Copyright © 2016, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. <zdoi;10.1097/ALN.0000000000001165> Anesthesiology, V 125 • No 2 346 August 2016 P ATIENTS with mild to moderate traumatic brain injury (TBI) constitute the majority of the patients admitted to the emergency room (ER). 1 Despite their reas- suring presentation, 5 to 20% of these patients will develop secondary neurologic deterioration (SND) within the frst post-traumatic week. 2,3 Neurologic worsening adds to the burden of initial lesions and infuences neurologic outcome. 4 Clinical examination including the Glasgow coma score (GCS) and pupil size measurements is not accurate enough to detect these high-risk patients. While cerebral computed tomography (CT) scan has an excellent negative predictive value (NPV), 5 mild to moderate brain lesions on CT weakly correlate with SND. 6 Terefore, triage of patients with minor to moderate TBI and minor lesions on CT scan is challenging in the emergency department (ED) and requires additional tool to screen this population. Transcranial Doppler (TCD) is a technique that explores cerebral blood fow velocities. 7 In patients with TBI, this technique can reveal low diastolic blood fow velocity (FVd) and high pulsatility index (PI) values induced by What We Already Know about This Topic • A substantial proportion of patients with mild to moderate traumatic brain injury, and who have minor lesions on an initial computed tomography scan, undergo secondary neurologic deterioration within the frst week • Transcranial Doppler thresholds for fow velocity and pulsatility index might allow for the differentiation of those patients who un- dergo secondary neurologic deterioration from those who do not • In a multicenter study, the transcranial Doppler thresholds for pulsatility index and fow velocity were validated for outcome prediction in mild to moderate traumatic brain injury What This Article Tells Us That Is New • Transcranial Doppler parameters had excellent negative pre- dictive value in that patients who did not undergo secondary neurologic deterioration were readily identifable • Patients with abnormal transcranial Doppler patterns had greater disability 4 weeks after injury • In combination with clinical examination and computed to- mography scan, transcranial Doppler monitoring can inform clinicians about neurologic outcome in patients with mild to moderate traumatic brain injury Copyright © 2016, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2016; 125:346-54 ABSTRACT Background: To assess the performance of transcranial Doppler (TCD) in predicting neurologic worsening after mild to moderate traumatic brain injury. Methods: Te authors conducted a prospective observational study across 17 sites. TCD was performed upon admission in 356 patients (Glasgow Coma Score [GCS], 9 to 15) with mild lesions on cerebral computed tomography scan. Normal TCD was defned as a pulsatility index of less than 1.25 and diastolic blood fow velocity higher than 25 cm/s in the two middle cerebral arteries. Te primary endpoint was secondary neurologic deterioration on day 7. Results: Twenty patients (6%) developed secondary neurologic deterioration within the frst posttraumatic week. TCD thresholds had 80% sensitivity (95% CI, 56 to 94%) and 79% specifcity (95% CI, 74 to 83%) to predict neurologic worsen- ing. Te negative predictive values and positive predictive values of TCD were 98% (95% CI, 96 to 100%) and 18% (95% CI, 11to 28%), respectively. In patients with minor traumatic brain injury (GCS, 14 to 15), the sensitivity and specifcity of TCD were 91% (95% CI, 59 to 100%) and 80% (95% CI, 75 to 85%), respectively. Te area under the receiver operating characteristic curve of a multivariate predictive model including age and GCS was signifcantly improved with the adjunction of TCD. Patients with abnormal TCD on admission (n = 86 patients) showed a more altered score for the disability rating scale on day 28 compared to those with normal TCD (n = 257 patients). Conclusions: TCD measurements upon admission may provide additional information about neurologic outcome after mild to moderate traumatic brain injury. This technique could be useful for in-hospital triage in this context. (ANESTHESIOLOGY 2016; 125:346-54) Transcranial Doppler to Predict Neurologic Outcome after Mild to Moderate Traumatic Brain Injury Pierre Bouzat, M.D., Ph.D., Luc Almeras, M.D., Pauline Manhes, Ph.D., Laurence Sanders, M.D., Albrice Levrat, M.D., Jean-Stephane David, M.D., Ph.D., Raphael Cinotti, M.D., Russel Chabanne, M.D., Aurélie Gloaguen, M.D., Xavier Bobbia, M.D., Sophie Thoret, M.Sc., Lydia Oujamaa, M.D., Jean-Luc Bosson, M.D., Ph.D., Jean-François Payen, M.D., Ph.D., for the TBI-TCD Study Investigators* This article is featured in “This Month in Anesthesiology,” page 1A. This work was presented at the 56th Annual Congress of the French Society of Anesthesiology and Intensive Care, Paris, France, September 18–20, 2014 and received the best abstract award. *Members of The TBI-TCD Study Group are listed in the appendix. CRITICAL CARE MEDICINE Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/125/2/346/487597/20160800_0-00020.pdf by guest on 05 June 2022