD signs of anterior circulation
vasospasm by TBI type
300
250
200
CBFV 150 Mild
(cm/sec)
Moderate
100 Severe
50
0
PHI PHI/IED CHI CHI/IED

23. TCD signs of posterior circulation
vasospasm by TBI type
180
160
140
120
100
CBFV
Mild
(cm/sec) 80
Moderate
60 Severe
40
20
0
PHI PHI/IED CHI CHI/IED

24. 25 yo, closed TBI, no SAH
TLA TLA
CBFV
(cm/sec) TLA
Calendar

25. 25 yo, CHI, no SAH
Before TLA After TLA
CBFV 120 cm/s CBFV 57 cm/s

26. 25 yo, CHI, no SAH
CBFV 112 cm/s CBFV 89 cm/s

27. 23 y/o patient, s/p IED blast injury with
penetrating fragments
300
RIGHT LEFT MC
250
AC
200 SevereVSP
ICA
150 Moderate VSP VA
BA
100 Mild VSP
MA
50 Hc
TLA
TLA ICP
0
Pa

28. 23 y/o patient, s/p IED blast injury with penetrating
fragments. TCD before and one hour after TLA
Left MCA 205 cm/sec; PI 0.8 Right MCA CBFV 195 cm/sec; PI 0.5
Left MCA CBFV 69 cm/sec; PI 1.7 Right MCA CBFV 66 cm/sec; PI 1.4

29. Role of TCD for post TBI vasospasm
 Posttraumatic vasospasm is a significant event
in a high proportion of patients after severe
TBI, close TCD monitoring is recommended
for the treatment of such patients
 The presence and temporal profile of CBFV’s
in all available vessels must be detected and
serially monitored

30. Role of TCD for post TBI vasospasm
 The pattern of CBFV’s elevation may indicate
the need to follow patient carefully for
evidence of deficits related to specific vascular
territory
 TCD waveform appearance either regionally,
or globally may be clinically significant

31. Role of TCD for post TBI vasospasm
 Vasospasm following TBI is a very important source
of morbidity and mortality. Too often, the first sign is
a neurologic deficit, which may be too late to reverse.
TCD assists in the clinical decision-making regarding
further diagnostic evaluation and therapeutic
interventions.
 As TCD-defined vasospasm preceded the
neurological deficit in 64%, earlier intervention might
reduce the incidence of vasospasm-related stroke in
military/civilian hospitals with similar practice
patterns

32. Role of TCD for post TBI vasospasm
• TCD can easily identify onset and time-course of
posttraumatic vasospasm and augments
neurological examination after TBI
• TCD can evaluate effect of treatment, especially
after endovascular interventions
• When performed in isolation, the contribution of
TCD to improving patient outcome has not been
established in the prospective studies.
Nevertheless, TCD has become a regularly
employed tool in neurocritical care

33. RESULTS: TCD &
INTRACRANIAL
HYPERTENSION

34. Presence of ICH (%)
57 58
52
50
PHI PHI/IED CHI CHI/IED

35. PI
ICP
CBFV
50
0
100
150
200
250
300
23-Jun
24-Jun
25-Jun
26-Jun
27-Jun
28-Jun
29-Jun
30-Jun
1-Jul
2-Jul
3-Jul
4-Jul
5-Jul
6-Jul
RIGHT
6-Jul
7-Jul
8-Jul
9-Jul
10-Jul
11-Jul
12-Jul
Patient with GSW
13-Jul
14-Jul
15-Jul
16-Jul
17-Jul
18-Jul
PI x 100 for demonstration
19-Jul
20-Jul
21-Jul
CALENDAR
23-Jun
24-Jun
25-Jun
26-Jun
27-Jun
28-Jun
29-Jun
LEFT
30-Jun
1-Jul
2-Jul
3-Jul
4-Jul
5-Jul
6-Jul
6-Jul
7-Jul
8-Jul
9-Jul
10-Jul
11-Jul
12-Jul
13-Jul
14-Jul
15-Jul
16-Jul
17-Jul
18-Jul
19-Jul
20-Jul
21-Jul
ICP
MCA PI
Trend shows almost direct inverse relationship between CBFV and PI,
MCA CBFV

36. PI
ICP
CBFV
250
100
0
50
350
200
150
300
27-Nov
29-Nov
1-Dec
3-Dec RIGHT
5-Dec
7-Dec
9-Dec
11-Dec
13-Dec
14-Dec
16-Dec
18-Dec
20-Dec
22-Dec
5-Jan
27-Nov
29-Nov
1-Dec
CALENDAR
3-Dec
5-Dec
7-Dec
9-Dec
LEFT
11-Dec
13-Dec
14-Dec
16-Dec
18-Dec
20-Dec
22-Dec
5-Jan
23 yo, PHI due to the IED (r =-0.7)
ICP
PI x 100 for demonstration
MCA PI
MCA M1

37. TCD role for intracranial hypertension
evaluation
 TCD wave-form changes indicates abnormally high ICP,
especially after 30 to 35 mm Hg
 TCD changes may alarm Neuro-ICU personnel and may
indicate malfunctioning of ICP probe
 Abnormally globally decreased pattern of the CBFV’s in
parallel with increased PI’s indicate onset of diffuse
intracranial hypertension
 Sudden onset of asymmetrical CBFV’s and PI’s changes
may indicate potential mid-line shift
 TCD quantitative and qualitative analysis must be taken
into account for evaluation of intracranial hypertension

38. CONCLUSION

39. TCD signs of VSP & high ICP
TBI Type Post TBI High ICP/%
VSP/%
CHI 13/14.4 12/13.3
CHI/IED 12/13.3 9/10
PHI 21/23.3 16/17.7
PHI/IED 11/12.2 12/13.3
Total 57/63.3 49/54.4

40. TCD is a Critical Tool in Critical Care
 The value of TCD in clinical practice is well established,
especially to measure and grade vasospasm following
SAH and TBI
 Based on AHA Guidelines and many years of clinical
practice TCD is a tool employed by the Neurosurgeon,
Neurointensivist and Neurologist in the management of
vasospasm
 Based on high frequency of posttraumatic vasospasm and
intracranial hypertension TCD testing must be utilized for
management of patient with wartime TBI

41. TCD is a Critical Tool in Critical Care
 The use of TCD at hospital admission allows
identification of patients with brain hypoperfusion due to
the vasospasm and/or intracranial hypertension. In such
high-risk patients, early TCD goal-directed therapy can
restore normal cerebral perfusion and might then
potentially help in reducing the extent of secondary brain
injury.
 TCD could provide information about abnormally high
ICP/brain death
 In the future incorporation of TCD data may facilitate
more injury- and time-specific therapies for wartime or
civilian TBI patients

42. Limitations
 Retrospective data analysis
 IRB protocol pending
 Complete data analysis and correlation with
clinical, imaging data and outcome will be
done after IRB approval

43. The European Brain Injury
Consortium:
Nemo solus satis sapit: nobody knows
enough alone.
Acta Neurochir (Wien).
1997;139(9):797-803
QUESTIONS?