Analytic Review

Journal of Intensive Care Medicine

1-8
Clinical Applications of Ultrasonography in ª The Author(s) 2020
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Neurocritically Ill Patients DOI: 10.1177/0885066620905796
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Andrés Fabricio Caballero-Lozada, MD1 , Kapil Laxman Nanwani, MD2,

Favio Pavón, MD1, Andrés Zorrilla-Vaca, MD1 , and Carolina Zorrilla-Vaca, MD1

Abstract
Ultrasonography is part of the multimodal monitoring of the neurocritical patient. Through transcranial color Doppler ultra-
sound, carotid-color Doppler ultrasound, and ocular ultrasound it is possible to diagnose and monitor a multitude of pathological
conditions, such as cerebrovascular events, vasospasm, Terson syndrome, carotid atheromatosis, and brain death. Furthermore,
these techniques enable the monitoring of the intracranial pressure, the cerebral perfusion pressure, and the midline deviation,
which allows us to understand the patient’s neurocritical pathology at their bedside, in a noninvasive way. Although none of these
tools have yet been shown to improve patient prognosis, the dissemination of knowledge and management of neurovascular
ultrasonography could significantly improve the comprehensive management of neurocritical patients.

Keywords
Doppler, critical care, ultrasonography, neurology

Introduction future,” through it, we would learn to “auscultate the brain.”5

Since time immemorial, neurocritical patients have aroused sci-
entific interest due to their complex semiology, morbidity, and
mortality. Evidence of this interest can be found from the archae-
ological remains of trepanations practiced in the Greek Bronze
Age (1900-1600 BC) and the pre-Columbian era.1 However, it is
only in the last century that we have experienced important
developments in the knowledge and management of the neuro-
critical patient, with multimodal neurological monitoring tech-
niques, which range from anatomy to specific metabolic
alterations: computerized axial tomography, magnetic resonance
imaging, ultrasonography, monitoring of intracranial pressure
(ICP), oximetry in the jugular bulb, tissue oxygen pressure, cer-
ebral microdialysis, and electroencephalography.2,3 Despite
advances and combinations of techniques, few measures have
actually been shown to improve the prognosis of these patients,
which implies in some way that neurocritical pathology remains
a mystery, and in medicine, every mystery is a challenge.
Unlike other multimodal neurological monitoring measures,
ultrasonography allows the noninvasive diagnosis and monitor-
ing of these patients at their bedside, without irradiation. In
addition to the many other advantages of ultrasonography in
the critical patient, it is widely available and relatively low
In the present review, the concepts and applications of ultra-
sonography in the neurocritical patient are examined.
Transcranial Color Doppler Ultrasound
The performance of TCD Ultrasound requires a low frequency
transducer (1.75-3.5 MHz), the convex probe being generally the
most useful in this context. The most commonly used ultrasound
windows are the transtemporal (in the region before the tragus of
the ear and above the zygomatic arch on the pterion), the sub-
occipital or transforaminal (in the midline below the occipital
scale and on the transverse process of the cervical vertebra with
semi flexed or cocked head) and orbital (through eyeball).6
In order to perform this ultrasound, it is also necessary to
know the anatomy of the circle of Willis (Figure 1) and the
main cerebral arteries. The circle of Willis is a vascular ring
that results from the union of branches of the internal carotid
arteries (ICAs) and the basilar artery (BA) which in turn is
1
Department of Anaesthesiology, Universidad del Valle, Cali, Colombia
2
Department of Intensive Medicine, University Hospital La Paz-Cantoblanco-
Carlos III, Madrid, Spain

