Noninvasive monitoring of cerebral perfusion pressure in patients with acute liver failure using transcranial doppler ultrasonography

Aggarwal, Shushma; Brooks, David; Kang, Yoogoo; Linden, Peter K.; Patzer, John F.

doi:10.1002/lt.21499

Cited by 120 publications

(67 citation statements)

References 31 publications

(36 reference statements)

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“…Transcranial doppler of the right internal carotid artery siphon and basilar artery of patient RH reveal a decreased diastolic flow, preserving relative normal TCD waveform, with the presence of the first systolic peak, Windkessel effect, and the diastolic notch. 23 (Figure 2).…”

Section: Resultsmentioning

confidence: 99%

“…[24][25][26] The first systolic peak is predominantly related to myocardial contractility, and the second one (Windkessel effect) is associated with the distensibility (compliance) of the arterial wall and subsequent volume displacement effect. 23 The diastolic perfusion pressure drops when intracranial pressure (ICP) increases, and the diastolic TCD wave gradually disappears. As the ICP rises the Windkessel effect disappears and the systolic peak sharpens and narrows, because elasticity of the intracranial vessels becomes dysfunctional (vasoparalysis) and extramural pressure rises because of cerebral swelling.…”

Section: Discussionmentioning

confidence: 99%

“…Both of these effects limit expansion of the intracranial arteries when the aortic valve opens in the cardiac cycle. 23,[27][28][29][30] When ICP rises to values higher than the diastolic blood pressure, the result is an oscillating flow with systolic spikes, and patterns that characterize cerebral circulatory arrest. 16,19,24,[31][32][33][34] Other conditions that increase cerebrovascular resistance, especially small vessel disease, could lower diastolic velocity and increase PI.…”

Section: Discussionmentioning

confidence: 99%

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TCD Diastolic Velocity Decay and Pulsatility Index Increment in PVS Cases

Pérez-Nellar

Machado

Scherle

et al. 2010

Can. j. neurol. sci.

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Patients in a persistent vegetative state (PVS) are awake but are apparently unaware of themselves or their environment. 1 The diagnosis of PVS has been made more difficult by recognition of the minimally conscious state as a transitional phase in the partial recovery of self-awareness or environmental awareness as a patient emerges from PVS, leading to a relative high proportion of diagnostic errors. 2-10Functional neuroimaging has provided new insights for assessing cerebral function in these patients. Compared to controls, positron emission tomography and single photon emission tomography have shown a substantial reduction of global brain cerebral glucose metabolism and perfusion in PVS. 11-15On the other hand, transcranial Doppler ultrasonography (TCD) assesses local blood flow velocity and direction in the ABSTRACT: Background: Functional neuroimaging has provided new insights for assessing cerebral function in persistent vegetative state patients (PVS). Compared to controls, positron emission tomography and single photon emission tomography have shown a substantial reduction of global brain cerebral glucose metabolism and perfusion in PVS. Doppler ultrasonography (TCD) assesses local blood flow velocity and direction in the proximal portions of large intracranial arteries; it is a noninvasive technique, and it can be carried out at the bedside. To date, few studies have applied TCD to study PVS. Methods: We assessed intracranial circulation by TCD in five PVS patients. The cause of brain insult was hypoxic encephalopathy in four cases, and the other suffered an embolic cerebral infarct causing a top of the basilar artery syndrome. The sample volume was set at 12 mm; power output and gain settings were maximized as needed. The temporal bone acoustic window was not suitable for intracranial vessel insonation in all patients. As an alternative, the internal carotid artery siphon was assessed by orbital insonation between 55-70 mm. Results: Systolic velocity was within a normal range, between 44 and 62 cm/second in all cases. However, the diastolic amplitude was reduced, as well as the end diastolic velocity, and the pulsatility index was increased in all patients. Conclusions: We conclude that TCD diastolic velocity decrement and PI augmentation in our cases might be related to uncoupling of cerebral blood flow and cerebral metabolic rate, arising from reduced cerebral glucose consumption and oxygen uptake, after extensive brain injury.RÉSUMÉ: Déclin de la vélocité diastolique à l'échographie Doppler et accroissement de l'index de pulsatilité chez les patients en état végétatif persistant. Contexte : La neuroimagerie fonctionnelle a fourni de nouvelles avenues pour l'évaluation de la fonction cérébrale chez les patients en état végétatif persistant (EVP). La tomographie par émission de positons et la tomographie par émission d'un seul photon ont démontré une diminution substantielle du métabolisme et de la perfusion cérébrale du glucose dans tout le cerveau chez les patients en EVP par rapport aux sujets témo...

