A Survey of Neuromonitoring Practices in North American Pediatric Intensive Care Units.

BACKGROUND: Neuromonitoring is the use of continuous measures of brain physiology to detect clinically important events in real-time. Neuromonitoring devices can be invasive or non-invasive and are typically used on patients with acute brain injury or at high risk for brain injury. The goal of this study was to characterize neuromonitoring infrastructure and practices in North American pediatric intensive care units (PICUs). METHODS: An electronic, web-based survey was distributed to 70 North American institutions participating in the Pediatric Neurocritical Care Research Group. Questions related to the clinical use of neuromonitoring devices, integrative multimodality neuromonitoring capabilities, and neuromonitoring infrastructure were included. Survey results were presented using descriptive statistics. RESULTS: The survey was completed by faculty at 74% (52 of 70) of institutions. All 52 institutions measure intracranial pressure and have electroencephalography capability, whereas 87% (45 of 52) use near-infrared spectroscopy and 40% (21/52) use transcranial Doppler. Individual patient monitoring decisions were driven by institutional protocols and collaboration between critical care, neurology, and neurosurgery attendings. Reported device utilization varied by brain injury etiology. Only 15% (eight of 52) of institutions utilized a multimodality neuromonitoring platform to integrate and synchronize data from multiple devices. A database of neuromonitoring patients was maintained at 35% (18 of 52) of institutions. Funding for neuromonitoring programs was variable with contributions from hospitals (19%, 10 of 52), private donations (12%, six of 52), and research funds (12%, six of 52), although 73% (40 of 52) have no dedicated funds. CONCLUSIONS: Neuromonitoring indications, devices, and infrastructure vary by institution in North American pediatric critical care units. Noninvasive modalities were utilized more liberally, although not uniformly, than invasive monitoring. Further studies are needed to standardize the acquisition, interpretation, and reporting of clinical neuromonitoring data, and to determine whether neuromonitoring systems impact neurological outcomes.

Monitoring of Neuroendocrine Changes in Acute Stage of Severe Craniocerebral Injury by Transcranial Doppler Ultrasound Image Features Based on Artificial Intelligence Algorithm.

This study was aimed at exploring the application value of transcranial Doppler (TCD) based on artificial intelligence algorithm in monitoring the neuroendocrine changes in patients with severe head injury in the acute phase; 80 patients with severe brain injury were included in this study as the study subjects, and they were randomly divided into the control group (conventional TCD) and the experimental group (algorithm-optimized TCD), 40 patients in each group. An artificial intelligence neighborhood segmentation algorithm for TCD images was designed to comprehensively evaluate the application value of this algorithm by measuring the TCD image area segmentation error and running time of this algorithm. In addition, the Glasgow coma scale (GCS) and each neuroendocrine hormone level were used to assess the neuroendocrine status of the patients. The results showed that the running time of the artificial intelligence neighborhood segmentation algorithm for TCD was 3.14 ± 1.02 s, which was significantly shorter than 32.23 ± 9.56 s of traditional convolutional neural network (CNN) algorithms (P < 0.05). The false rejection rate (FRR) of TCD image area segmentation of this algorithm was significantly reduced, and the false acceptance rate (FAR) and true acceptance rate (TAR) were significantly increased (P < 0.05). The consistent rate of the GCS score and Doppler ultrasound imaging diagnosis results in the experimental group was 93.8%, which was significantly higher than the 80.3% in the control group (P < 0.05). The consistency rate of Doppler ultrasound imaging diagnosis results of patients in the experimental group with abnormal levels of follicle stimulating hormone (FSH), prolactin (PRL), growth hormone (GH), adrenocorticotropic hormone (ACTH), and thyroid stimulating hormone (TSH) was significantly higher than that of the control group (P < 0.05). In summary, the artificial intelligence neighborhood segmentation algorithm can significantly shorten the processing time of the TCD image and reduce the segmentation error of the image area, which significantly improves the monitoring level of TCD for patients with severe craniocerebral injury and has good clinical application value.

Serial neurosonography in fetuses with congenital heart defects shows mild delays in cortical development.

