Assessment of cerebral blood flow velocities, brain midline shift and optic nerve sheath diameter by ultrasound in patients undergoing elective craniotomy: A prospective observational feasibility study | Revista Española de Anestesiología y Reanimación (English Edition)

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Valencia, N. Fabregas, J. Tercero, R. Valero" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J.A." "apellidos" => "Valencia" "email" => array:1 [ 0 => "javalbar@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Fabregas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Tercero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "R." "apellidos" => "Valero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Sección Neuroanestesia, Department of Anesthesiology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sección Neuroanestesia, Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Medición de las velocidades de flujo sanguíneo cerebral, desviación de la línea media y diámetro de la vaina del nervio óptico mediante ecografía en pacientes sometidos a craneotomía electiva: estudio observacional prospectivo" ] ] "textoCompleto" => "IntroductionThe complication rate for neurosurgical procedures is approximately 14.3%. Postoperative brain haemorrhage, seizures, cerebrovascular accidents, cerebral oedema, intracranial hypertension, and delayed cerebral ischaemia, among other complications, increase morbidity, mortality, hospital stay, and care costs.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Understanding and assessing perioperative cerebral haemodynamics could give clinicians data that will help them detect complications and intervene immediately in order to avoid unfavourable neurological outcomes.Transcranial colour doppler (TCD), first introduced into clinical practice in the 1980s, is a useful tool for monitoring cerebrovascular haemodynamics.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Now, traditional TCD has been supplemented with other ultrasound devices that facilitate additional evaluations, such as transcranial colour Doppler (TCCD) and cranial ultrasound, which measure cerebral blood flow velocity (CBFV), determine optic nerve sheath diameter (ONSD), and show different brain structures such as the third ventricle and midline shift (MLS). These measurements can be performed perioperatively and when certain clinical conditions are present.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a> Cranial ultrasound has many uses: for example, it can detect embolism, stroke, vasospasm, cerebral haemorrhage, evaluate cerebral hypoperfusion, preeclampsia, liver failure, and intracranial pressure (ICP).<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>These measurements and assessments, which are usually performed in intensive care and emergency units, are rarely used in the perioperative setting.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>Cranial ultrasound can be used to detect several perioperative changes in patients scheduled for craniotomy, including fluctuations in flow velocities that could indicate hyperaemia, hypoperfusion or vasospasm, MLS, and changes in CBFV in patients with cranial hypertension.The cranial ultrasound wave must penetrate bone, but due to thicker cranial vaults in some cases, transcranial windows and images will be un-interpretable in 5%–20% of patients.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Very few studies have explored preoperative and postoperative cerebral haemodynamics in patients undergoing elective neurosurgery.The aim of our study was to assess the feasibility of using TCCD in patients scheduled for craniotomy, and to describe the changes from baseline in CBFV, MLS, and ONSD in each patient at different postoperative time points.The secondary outcome was to determine the correlation between these changes and perioperative complications.Materials and methodsThis prospective observational study was approved by the Research Ethics Committee of the Hospital Clínic de Barcelona (HCB/2019/0587) and the Fundación Santa Fe de Bogotá University Hospital (CCEI-5621-2017), and adheres to the Declaration of Helsinki. The study was performed over a 7-month period at both hospitals. Written informed consent was obtained from all participants after they had been screened for eligibility.Inclusion criteria were: age over 18 years, ASA I-III, scheduled for craniotomy due to brain tumour or unruptured brain aneurysm. Exclusion criteria were: emergency surgery, reinterventions, decompressive craniectomy, and pregnancy.Patients were identified by an anonymous id number. Two anaesthesiologists with prior training and experience in bedside ultrasound and TCCD performed the evaluations.Two portable ultrasound machines were used: Sonosite M-Turbo, Edge (©FUJIFILM SonoSite, Tokyo, Japan) and Phillips Sparq© (Koninklijke Philips, Amsterdam, Holland) with a sector transducer pre-set for transcranial examination. With the patient in the supine position, the transducer was placed on the transtemporal window to identify the sphenoid wing and the midbrain butterfly sign. Then colour Doppler was used to identify the circle of Willis and the M1 and M2 segments of the middle cerebral artery (MCA) at a depth of between 45 and 60 mm. After adjusting the angle of insonation to obtain 3 continuous symmetric waves within at least 10 heartbeats, CBFV was measured in the M1 segment of the MCA, including peak systolic velocity (PSV), end-diastolic velocity (EDV), and mean velocity (MV) with their respective composite indices: pulsatility index (PI) and resistance index (RI).The estimated cerebral perfusion pressure (eCPP) on TCCD was calculated using the Schmidt and Czosnika formula (eCPP = MAP × EDV/MV + 14 mmHg).<a class="elsevierStyleCrossRef" href="#bib0035">7</a>MLS was assessed by identifying the midbrain and then the third ventricle, which appears as a double hyperechoic line, and measuring the distance between the third ventricle and the lateral aspect of the temporal bone on both sides. The difference between the 2 measurements (A and B) divided by 2 was used to calculate the MLS as follows: MLS = (B−A)/2, A being the measurement taken from the left side and B from the right side. The result is positive if the mass effect is on the right side and negative if the mass effect is on the left side.<a class="elsevierStyleCrossRefs" href="#bib0030">6–8</a>ONSD was measured using a high frequency linear transducer (4−12 MHz) placed on the closed upper eyelid after applying an appropriate amount of gel and reducing power by 50%. Three measurements were taken in the axial and longitudinal plane at a depth of 3 mm from the surface of the retina, and the values were averaged in each eye.