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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 231-234

The Doppler ultrasound: A bedside tool to understand cerebral autoregulation in neonates


Consultant Neonatologist, Department of Neonatology, Manipal Hospital, Bangalore, Karnataka, India

Date of Submission25-Nov-2019
Date of Decision17-Apr-2020
Date of Acceptance11-Jul-2020
Date of Web Publication01-Oct-2020

Correspondence Address:
Dr. Iyer Harohallli Venkatesh
Manipal Hospital, Old Airport Road, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_123_19

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  Abstract 


Cerebral blood flow is a unique circulation in the human body, constituting around 15% of cardiac output with the brain comprising 2% of the total body weight. The cerebral autoregulation is maintained physiologically to keep the oxygen extraction constant from the brain cells. There are different ways to measure cerebral circulation, including near-infrared spectroscopy and diffuse optical spectroscopy. The limitation of using such equipment is because of the cost and nonavailability. The bedside Doppler ultrasound because of its easy availability it is used in the assessment of cerebral blood flow. There are many factors that contribute to cerebral blood flow. Understanding the variation in the cerebral blood flow by calculating the resistive index of play in the cerebral vessels will help the physician to understand the autoregulation – compensated or uncompensated.

Keywords: Cerebral blood flow, Doppler ultrasound, neonate, resistive index


How to cite this article:
Venkatesh IH. The Doppler ultrasound: A bedside tool to understand cerebral autoregulation in neonates. J Clin Neonatol 2020;9:231-4

How to cite this URL:
Venkatesh IH. The Doppler ultrasound: A bedside tool to understand cerebral autoregulation in neonates. J Clin Neonatol [serial online] 2020 [cited 2020 Dec 4];9:231-4. Available from: https://www.jcnonweb.com/text.asp?2020/9/4/231/296999




  Introduction Top


The cerebral autoregulation is maintained physiologically for the normal activities of the brain. The vertebral and carotid arteries merge at the base of the brain to form the circle of Willis.

Many physiological factors such as carbon dioxide, oxygen, hydrogen ion concentration in the blood and adenosine, arachidonic acid, nitric oxide, and potassium ions secreted by astrocytes play a significant role in the cerebral autoregulation.[1]

The carbonic acid formed by carbon dioxide in the brain dissociates and liberates hydrogen ions, in turn, causing cerebral vasodilatation. Subsequently, the hydrogen ion gets washed away due to cerebral vasodilatation preventing depressed neuronal activity that is caused by the ion.

The oxygen is essential to the brain. The oxygen utilization of the brain is around 3.5 ml of oxygen/100 g of the brain/min. Any clinical condition that brings down the level of oxygen in the brain will make the cerebral arteries to dilate to get more blood into the brain making the oxygen available to the cerebral tissue. The normal cerebral tissue PO2 is 35–40 mm of Hg and anything <30 mm of Hg makes the cerebral blood flow to increase.

The astrocytes, ensheathing brain capillaries play a major role in the cerebral circulation. The uptake of excess extracellular potassium and an increase in the intracellular calcium causes cerebral vasodilatation.[2],[3]

Depending upon the activities, the arterial pressure fluctuates, the cerebral autoregulation maintains the brain activity during such changes. When the mean arterial blood pressure drops to the critical level, the cerebral blood flow increases.

The middle cerebral and anterior cerebral arteries are used historically to demonstrate the cerebral hemodynamics through transcranial Doppler with the limitation of defining only the velocity and not the flow.[4],[5],[6],[7],[8],[9]

The cerebral blood flow can be measured by injecting radioactive xenon into the carotid artery. Recently, the near-infrared spectroscopy (NIRS) and diffusion optical correlation spectroscopy (DCS) are used. The oxyhemoglobin optical density using NIRS is utilized to estimate the cerebral blood flow.[10] The utility of NIRS is limited in developing countries.

The bedside Doppler ultrasound in view of easy bedside availability is used to look at the blood flow in the cerebral arteries and to define the systolic and diastolic velocities. The resistive index (RI) is derived from these two velocities.

The RI = peak systolic velocity (PSV) − end-diastolic velocity (EDV)/PSV.

where PSV is peak systolic velocity and EDV is the end-diastolic velocity.

The anterior fontanel [Figure 1] and the transtemporal regions [Figure 2] are used to place the probe with high frequency to demonstrate the anterior cerebral [Figure 3] and middle cerebral artery [Figure 4], respectively.
Figure 1: The probe is placed in the anterior fontanel transversely to view Anterior cerebral artery on colour Doppler

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Figure 2: The probe is placed in the pterion area to view middle cerebral artery using transtemporal plane

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Figure 3: Coronal view of brain – colour Doppler demonstrating anterior cerebral artery, middle cerebral artery and internal carotid artery

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Figure 4: The color Doppler demonstrating middle cerebral artery, internal carotid artery and anterior cerebral artery on transtemporal plane

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Minarik (2000) determined the reference values of the anterior cerebral artery using transcranial Doppler. The normal cerebral artery RI ranges from 0.56 and 0.8 in neonates [Figure 5]. Any value <0.56 [Figure 6] or >0.8 [Figure 7] will indicate increased and decreased blood flow into the brain, respectively. The reversal of diastolic blood flow [Figure 8] indicates the loss of cerebral autoregulation and could be a strong prognosticating factor.
Figure 5: The pulse wave Doppler demonstrating peak systolic velocity and end diastolic velocity with normal resistive index

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Figure 6: Pulse wave Doppler of middle cerebral artery demonstrating increased diastolic flow making the resistive index to decrease – luxury perfusion. The image was taken in a neonate with hypoxic ischemic encephalopathy