INTRODUCTION: Neurodevelopmental delay is more common in children born with congenital heart defects (CHD), even with optimal perinatal and peri-operative care. It is hypothesized that fetuses with CHD are prone to neurological impairment in utero due to their cardiac defect, possibly leading to delayed cortical development. METHODS: Cerebral cortical maturation was assessed with advanced neurosonographic examinations every 4 weeks in fetuses with CHD and compared to control fetuses. Five different primary fissures and four areas were scored (ranging 0-5) by blinded examiners using a cortical maturation scheme. RESULTS: Cortical staging was assessed in 574 ultrasound examinations in 85 CHD fetuses and 61 controls. Small differences in grading were seen in Sylvian and cingulate fissures. (Sylvian fissure: -0.12 grade, 95% CI (-0.23; -0.01) p = 0.05, cingulate fissure: -0.24 grade, 95% CI (-0.38; -0.10) p = <0.001. Other cortical areas showed normal maturation as compared to control fetuses. CONCLUSION: Small differences were seen in three of the nine analyzed cortical areas in CHD fetuses, in contrast to previous reports on progressive third-trimester delay. The clinical implications of the small differences however, remain unknown.

Recommendation to reality: Closing the transcranial Doppler screening gap for children with sickle cell anemia.

BACKGROUND: Although annual transcranial Doppler (TCD) screening is recommended for children with sickle cell anemia (SCA), compliance is low and variable. Our objective was to utilize an electronic health record (EHR)-based registry to improve TCD adherence among children with SCA, 2-16 years of age, at our institution. METHODS: We developed an in-EPIC real time registry for children with sickle cell disease in year 2016. Since end of year 2016, we have been extracting data quarterly to examine TCD rates and share the list of children who have not received a TCD screen in the past 18 months with the clinical team. The registry also includes a TCD risk score to enhance point of care. We also added Child Life support to increase TCD compliance among children <7 years. Control charts are used to examine TCD rates. RESULTS: At baseline, prior to and start of quarterly data audit and feedback, 63% of children received the recommended annual TCD screen. TCD rates steadily increased to 80% by the third quarter of 2017. We observed a dip in TCD rates, driven by failure of screening young children. Since the initiation of Child Life support for children <7 years, we have sustained TCD screen rates >70%. Overall, our data meet criteria for special cause variation, indicating improvement in TCD rates since 2015. CONCLUSIONS: Regular tracking and identification of patients overdue for a TCD screen using an EHR-based registry resulted in sustained improvement in TCD screening rates. Involvement of Child Life support further improved TCD rates.

Improved stenosis outcome in stroke-free sickle cell anemia children after transplantation compared to chronic transfusion.

We report here the 3-year stenosis outcome in 60 stroke-free children with sickle cell anaemia (SCA) and an abnormal transcranial Doppler history, enrolled in the DREPAGREFFE trial, which compared stem cell transplantation (SCT) with standard-care (chronic transfusion for 1-year minimum). Twenty-eight patients with matched sibling donors were transplanted, while 32 remained on standard-care. Stenosis scores were calculated after performing cerebral/cervical 3D time-of-flight magnetic resonance angiography. Fourteen patients had stenosis at enrollment, but only five SCT versus 10 standard-care patients still had stenosis at 3 years. Stenosis scores remained stable on standard-care, but significantly improved after SCT (P = 0·006). No patient developed stenosis after SCT, while two on standard-care did, indicating better stenosis prevention and improved outcome after SCT.

Changes in Care Delivery for Children With Sickle Cell Anemia During the COVID-19 Pandemic.

BACKGROUND: Specialty care for children with sickle cell disease (SCD) may be disrupted during the coronavirus (COVID-19) pandemic. Our DISPLACE consortium includes 28 pediatric SCD centers. METHODS: In May 2020, we surveyed the consortium on the impact of COVID-19 on their practice focusing on transcranial Doppler ultrasound, chronic red cell transfusions, telehealth, and COVID-19 testing. OBSERVATION: Twenty-four DISPLACE providers completed the survey. Transcranial Doppler ultrasound screening decreased to 67% but chronic red cell transfusions remained at 96%. Most investigators (92%) used telehealth and 40% of providers had patients test positive for COVID-19. CONCLUSION: The COVID-19 pandemic has affected routine care and necessitated changes in practice in SCD.

The Impact of Sickle Cell Anemia and Mental Health Diagnoses on Healthcare Use and Preventive Care among Children Enrolled in Medicaid, 2005-2012.