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>All measurements were performed prior to anaesthesia induction, after extubation, and at 6 and 24 postoperative hours in the intensive care unit. Assessments were recorded, saved, and stored on an external hard drive by one anaesthesiologist and then reviewed and validated by another anaesthesiologist.All patients received total intravenous anaesthesia with target-controlled infusion (TCI) of propofol and remifentanil (point-of-effect concentration 3−5 μg/mL and 2−5 ηg/mL, respectively). Rocuronium was administered for neuromuscular blockade. Intraoperative mechanical ventilation was delivered with a tidal volume of 6−8 ml/kg and PEEP (5−7 cm H2O). ETCO2 remained at normocapnic levels. The fraction of inspired oxygen was 0.5, regional cerebral oximetry was measured using the INVOS™ 5100c system (Medtronic Jacksonville, FL, USA) ipsilateral to surgery, and depth of anaesthesia was monitored using the BIS bispectral index (Medtronic Jacksonville, FL, USA) on the contralateral side.At each ultrasound evaluation time point, arterial blood samples were obtained to determine PaCO2 and haematocrit. Mean arterial pressure (MAP) was recorded using a radial artery catheter zeroed at the level of the external auditory meatus. The first measurement of CO2 was obtained by ETCO2 through a face mask with the patient awake. Nasopharyngeal temperature was recorded during surgery and axillary temperature was recorded postoperatively.Descriptive statistics were generated with frequency and proportion for discrete variables and average, mean, and standard deviation for continuous variables. The D'Agostino test was used to determine normal or non-normal distribution. We used repeated measures ANOVA to compare variables measured at different times and variables compared by more than 2 groups. The Friedman test was used in the case of non-parametric data and repeated measures, and ANOVA was used for parametric data. Statistical significance was established at p ≤ 0.05. Data analysis was performed on R Statistical Software (version 5.3.2. 2018).ResultsA total of 16 patients were included in the study, of which 2 were excluded from the analysis due to inadequate ultrasound window. Patient demographics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>None of the patients presented haemodynamic changes that required continuous vasopressor, inotropic, or antihypertensive support during anaesthesia induction or the intraoperative or postoperative period. None of the patients required blood transfusion. There were no immediate postoperative complications such as delayed awakening, seizures, new neurological deficit, or need for reintubation. CBFV did not differ significantly from baselines in any patient, and none presented complications in the first 24 postoperative hours.We were able to measure perioperative CBFV, ONSD, and MLS using TCCD in all patients included in the analysis. EDCT and its respective composite indices are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. MLS, ONSD and eCPP are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>All parameters remained within physiological ranges and no significant variations were observed during the study.DiscussionThe results of our study show that variables such as CBFV, ONSD, and MLS can be measured simultaneously in patients scheduled for craniotomy in order to obtain additional information on baseline cerebral haemodynamics and to monitor changes during the first 24 postoperative hours. Determining the baseline status of each patient and tracking changes over time will allow anaesthesiologists to detect early complications.Although several studies have been published on the use of TCD ultrasound to evaluate cerebral haemodynamics, we evaluated CBFV, ONSD, and MLS jointly in patients undergoing scheduled craniotomy.Very few studies have attempted to identify intraoperative and postoperative changes in CBFV in patients undergoing scheduled neurosurgery.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a> However, there is ample evidence that TCD and TCCD are useful for monitoring conditions such as head trauma, decompressive craniectomy, intracranial hypertension, and stroke, among others.<a class="elsevierStyleCrossRefs" href="#bib0060">12–14</a>The few studies investigating the effect of anaesthetics on pre- and immediate post-operative changes in CBFV in patients undergoing neurosurgery have shown that CBFV is elevated briefly in the immediate postoperative period, although this has no clinical significance.<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a>We, however, did not observe any statistically significant changes in blood flow through the MCA, possibly because our patients presented stable haemodynamics and no perioperative complications, despite general anaesthesia. However, our study did not have the statistical power required to assess these variables.Optic nerve sheath diameter (ONSD) is a reproducible, low-cost, rapidly measured variable that is now increasingly used in intensive care units and in both adult and paediatric emergency services. Although a cut-off value has yet to be established, values greater than 5−6 mm are considered abnormal; however, measuring trends and changes from baselines could be more important. The recent development of training models to shorten the learning curve of ONSD assessment could further extend the use of this technique.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Very few studies have evaluated the usefulness of ONSD in patients presenting changes in intracranial pressures due to extreme surgical positioning or certain surgical procedures, such a craniotomy.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Although ultrasound ONSD assessment could be a useful non-invasive method of determining intracranial hypertension, magnetic resonance imaging is still the technique of choice.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> It is important to bear in mind certain factors that can confound ONSD determinations, such as inter/intra-observer variability, age, neuroanatomical variations (differences in the width of the optic nerve, the elasticity of the optic nerve sheath), and acute fluctuations in ICP, since changes in ICP occurring over a short time disrupt the balance of cerebrospinal fluid in the optic nerve sheath.<a class="elsevierStyleCrossRefs" href="#bib0100">20–22</a>Previous studies performed in intensive care units and emergency departments to evaluate the accuracy of cranial ultrasound MLS measurements in patients with acute brain injury have shown good correlation between ultrasound and computed tomography findings. However, anatomical changes after craniotomy and cranioplasty could affect the accuracy of this ultrasound values.<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a>In our patients, we observed no significant MLS (using a cut-off value or >2.5 mm) or pathological ONSD values suggestive of intracranial hypertension. This is consistent with the absence of neurological complications during emergence and at 6 and 24 postoperative hours.In our patients, certain variables that can affect CBFV such as temperature, PaCO2 and haematocrit, remained within physiological ranges throughout the study, which could explain why changes only minor changes in CBFV were observed.Our study has some limitations: our patients were haemodynamically stable during the perioperative period and did not present postoperative complications; therefore we were unable to detect the early pathological changes known to be observable on cranial ultrasound. This limitation is partly due to the small sample size.Intra- and inter-observer variability was not taken into account, and it should be noted that the formula used to calculate eCPP was first used in clinical practice for head trauma, and not for patients undergoing scheduled craniotomy; therefore, the values obtained should be interpreted with caution.Although we estimated eCPP using the formula described above, it can also be calculated on the basis of critical closing pressure, i.e., the arterial blood pressure at which brain vessels collapse and cerebral blood flow ceases. Critical closing pressure was not used in our study, and this is another limitation.