Asymmetric TCD Findings in Malignant MCA Infarction, Resolution after Decompressive Hemicraniectomy: A Case Report

Abstract

Transcranial Doppler (TCD) is a non-invasive method for assessing cerebral hemodynamics in the acute phase of stroke. We report a case of a 33-year-old man who presented with a massive left hemispheric infarct developing into “malignant” MCA infarction. TCD was utilized to monitor intracranial hemodynamics while the clinical and neuroimaging findings were used to help us in the decision to proceed with decompressive craniectomy (DC). Pre-operatively, there was reduced mean flow velocities (MFV) of the middle cerebral artery (MCA) with increasing pulsatility index (PI) ipsilateral to the infarct. The subsequent but smaller rise in the PI in the contralateral MCA was suggestive of very high intracranial pressure (ICP) from massive brain swelling. Serial TCD examinations post-operatively showed normalization of the PI, and subsequent rise in the left MCA MFV. Clinical improvement was also noted as the TCD findings improved. The asymmetry in TCD findings can be attributed to occlusion of the MCA with subsequent spontaneous recanalisation, occlusion of the MCA with subsequent recanalisation due to the DC, or initial occlusion and subsequent pressure effects on the arterioles of the MCA due to the “malignant” edema of that hemisphere that was relieved by DC. This case illustrates the value of TCD as a useful modality in monitoring intracranial hemodynamics in acute stroke.

Transcranial Doppler Ultrasound Role for Patients with Traumatic Brain Injury

“…67,68,100 TCD can be used to evaluate ICP, either independent of or in conjunction with other invasive and non-invasive imaging studies. [105][106][107][108][109][110][111][112][113][114][115][116][117][118] To the best of our knowledge, nobody yet suggests use of PI as an accurate method to quantitatively express ICP in mmHg. Nevertheless, in numerous publications it was shown that PI correlates well with ICP as measured by invasive methods and support use of TCD PI measurement as a predictor of elevated ICP and showed positive linear correlation between PI and ICP.…”

“…1) TCD waveform changes indicates abnormally high ICP, especially above 20 to 30 mmHg (PI must be 1.2 or higher and end-diastolic CBFV 25 cm/sec or lower for all anterior circulation vessels uni-or bilaterally); 67,68,94 2) TCD changes may alert Neuro-ICU personnel and may indicate malfunctioning of ICP probe; 105,106 3) Abnormally globally decreased pattern of the CBFV's in parallel with increased PI's indicates onset of diffuse ICH; [107][108][109] 4) Sudden onset of asymmetrical CBFV's and PI's changes may indicate a potential mid-line shift. [110][111][112] However, we would like to stress that at present TCD 30 http://www.j-nn.org Razumovsky TCD and TBI alone cannot substitute invasive and quantitative ICP monitoring modalities. 113 Nevertheless, in cases when invasive ICP measurements are unobtainable TCD can be used to evaluate ICP either independent of or in conjunction with other non-invasive imaging studies.…”