Clinical Application Study Of Non-invasive Monitoring Cerebral Hemodynamic Changes For Traumatic Brain Injury

Traumatic brain injury is neurosurgery common diseases and frequently-occurring disease, dangerous disease, especially in severe traumatic brain injury, the high rate of mortality and disability, has been the focus and difficulty of neurosurgery. In with severe head trauma patients with intracranial pressure control and cerebral perfusion pressure was maintained rescue success, mainly using invasive methods for monitoring intracranial pressure and cerebral perfusion pressure. But there is the risk of invasive intracranial pressure monitoring (such as infection and intracranial bleeding, etc.) as well as the expensive cost of the clinical application is limited. With the development of minimally invasive and non-invasive neurosurgery ideas and technology, gradually by academic attach importance to seek an effective, non-invasive intracranial pressure and cerebral perfusion pressure monitoring methods. Explore the cerebral hemodynamic status of non-invasive monitoring of traumatic brain injury, assessment of intracranial pressure, cerebral perfusion pressure, cerebral autoregulation function and prognosis has received extensive attention.Cerebrovascular lesions due to traumatic brain injury (such as traumatic internal carotid artery cavernous fistula and aneurysm) disease danger of early detection and treatment, there are certain difficulties. In particular, the screening of traumatic carotid-cavernous fistula patients, endovascular embolization therapy monitoring and postoperative follow-up is one of the problems of neurosurgery. Explore non-invasive means of detection of cerebral hemodynamics in the practical value of the screening and diagnosis of traumatic brain vascular lesions, embolization monitoring and follow-up, has important clinical implications.In1982Norwegian scholar Professor Aaslid developed the world’s first transcranial Doppler ultrasound. Since then, the non-invasive clinical detection of cerebral hemodynamics research and application into a new era. Transcranial Doppler is a good penetration of the use of low-frequency ultrasound, low-frequency ultrasound probe by specific skull acoustic window, noninvasive method for detection of intracranial vascular hemodynamic parameters. Compared to other brain Department checks its non-invasive, convenient, fast, inexpensive, reproducible, and the characteristics of the dynamic monitoring. The technology into more than10years, is mainly used to detect whether the patient cerebral vasospasm and cerebral insufficiency, etc., in the neurosurgery clinical applications are still at an exploratory stage.The purpose of this study is to compare the use of non-invasive transcranial Doppler technology for monitoring patients with traumatic brain injury cerebral hemodynamics parameters change, and invasive intracranial pressure, cerebral perfusion pressure, arterial blood pressure and cerebral angiography gold standard establish a non-invasive real-time qualitative and quantitative intracranial pressure, cerebral perfusion pressure, cerebral blood flow and cerebral autoregulation status assessment methods; explore the variation of cerebral hemodynamics and prognosis and to choose the best timing of treatment and methods for clinical to guide surgery, vascular intervention and drug therapy, provide a theoretical basis, and also provides an effective means for the future new clinical therapies and drug selection to determine the efficacy and prognosis. The study by the non-invasive detection technology control study, no risk of the impact of the disease, there is no ethical hazards exist. The study includes the following four parts.PartⅠ The study of correlation on cerebral blood flow changes and intracranial pressure and cerebral perfusion pressure in middle-severe traumatic brain injuryObjective To explore the correlation of cerebral hemodynamic parameters of changes in intracranial pressure and cerebral perfusion pressure in severe traumatic brain injury after. Methods Noninvasive transcranial Doppler blood flow detection technology, prospective randomized controlled study in62patients with acute severe traumatic brain injury patients bilateral cerebral artery blood flow velocity detection indicators relevant parameters and spectral shape. The main parameters of detecting cerebral hemodynamics including:peak systolic velocity (Vs), diastolic low value of flow speed (Vd) mean blood flow velocity (Vm), pulsatility index (PI), resistance index (RI); same period in intracranial pressure monitor and ECG continuous monitoring of intracranial pressure (ICP), cerebral perfusion pressure (CPP) and mean arterial blood pressure (MABP). The statistical analysis of the relevant parameters of cerebral hemodynamics, MABP and ICP, CPP, analysis of the parameters of the relationship and relevance. The statistical analysis of the relevant parameters of cerebral hemodynamics, MABP and ICP, CPP, analysis of the parameters of the relationship and relevance. Results PI, RI and ICP showed a positive correlation, correlation coefficient, respectively, for r=0.898(P<0.0001), r=0.812(P<0.0001), ICP and CPP and PI, RI, Vd, Vm, MABP multi-step-by-step regression analysis found that PI and ICP, CPP and PI, MABP relationship is most closely related (P<0.0001). The non-invasive detection of cerebral hemodynamics parameters and spectral patterns can be reflected in real time in severe traumatic brain injury patients ICP and CPP changes. Cerebral blood flow detection noninvasive assessment of intracranial pressure and cerebral perfusion pressure with a non-invasive, convenient, inexpensive, reproducible, easy to clinical neurosurgical clinical intracranial pressure and cerebral perfusion pressure monitoring as an effective method.Conclusions The noninvasively cerebral hemodynamics may actual time reflect the changes of ICP and CPP in patients with moderate and severe head injuries,this is a effective means for monitoring ICP and CPP.Part II The study of Clinical value of non-invasive detecting on cerebral blood flow for evaluating prognosis of patients with middle-severe traumatic brain injuryObjective To explore parameters of cerebral hemodynamics and prognosis parameter index (GCS and GOS) correlation; investigate the clinical