<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a>It is also important to consider the limitations of cerebral ultrasound, such as the suboptimal resolution of some ultrasound machines, the level of experience of the operator, and occasional inaccurate measurements.<a class="elsevierStyleCrossRefs" href="#bib0135">27–29</a>In conclusion, our study shows that cranial ultrasound is a useful point-of-care examination not only in the emergency room and intensive care unit, but also in the perioperative period in neurosurgical patients, in whom ultrasound assessment of CBFV, ONSD and MLS can be used to individualize their cerebrovascular status. In some specific clinical situations, these studies could replace other techniques that require patients to be transferred out of the operating room. Nevertheless, further studies using a larger, more heterogeneous sample are needed to determine whether these combined measures can provide early diagnosis of pathology and predict its clinical impact on neurological outcomes in craniotomy patients who present intraoperative or postoperative complications." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1913596" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1652322" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1913597" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1652321" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-06-28" "fechaAceptado" => "2022-02-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1652322" "palabras" => array:6 [ 0 => "Transcranial Doppler ultrasonography" 1 => "Neurosurgical procedure" 2 => "Transcranial color-coded duplex ultrasonography" 3 => "Craniotomy" 4 => "Blood flow velocity" 5 => "Optic" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1652321" "palabras" => array:7 [ 0 => "Ultrasonografía Doppler transcraneal" 1 => "Neurocirugía" 2 => "Ecografía Doppler color transcraneal" 3 => "Craneotomía" 4 => "Velocidad del flujo sanguíneo cerebral" 5 => "Nervio óptico" 6 => "Ultrasonido cerebral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundBrain ultrasound allows measuring the cerebral flow velocity, brain midline shift and optic nerve sheath diameter. Literature is scarce in determining the feasibility to perioperatively perform these measurements altogether and the cerebrovascular behavior in patients scheduled for elective craniotomy. MethodsWe assessed bilateral cerebral flow velocities, composite index, brain midline shift and optic nerve sheath diameter by cerebral ultrasound in patients scheduled for elective craniotomy before anesthetic induction, at extubation, and at 6 and 24 h after.The aim was to assess the feasibility of brain ultrasound in patients for elective craniotomy and to describe the changes in cerebral flow velocities, brain midline shift and optic nerve sheath diameter from baseline values at different times in the postoperative period. ResultsSixteen patients were included, of these two were excluded from analysis due to an inadequate sonographic window. There were no changes throughout the study regarding cerebral flow velocity, brain midline shift nor optic nerve sheath diameter assessments. All parameters were maintained in the physiological range without significant variations during the procedure. No perioperative complications were detected. ConclusionsThe results of our study show the feasibility to perform a perioperative assessment of cerebral flow velocity, brain midline shift or optic nerve sheath diameter jointly and successfully to obtain additional information of baseline cerebral hemodynamics in patients scheduled for elective craniotomy and their postoperative changes during the first 24 h. Future studies with lager samples are needed to address the efficacy of cerebral ultrasound as a monitoring tool." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa ecografía cerebral permite valorar las velocidades del flujo sanguíneo cerebral (FSC), la desviación de la línea media y el diámetro de la vaina del nervio óptico. La literatura es escasa en determinar la viabilidad de realizar dichas medidas, de forma conjunta en el perioperatorio, en pacientes programados para craneotomía electiva. MétodosEvaluamos las velocidades del FSC de forma bilateral con sus índices compuestos, la desviación de la línea media y el diámetro de la vaina del nervio óptico por medio de ultrasonido cerebral en pacientes programados para craneotomía electiva antes de la inducción anestésica, tras la extubación y tras 6 y 24 horas. El objetivo fue evaluar la viabilidad del uso de la ecografía cerebral en pacientes sometidos a craneotomía electiva y describir los cambios de estas mediciones en diferentes momentos con respecto a los valores basales. ResultadosDieciséis pacientes fueron incluidos en el estudio, de los cuales dos se excluyeron del análisis debido a una mala ventana ecográfica. No hubo cambios a lo largo del estudio con respecto a las velocidades del FSC, tampoco en la desviación de la línea media o en el diámetro de la vaina del nervio óptico. Todos los parámetros se mantuvieron dentro de los rangos fisiológicos sin variaciones significativas durante el procedimiento. No hubo complicaciones perioperatorias. ConclusionesLos resultados de nuestro trabajo muestran la factibilidad de realizar una valoración perioperatoria de las velocidades del FSC, desviación de la línea media y diámetro de la vaina del nervio óptico de forma conjunta y exitosa para obtener información de la hemodinámica cerebral basal en pacientes programados para craneotomía electiva y valorar sus cambios durante las primeras 24 horas del postoperatorio. Son necesarios estudios con mayor número de pacientes para evaluar la eficacia del ultrasonido cerebral como herramienta de monitorización neurológica perioperatoria." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Data shown as median and interquartile range or number and percentage, as appropriate." "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (57.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (42.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 (34−76) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Body mass index (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.6 (22−30.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight (kg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70 (55−101) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Height (metres) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.65 (1.48–1.92) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pathology n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parietal tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (21.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frontal lobe tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (21.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Temporal lobe tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (21.