Cerebral ultrasound is a developing point of care tool for intensivists and emergency physicians, with an important role in the diagnosis of acute intracranial pathology, such as the assessment of cerebrovascular diseases and in the noninvasive intracranial pressure measurement both in the acute clinical settings and in intensive care unit (ICU). The traditional application of transcranial doppler (TCD) by assessing blood flow velocities in the main cerebral arteries, allows the evaluation and follow up of cerebral vasospasm, cerebral perfusion pressure, cerebral autoregulation and intracranial hypertension. The use of TCD, traditionally limited to the neurosonology laboratories settings, has expanded over the last years following the introduction of B-mode ultrasound and color Doppler, the transcranial color-coded duplex ultrasonography (TCCS), opening a new window to the assessment of cerebral anatomy not only in the neurocritical patients, but also in general ICU and emergency room patients. Here we report a brief review with the intent to up-to-date and describe the main applications and use of TCD/TCCS in the setting of Neurointensive Care.

Objective: To evaluate the frequency, types, and location of posttraumatic cerebral infarction, to assess if secondary cerebral insults were associated with cerebral infarction, and to determine if cerebral infarction affected patients9 outcome. Methods: We based diagnosis of cerebral infarction on review of brain CT scans. We assessed frequency of secondary cerebral insults, including intracranial hypertension, cerebral hypoperfusion, systolic hypo- and hypertension, arterial blood oxygen desaturation, hypocapnia, and hyperthermia, using clinical charts. We used the Glasgow Outcome Scale to evaluate outcome at 6 months after trauma. Results: Of the 89 patients included, a total of 28 cerebral infarctions were found in 17 cases (19.1%). Infarctions were territorial in 23 (82.1%) and watershed in 5 (17.9%) cases. Territorial infarctions were localized to the middle cerebral artery (n = 9, 32.1%), lenticulostriate arteries (n = 6, 21.4%), posterior cerebral artery (n = 3, 10.7%), anterior cerebral artery (n = 3, 10.7%), thalamoperforating arteries (n = 1, 3.6%), and basilar artery (n = 1, 3.6%) territories. Watershed infarctions were in the boundary (n = 4, 14.3%) and terminal (n = 1, 3.6%) zones. Intracranial hypertension was the only independent variable predicting cerebral infarction (odds ratio [OR] 13.3; 95% CI 2.8 to 62.6). At 6 months after trauma, there was a lower proportion of patients with good outcome among patients with cerebral infarction vs patients without (23.5 and 61.1%; p = 0.005). Cerebral infarction was the only independent predictor of 6-month outcome (OR of good outcome 0.19, 95% CI 0.06 to 0.66). Conclusions: The risk of developing posttraumatic cerebral infarction may be higher in patients with intracranial hypertension than in those without. Patients with posttraumatic cerebral infarction may be at increased risk of residual disability.

Cerebral venous and dural sinus thrombosis (CVDST) is a rare cause of stroke in young and middle-aged adults. When the clinical course is complicated by uncontrollable intracranial hypertension and brainstem compression due to edema or cerebral hemorrhage, the prognosis is poor. The authors evaluated the therapeutic role of surgical decompression in patients with clinical signs of impending herniation. Cerebral venous and dural sinus thrombosis complicated by impending brain herniation a very rare, life-threatening but potentially treatable clinical condition. Three patients with pupillary signs of transtentorial herniation due to brain edema and hemorrhage caused by CVDST (superior sagittal sinus in 1 patient and transverse and sigmoid sinus in 2 patients) were treated surgically. The intervention consisted of clot removal, infarcted tissue resection, and frontotemporoparietooccipital craniectomy with duraplasty. According to the Glasgow Outcome Scale, 2 patients were classified as having good recovery and 1, moderate disability. The results of neuropsychological assessment were normal in 2 patients and demonstrated a partial neuropsychological deficit (neglect) in the other. Surgery may be indicated in selected patients with CVDST whose condition is deteriorating because of intractable intracranial hypertension and impending brain herniation.