title: Contrast ultrasonographic assessment of cerebral perfusion in patients undergoing decompressive craniectomy for traumatic brain injury.
abstract: OBJECTIVE
  The aims of this study were to determine whether contrast-enhanced ultrasonography (CEU) could be used for noninvasive evaluation of cerebral perfusion in patients with traumatic brain injury (TBI) and to assess the effect of decompressive surgery on cerebral perfusion as measured by CEU.
  
  
  METHODS
  Contrast-enhanced ultrasonography with intravenous administration of a microbubble contrast agent was performed in six patients with TBI undergoing decompressive craniectomy. Contrast-enhanced ultrasonography was performed through a bur hole before craniectomy and through the calvarial defect immediately after craniectomy and on postoperative Days 1 and 2. For the latter two studies, patients were placed in the recumbent position and at a 35 degrees incline to investigate changes in perfusion produced by modulation of intracranial pressure (ICP). Cerebral microvascular blood flow increased by almost threefold immediately after craniectomy, from a mean of 7.5 +/- 6.9 (standard deviation [SD]) to 20.9 +/- 11.6 (p < 0.05), and further improved on postoperative Day 1 (mean 37.1 +/- 13.9 [SD], p < 0.05, compared with postcraniectomy microvascular blood flow) without subsequent change on Day 2. The change in microvascular perfusion correlated inversely with the initial ICP (p < 0.01), indicating less recovery of flow when preoperative ICP was markedly elevated. On postoperative Days 1 and 2, head-of-bed elevation produced an increase in microvascular perfusion on CEU (mean 37 +/- 11 compared with 51 +/- 20, p < 0.05) and a small decrease in ICP (mean 16 +/- 5 mm Hg compared with 12 +/- 4 mm Hg, p < 0.05). In patients with parenchymal hematoma, CEU provided spatial information on perfusion abnormalities in the hemorrhagic core and surrounding tissues.
  
  
  CONCLUSIONS
  Contrast-enhanced ultrasonography has potential for the intraoperative and bedside assessment of cerebral perfusion in patients with TBI. The technique may be appropriate for evaluating responses to therapies aimed at preventing secondary ischemia and for assessing regional perfusion abnormalities.
authors.affiliation: Cardiovascular Division, and Departments of Neurological Surgery and Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Heppner
authors.forename: Dilantha B
authors.initials: DB
authors.lastname: Ellegala
authors.forename: Marcel
authors.initials: M
authors.lastname: Durieux
authors.forename: John A
authors.initials: JA
authors.lastname: Jane
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Lindner
mesh_terms: D000293:Adolescent; D000328:Adult; D001794:Blood Pressure / Q000502:physiology; D001921:Brain / Q000098:blood supply*; D001930:Brain Injuries / Q000000981:diagnostic imaging / Q000601:surgery*; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000517:prevention & control; D020202:Cerebral Hemorrhage, Traumatic / Q000000981:diagnostic imaging / Q000601:surgery; D003287:Contrast Media / Q000008:administration & dosage; D003399:Craniotomy; D019299:Decompression, Surgical; D005260:Female; D005466:Fluorocarbons; D015600:Glasgow Coma Scale; D006801:Humans; D007089:Image Enhancement; D007091:Image Processing, Computer-Assisted; D007427:Intracranial Pressure / Q000502:physiology; D008297:Male; D045423:Microbubbles; D008833:Microcirculation / Q000502:physiology; D008875:Middle Aged; D019095:Point-of-Care Systems; D011183:Postoperative Complications / Q000000981:diagnostic imaging; D012039:Regional Blood Flow / Q000502:physiology; D013223:Statistics as Topic; D017585:Ultrasonography, Doppler, Transcranial
chemical_list: D003287:Contrast Media; D005466:Fluorocarbons; C042852:perflutren