Introduction: The incidence of vasospasm in children after moderate to severe traumatic brain injury is reported between 18 and 46%. Transcranial Doppler ultrasound (TCD) can be performed at the bedside without need for sedation. In this patient population, a clinical exam is often impossible due to induced coma for treatment of the brain injury. Vasospasm may not result in changes of other parameters, such as intracranial pressure, or brain oxygenation. CT and MR angiography, followed by digital subtraction angiography (DS) are often used to confirm findings suspected from elevated TCDs.
Methods: Three patients with severe traumatic brain injuries underwent daily TCD monitoring of intracranial arterial blood flow. In the first two patients, elevation of TCDs in the MCA distribution was found on post-trauma days 6 and 8 (Figures 1 and 2). The third patient developed retrograde flow in the basilar artery on day 6(Figure 3). All three underwent MR angiography followed by DS angiography with verapamil injection.
Results: Immediate post-injection angiography revealed improved parent vessel and distal flow in all 3(Example:Figure 4). Decline in TCD velocities (Patients 1 and 2) and anterograde flow (Patient 3) were obtained, respectively (Figure 5). No areas of diffusion change occurred in the territories supplied by treated vessels. No patient exhibited change in ICP or other clinical metric. There was no recurrence of spasm and all three patients have recovered to a Glascow outcome score of 5, followed at 2, 10, and 16 months.
Conclusions: We propose that TCDs are sensitive and specific enough that 4 vessel angiography with the potential for intra-arterial calcium channel blocker should be obtained for acute and sustained elevations. TCDs can be obtained safely, without moving the patient, or need for sedation. The incidence of vasospasm in the pediatric population may be under-reported, and warrants further investigation.
Patient Care: Utilization of TCDs on a routine basis may identify vasospasm that is not clinically detectable
Learning Objectives: Understand the utility of transcranial doplers and the risk of vasospasm in pediatric brain injury