Review
Ultrasound applications in the central nervous system for neuroanaesthesia and neurocritical care
Aplicaciones de la ultrasonografía en el sistema nervioso central para Neuroanestesia y cuidado neurocrítico
Lucas Ochoa-Péreza,
, Alejandro Cardozo-Ocampob
Corresponding author
lucas8a1000@hotmail.com
Corresponding author at: Calle 26 sur # 43 a 41 Apartamento 941, Medellín, Colombia.
Corresponding author at: Calle 26 sur # 43 a 41 Apartamento 941, Medellín, Colombia.
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Specialist in Emergency Medicine, Special Care Unit, Clínica CES. Emergency Director, Instituto Neurológico de Colombia, Medellín, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author at</span>: Calle 26 sur # 43 a 41 Apartamento 941, Medellín, Colombia." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aplicaciones de la ultrasonografía en el sistema nervioso central para Neuroanestesia y cuidado neurocrítico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 993 "Ancho" => 2666 "Tamanyo" => 190551 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Visualization of the structures in a patient through the temporal bone window.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Source: authors.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Ultrasound performed by non-radiologist physicians has gradually positioned itself as a low-cost, non-invasive, safe, effective and fast tool to facilitate the work of paediatricians,<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">1</span></a> emergency medicine and critical care specialists,<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">2</span></a> and anaesthetists,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">3</span></a> among others. Routine use of ultrasound improves safety, and timeliness, and could even improve outcomes in different clinical situations.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The most common applications include ultrasound-guided catheterization,<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">4</span></a> abdominal assessment in trauma (Fast) and extended assessment (e-Fast),<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">5</span></a> echocardiography,<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">6</span></a> screening in aortic disease,<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">7</span></a> and procedures such as drainage in ascitis and pleural effusion, and guidance of anaesthetic blockades.</p><p id="par0015" class="elsevierStylePara elsevierViewall">However, different scenarios have been proposed for the use of ultrasound as a tool for solving specific clinical problems: what is the volemic status? Are inotropes required? Is decompressive craniotomy required? Some of the answers to these questions may be elicited by means of new applications such as inferior vena cava measurement for volemic status assessment,<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">8</span></a> thoracic ultrasound, critical care protocols,<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">9–11</span></a> ocular ultrasound,<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">12</span></a> or CNS ultrasound.</p><p id="par0020" class="elsevierStylePara elsevierViewall">This review focuses on relevant CNS applications in anaesthesia and critical care.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0025" class="elsevierStylePara elsevierViewall">A search of the terms echography, ultrasound, cerebral midline, CNS ultrasound, cerebral Doppler ultrasound, optic nerve ultrasound was conducted in the medical literature available in the Pubmed database until April 2014. Relevant articles were selected and reviewed with no date restriction and, finally, a narrative review on the applications of ultrasound in the CNS was performed.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Visualization of the midline and ventricles, and of parenchymal brain lesions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cerebral midline shift is one of the severity indicators in neurological disease and it determines surgical management in certain instances. Case reports have shown that it is possible to visualize the midline in the bone window though the temporal bone squama.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">13</span></a> Brain ultrasound requires a low-frequency transducer (1–5<span class="elsevierStyleHsp" style=""></span>MHz) together with the transcranial Doppler software for image optimization.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The technique is essentially the same as in transcranial colour Doppler, except that the structures are visualized in the B mode (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Lateral ventricles and midline may be visualized, and there are reports of midline shifts in patients with stroke, dural haematomas and, occasionally, basal ganglia haemorrhage.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Shunts may be localized using this technique.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">14,15</span></a> It is important to remember that the ultrasound window is not good in up to 15% of cases, preventing the visualization of the brain structures.