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Figure 7: Pulse wave Doppler of middle cerebral artery demonstrating increased resistive index. This was demonstrated in a neonate subdural hematoma

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Figure 8: Pulse wave Doppler of a middle cerebral artery demonstrating reversal of diastolic flow, where the cerebral autoregulation is lost

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The prospective study was conducted at a tertiary care hospital catering outborn neonates looking at the RI as a prognosticating marker in neonates with hypoxic-ischemic encephalopathy.[11] The newborns delivered after 37 weeks were enrolled in the study satisfying the criteria of perinatal asphyxia.[12],[13] The RI was evaluated using anterior cerebral artery Doppler in the prediction of adverse neurological outcomes. The RI of the cerebral artery between 0.56 and 0.8 was considered normal.[14],[15] The presence of abnormal resistance index was associated with significantly higher risk of death and abnormal neurodevelopmental outcomes at 6–12 months of age.


  Factors Affecting Cerebral Circulation Top


There are many clinical conditions such as prematurity, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, and congenital heart disease will affect the cerebral autoregulation. The factors influencing the cerebral blood flow are listed in [Table 1].
Table 1: Factors affecting the resistive index of cerebral vessel

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  Conclusion Top


The management of sick neonates is a real challenge. The continuous monitoring of these neonates will be done to understand the well-being. The arterial level of carbon dioxide, the oxygen, the blood pressure, and conditions such as patent ductus arteriosus and cerebral pathology have a role in altering the cerebral circulation. Understanding the ongoing cerebral hemodynamics is also crucial in the care of sick neonates and might help in the therapeutic intervention or in prognostication. The bedside ultrasound could be used in the assessment of cerebral autoregulation, where NIRS and DCS would be a dream in most of the centers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lassen NA, Christensen MS. Physiology of cerebral blood flow. Br J Anaesth 1976;48:719-34.  Back to cited text no. 1
    
2.
Zonta M, Sebelin A, Gobbo S, Fellin T, Pozzan T, Carmignoto G. Glutamate-mediated cytosolic calcium oscillations regulate a pulsatile prostaglandin release from cultured rat astrocytes. J Physiol 2003;553:407-14.  Back to cited text no. 2
    
3.
Zonta M, Sebelin A, Gobbo S, Fellin T, Pozzan T, Carmignoto G. Glutamate-mediated cytosolic calcium oscillations regulate a pulsatile prostaglandin release from cultured rat astrocytes. J Physiol 2003;553:407-14.  Back to cited text no. 3
    
4.
Rhee CJ, Fraser CD III, Kibler K, Easley RB, Andropoulos DB, Czosnyka M, et al. The ontogeny of cerebrovascular pressure autoregulation in premature infants. J Perinatol 2014;34:926-31. doi:10.1038/jp.2014.122.  Back to cited text no. 4
    
5.
Wladimiroff JW, van Bel F. Fetal and neonatal cerebral blood flow. Semin Perinatol 1987;11:335-46.  Back to cited text no. 5
    
6.
Kaiser JR, Gauss CH, Williams DK. The effects of hypercapnia on cerebral autoregulation in ventilated very low birth weight infants. Pediatr Res 2005;58:931-5.  Back to cited text no. 6
    
7.
Kaiser J, Gauss C, Williams D. Tracheal suctioning is associated with prolonged disturbances of cerebral hemodynamics in very low birth weight infants. J Perinatol 2007;28:34-41.  Back to cited text no. 7
    
8.
Kaiser J, Gauss C, Williams D. The effects of closed tracheal suctioning plus volume guarantee on cerebral hemodynamics. J Perinatol 2011;31:671-6.  Back to cited text no. 8
    
9.
Kaiser JR, Gauss CH, Williams DK. Surfactant administration acutely affects cerebral and systemic hemodynamics and gas exchange in very-low-birth-weight infants. J Pediatr 2004;144;809-14.  Back to cited text no. 9
    
10.
Brady KM, Lee JK, Kibler KK, Easley RB, Koehler RC, Shaffner DH. Continuous measurement of autoregulation by spontaneous fluctuations in cerebral perfusion pressure: Comparison of 3 methods. Stroke 2008;39:2531-7.  Back to cited text no. 10
    
11.
Kumar AS, Chandrasekaran A, Asokan R, Gopinathan K. Prognostic Value of Resistive Index in Neonates with Hypoxic Ischemic Encephalopathy. Indian Pediatr 2016;53:1079-82.  Back to cited text no. 11
    
12.
Thomas N, George KC, Sridhar S, Kumar M, Kuruvilla KA, Jana AK. Whole body cooling in newborn infants with perinatal asphyxial encephalopathy in a low resource setting: A feasibility trial. Indian Pediatr 2011;48:445-51.  Back to cited text no. 12
    
13.
Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. A clinical and electroencephalo-graphic study. Arch Neurol 1976;33:696-705.  Back to cited text no. 13
    
14.
Jongeling BR, Badawi N, Kurinczuk JJ, Thonell S, Watson L, Dixon G, et al. Cranial ultrasound as a predictor of outcome in term newborn encephalopathy. Pediatr Neurol 2002;26:37-42.  Back to cited text no. 14
    
15.
Zamora C, Tekes A, Alqahtani E, Kalayci OT, Northington F, Huisman TA. Variability of resistive indices in the anterior cerebral artery during fontanel compression in preterm and term neonates measured by transcranial duplex sonography. J Perinatol 2014;34:306-10.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1]



 

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