cost. All this makes it a “Point-Of-Care” tool for the attending
physician, who through transcranial color Doppler (TCD)
ultrasound, carotid-color Doppler ultrasound, and ocular ultra-
sound (OU) would be able to identify deviations of the cerebral
midline, echographic signs of vasospasm, among others.4 In
short, if ultrasound is considered the “stethoscope of the
Received September 15, 2019. Received revised January 20, 2020.
Accepted January 22, 2020.
Corresponding Author:
Andrés Fabricio Caballero-Lozada, Department of Anaesthesiology,
Universidad del Valle, Street 4b 36-00, Cali, 76001, Colombia.
Email: andres.caballero@correounivalle.edu.co
2 Journal of Intensive Care Medicine XX(X)
Figure 1. Vascular anatomy of the circle of Willis.
formed by the union of the 2 vertebral arteries (VAs). In the
anterior region and originating in the ICAs, there are the ante-
rior cerebral arteries (ACAs), united by the anterior commu-
nicating artery (ACoA). In the middle region and originating in
the ICAs, there are the middle cerebral arteries (MCAs) with
their more horizontal proximal trajectory (M1), and their distal
and more tortuous path which is introduced by the Silvio sulcus
(M2). Finally, in the posterior region and originating in the BA,
the posterior cerebral arteries (PCAs) are found with their pre-
communicating (P1) and postcommunicating (P2), in reference
to the posterior communicating arteries (PCoAs), which join
the ICAs with the PCAs, and in this way form a 7-sided poly-
gon. It is important to note that P1 and P2 exhibit different
directions, since P1 initially goes to the middle region and then
in portion P2 it rotates and changes course toward the posterior
zone. The ophthalmic artery, on the other hand, is a direct
branch of the ICA and is directed toward the eyeball. This
complex structure that surrounds the sella turcica protects the
brain from ischemic events since it can reverse the direction
and increase the flow of certain arteries, in order to replace a
perfusion defect.7
When identifying the cerebral arteries, the characteristics of
the cerebral circulation, the ultrasound window, its depth, the
direction of flow, and its mean flow velocity (MFV) must be
considered. It is necessary to remember that the cerebral circu-
lation has a low cerebral vascular resistance (CVR) so the
diastolic flow will be determinant, and therefore, in comparison
with the rest of arteries of the organism, the diastolic flow
velocities (DV) will be higher, and the difference between the
peak systolic velocity (SV) and DV will be smaller.8 As for the
other parameters, they are explained below.
The transtemporal window allows the evaluation of ACAs,
MCAs, and PCAs. The patient is placed in the supine position
with a cephalic inclination of 15 to 30 , orienting the transdu-
cer toward the tip of the patient’s nose (in such a way that in the
image, the anterior side is shown on the left side of the screen).
The first thing to identify is a semicircular hyperechoic line that
corresponds to the contralateral skull, since it allows adjust-
ment of image depth. With the transducer perpendicular to the
bone, a double hypoechoic structure in the form of a butterfly
corresponding to the mesencephalon should be identified. In
front of it, is the sella turcica and the temporal bone, a region in
which it is possible to locate the circle of Willis by applying the
color Doppler.
Below the temporal bone is the internal carotid artery (ACI)
in its portion of the carotid siphon along with the MCA. Ante-
rior to the MCA and going to the frontal lobe is the ACA, and
after the MCA embracing the mesencephalon toward the pos-
terior region, the PCA is found. By tilting the transducer 10
toward cephalic, it is possible to identify 2 hyperechoic lines
which correspond to the midline in the area of the diencepha-
lon, and if we continue tilting toward cephalic, we will identify
the lateral ventricles and the thalamus.6,8,9
It is important to bear in mind that with the transtemporal
window, the circle of Willis is accessed from the side, therefore
the ultrasound image will not be the same as that of the computed
tomography (CT), but will be rotated 90 . This is important since
the Doppler-color allows determination of the flow direction, in
such a way that, depending on the configuration of the ultrasound
equipment, it is possible to identify by means of a color system,
whether the blood vessel approaches or moves away from the
transducer. In addition, it is important to identify the middle line
so as not to be confused with the vessels on the opposite side to the
one being studied, since they will present opposite flow direc-
tions. In that order of ideas, the artery closest to the insonated zone
would be the MCA that is characterized by approaching the trans-
ducer (30-55 mm, MFV: 55-80 cm/s), while both the ACA and the
PCA would be found deeper (60-80 mm). The ACA is character-
ized by moving away from the transducer in the anterior region
(MFV: 50-60 cm/s) while the PCA in its P1 portion approaches
the transducer, and in its P2 portion it moves away from the
transducer (MFV: 42-53 cm/s).6,8,9 Figure 2 shows the increased
peak velocity in temporoparietal windows.
The suboccipital or transforaminal window allows the
visualization of both VAs that come together to form the
basilar. Since it is insonated in the cephalic direction and the 3
mentioned arteries are directed toward the foramen magnum,
both the VA (55 mm, MFV: 33-44 cm/s) and the BA (60-80
mm, MFV: 35-50 cm/s) will move away from the transducer,
with the VA being closest to it (see Figure 3). Finally, the
Caballero-Lozada et al 3

Figure 2. Transducer orientation in temporal window (A) showing the blood flow velocity chart (B) in transcranial Doppler ultrasound of the
middle cerebral artery (C).