OBJECTIVE: To examine mental health diagnoses, healthcare use, and receipt of age-appropriate preventive care, including antibiotic prophylaxis, hydroxyurea therapy, and transcranial Doppler screenings, among children with sickle cell anemia (SCA). STUDY DESIGN: Children aged 1-17 years with SCA from 6 states having 3 or more Medicaid claims with a SCA diagnosis within a year (2005-2012) were included. Children with mental health diagnoses were identified with 1 or more mental health encounters. Poisson and logistic regression models with general estimating equations assessed the relationship between mental health diagnoses, healthcare use, and receipt of age-appropriate preventive care. RESULTS: In total, 7963 children with SCA were identified (22 424 person-years); 1593 person-years (7.1%) included 1 or more mental health diagnoses. Children with a mental health diagnosis were more likely to have inpatient admissions (incidence rate ratio [IRR] 1.46, 95% CI 1.36-1.56) and outpatient (IRR 1.27, 95% CI 1.21-1.34), emergency department (IRR 1.39, 95% CI 1.30-1.48), and well-child visits (IRR 1.19, 95% CI 1.11-1.29). Those with a mental health diagnosis were more likely to receive hydroxyurea therapy (odds ration [OR] 1.17, 95% CI 1.03-1.33) and less likely to receive transcranial Doppler screenings (OR 0.79, 95% CI 0.68-0.93). CONCLUSIONS: Children with SCA do not receive adequate age-appropriate preventive care. Further research is necessary to identify key points of coordination between mental health and SCA services throughout the life course. This approach may help to increase receipt of age-appropriate preventive care and decrease reliance on acute care.

How is vasospasm screening using transcranial Doppler associated with delayed cerebral ischemia and outcomes in aneurysmal subarachnoid hemorrhage?

BACKGROUND: Delayed cerebral ischemia (DCI) is an independent predictor of an unfavorable outcome after aneurysmal subarachnoid hemorrhage (aSAH). Many centers, but not all, use transcranial Doppler (TCD) to screen for vasospasm to help predict DCI. We used the United Kingdom and Ireland Subarachnoid Haemorrhage (UKISAH) Registry to see if outcomes were better in centers that used TCD to identify vasospasm compared to those that did not. METHODS: TCD screening practices were ascertained by national survey in 13 participating centers of the UKISAH. The routine use of TCD was reported by 5 "screening" centers, leaving 7 "non-screening" centers. Using a cross-sectional cohort study design, prospectively collected data from the UKISAH Registry was used to compare DCI diagnosis and favorable outcome (Glasgow Outcome Score 4 or 5) at discharge based on reported screening practice. RESULTS: A cohort of 2028 aSAH patients treated ≤ 3 days of hemorrhage was analyzed. DCI was diagnosed in 239/1065 (22.4%) and 220/963 (22.8%) of patients in non-screening and screening centers respectively while 847/1065 (79.5%) and 648/963 (67.2%) achieved a favorable outcome. Odds ratios adjusted for age, injury severity, comorbidities, need for cerebrospinal fluid diversion, and re-bleed returned neutral odds of diagnosing DCI of 0.90 (95% CI 0.72-1.12; p value = 0.347) in screening units compared to those of non-screening units but significantly decreased odds of achieving a favorable outcome 0.56 (95% CI 0.42-0.82; p value < 0.001). CONCLUSIONS: Centers that screened for vasospasm using TCD had poorer in-hospital outcomes and similar rates of DCI diagnosis compared to centers that did not.

Factors influencing quality of life in patients followed in the neurosonology laboratory for carotid stenosis.

BACKGROUND: Quality of life (QoL) is one of the main endpoints in stroke prevention or acute stroke treatment studies. The aim of the current study was to identify risk factors affecting the QoL of patients with carotid stenosis in stroke prevention. METHODS: Self-sufficient patients (50-80 years of age) with ≥20% carotid artery stenosis followed in the neurosonology laboratory, and without any severe illnesses within the last 12 months, dementia, or psychiatric disorders were selected for the study after signing informed consent. Patients completed two standardized QoL questionnaires (WHOQoL-BREF and EQ-5D-3 L) and a visual pain scale, provided covariate variables (medication, age, gender, education, and social situation), and the blood pressure and body mass indexes were recorded. Logistic regression (forward stepwise method) was used to identify factors affecting the individual domains of QoL questionnaires. RESULTS: Of the 584 consecutive patients, 502 met the inclusion criteria and 344 completely filled both QoL questionnaires (164 men; mean age, 69.7 ± 7.8 years). An independent predictor of worse QoL in all domains was pain. Independent factors decreasing the QoL were lower level of education and blood pressure in the physical health domain, female gender in the psychological domain, and male gender in the social relationships domain. Independent factors decreasing satisfaction with health status were female gender and higher blood pressure. Factors negatively influencing the satisfaction with the QoL were living alone, lower level of education, and higher diastolic blood pressure (WHOQoL-BREF). Factors negatively influencing mobility were age, male gender, living alone, lower level of education, and higher body mass index (EQ-5D-3 L; p < 0.05 in all cases). CONCLUSIONS: Pain, blood pressure, body mass index, education, living alone, gender, and age were associated with the QoL in patients with carotid stenosis. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02360137 . Registered on 26 January 2015.

