Transcranial Doppler ultrasound goal-directed therapy for the early management of severe traumatic brain injury.

OBJECTIVE

To evaluate the usefulness of early transcranial Doppler ultrasound (TCD) goal-directed therapy after severe traumatic brain injury initiated before invasive cerebral monitoring is available.

DESIGN

Prospective, observational clinical study.

SETTING

Surgical intensive care unit, university hospital.

PATIENTS AND PARTICIPANTS

Twenty-four severely brain-injured patients.

INTERVENTIONS

All patients had TCD measurements immediately on admission (T0) and when invasive cerebral monitoring was available (T1). TCD was considered abnormal when two out of three measured values were outside the following limits: Vm<30 cm/s, Vd<20 cm/s, PI > 1.4. When admission TCD was abnormal, attending physicians modified treatment to increase cerebral perfusion pressure.

MEASUREMENTS AND RESULTS

Admission TCD was performed 18+/-11 min (T0) after admission, whereas cerebral invasive monitoring was available 242+/-116 min (T1) after admission. At T0, 11 (46%) patients had abnormal TCD values (group 1) and 13 had normal TCD values (group 2); mean arterial pressure was comparable between groups. All group 1 patients received mannitol and/or norepinephrine. At T1, mean arterial pressure was increased compared to admission in group 1 (105+/-17 mmHg vs. 89+/-15 mmHg, p<0.05) and only two patients had still an abnormal TCD. Although group 1 patients had higher intracranial pressure than those of group 2 (32+/-13 mmHg vs. 22+/-10 mmHg, p<0.01), both cerebral perfusion pressure and jugular venous oxygen saturation were comparable between the groups.

CONCLUSIONS

The use of TCD at hospital admission allows identification of severely brain-injured patients with brain hypoperfusion. 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.