Figure 3. Transducer orientation in suboccipital window (A) suboccipital approach of ultrasound measuring the blood flow velocity of basilar
artery (B and C).

ophthalmic window would allow identification of the ophthal-
mic artery (40 mm, MFV: 20-30 cm/s and morphology of the
peripheral artery), and the internal carotid at the height of the
carotid siphon (60-80 mm), both going toward the transducer
6,8,9
(Figure 4).
Carotid Color Doppler Ultrasound
The performance of Carotid Color Doppler Ultrasound
(CCD Ultrasound) requires a high frequency linear transducer
(10-12 MHz) that is placed in the lateral cervical region to
identify the common carotid artery (CCA) and its posterior
4 Journal of Intensive Care Medicine XX(X)
Figure 4. Transducer orientation in ophthalmic window (A) ocular ultrasonography estimating the measurements of the ophthalmic artery (B
and C).
bifurcation in the external carotid artery (ECA) and the ICA. In
the longitudinal plane, it is possible to evaluate the existence of
atheromatous plaques, and whether or not they produce signif-
icant stenosis as a function of flow velocities by means of
Doppler.10,11 Likewise, the measurement of the thickness of
the intima-media of the CCA could be performed on its poster-
ior wall at 1 cm from the bulb, since it constitutes an indepen-
dent factor of coronary risk, its normal value being less than 0.9
mm.12 Finally, the ECA differs from the ICA since it is directed
toward the jaw, because it has an increased systolic and a lower
diastolic peak velocity (unlike the ICA which behaves like a
cerebral artery), and responds to the “tapping,” which consists
in percussing the temporal artery (branch of the ECA) and
objectifying the percussion transmitted in the ECA.10,11 The
measurement of the average speed of the ICA makes it possible
to calculate the Lindegaard index (LI), as will be seen later.13
In Figure 5, measurement of flow at the level of the carotid and
measurement of the intima are shown.
Ocular Ultrasound
Ocular Ultrasound is performed with a high-frequency linear
transducer (10-12 MHz) that is placed with abundant ultra-
sound gel on the closed eye to visualize the optic nerve and
determine the existence of papillary edema, which has been
associated with the presence of ICP.14 To do this, a 3-mm line
is drawn perpendicular to the vitreoretinal junction and from
there the diameter of the optic nerve sheath (ONSD) is mea-
sured (reported as being pathological from 5-5.9 mm15), along
with the ONSD. In addition, this technique allows the evalua-
tion of pupillary reflexes, as well as an examination of the
integrity of the retina and vitreous humor to rule out Terson
syndrome, which consists of the presence of a vitreous hemor-
rhage associated with a subarachnoid hemorrhage (SAH) that
could cause blindness if left untreated. The presence of vitreous
hemorrhages generates suspicion of this entity, so a regulated
assessment by ophthalmology must be requested.16,17
Clinical Applications of Ultrasonography in
the Neurocritical Patient
Cerebral Vascular Pathology
As a first step, it should be remembered that the Doppler func-
tion does not measure flow but flow velocities in cm/s, the use of
the average velocities of the cerebral arteries being standardized
to detect vascular pathology. Indirectly, brain perfusion pressure
(BPP) could be estimated using mean arterial pressure (MAP)
using the formula BPP ¼ (MAP  DV/MFV) þ 14.18 In the
presence of a cerebrovascular event due to an intracranial ste-
nosis or an embolism, very high intrastent velocities would be
observed (SV > 120 cm/s or MFV > 75 cm/s), while the pre and
Caballero-Lozada et al
Figure 5. Longitudinal plane in cervical window showing the common carotid artery, the thickness of its intima-media and its normal blood flow
velocity (A and B).
poststent velocities would both decrease with asymmetry
between the right and left sides, and differences of SV >20%
between the healthy side and the affected side. In addition, as
previously explained, changes are observed in other vascular
territories. For example, in the case of an MCA obstruction, the
MFV of the contralateral ACA, as well as the ipsilateral PCA
and PCoA would be elevated, with inversion of the ipsilateral
ACA. It is possible to classify these alterations according to the
thrombolysis in brain ischemia (TIBI) scale or the consensus on
grading intracranial flow obstruction (COGIF) scale, which will
serve to assess the direct recanalization during fibrinolysis.19-21
In the presence of a carotid obstruction due to an atheroma-
tous plaque or trauma, a decrease in the speed of the ipsilateral
MCA, an inversion of the flow of the ipsilateral ACA, an
inversion of the flow of the ipsilateral ophthalmic artery, and