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Occipital lobe tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.16%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infraorbital nerve tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.16%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cerebellopontine angle tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (14.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unruptured brain aneurysm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comorbidities n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Overweight (25−29.9 kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (42.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obesity (≥30 kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypothyroidism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epilepsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (14.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic variables." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Data shown as mean and standard deviation; measurements obtained by TCCD. EDV: end diastolic velocity; MV: mean velocity; PI: pulsatility index; PSV: peak systolic velocity; RI: resistive index." "tablatextoimagen" => array:1 [ 0 => array:1 [ "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Before anaesthesia induction \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">After extubation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">6 h Postoperative \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">24 postoperative hours \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PSV [cm/s]</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.6 ± 15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84 ± 14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82.2 ± 16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84.2 ± 18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.34 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86.2 ± 15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84.1 ± 13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83.6 ± 13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84.2 ± 16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">EDV [cm/s]</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.9 ± 8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.8 ± 12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.1 ± 11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.4 ± 7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.92 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.4 ± 7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.2 ± 6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.2 ± 5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.7 ± 7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MV [cm/s]</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52 ± 10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50.3 ± 12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50.2 ± 12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51.4 ± 10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.46 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 ± 8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54.3 ± 7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54.9 ± 7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54.3 ± 9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PI</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 ± 0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 ± 0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 ± 0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 ± 0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.71 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 ± 0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 ± 0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 ± 0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 ± 0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RI</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 ± 0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 ± 0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 ± 0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 ± 0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 ± 0.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 ± 0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 ± 0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 ± 0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.30 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Cerebral blood flow velocities and composite indices." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Data shown as mean and standard deviation. eCPP, estimated cerebral perfusion pressure [eCPP = MAP × EDV/MV + 14 mmHg] measurement obtained by TCCD; ONSD: optic nerve sheath diameter; MLS: midline shift." "tablatextoimagen" => array:1 [ 0 => array:1 [ "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Before anaesthesia induction \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">After extubation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">6 h Postoperative \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">24 postoperative hours \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">eCPP [mmHg]</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83.1 ± 8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80.7 ± 5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80.3 ± 7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78.5 ± 11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81.9 ± 9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80.7 ± 7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78.3 ± 8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75.9 ± 9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ONSD [mm]</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8 ± 0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7 ± 0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7 ± 0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7 ± 0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7 ± 0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7 ± 0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7 ± 0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8 ± 0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.76 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MLS [mm] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.04 ± 0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.08 ± 0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.3 ± 0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.17 ± 0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.89 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Midline shift values, optic nerve sheath diameter, and estimated cerebral perfusion pressure." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications of neurosurgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.E. 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Assessment of cerebral blood flow velocities, brain midline shift and optic nerve sheath diameter by ultrasound in patients undergoing elective craniotomy: A prospective observational feasibility study

Medición de las velocidades de flujo sanguíneo cerebral, desviación de la línea media y diámetro de la vaina del nervio óptico mediante ecografía en pacientes sometidos a craneotomía electiva: estudio observacional prospectivo

J.A. Valenciaa,

Corresponding author

javalbar@hotmail.com

Corresponding author.

