The brain shock index: repurposing the Lindegaard ratio for detecting cerebral hypoperfusion in children with cerebral malaria
Abstract Background Transcranial doppler ultrasound (TCD) allows for the assessment of the cerebrovascular hemodynamics in critically ill children. Given the increasing availability of machines equipped with TCD capabilities globally, it may be a useful approach to detect cerebral hypoperfusion and...
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SpringerOpen
2025-05-01
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| Series: | The Ultrasound Journal |
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| Online Access: | https://doi.org/10.1186/s13089-025-00430-8 |
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| author | Nicole F. O’Brien Taty Tshimanga Florette Yumsa Mangwangu Ludovic Mayindombe Robert Tandjeka Ekandji Jean Pongo Mbaka Tusekile Phiri Sylvester June Montfort Bernard Gushu Hunter Wynkoop Marlina Lovett |
| author_facet | Nicole F. O’Brien Taty Tshimanga Florette Yumsa Mangwangu Ludovic Mayindombe Robert Tandjeka Ekandji Jean Pongo Mbaka Tusekile Phiri Sylvester June Montfort Bernard Gushu Hunter Wynkoop Marlina Lovett |
| author_sort | Nicole F. O’Brien |
| collection | DOAJ |
| description | Abstract Background Transcranial doppler ultrasound (TCD) allows for the assessment of the cerebrovascular hemodynamics in critically ill children. Given the increasing availability of machines equipped with TCD capabilities globally, it may be a useful approach to detect cerebral hypoperfusion and guide neurologic resuscitation for pediatric patients in resource limited settings where other neuromonitoring techniques are unavailable. However, the current need to evaluate waveform characteristics and to age correct values to determine if a study is abnormal decreases the feasibility of using point of care TCD in this way. The brain shock index (BSI), a repurposing of the Lindegaard Ratio, overcomes these limitations. Methods We performed a prospective study of children with cerebral malaria (CM). On admission and daily thereafter, TCD was used to evaluate the middle cerebral (MCA) and extra-cranial carotid arteries (Ex-ICA), and the BSI was calculated bilaterally (MCA mean flow velocity ((Vm))/Ex-ICA Vm). Neurologic outcome at discharge was assessed. Results A cohort of 291 children with CM were evaluated. BSI calculation was successful in all of them. The mean time to perform TCD and calculate the BSI was 4 ± 2 min. Overall, 222 participants (76%) had a good outcome and 69 (24%) a poor outcome. The BSI had an AUC of 0.98 (95% CI 0.97–0.99, p < 0.0001) to predict death or moderate to severe disability. The highest sensitivity and specificity of the BSI to predict adverse outcomes occurred at a cut off value ≤ 1.1. The adjusted odds ratio of poor outcome was 3.2 (95% CI 1.6–6.1, p = 0.001) if any BSI measurement during hospitalization fell below this threshold. No intracranial pressure monitoring was available to determine the relationship between the BSIs and an invasively measured cerebral perfusion pressure. Conclusion The BSI is a rapid, feasible point of care ultrasound measurement of cerebral hypoperfusion, with values ≤ 1.1 strongly correlating with poor neurologic outcomes in children with CM. Future studies should be performed to assess the utility of BSI to detect the presence and measure the severity of reduced cerebral perfusion pressure in other populations of critically ill children. |
| format | Article |
| id | doaj-art-b2034229cf35406b9ac41a375d5dce04 |
| institution | DOAJ |
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| language | English |
| publishDate | 2025-05-01 |
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| spelling | doaj-art-b2034229cf35406b9ac41a375d5dce042025-08-20T03:22:12ZengSpringerOpenThe Ultrasound Journal2524-89872025-05-011711810.1186/s13089-025-00430-8The brain shock index: repurposing the Lindegaard ratio for detecting cerebral hypoperfusion in children with cerebral malariaNicole F. O’Brien0Taty Tshimanga1Florette Yumsa Mangwangu2Ludovic Mayindombe3Robert Tandjeka Ekandji4Jean Pongo Mbaka5Tusekile Phiri6Sylvester June7Montfort Bernard Gushu8Hunter Wynkoop9Marlina Lovett10Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children’s Hospital, The Ohio State UniversityDepartement de Pediatrie, Cliniques Universitaires de Kinshasa, Hopital Pediatrique de Kalembe LembeDepartement de Pediatrie, Cliniques Universitaires de Kinshasa, Hopital Pediatrique de Kalembe LembeDepartement de