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">16</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In patients taken to decompressive craniotomy (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), the brain parenchyma may be visualized more readily given the absence of artefacts and bone acoustic shadowing. In these patients, the transducer is placed on sites with no bone tissue present, and no specific anatomic landmark is required. There are reports of the ability to follow-up on the size of intracranial haematomas, position shunt catheters,<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">17</span></a> monitor midline shifts, or follow-up after treatment.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">18</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Optic nerve measurement and correlation with intracranial hypertension</span><p id="par0050" class="elsevierStylePara elsevierViewall">Intracranial hypertension is a life-threatening condition. It is measured with the help of intracranial devices, but this is associated with complications such as infection, bleeding or dysfunction.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">19</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The search for diagnostic tools associated with less morbidity has focused on non-invasive methods such as nuclear magnetic resonance, computed axial tomography and transcranial Doppler ultrasound. However, there is limited correlation between these methods and specific intracranial pressure values.<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">20,21</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The use of ocular ultrasound was first reported in 1965.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">22</span></a> It has recently been proposed that measurement of the optic nerve sheath diameter through the ocular window may be a non-invasive method for the detection of intracranial hypertension.<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">19,23</span></a> Moreover, good intra- and inter-observer reproducibility has been demonstrated.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">24</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">This measurement is based on the fact that the most distal portion of the nerve has a dural covering known as the optic nerve sheath,<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">25</span></a> which becomes dilated as intracranial pressure rises and CSF is distributed through along the dura. These changes are greater in the anterior portion of the nerve sheath, just behind the eyeball, an area that is easily accessible by ultrasound.<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">26–28</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Given the late onset of clinical signs in cases of intracranial hypertension, early ultrasound detection allows for prompt therapeutic action, thus contributing to improved outcomes.<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">29,30</span></a> Ultrasound is less time consuming when compared with other neuroimaging studies, and eliminates the need to transfer critically ill patients. Moreover, it offers the possibility of assessing response to treatment by means of serial measurements.<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">31–33</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">A learning curve of 10 measurements with 3 abnormal scans is proposed for physicians with experience in ultrasound, and 25 scans may be adequate for a non-experienced ultrasonographer.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">32</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">How to measure the optic nerve sheath</span><p id="par0080" class="elsevierStylePara elsevierViewall">A high-frequency (7–10<span class="elsevierStyleHsp" style=""></span>MHz) linear transducer is required.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">22</span></a> The ultrasound machine is set to visualize structures up to 5–6<span class="elsevierStyleHsp" style=""></span>cm deep. The transducer is placed over the closed eyelid after generous gel application.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The optic nerve is identified as the hypoechoic structure traversing along a regular course behind the eyeball. For measurement, a vertical line is drawn from the junction between the optic nerve and the eyeball. This line serves just as a reference and must be 3<span class="elsevierStyleHsp" style=""></span>mm long. Once the 3<span class="elsevierStyleHsp" style=""></span>mm length is established, a horizontal line is drawn across the optic nerve. This second line provides the measurement of the optic nerve in mm (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>).<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">32,33</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">For most of the authors included in the review, 5<span class="elsevierStyleHsp" style=""></span>mm is the cut-off point for determining that the scan is positive for intracranial hypertension; other authors propose different values (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Worth mentioning is a systematic review published by Dubourg et al.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">33</span></a> in 2011 in which the authors assess the diagnostic accuracy of optic nerve measurement compared with the invasive measurement of the intra-parenchymal pressure as the gold standard; 6 prospective cohort studies totalling 231 patients were included, but no significant heterogeneity was found for the sensitivity or the specificity of the ultrasound measurement.