a flow through the ACoA should be observed toward the
injured side, and a generalized increase in speeds on the con-
tralateral side.21 Given these findings, CCD ultrasound would
be performed to confirm the existence of a carotid obstruction
that would be classified according to the percentage of obstruc-
tion consistent to the velocity of the obstruction.21,22
Another frequent entity in the neurocritical patient is the
vasospasm. Although the physiopathological mechanism is
unknown, it is more frequent in patients who have a SAH, due
to either a spontaneous or traumatic aneurysm. It is a vasocon-
striction of a brain territory that can lead to ischemia of this
region in a secondary way, and its presence worsens the prog-
nosis in these patients, given that its management is also not
clear. Because the presentation time from the neurovascular
event is variable, the patient should be scanned ultrasonogra-
phically in a serial manner in order to be able to identify it,
especially in the first 3 weeks following the event. For the
diagnosis of vasospasm, the MFV of the MCA or the BA and
the Lindegaard index should be considered, and can be done on
the MCA or on the BA by comparing the average speeds of
these with the MFV of the internal carotid artery (ICA) (which
is calculated similarly to the MAP as 1/3SV þ 2/3DV). This
5
makes the combination of TCD ultrasound and CCD ultra-
sound necessary. In the case of the MCA, a high MVF (and
especially an MVF > 180 cm/s) should generate suspicion of
the presence of vasospasm, making it necessary to calculate the
LI dividing the MVF of the MCA between the MVF of the
ipsilateral ICA. An increase in velocities by itself can indicate
in a practical way hyperemia or vasospasm/stenosis, which is
why the MVF of the MCA is compared to the MVF in the ICA,
to discern between both entities.
In the event that both MFVs increase in parallel, the LI would
remain below 3, indicating a situation of hyperemia, where both
MFVs are elevated or normal. Conversely, an elevation of the
MFV of the MCA that is not accompanied by an increase in
the MFV of the ICA would imply an LI > 3 which would suggest
the presence of vasospasm and would allow it to be classified as
mild, moderate, severe, or critical depending on the MFV of the
MCA and the LI. With the BA, the calculations are similar
except that in this case, the MFV of the BA4,23,24 would be used.
Structural Brain Pathology
In terms of cerebral and systemic structural pathology, the Gosl-
ing pulsatility index (PI) and the Pourcelot resistance index (RI)
calculated by Doppler should be considered. The PI is calculated
as (SV-DV)/MFV, with the normal range between 0.85 and 1.1.
The PI indirectly shows the cerebral vascular resistance, indicat-
ing the maximum variability of the flow in the cardiac cycle and
the cerebral receptivity to the blood bolus, in such a way that it is
proportional (though not linearly) to the compliance of the cere-
bral vascular tissue, heart rate, and CVR. Furthermore, the RI is
calculated as (SV-DV)/SV, with the normal range between 0.42
and 0.62. The RI allows estimation of the resistance of the
circulatory system to the flow.
Both parameters will be elevated before ICP, with
decreased BPP, hypocapnia, hypothermia, brain death, hyper-
viscosity syndrome, intracranial occlusion, and advanced age
(arteriosclerosis). Conversely, both parameters decrease in
6 Journal of Intensive Care Medicine XX(X)
situations of hyperemia, hypertension, hypercapnia, vasos-
pasm, intracranial stenosis, arteriovenous malformation, and
rewarming due to cardiorespiratory arrest. These parameters
are important for differentiating cerebral vascular pathology
from cerebral and systemic structural pathology, for example,
a patient with ICP secondary to a brain space-occupying
lesion (SOL) will have a decreased MFV with a high PI, since
it produces an increase in CVR due to the ICP and extrinsic
compression of the vascular system. Instead, a patient with an
intracranial stenosis will present decreased MFV with a low
(IP) in the poststenotic area, given that the CVR is lower in
this zone.4-6 The relationship between the PI and the ICP has
been studied, establishing a relationship between both in such
a way that ICP ¼10.93  PI  1.28 (E92%; S89%), that is, an
PI >13 correlates with a ICP >22 mm Hg.4 Additionally, there
are studies that suggest using TCD ultrasound for the moni-
toring of BPP and CVR in the septic patient to individualize
hemodynamic goals.25
The TCD ultrasound also allows the monitoring of intracra-
nial lesions and cerebral SOLs without the need to perform
serial CT scans, substantially improving the quality of the
image if the patient has undergone a craniectomy. It makes it