Utility of Transcranial Doppler in the Coordination of Transplants: 10 Years of Experience.

Transcranial Doppler (TCD) integrated to multimodal neuromonitoring of neurocritical patients is a useful tool in the clinical follow-up. A retrospective and descriptive study of 194 patients who were admitted into the intensive care unit (ICU) was carried out from December 2007 to February 2017. We analyzed the distribution of study frequencies with respect to the pathologies that motivated them, the characteristics of patients who evolved to brain death (BD), and most frequent patterns of cerebral circulatory arrest. Ninety-four of the patients that evolved to BD required 126 studies during their follow-up. The insonation of the 2 middle cerebral arteries and the basilar artery was the most frequent combination (30%). Most frequent reasons of request for a TCD included apnea test intolerance and reduction of waiting time and sedation analgesia. These 10 years of experience have enabled a deeper understanding of the cerebral hemodynamics and the identification of common patterns of high resistance to different pathologies (subarachnoid hemorrhage, severe skull trauma, anoxic ischemia, ammonia encephalopathy) that explain the severity of the acute brain injury, related to the increase of brain volume and its deleterious consequence: the elevation of intracranial pressure (ICP). In the same way, because invasive ICP monitoring is not available in all cases, with a tomographic scan of the skull we have been able to observe a correlation of some imaging signs suggestive of intracranial hypertension with patterns of high resistance obtained by the TCD in the pathologies mentioned. We recommend that each ICU that assists neurocritical patients should have TCD equipment and the skilled personnel to carry out the technique.

Transcranial Doppler combined with quantitative EEG brain function monitoring and outcome prediction in patients with severe acute intracerebral hemorrhage.

BACKGROUND: Neurological deterioration after intracerebral hemorrhage (ICH) is thought to be closely related to increased intracranial pressure (ICP), decreased cerebral blood flow (CBF), and brain metabolism. Transcranial Doppler (TCD) is increasingly used as an indirect measure of ICP, and quantitative EEG (QEEG) can reflect the coupling of CBF and metabolism. We aimed to combine TCD and QEEG to comprehensively assess brain function after ICH and provide prognostic diagnosis. METHODS: We prospectively enrolled patients with severe acute supratentorial (SAS)-ICH from June 2015 to December 2016. Mortality was assessed at 90-day follow-up. We collected demographic data, serological data, and clinical factors, and performed neurophysiological tests at study entry. Quantitative brain function monitoring was performed using a TCD-QEEG recording system at the patient's bedside (NSD-8100; Delica, China). Univariate and multivariable analyses and receiver operating characteristic (ROC) curves were employed to assess the relationships between variables and outcome. RESULTS: Forty-seven patients (67.3 ± 12.6 years; 23 men) were studied. Mortality at 90 days was 55.3%. Statistical results showed there were no significant differences in brain symmetry index between survivors and nonsurvivors, nor between patients and controls (all p > 0.05). Only TCD indicators of the pulsatility index from unaffected hemispheres (UPI) (OR 2.373, CI 1.299-4.335, p = 0.005) and QEEG indicators of the delta/alpha ratio (DAR) (OR 5.306, CI 1.533-18.360, p = 0.008) were independent predictors for clinical outcome. The area under the ROC curve after the combination of UPI and DAR was 0.949, which showed better predictive accuracy compared to individual variables. CONCLUSIONS: In patients with SAS-ICH, multimodal neuromonitoring with TCD combined with QEEG indicated that brain damage caused diffuse changes, and the predictive accuracy after combined use of TCD-QEEG was statistically superior in performance to any single variable, whether clinical or neurophysiological.