value of the parameters of non-invasive detection of cerebral hemodynamics in severe traumatic brain injury patient prognosis. Methods A prospective study of72cases of acute severe traumatic brain injury patients hurt the days1,3,7bilateral anterior cerebral, middle cerebral artery, posterior cerebral artery and vertebrobasilar hemodynamic parameters of detected by using non-invasive transcranial Doppler:pulsatility index (PI), resistance index (RI), peak systolic speed (Vs), end-diastolic blood flow velocity (Vd) and mean blood flow velocity (Vm). Dynamic record week after admission the patient’s GCS score, GOS score, and six months after injury. Analysis, Vs, Vd, Vm, PI, RI, GCS score after injury six months GOS prognostic score relationship. Results PI and RI GOS score was negatively correlated (PI:r=-0.553, P <0.0001; RI:r=-0.562, P<0.0001). Cerebral vasospasm is also independent prognostic factors affect patients, the the vasospasm group with vasospasm group prognosis there was a significant difference (X2=5.98, P<0.05), basilar artery blood flow velocity anomaly is the important factor affecting the prognosis of patients (X2=17.86, P<0.01), PI is the most sensitive indicator of the assessment of prognosis, PI>1.8indicates a poor prognosis. GCS score of the third day and the EICA-Vm prognosis maximum (P<0.0001), the correlation coefficient R=0.879, coefficient of determination R=0.763. Conclusions Effective method of non-invasive detection of cerebral hemodynamics parameters of the assessment of heavy traumatic brain injury patient prognosis; cerebral vasospasm and basilar artery blood flow velocity anomaly is an important factor affecting the prognosis of patients. PI is to assess the prognosis of the most sensitive indicators. After injury, the third day of the GCS score and EICA-Vm assess important prognostic indicators.Part Ⅲ The study of the clinical value of Noninvasive detecting cerebral blood flow for early evaluating brain death in patients with severe trauma brain injuryObjective To Explore non-invasive transcranial Doppler detection of patients with severe traumatic brain injury cerebral hemodynamic parameters parameters for the diagnosis of brain death clinical value, as well as the assessment of severe craniocerebral trauma after severe coma patient clinical prognostic value.Mothods Dynamically using transcranial Doppler non-invasive detection of60cases of severe traumatic brain injury patients (GCS<8, the duration of six hours or more), collecting the patient’s brain before, during and after arterial hemodynamics parameters of a double The parameters of the spectral shape of the side of the middle cerebral artery (MCA) blood flow MAIN OUTCOME MEASURES, combined with the clinical condition and CT, the ICP data control studies and statistical analysis. Results Deep coma after severe traumatic brain injury patients with bilateral cerebral artery mean blood flow velocity (MCA-Vm)<10cm/s, and two or more blood vessels appear diastolic reverse blood flow or a nail-like spectrum, the direction of blood flow index (DFI)<0.8, prompted a reliable indicator of brain death. Intracranial pressure (ICP)60mmHg is the critical pressure irreversible brain function indicators. Conclusion Noninvasive detection of cerebral hemodynamic parameters of the initial diagnosis of brain death for patients with severe traumatic brain injury and severe traumatic brain injury deep coma patient prognosis with high accuracy and reliability. The characteristic spectrum of brain death (RDF, and nails spectrum) as early as in the clinical brain death and6-12h, summed up the cerebral blood flow monitoring MCA-Vm<10cm/s, PI>2quantitative indicators of brain death may occur.Part IV The study of the clinic value of noninvasive cerebral blood flow detecting on the diagnosis and treatment of traumatic carotid-cavernous fistulaObjective To explore the value of detecting cerebral hemodynamics by transcranial Doppler (TCD) in diagnosis, treatment and monitoring for operation of traumatic carotid-cavernous fistula(TCCF). Methods Detected28cases of brain injury after merger eye conjunctival hyperemia, proptosis, intracranial vascular murmur and other suspicious internal carotid artery-cavernous fistula patients using noninvasive transcranial Doppler detection of indicator parameters including bilateral cerebral, anterior cerebral posterior cerebral artery blood flow parameters, the vertebrobasilar arterial blood flow parameters, extracranial segment of the internal carotid artery blood flow parameters. All cases were confirmed by digital subtraction cerebral angiography (DSA) confirm the diagnosis. Another reasons for DSA cerebral angiography18patients no brain vascular abnormalities Noninvasive transcranial Doppler parameters of cerebral blood flow detection and spectral shape as controls. Results Found that cerebral blood flow in non-invasive detection of extracranial internal carotid artery segment high-velocity, low-resistance spectrum, middle cerebral artery low flow low-resistance spectrum and ophthalmic vein abnormalities spectrum characteristic changes of the internal carotid artery-cavernous fistula with DSA cerebral angiography control with high accuracy and specificity. The ipsilateral the EICA-Vm higher than the contralateral EICA-Vm (P<0.05), see; the ipsilateral the EICA-PI lower than the contralateral EICA-PI (P<0.05). Surgery, non-invasive cerebral blood flow monitoring in real-time accurate assessment of carotid cavernous fistula embolization was successful. Noninvasive diagnosis TCCF results of cerebral blood flow detection sensitivity=85.71%, specificity=88.89%, Youden index=74.60%. Successfully embolized before Vm and PI surgery, after comparing the performance as Vm increased (P <0.01)and PI increased.Conclusion Noninvasive transcranial Doppler detection of cerebral blood flow carotid cavernous fistula preliminary clinical diagnosis and timely impact assessment and the patients were followed up for an effective means of intervention therapy. Extracranial internal carotid artery segment high flow, low flow low resistance and brain artery, low resistance for screening TCCF the accurate indicators of brain artery embolization of cerebral blood flow monitoring is an effective method of real-time evaluation of fistula thrombosis.(Figure22, table12, reference articles88).