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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TCD Diastolic Velocity Decay and Pulsatility Index Increment in PVS Cases

Pérez-Nellar

Machado

Scherle

et al. 2010

Can. j. neurol. sci.

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“…37 Its utility in ICP detection in ALF has not been validated prospectively and must be interpreted with caution. Trends in TCD indicating cerebral perfusion could be useful; however, an easy method for continuous monitoring is not yet available.…”

Section: Noninvasive Neuromonitoring Strategy In Acute Liver Failurementioning

confidence: 99%

Hepatic Encephalopathy—the Old and the New

Kandiah

Kumar

2016

Critical Care Clinics

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“…Some centers use invasive intracranial pressure (ICP) monitoring; however, non-invasive monitoring of cerebral arterial flow is becoming a useful tool to identify ICH. 1 Two relevant articles 4,5 tried to demonstrate the usefulness of TCD to characterize the cerebral hemodynamics patterns in patients diagnosed with ALF. TCD is becoming an important tool since there is no risk of complications like bleeding or infection, which can occur in the use of invasive ICP monitoring.…”

mentioning

confidence: 99%

Pediatric Acute Liver Failure: Current Perspectives

Colleti¹,

Azevedo²,

Carvalho³

2017

Liver Res Open J

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It is well known that acute liver failure (ALF) in children is rare but potentially a life-threatening disorder. Its true incidence in the pediatric population is undetermined but is responsible for 10-15% of all pediatric liver transplantations. 1 Unlike adults, a specific cause of pediatric ALF is not identified in almost half of the cases, 2 and the etiology is classified as indeterminate in 18-47% of all patients. 1 The etiology is important because the survival rate and need for liver transplantation vary depending on the diagnosis. Spontaneous recovery is better in children with toxic etiology and worst for those with indeterminate or other causes. 1,2 There is no specific treatment for most ALF cases, and the mainstay of medical care is to minimize complications and to limit additional morbidity. 3 ALF can be associated with rapidly progressive multiorgan failure and high mortality rates. One of the leading causes of death is cerebral edema and intracranial hypertension (ICH), responsible for about 20-25% of all deaths. 3 From that perspective, it is desirable to develop new therapies/technologies for diagnostic investigation and interventions.The use of transcranial Doppler (TCD) is an important component in the assessment of cerebral edema, which should be monitored. Some centers use invasive intracranial pressure (ICP) monitoring; however, non-invasive monitoring of cerebral arterial flow is becoming a useful tool to identify ICH. 1 Two relevant articles 4,5 tried to demonstrate the usefulness of TCD to characterize the cerebral hemodynamics patterns in patients diagnosed with ALF. TCD is becoming an important tool since there is no risk of complications like bleeding or infection, which can occur in the use of invasive ICP monitoring. 4,6 The complication risk is around 20%, and there are limited therapeutic options for ICH, 6 which should be taken into consideration to indicate invasive procedures. Besides that, Aggarwal et al 6 studied whether TCD waveform features could be used to differentiate ALF patients with respect to ICP or cerebral perfusion pressure (CPP) levels. They concluded that TCD could provide information about the dynamic state of the intracranial circulation and perfusion with clinical complications.Another issue is the use of continuous renal replacement therapy (CRRT) on pediatric ALF. 7 As mentioned before, the pediatric ALF is a dramatic clinical syndrome in which children has rapid deterioration of hepatic function and can evolve to multiorgan failure and cerebral edema. As found by Deep et al 7 patients who benefited most from CRRT were those with toxic cause unlike the patients with metabolic causes. Therefore, clinicians should be careful in the selection of patients who underwent CRRT, as the cause of pediatric ALF is determinant for prognosis. That is important to consider because of the possible complications related to CRRT. Santiago et al 8 found in their study that CRRT-complications are common in children and some are potentially serious, the majority were problems o...

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Noninvasive monitoring of cerebral perfusion pressure in patients with acute liver failure using transcranial doppler ultrasonography

Cited by 120 publications

References 31 publications

TCD Diastolic Velocity Decay and Pulsatility Index Increment in PVS Cases

TCD Diastolic Velocity Decay and Pulsatility Index Increment in PVS Cases

Hepatic Encephalopathy—the Old and the New

Pediatric Acute Liver Failure: Current Perspectives

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