The significance of inadequate transcranial Doppler studies in children with sickle cell disease.

Sickle cell disease (SCD) is a common cause of cerebrovascular disease in childhood. Primary stroke prevention is effective using transcranial Doppler (TCD) scans to measure intracranial blood velocities, and regular blood transfusions or hydroxycarbamide when these are abnormal. Inadequate TCD scans occur when it is not possible to measure velocities in all the main arteries. We have investigated the prevalence and significance of this in a retrospective audit of 3915 TCD scans in 1191 children, performed between 2008 and 2015. 79% scans were normal, 6.4% conditional, 2.8% abnormal and 12% inadequate. 21.6% of 1191 patients had an inadequate scan at least once. The median age of first inadequate scan was 3.3 years (0.7-19.4), with a U-shaped frequency distribution with age: 28% aged 2-3 years, 3.5% age 10 years, 25% age 16 years. In young children reduced compliance was the main reason for inadequate TCDs, whereas in older children it was due to a poor temporal ultrasound window. The prevalence of inadequate TCD was 8% in the main Vascular Laboratory at King's College Hospital and significantly higher at 16% in the outreach clinics (P<0.0001), probably due to the use of a portable ultrasound machine. Inadequate TCD scans were not associated with underlying cerebrovascular disease.

Progression of Cerebral White Matter Hyperintensities and the Associated Sonographic Index.

Purpose To evaluate the relationship between penetrating arterial pulsation and the progression of white matter hyperintensities (WMHs) by using the sonographic resistance index (RI) along the M1 segment of the middle cerebral artery (MCA). Materials and Methods The study design was approved by the institutional review board of Seoul National University Hospital. The study included 450 individuals who had undergone initial transcranial Doppler (TCD) sonography and magnetic resonance imaging, with follow-up imaging performed within 34-45 months, and who had no stenosis of 30% or more in the internal carotid artery or MCA or a history of stroke other than an old lacunar infarction. MRIR was defined as distal RI divided by proximal RI, where the distance between proximal MI and distal M1 was approximately 20 mm based on TCD evaluation. WMH progression was quantitatively evaluated by subtracting WMH volume at baseline from WMH volume at follow-up. Results At baseline, mean MRIR was 0.974 ± 0.045 (standard deviation), and mean WMH volume was 9.66 mL ± 14.54. After a mean of 38.3 months ± 3.4, the WMH volume change was 4.06 mL ± 7.35. WMH volume change was linearly associated with MRIR (r = 0.328, P < .001), along with the baseline WMH volume (r = 0.433, P < .001) and mean MCA pulsatility index (r = 0.275, P = .037). MRIR values greater than or equal to 1.000 were associated with a greater increase in WMH volume (P < .001). Conclusion MRIR might reflect the pulsation of penetrating arteries and is independently associated with WMH progression. © RSNA, 2017 Online supplemental material is available for this article.

Characteristics of Accredited Transcranial Doppler Ultrasound Laboratories in the United States.

PURPOSE: The aim of this study was to describe in detail the characteristics and accreditation compliance of laboratories in the United States applying for Intersocietal Accreditation Commission (IAC) transcranial Doppler (TCD) accreditation. METHODS: This was a retrospective study of all applicant laboratories from 2012 to 2015. We used the IAC database to extract laboratory characteristics and guideline compliance metrics. RESULTS: Evaluation of 97 laboratories demonstrated that 67% were hospital-based and located in the South (43.3%), corresponding to the location of "Stroke Belt" states. Cases from 186 interpreting physicians, of which 110 (59%) were neurologists, were evaluated during the accreditation process. Established practice was the most common training pathway (54.8%), and a majority had not obtained an additional vascular interpretation credential (72.6%). From 318 case studies, the most frequent indications were subarachnoid hemorrhage (31.0%), stroke (17.0%), and carotid stenosis (14.3%). Although most laboratories had been previously accredited, accreditation was delayed for 77.3% due to incomplete studies (33.0%), discrepant findings between the report and the laboratory's diagnostic criteria (23.7%), and discrepant findings between the report and the waveforms/images (17.5%). CONCLUSIONS: The results suggest that there are significant differences between IAC applicant laboratories and laboratories represented by Centers for Medicaid and Medicare Services (CMS) claims data. In addition, accurate study reporting, physician training, and ongoing quality improvement activities may not be optimized in laboratories applying for accreditation. With the information learned from this study, educational strategies by professional organizations, including the IAC, can be tailored to help improve TCD practice.