Pediatrie, Cliniques Universitaires de Kinshasa, Hopital Pediatrique de Kalembe LembeUniversite des Sciences et des Technologie de Lodja (USTL), L’Hopital General de Reference de Lodja, Sankuru District Lodja, Republique Democratic du CongoUniversite des Sciences et des Technologie de Lodja (USTL), L’Hopital General de Reference de Lodja, Sankuru District Lodja, Republique Democratic du CongoQueen Elizabeth Central HospitalQueen Elizabeth Central HospitalQueen Elizabeth Central HospitalDepartment of Pediatrics, Division of Critical Care Medicine, Nationwide Children’s Hospital, The Ohio State UniversityDepartment of Pediatrics, Division of Critical Care Medicine, Nationwide Children’s Hospital, The Ohio State UniversityAbstract Background Transcranial doppler ultrasound (TCD) allows for the assessment of the cerebrovascular hemodynamics in critically ill children. Given the increasing availability of machines equipped with TCD capabilities globally, it may be a useful approach to detect cerebral hypoperfusion and guide neurologic resuscitation for pediatric patients in resource limited settings where other neuromonitoring techniques are unavailable. However, the current need to evaluate waveform characteristics and to age correct values to determine if a study is abnormal decreases the feasibility of using point of care TCD in this way. The brain shock index (BSI), a repurposing of the Lindegaard Ratio, overcomes these limitations. Methods We performed a prospective study of children with cerebral malaria (CM). On admission and daily thereafter, TCD was used to evaluate the middle cerebral (MCA) and extra-cranial carotid arteries (Ex-ICA), and the BSI was calculated bilaterally (MCA mean flow velocity ((Vm))/Ex-ICA Vm). Neurologic outcome at discharge was assessed. Results A cohort of 291 children with CM were evaluated. BSI calculation was successful in all of them. The mean time to perform TCD and calculate the BSI was 4 ± 2 min. Overall, 222 participants (76%) had a good outcome and 69 (24%) a poor outcome. The BSI had an AUC of 0.98 (95% CI 0.97–0.99, p < 0.0001) to predict death or moderate to severe disability. The highest sensitivity and specificity of the BSI to predict adverse outcomes occurred at a cut off value ≤ 1.1. The adjusted odds ratio of poor outcome was 3.2 (95% CI 1.6–6.1, p = 0.001) if any BSI measurement during hospitalization fell below this threshold. No intracranial pressure monitoring was available to determine the relationship between the BSIs and an invasively measured cerebral perfusion pressure. Conclusion The BSI is a rapid, feasible point of care ultrasound measurement of cerebral hypoperfusion, with values ≤ 1.1 strongly correlating with poor neurologic outcomes in children with CM. Future studies should be performed to assess the utility of BSI to detect the presence and measure the severity of reduced cerebral perfusion pressure in other populations of critically ill children.https://doi.org/10.1186/s13089-025-00430-8Transcranial doppler ultrasoundTCDBrain shockBrain shock indexBSIPOCUS |
| spellingShingle | Nicole F. O’Brien Taty Tshimanga Florette Yumsa Mangwangu Ludovic Mayindombe Robert Tandjeka Ekandji Jean Pongo Mbaka Tusekile Phiri Sylvester June Montfort Bernard Gushu Hunter Wynkoop Marlina Lovett The brain shock index: repurposing the Lindegaard ratio for detecting cerebral hypoperfusion in children with cerebral malaria The Ultrasound Journal Transcranial doppler ultrasound TCD Brain shock Brain shock index BSI POCUS |
| title | The brain shock index: repurposing the Lindegaard ratio for detecting cerebral hypoperfusion in children with cerebral malaria |
| title_full | The brain shock index: repurposing the Lindegaard ratio for detecting cerebral hypoperfusion in children with cerebral malaria |
| title_fullStr | The brain shock index: repurposing the Lindegaard ratio for detecting cerebral hypoperfusion in children with cerebral malaria |
| title_full_unstemmed | The brain shock index: repurposing the Lindegaard ratio for detecting cerebral hypoperfusion in children with cerebral malaria |
| title_short | The brain shock index: repurposing the Lindegaard ratio for detecting cerebral hypoperfusion in children with cerebral malaria |
| title_sort | brain shock index repurposing the lindegaard ratio for detecting cerebral hypoperfusion in children with cerebral malaria |
| topic | Transcranial doppler ultrasound TCD Brain shock Brain shock index BSI POCUS |
| url | https://doi.org/10.1186/s13089-025-00430-8 |
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