, N. Fabregasb, J. Tercerob, R. Valerob

a Sección Neuroanestesia, Department of Anesthesiology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia

b Sección Neuroanestesia, Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The complication rate for neurosurgical procedures is approximately 14&#46;3&#37;&#46; Postoperative brain haemorrhage&#44; seizures&#44; cerebrovascular accidents&#44; cerebral oedema&#44; intracranial hypertension&#44; and delayed cerebral ischaemia&#44; among other complications&#44; increase morbidity&#44; mortality&#44; hospital stay&#44; and care costs&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Understanding and assessing perioperative cerebral haemodynamics could give clinicians data that will help them detect complications and intervene immediately in order to avoid unfavourable neurological outcomes&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Transcranial colour doppler &#40;TCD&#41;&#44; first introduced into clinical practice in the 1980s&#44; is a useful tool for monitoring cerebrovascular haemodynamics&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Now&#44; traditional TCD has been supplemented with other ultrasound devices that facilitate additional evaluations&#44; such as transcranial colour Doppler &#40;TCCD&#41; and cranial ultrasound&#44; which measure cerebral blood flow velocity &#40;CBFV&#41;&#44; determine optic nerve sheath diameter &#40;ONSD&#41;&#44; and show different brain structures such as the third ventricle and midline shift &#40;MLS&#41;&#46; These measurements can be performed perioperatively and when certain clinical conditions are present&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Cranial ultrasound has many uses&#58; for example&#44; it can detect embolism&#44; stroke&#44; vasospasm&#44; cerebral haemorrhage&#44; evaluate cerebral hypoperfusion&#44; preeclampsia&#44; liver failure&#44; and intracranial pressure &#40;ICP&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">These measurements and assessments&#44; which are usually performed in intensive care and emergency units&#44; are rarely used in the perioperative setting&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Cranial ultrasound can be used to detect several perioperative changes in patients scheduled for craniotomy&#44; including fluctuations in flow velocities that could indicate hyperaemia&#44; hypoperfusion or vasospasm&#44; MLS&#44; and changes in CBFV in patients with cranial hypertension&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The cranial ultrasound wave must penetrate bone&#44; but due to thicker cranial vaults in some cases&#44; transcranial windows and images will be un-interpretable in 5&#37;&#8211;20&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Very few studies have explored preoperative and postoperative cerebral haemodynamics in patients undergoing elective neurosurgery&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The aim of our study was to assess the feasibility of using TCCD in patients scheduled for craniotomy&#44; and to describe the changes from baseline in CBFV&#44; MLS&#44; and ONSD in each patient at different postoperative time points&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The secondary outcome was to determine the correlation between these changes and perioperative complications&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0045" class="elsevierStylePara elsevierViewall">This prospective observational study was approved by the Research Ethics Committee of the Hospital Cl&#237;nic de Barcelona &#40;HCB&#47;2019&#47;0587&#41; and the Fundaci&#243;n Santa Fe de Bogot&#225; University Hospital &#40;CCEI-5621-2017&#41;&#44; and adheres to the Declaration of Helsinki&#46; The study was performed over a 7-month period at both hospitals&#46; Written informed consent was obtained from all participants after they had been screened for eligibility&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Inclusion criteria were&#58; age over 18 years&#44; ASA I-III&#44; scheduled for craniotomy due to brain tumour or unruptured brain aneurysm&#46; Exclusion criteria were&#58; emergency surgery&#44; reinterventions&#44; decompressive craniectomy&#44; and pregnancy&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients were identified by an anonymous id number&#46; Two anaesthesiologists with prior training and experience in bedside ultrasound and TCCD performed the evaluations&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Two portable ultrasound machines were used&#58; Sonosite M-Turbo&#44; Edge &#40;&#169;FUJIFILM SonoSite&#44; Tokyo&#44; Japan&#41; and Phillips Sparq&#169; &#40;Koninklijke Philips&#44; Amsterdam&#44; Holland&#41; with a sector transducer pre-set for transcranial examination&#46; With the patient in the supine position&#44; the transducer was placed on the transtemporal window to identify the sphenoid wing and the midbrain butterfly sign&#46; Then colour Doppler was used to identify the circle of Willis and the M1 and M2 segments of the middle cerebral artery &#40;MCA&#41; at a depth of between 45 and 60&#160;mm&#46; After adjusting the angle of insonation to obtain 3 continuous symmetric waves within at least 10 heartbeats&#44; CBFV was measured in the M1 segment of the MCA&#44; including peak systolic velocity &#40;PSV&#41;&#44; end-diastolic velocity &#40;EDV&#41;&#44; and mean velocity &#40;MV&#41; with their respective composite indices&#58; pulsatility index &#40;PI&#41; and resistance index &#40;RI&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The estimated cerebral perfusion pressure &#40;eCPP&#41; 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placed on the closed upper eyelid after applying an appropriate amount of gel and reducing power by 50&#37;&#46; Three measurements were taken in the axial and longitudinal plane at a depth of 3&#160;mm from the surface of the retina&#44; and the values were averaged in each eye&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">All measurements were performed prior to anaesthesia induction&#44; after extubation&#44; and at 6 and 24 postoperative hours in the intensive care unit&#46; Assessments were recorded&#44; saved&#44; and stored on an external hard drive by one anaesthesiologist and then reviewed and validated by another anaesthesiologist&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">All patients received total intravenous anaesthesia with target-controlled infusion &#40;TCI&#41; of propofol and remifentanil &#40;point-of-effect concentration 3&#8722;5&#160;&#956;g&#47;mL and 2&#8722;5&#160;&#951;g&#47;mL&#44; respectively&#41;&#46; Rocuronium