Primary and Secondary Stroke Prevention in Children With Sickle Cell Disease.

Children with sickle cell disease (SCD) have numerous acute and chronic complications, including central nervous system (CNS) disease, which can be debilitating over their life span. Recognition of risk factors for CNS disease and overt CNS disease should be properly identified by primary care providers, including physicians, physician assistants, and nurse practitioners. Here, we discuss an emerging and important early indicator of CNS disease in the form of silent cerebral infarcts and review overt stroke in patients with SCD. We also discuss transcranial Doppler ultrasonography, when and how often transcranial Doppler ultrasounds should be performed, and management of abnormal results. Lastly, we review the clinical data for the management and prevention of silent cerebral infarcts and overt stroke in children with SCD.

Use of Transcranial Doppler in Patients with Severe Traumatic Brain Injuries.

Severe traumatic brain injuries (TBI) are associated with a high rate of mortality and disability. Transcranial Doppler (TCD) sonography permits a noninvasive measurement of cerebral blood flow. The purpose of this study is to determine the usefulness of TCD in patients with severe TBI. TCD was performed, from April 2008 to April 2013, on 255 patients with severe TBI, defined as a Glasgow Coma Scale score of ≤8 on admission. TCD was performed on hospital days 1, 2, 3, and 7. Hypoperfusion was defined by having two out of three of the following: 1) mean velocity (Vm) of the middle cerebral artery <35 cm/sec, 2) diastolic velocity (Vd) of the middle cerebral artery <20 cm/sec, or 3) pulsatility index (PI) of >1.4. Vasospasm was defined by the following: Vm of the middle cerebral artery >120 cm/sec and/or a Lindegaard index (LI) >3. One hundred fourteen (45%) had normal measurements. Of these, 92 (80.7%) had a good outcome, 6 (5.3%) had moderate disability, and 16 (14%) died, 4 from brain death. Seventy-two patients (28%) had hypoperfusion and 71 (98.6%) died, 65 from brain death, and 1 patient survived with moderate disability. Sixty-nine patients (27%) had vasospasm, 31 (44.9%) had a good outcome, 16 (23.2%) had severe disability, and 22 (31.9%) died, 13 from brain death. The vasospasm was detected on hospital day 1 in 8 patients, on day 2 in 23 patients, on day 3 in 22 patients, and on day 7 in 16 patients. Patients with normal measurements can be expected to survive. Patients with hypoperfusion have a poor prognosis. Patients with vasospasm have a high incidence of mortality and severe disability. TCD is useful in determining early prognosis.

Use of Transcranial Doppler for Management of Central Nervous System Infections in Critically Ill Children.

BACKGROUND: The primary objective of this study was to characterize changes in cerebral blood flow measured using transcranial Doppler in children with central nervous system infections. We hypothesized that children with central nervous system infections have abnormal cerebral blood flow, associated with a greater frequency of complications and poor neurological outcome. METHODS: We conducted a single-center, retrospective study of children admitted to the neonatal or pediatric intensive care unit with central nervous system infection and undergoing transcranial Doppler as part of routine care between March 2011 and July 2015. RESULTS: A total of 20 children with central nervous system infection underwent 35 transcranial Dopplers. The mean age was 8.2 ± 6.3 years, including 12 boys and eight girls. The most common infection was meningitis (n = 11, 55%), with the remainder comprising encephalitis (15%), meningoencephalitis (20%), and abscess or empyema (10%). Bacterial (n = 10, 50%) and viral (n = 6) sources were common with only one (5%) fungal infection and three (15%) unknown but presumed viral etiology. The patients underwent transcranial Doppler 4 ± 9 days after intensive care unit admission. Mean cerebral blood flow velocities were overall increased compared with reference values for age (healthy children and critically ill children) mostly because of hyperemia (n = 21, 60%) and vasospasm (6%). Hypoperfusion (cerebral blood flow velocity <1 S.D. of normal value) in at least one vessel was associated with morbidity (intubation, vasoactive medications, neurosurgery, cardiac arrest) (P = 0.04) and mortality (P = 0.03). Two patients had increased intracranial pressure and hyperventilation was safely achieved with transcranial Doppler monitoring to avoid ischemia. Serial transcranial Dopplers were used to guide blood pressure management. CONCLUSIONS: Transcranial Doppler can be used in children with central nervous system infection as a tool to assess cerebral blood flow. In this retrospective study, cerebral hypoperfusion was associated with increased morbidity and mortality. If transcranial Doppler is to guide medical therapy and management of cerebral blood flow in children with central nervous system infections, these results will need to be validated in prospective studies with a more homogenous population of children with encephalitis or meningitis.