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">33</span></a> The sensitivity and specificity of the optic nerve sheath measurement are 0.90 (95% CI, 0.80–0.95) and 0.85 (95% CI, 0.73–0.93), respectively. This review also showed a reliability of 0.2–0.3<span class="elsevierStyleHsp" style=""></span>mm among reviewers. The problem was the lack of an accurate cut-off point for defining optic nerve sheath dilatation in all the studies. The measurement of the optic nerve sheath diameter has been found to have good diagnostic accuracy for detecting intracranial hypertension and influences the decision of patient referral to specialized centres.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">33</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">There are authors who are against the use of optic nerve measurement for determining intracranial hypertension.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">34</span></a> However, the absence of correlation so far does not seem to be associated with the technique or the pathophysiological process but rather with the lack of a standard cut-off point suggesting the boundary between normalcy and hypertension.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">35</span></a> There is also a need to standardize the scanning technique because, as a sphere, the eye may be scanned longitudinally or cross-sectionally and there is no way of knowing how this may affect the results.<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">24,35–37</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">To solve this issue, the PROSPERO initiative was created in 2013 with the aim of assessing the diagnostic accuracy of ultrasound measurement of the optic nerve sheath for the detection of intracranial hypertension and the establishment of an accurate cut-off point for the creation of an individualized patient database.<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">38</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Transcranial colour Doppler</span><p id="par0110" class="elsevierStylePara elsevierViewall">The sonographic approach to the intracranial arteries poses greater difficulties when compared with optic nerve or midline assessment. The learning curve is steep and a good sonograhic window will not be achieved in 15% of patients, making access to that form of imaging difficult.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">16</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">This may be overcome in part with the use of transcranial colour Doppler, which requires a machine equipped with a 1–5<span class="elsevierStyleHsp" style=""></span>MHz microconvex transducer and colour Doppler functionality. The sonographic window is obtained through the squama of the temporal bone (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). A second window may be performed through the eye in order to find the ophthalmic artery, with a third window through the post-auricular area in order to access the posterior cerebral artery. The use of the colour function allows visualization of the intracranial arteries, in particular the middle cerebral artery<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">38</span></a> (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">The two most widely accepted applications for transcranial Doppler ultrasound are vasospasm control in patients with subarachnoid haemorrhage (Class IIa evidence),<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">16,38–47</span></a> and brain death confirmation (Class IIa evidence).<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">39–48</span></a> Other applications, although with limited evidence, include the use of flow velocities in the main cerebral arteries as a means to monitor brain haemodynamics.<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">42–45</span></a> The use of the relationship between the middle cerebral artery flow and velocities as measured by Doppler and the mean arterial pressure has been proposed for assessing the integrity of cerebral autoregulation.<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">46</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Of interest in neurocritical care and neuroanaesthesia has been the possibility of having a way to monitor critically ill patients in the intensive care room or in the operating room. Transcranial colour Doppler has the invaluable potential of providing non-invasive, real time and dynamic information about modifiable brain haemodynamic variables that may have an impact on patient outcomes.<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">49,50</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">Central nervous system ultrasound performed by non-radiologist specialists is an increasingly available low-cost, versatile and accurate approach that helps improve timeliness and objective decision-making. These applications are expected to expand greatly in the near future and to offer improved correlation with specific pathophysiological processes that influence decision-making in neurocritical patients.