was administered for neuromuscular blockade&#46; Intraoperative mechanical ventilation was delivered with a tidal volume of 6&#8722;8&#160;ml&#47;kg and PEEP &#40;5&#8722;7&#160;cm H<span class="elsevierStyleInf">2</span>O&#41;&#46; ETCO<span class="elsevierStyleInf">2</span> remained at normocapnic levels&#46; The fraction of inspired oxygen was 0&#46;5&#44; regional cerebral oximetry was measured using the INVOS&#8482; 5100c system &#40;Medtronic Jacksonville&#44; FL&#44; USA&#41; ipsilateral to surgery&#44; and depth of anaesthesia was monitored using the BIS bispectral index &#40;Medtronic Jacksonville&#44; FL&#44; USA&#41; on the contralateral side&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">At each ultrasound evaluation time point&#44; arterial blood samples were obtained to determine PaCO<span class="elsevierStyleInf">2</span> and haematocrit&#46; Mean arterial pressure &#40;MAP&#41; was recorded using a radial artery catheter zeroed at the level of the external auditory meatus&#46; The first measurement of CO<span class="elsevierStyleInf">2</span> was obtained by ETCO<span class="elsevierStyleInf">2</span> through a face mask with the patient awake&#46; Nasopharyngeal temperature was recorded during surgery and axillary temperature was recorded postoperatively&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Descriptive statistics were generated with frequency and proportion for discrete variables and average&#44; mean&#44; and standard deviation for continuous variables&#46; The D&#39;Agostino test was used to determine normal or non-normal distribution&#46; We used repeated measures ANOVA to compare variables measured at different times and variables compared by more than 2 groups&#46; The Friedman test was used in the case of non-parametric data and repeated measures&#44; and ANOVA was used for parametric data&#46; Statistical significance was established at p&#160;&#8804;&#160;0&#46;05&#46; Data analysis was performed on R Statistical Software &#40;version 5&#46;3&#46;2&#46; 2018&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">A total of 16 patients were included in the study&#44; of which 2 were excluded from the analysis due to inadequate ultrasound window&#46; Patient demographics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">None of the patients presented haemodynamic changes that required continuous vasopressor&#44; inotropic&#44; or antihypertensive support during anaesthesia induction or the intraoperative or postoperative period&#46; None of the patients required blood transfusion&#46; There were no immediate postoperative complications such as delayed awakening&#44; seizures&#44; new neurological deficit&#44; or need for reintubation&#46; CBFV did not differ significantly from baselines in any patient&#44; and none presented complications in the first 24 postoperative hours&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">We were able to measure perioperative CBFV&#44; ONSD&#44; and MLS using TCCD in all patients included in the analysis&#46; EDCT and its respective composite indices are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; MLS&#44; ONSD and eCPP are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">All parameters remained within physiological ranges and no significant variations were observed during the study&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">The results of our study show that variables such as CBFV&#44; ONSD&#44; and MLS can be measured simultaneously in patients scheduled for craniotomy in order to obtain additional information on baseline cerebral haemodynamics and to monitor changes during the first 24 postoperative hours&#46; Determining the baseline status of each patient and tracking changes over time will allow anaesthesiologists to detect early complications&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Although several studies have been published on the use of TCD ultrasound to evaluate cerebral haemodynamics&#44; we evaluated CBFV&#44; ONSD&#44; and MLS jointly in patients undergoing scheduled craniotomy&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Very few studies have attempted to identify intraoperative and postoperative changes in CBFV in patients undergoing scheduled neurosurgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> However&#44; there is ample evidence that TCD and TCCD are useful for monitoring conditions such as head trauma&#44; decompressive craniectomy&#44; intracranial hypertension&#44; and stroke&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The few studies investigating the effect of anaesthetics on pre- and immediate post-operative changes in CBFV in patients undergoing neurosurgery have shown that CBFV is elevated briefly in the immediate postoperative period&#44; although this has no clinical significance&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">We&#44; however&#44; did not observe any statistically significant changes in blood flow through the MCA&#44; possibly because our patients presented stable haemodynamics and no perioperative complications&#44; despite general anaesthesia&#46; However&#44; our study did not have the statistical power required to assess these variables&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Optic nerve sheath diameter &#40;ONSD&#41; is a reproducible&#44; low-cost&#44; rapidly measured variable that is now increasingly used in intensive care units and in both adult and paediatric emergency services&#46; Although a cut-off value has yet to be established&#44; values greater than 5&#8722;6&#160;mm are considered abnormal&#59; however&#44; measuring trends and changes from baselines could be more important&#46; The recent development of training models to shorten the learning curve of ONSD assessment could further extend the use of this technique&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Very few studies have evaluated the usefulness of ONSD in patients presenting changes in intracranial pressures due to extreme surgical positioning or certain surgical procedures&#44; such a craniotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Although ultrasound ONSD assessment could be a useful non-invasive method of determining intracranial hypertension&#44; magnetic resonance imaging is still the technique of choice&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> It is important to bear in mind certain factors that can confound ONSD determinations&#44; such as inter&#47;intra-observer variability&#44; age&#44; neuroanatomical variations &#40;differences in the width of the optic nerve&#44; the elasticity of the optic nerve