Impact of clinical training on supra-aortic duplex and transcranial doppler examination concordance.

Sonographic tests are observer-dependent. With 1,527 consecutive patients, 22 trainees were assessed at baseline and after a hands-on 1:1 program, with a pre-examination median of 76 studies/trainee. We evaluated the required number of supervised examinations to reach a 0.80 kappa index (ki). Statistics included linear and exponential generalized estimating equation models. In the exponential model, 76 studies for carotid-duplex and >102 for vertebral-duplex and transcranial Doppler were needed for a 0.80 ki. "Relevant-categories" after-training ki was 0.80 in carotid-duplex and transcranial Doppler but 0.60 in vertebral-duplex. A fixed training does not guarantee a high ki. Measuring the acquired skills of every trainee would improve quality. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:571-579, 2016.

Current Opinion and Use of Transcranial Doppler Ultrasonography in Traumatic Brain Injury in the Pediatric Intensive Care Unit.

The purpose of this study was to identify and review clinical studies using transcranial Doppler (TCD) ultrasonography in children with severe traumatic brain injury (TBI) in the pediatric intensive care unit (PICU). We identified 16 articles from January 2005 to July 2015 that met inclusion (TBI, five or more cases in case series, subjects <18 years old, TCD performed in PICU) and exclusion criteria (age not stated, data from subjects <18 years not separated from adult data, <85% study population <18 years in mixed population with adults). TCD parameters were used to assess autoregulation, intracranial pressure, and vasospasm, and to predict neurological outcome. Incidence of impaired autoregulation varied in severe TBI from 25% to 80%. Altered TCD flows and pulsatility index variably predicted intracranial hypertension across studies. Sonographic vasospasm in the middle cerebral artery occurred in 34% of 69 children with severe TBI. Outcomes seem to be related to altered TCD-derived flow velocities while in the ICU. TCD may be a useful tool to assess autoregulation, intracranial pressure, and vasospasm following TBI in the PICU. Further research is needed to establish gold standards and validate the findings in children. TCD may then impact day-to-day management in the PICU, and potentially improve outcomes in children with severe TBI.

Is There an Influence of Routine Daily Transcranial Doppler Examination on Clinical Outcome in Patients After Aneurysmal Subarachnoid Hemorrhage?

BACKGROUND: Transcranial Doppler (TCD) is widely used as a daily routine method to detect vasospasm in patients after aneurysmal subarachnoid hemorrhage (aSAH); however, there are only limited data about the real benefit of this examination. Therefore, the clinical outcome of 2 cohorts with and without daily TCD after aSAH was assessed. METHODS: All patients included in this study received a standardized diagnostic and treatment protocol. Fifty patients admitted with aSAH from January 2013 to December 2013 received daily TCD measurements; 39 patients admitted from January 2014 to September 2014 received no TCD measurements. Data on clinical grade (Hunt and Hess grade), severity of bleeding (Barrow Neurological Institute grade), localization of aneurysm, and angiographic or clinically relevant vasospasm were collected prospectively. The Glasgow Outcome Scale, modified Rankin Scale, and the National Institute of Health Stroke Scale were used as clinical outcome parameters. RESULTS: Patient baseline characteristics and clinical data were comparable; treatment modality of the aneurysm was not different between the groups (P = 0.7756). No significant difference between the Hunt and Hess grade (P = 0.818) and the Barrow Neurological Institute grade (P = 0.1551) was observed. There was also no significance concerning the incidence of angiographic or clinically relevant vasospasm between both groups (P = 0.5842 and P = 0.7933). Glasgow Outcome Scale, mRS, and National Institute of Health Stroke Scale as the primary outcome parameters showed no significant difference in morbidity and mortality between both groups (mortality P = 0.8544). CONCLUSIONS: With the limitation of an explorative cohort study, the results indicate that routine TCD studies do not improve the overall outcome of patients after aSAH.