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors did not receive sponsorship to undertake this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres573664" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec590593" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres573663" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec590592" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Visualization of the midline and ventricles, and of parenchymal brain lesions" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Optic nerve measurement and correlation with intracranial hypertension" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "How to measure the optic nerve sheath" ] ] ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Transcranial colour Doppler" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-07-31" "fechaAceptado" => "2015-03-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec590593" "palabras" => array:5 [ 0 => "Ultrasonography" 1 => "Optic nerve" 2 => "Intracranial hypertension" 3 => "Central nervous system" 4 => "Intensive care" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec590592" "palabras" => array:5 [ 0 => "Ultrasonografía" 1 => "Nervio óptico" 2 => "Hipertensión intracraneal" 3 => "Sistema nervioso central" 4 => "Cuidado intesivo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ultrasonography performed by non-radiologist specialists is a tool that contributes to the diagnosis and monitoring of neurocritical patients. It is a non-invasive, low-cost, accurate and fast method that helps improve safety and timeliness in settings where prompt decision-making is imperative, such as in the operating room, critical care units or the emergency room.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The objective is to conduct a narrative review, presenting ultrasound applications focused on the central nervous system that may be useful in neuroanaesthesia and neurocritical care. A search was performed of related terms on databases in the medical literature. Relevant papers where selected and reviewed to perform a non-systematic review focusing on the visualization of the midline and lateral ventricles, the measurement of the optic nerve sheath as a surrogate marker of intracranial hypertension, and the use of colour Doppler for visualizing the middle cerebral artery.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">It is expected that the use of ultrasound examination of the central nervous system will continue to evolve given its advantages, good correlation with studies considered as the gold standard, and the growing availability of the device. Advancements in this field are expected to improve timeliness and provide objective guidance for decision-making. We recognize the importance of developing skills in the use of this method of exploration in those services where it is required.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La ultrasonografía realizada por especialistas no radiólogos es una herramienta que contribuye al diagnóstico y monitoreo de los pacientes neurocríticos. Adicionalmente es económica, precisa, no invasiva y rápida, lo que mejora la seguridad y oportunidad en escenarios donde la toma inmediata de decisiones es imperativa tales como salas de cirugía, unidades de cuidado crítico o servicios de urgencias.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo es realizar una revisión narrativa presentando las aplicaciones ultrasonográficas enfocadas al sistema nervioso central (SNC) que pueden ser útiles en neuroanestesia y cuidado neurocrítico. Se realizó una búsqueda en bases de datos de los términos relacionados en la literatura médica. Se seleccionaron y revisaron artículos de relevancia para realizar una revisión no sistemática que se centró en la visualización de la línea media, ventrículos laterales, medición de la vaina del nervio óptico como subrogador de hipertensión endocraneana y en la visualización de la arteria cerebral media a través de doppler color.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se prevé que continuarán los avances en la exploración ultrasonográfica del SNC debido a sus ventajas, la buena correlación con los estudios considerados como estándar de oro y la creciente disponibilidad de ecógrafo. Es de esperar que se mejore la oportunidad y ayude a dirigir la toma de decisiones objetivamente. Se reconoce la importancia del desarrollo de habilidades en el manejo de este método de exploración para aplicarlo en los servicios donde sea requerido.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ochoa-Pérez L, Cardozo-Ocampo A. Aplicaciones de la ultrasonografía en el sistema nervioso central para Neuroanestesia y cuidado neurocrítico. Rev Colomb Anestesiol. 2015;43:314–320.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 993 "Ancho" => 2666 "Tamanyo" => 190551 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Visualization of the structures in a patient through the temporal bone window.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Source: authors.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1047 "Ancho" => 2666 "Tamanyo" => 219047 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Patient with decompressive craniotomy.</p> <p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Source: authors.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1191 "Ancho" => 2666 "Tamanyo" => 229487 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">View of the optic nerve sheath. Normal diameter.</p> <p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Source: authors.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1035 "Ancho" => 2332 "Tamanyo" => 172522 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Optic nerve view. Increased diameter.