sheath&#41;&#44; and acute fluctuations in ICP&#44; since changes in ICP occurring over a short time disrupt the balance of cerebrospinal fluid in the optic nerve sheath&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;22</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Previous studies performed in intensive care units and emergency departments to evaluate the accuracy of cranial ultrasound MLS measurements in patients with acute brain injury have shown good correlation between ultrasound and computed tomography findings&#46; However&#44; anatomical changes after craniotomy and cranioplasty could affect the accuracy of this ultrasound values&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In our patients&#44; we observed no significant MLS &#40;using a cut-off value or &#62;2&#46;5&#160;mm&#41; or pathological ONSD values suggestive of intracranial hypertension&#46; This is consistent with the absence of neurological complications during emergence and at 6 and 24 postoperative hours&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In our patients&#44; certain variables that can affect CBFV such as temperature&#44; PaCO<span class="elsevierStyleInf">2</span> and haematocrit&#44; remained within physiological ranges throughout the study&#44; which could explain why changes only minor changes in CBFV were observed&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Our study has some limitations&#58; our patients were haemodynamically stable during the perioperative period and did not present postoperative complications&#59; therefore we were unable to detect the early pathological changes known to be observable on cranial ultrasound&#46; This limitation is partly due to the small sample size&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Intra- and inter-observer variability was not taken into account&#44; and it should be noted that the formula used to calculate eCPP was first used in clinical practice for head trauma&#44; and not for patients undergoing scheduled craniotomy&#59; therefore&#44; the values obtained should be interpreted with caution&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Although we estimated eCPP using the formula described above&#44; it can also be calculated on the basis of critical closing pressure&#44; i&#46;e&#46;&#44; the arterial blood pressure at which brain vessels collapse and cerebral blood flow ceases&#46; Critical closing pressure was not used in our study&#44; and this is another limitation&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">It is also important to consider the limitations of cerebral ultrasound&#44; such as the suboptimal resolution of some ultrasound machines&#44; the level of experience of the operator&#44; and occasional inaccurate measurements&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;29</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">In conclusion&#44; our study shows that cranial ultrasound is a useful point-of-care examination not only in the emergency room and intensive care unit&#44; but also in the perioperative period in neurosurgical patients&#44; in whom ultrasound assessment of CBFV&#44; ONSD and MLS can be used to individualize their cerebrovascular status&#46; In some specific clinical situations&#44; these studies could replace other techniques that require patients to be transferred out of the operating room&#46; Nevertheless&#44; further studies using a larger&#44; more heterogeneous sample are needed to determine whether these combined measures can provide early diagnosis of pathology and predict its clinical impact on neurological outcomes in craniotomy patients who present intraoperative or postoperative complications&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "titulo" => "Abstract"
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          "titulo" => "Resumen"
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              "titulo" => "Introducci&#243;n"
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            1 => array:2 [
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    "fechaRecibido" => "2021-06-28"
    "fechaAceptado" => "2022-02-16"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1652322"
          "palabras" => array:6 [
            0 => "Transcranial Doppler ultrasonography"
            1 => "Neurosurgical procedure"
            2 => "Transcranial color-coded duplex ultrasonography"
            3 => "Craniotomy"
            4 => "Blood flow velocity"
            5 => "Optic"
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        ]
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      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1652321"
          "palabras" => array:7 [
            0 => "Ultrasonograf&#237;a Doppler transcraneal"
            1 => "Neurocirug&#237;a"
            2 => "Ecograf&#237;a Doppler color transcraneal"
            3 => "Craneotom&#237;a"
            4 => "Velocidad del flujo sangu&#237;neo cerebral"
            5 => "Nervio &#243;ptico"
            6 => "Ultrasonido cerebral"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Brain ultrasound allows measuring the cerebral flow velocity&#44; brain midline shift and optic nerve sheath diameter&#46; Literature is scarce in determining the feasibility to perioperatively perform these measurements altogether and the cerebrovascular behavior in patients scheduled for elective craniotomy&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">We assessed bilateral cerebral flow velocities&#44; composite index&#44; brain midline shift and optic nerve sheath diameter by cerebral ultrasound in patients scheduled for elective craniotomy before anesthetic induction&#44; at extubation&#44; and at 6 and 24&#160;h after&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The aim was to assess the feasibility of brain ultrasound in patients for elective craniotomy and to describe the changes in cerebral flow velocities&#44; brain midline shift and optic nerve sheath diameter from baseline values at different times in the postoperative period&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Sixteen patients were included&#44; of these two were excluded from analysis due to an inadequate sonographic window&#46; There were no changes throughout the study regarding cerebral flow velocity&#44; brain midline shift nor optic nerve sheath diameter assessments&#46; All parameters were maintained in the physiological range without significant variations during the procedure&#46; No perioperative complications were detected&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The results of our study show the feasibility to perform a perioperative assessment of cerebral flow velocity&#44; brain midline shift or optic nerve sheath diameter jointly and successfully to obtain additional information of baseline cerebral hemodynamics in patients scheduled for elective craniotomy and their postoperative changes during the first 24&#160;h&#46; Future studies with lager samples are needed to address the efficacy of cerebral ultrasound as a monitoring tool&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0005"