possible to evaluate the dimension of the lesion and if it pro-
duces mass effect, the deviation of the midline and the presence
of subfacial herniation. To measure the volume of the lesion,
the height, width, and length of the lesion would be multiplied
and the result would be divided by 2. To measure the deviation
of the midline, the transtemporal window is accessed to iden-
tify the double hyperechoic line ahead of the mesencephalon
corresponding to the third ventricle, comparing the measure-
ments from the beginning of the insonated region and from the
midline to the contralateral cranium (which should correspond
to half of the previously performed measurement), thus permit-
ting determination of whether or not there is a deviation from
the midline and enabling its quantification.4,6
Furthermore, TCD ultrasound identifies inappropriate flows
related to “encephalic death.” The progressive decrease of the
BPP, either in relation to a decrease in the MAP or an increase in
the ICP, generates cerebral flow waves that will be distinguished
from the normal pattern, since they will gradually present a
decrease in the DV until they are reversed, and disappear pro-
ducing a separation between systole and diastole with a rever-
berant flow, isolated systolic spikes and finally absence of
cerebral flow. The PI begins to rise progressively and in parallel
with the evolution of the waves previously described.21,26
In short, ultrasonography in neurocritical patients allows the
physician to monitor ICP and BPP, to assess self-regulation,
detect vasospasm, vascular stenosis and occlusions, as well as
recanalizations, thereby facilitating the diagnosis of brain death,
the detection of shunts, cardiac events, cerebrovascular events in
patients with sickle cell anemia, to assess hydrocephalus and
ICP, among other things. However, all these applications cur-
rently present relatively low evidence compared to the reference
techniques (except for sickle cell anemia in pediatric age), which
invites us to continue working on the dissemination and knowl-
edge of ultrasonography in the neurocritical patient.5,27
As any diagnostic technique, the transcranial ultrasonography
in critical patients has its limitations which can be diminished
with an adequate physics-based understanding of the technique
and an adequate training curve for the hands-on component. The
technique is operator-dependent, that is why it is important the
correct data analysis, the sufficient time for the study, and the
expertise of the operator. In many occasions, the windows are
not adequate due to individual features of the bone; in general,
the percentage of this situation is around 5% to 15% of the
patients. In women older than 60 years, the window is difficult
for the study, especially the temporal window. Given this cir-
cumstance, it is necessary to analyze other possibilities such as
the orbital window or the occipital window among others. In
most cases, the individual anatomic variations of the patient,
of the Circle of Willis, may cause errors of inexpert people such
as the wrong identification of the vessel and a mistaken inter-
pretation of the fluxes analysis. The interferences with other
electronic devices are minimum.28-32
Conclusions
Ultrasound in the neurocritical patient allows, through TCD
ultrasound, carotid-color Doppler ultrasound, and OU, the
diagnosis and monitoring of multiple pathological conditions,
both neurological and non-neurological. The knowledge of
both vascular and structural brain pathology is part of the multi-
modal monitoring of the neurocritical patient, and although it
has not been shown to improve the prognosis of these patients,
it has allowed for a better understanding of this pathology,
therefore further studies are needed to demonstrate the benefits
of ultrasonography in this context.
Authors’ Note
All authors contributed to the study conception and design. Material
preparation, data collection and analysis were performed by Andrés
Fabricio Caballero-Lozada, Kapil Laxman Nanwani, Favio Pavón,
Andrés Zorrilla-Vaca, and Carolina Zorrilla-Vaca. The first draft of the
manuscript was written by Andrés Fabricio Caballero-Lozada and
Andrés Zorrilla-Vaca, and all authors commented on previous versions
of the manuscript. All authors read and approved the final manuscript.
Acknowledgments
The authors would like to thank to all the members of the Anaesthe-
siology and Resuscitation research group of Universidad del Valle.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Andrés Fabricio Caballero-Lozada, MD https://orcid.org/0000-
0002-4161-4805
Andrés Zorrilla-Vaca, MD https://orcid.org/0000-0001-8140-8486
Caballero-Lozada et al
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