</p> <p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Source: authors.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 718 "Ancho" => 950 "Tamanyo" => 81430 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Colour Doppler of middle cerebral artery.</p> <p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Source: authors.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Optic nerve diameter (mm) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">% Sensitivity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">% Specificity \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Blaivas et al.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">19</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Goel et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tayal et al.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">19</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Kimberly et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Moretti et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Moretti et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Geeraerts et al.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">27</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Geeraerts et al.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">27</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Soldatos et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Major et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab936487.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Adapted from Hasan.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">23</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:50 [ 0 => array:3 [ "identificador" => "bib0245" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Advances in point-of-care ultrasound in pediatric emergency medicine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.A. Gallagher" 1 => "J.A. Levy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MOP.0000000000000097" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Pediatr" "fecha" => "2014" "volumen" => "26" "paginaInicial" => "265" "paginaFinal" => "271" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24786367" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0250" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound in critical care" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Andruszkiewicz" 1 => "D. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 0 | 11 |
| 2024 October | 64 | 10 | 74 |
| 2024 September | 97 | 3 | 100 |
| 2024 August | 59 | 6 | 65 |
| 2024 July | 92 | 8 | 100 |
| 2024 June | 44 | 8 | 52 |
| 2024 May | 53 | 0 | 53 |
| 2024 April | 68 | 4 | 72 |
| 2024 March | 105 | 12 | 117 |
| 2024 February | 108 | 12 | 120 |
| 2024 January | 133 | 9 | 142 |
| 2023 December | 116 | 15 | 131 |
| 2023 November | 114 | 16 | 130 |
| 2023 October | 108 | 7 | 115 |
| 2023 September | 71 | 9 | 80 |
| 2023 August | 60 | 10 | 70 |
| 2023 July | 45 | 11 | 56 |
| 2023 June | 80 | 3 | 83 |
| 2023 May | 138 | 13 | 151 |
| 2023 April | 113 | 2 | 115 |
| 2023 March | 80 | 2 | 82 |
| 2023 February | 54 | 7 | 61 |
| 2023 January | 40 | 6 | 46 |
| 2022 December | 64 | 6 | 70 |
| 2022 November | 50 | 6 | 56 |
| 2022 October | 44 | 8 | 52 |
| 2022 September | 45 | 16 | 61 |
| 2022 August | 69 | 15 | 84 |
| 2022 July | 37 | 10 | 47 |
| 2022 June | 33 | 10 | 43 |
| 2022 May | 42 | 9 | 51 |
| 2022 April | 34 | 13 | 47 |
| 2022 March | 66 | 6 | 72 |
| 2022 February | 63 | 17 | 80 |
| 2022 January | 82 | 7 | 89 |
| 2021 December | 48 | 21 | 69 |
| 2021 November | 70 | 9 | 79 |
| 2021 October | 99 | 14 | 113 |
| 2021 September | 73 | 10 | 83 |
| 2021 August | 93 | 13 | 106 |
| 2021 July | 43 | 17 | 60 |
| 2021 June | 38 | 13 | 51 |
| 2021 May | 56 | 5 | 61 |
| 2021 April | 99 | 66 | 165 |
| 2021 March | 52 | 7 | 59 |
| 2021 February | 58 | 5 | 63 |
| 2021 January | 43 | 10 | 53 |
| 2020 December | 52 | 11 | 63 |
| 2020 November | 34 | 16 | 50 |
| 2020 October | 24 | 9 | 33 |
| 2020 September | 40 | 8 | 48 |
| 2020 August | 30 | 10 | 40 |
| 2020 July | 16 | 12 | 28 |
| 2020 June | 15 | 2 | 17 |
| 2020 May | 21 | 6 | 27 |
| 2020 April | 14 | 6 | 20 |
| 2020 March | 17 | 3 | 20 |
| 2020 February | 13 | 2 | 15 |
| 2020 January | 14 | 5 | 19 |
| 2019 December | 19 | 7 | 26 |
| 2019 November | 4 | 2 | 6 |
| 2019 October | 10 | 2 | 12 |
| 2019 September | 9 | 1 | 10 |
| 2019 August | 0 | 1 | 1 |
| 2019 July | 0 | 8 | 8 |
| 2019 June | 6 | 20 | 26 |
| 2019 May | 1 | 12 | 13 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 10 | 0 | 10 |
| 2018 May | 49 | 8 | 57 |
| 2018 April | 53 | 5 | 58 |
| 2018 March | 53 | 7 | 60 |
| 2018 February | 43 | 8 | 51 |
| 2018 January | 63 | 5 | 68 |
| 2017 December | 62 | 4 | 66 |
| 2017 November | 69 | 6 | 75 |
| 2017 October | 58 | 10 | 68 |
| 2017 September | 49 | 5 | 54 |
| 2017 August | 63 | 8 | 71 |
| 2017 July | 59 | 3 | 62 |
| 2017 June | 79 | 10 | 89 |
| 2017 May | 84 | 10 | 94 |
| 2017 April | 80 | 8 | 88 |
| 2017 March | 67 | 9 | 76 |
| 2017 February | 52 | 4 | 56 |
| 2017 January | 40 | 7 | 47 |
| 2016 December | 80 | 16 | 96 |
| 2016 November | 71 | 13 | 84 |
| 2016 October | 121 | 10 | 131 |
| 2016 September | 179 | 5 | 184 |
| 2016 August | 129 | 23 | 152 |
| 2016 July | 32 | 13 | 45 |
| 2016 May | 2 | 0 | 2 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 4 | 29 | 33 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 8 | 11 | 19 |
| 2015 November | 31 | 19 | 50 |
| 2015 October | 4 | 1 | 5 |
Show all