            "titulo" => "Background"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La ecograf&#237;a cerebral permite valorar las velocidades del flujo sangu&#237;neo cerebral &#40;FSC&#41;&#44; la desviaci&#243;n de la l&#237;nea media y el di&#225;metro de la vaina del nervio &#243;ptico&#46; La literatura es escasa en determinar la viabilidad de realizar dichas medidas&#44; de forma conjunta en el perioperatorio&#44; en pacientes programados para craneotom&#237;a electiva&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Evaluamos las velocidades del FSC de forma bilateral con sus &#237;ndices compuestos&#44; la desviaci&#243;n de la l&#237;nea media y el di&#225;metro de la vaina del nervio &#243;ptico por medio de ultrasonido cerebral en pacientes programados para craneotom&#237;a electiva antes de la inducci&#243;n anest&#233;sica&#44; tras la extubaci&#243;n y tras 6 y 24 horas&#46; El objetivo fue evaluar la viabilidad del uso de la ecograf&#237;a cerebral en pacientes sometidos a craneotom&#237;a electiva y describir los cambios de estas mediciones en diferentes momentos con respecto a los valores basales&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Diecis&#233;is pacientes fueron incluidos en el estudio&#44; de los cuales dos se excluyeron del an&#225;lisis debido a una mala ventana ecogr&#225;fica&#46; No hubo cambios a lo largo del estudio con respecto a las velocidades del FSC&#44; tampoco en la desviaci&#243;n de la l&#237;nea media o en el di&#225;metro de la vaina del nervio &#243;ptico&#46; Todos los par&#225;metros se mantuvieron dentro de los rangos fisiol&#243;gicos sin variaciones significativas durante el procedimiento&#46; No hubo complicaciones perioperatorias&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Los resultados de nuestro trabajo muestran la factibilidad de realizar una valoraci&#243;n perioperatoria de las velocidades del FSC&#44; desviaci&#243;n de la l&#237;nea media y di&#225;metro de la vaina del nervio &#243;ptico de forma conjunta y exitosa para obtener informaci&#243;n de la hemodin&#225;mica cerebral basal en pacientes programados para craneotom&#237;a electiva y valorar sus cambios durante las primeras 24 horas del postoperatorio&#46; Son necesarios estudios con mayor n&#250;mero de pacientes para evaluar la eficacia del ultrasonido cerebral como herramienta de monitorizaci&#243;n neurol&#243;gica perioperatoria&#46;</p></span>"
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;57&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;21&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Temporal lobe tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;21&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Occipital lobe tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;16&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Infraorbital nerve tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;16&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cerebellopontine angle tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;14&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unruptured brain aneurysm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbidities n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Overweight &#40;25&#8722;29&#46;9&#160;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;42&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesity &#40;&#8805;30&#160;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypothyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Epilepsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Respiratory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Data shown as mean and standard deviation&#59; measurements obtained by TCCD&#46; EDV&#58; end diastolic velocity&#59; MV&#58; mean velocity&#59; PI&#58; pulsatility index&#59; PSV&#58; peak systolic velocity&#59; RI&#58; resistive index&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Before anaesthesia induction&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">After extubation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">6&#160;h Postoperative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">24 postoperative hours&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P value&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PSV &#91;cm&#47;s&#93;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">85&#46;6&#160;&#177;&#160;15&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&#160;&#177;&#160;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&#46;2&#160;&#177;&#160;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">84&#46;2&#160;&#177;&#160;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">86&#46;2&#160;&#177;&#160;15&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&#46;1&#160;&#177;&#160;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#46;6&#160;&#177;&#160;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&#46;2&#160;&#177;&#160;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">EDV &#91;cm&#47;s&#93;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;9&#160;&#177;&#160;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;8&#160;&#177;&#160;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;1&#160;&#177;&#160;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;4&#160;&#177;&#160;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;4&#160;&#177;&#160;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;2&#160;&#177;&#160;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;2&#160;&#177;&#160;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;7&#160;&#177;&#160;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Data shown as mean and standard deviation&#46; eCPP&#44; estimated cerebral perfusion pressure &#91;eCPP&#160;&#61;&#160;MAP&#160;&#215;&#160;EDV&#47;MV&#160;&#43;&#160;14&#160;mmHg&#93; measurement obtained by TCCD&#59; ONSD&#58; optic nerve sheath diameter&#59; MLS&#58; midline shift&#46;</p>"
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Article information

ISSN: 23411929
Original language: English

DOI:10.1016/j.redare.2022.02.008

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