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Transcranial Doppler Sonography in the Early Stage of Critical Enteroviral Infection

Divisions of Pediatric Neurology (K.-S.C., K.-L.L., H.-S.W.), Pediatric Critical Care Medicine (S.-H.H.), and Pediatric Infection (T.-Y.L., P.-Y.L.), Chang Gung Children’s Hospital, Medical College of Chang Gung University, Taoyuan, Taiwan, Republic of China; and Department of Pediatrics, St Paul’s Hospital, Taoyuan, Taiwan, Republic of China (K.-S.C.).

Address correspondence and reprint requests to Kuang-Lin Lin, MD, Chang Gung Children’s Hospital, 5 Fu-Shin St, Kwei-Shan, Taoyuan 333, Taiwan, Republic of China. E-mail: lincgh{at}adm.cgmh.org.tw.

Objective. There is a high fatality rate in enteroviral infection with central nervous system involvement. Our aim was to investigate the change in intracranial blood flow to disclose the characteristic findings in the early stage of critical enteroviral infection. Methods. We examined 27 patients in critical condition with enteroviral infection in our pediatric intensive care unit. We performed transcranial Doppler sonography within 12 hours of admission to the unit. The data were compared with those of a group of 11 patients with nonenteroviral encephalitis. Results. The peak systolic, end-diastolic, and mean velocities of the critical enteroviral infection group were significantly higher than those of the control group (P < .05). Gosling pulsatility index and Pourcelot resistive index values for the right and left middle cerebral arteries (pulsatility index, [mean ± SD], 0.68 ± 0.22 and 0.77 ± 0.19, respectively; resistive index, 0.48 ± 0.01 and 0.52 ± 0.01) in patients with critical enteroviral infection were significantly lower than those of patients with nonenteroviral encephalitis (pulsatility index, 1.10 ± 0.30 and 0.98 ± 0.22; resistive index, 0.62 ± 0.01 and 0.60 ± 0.01; P < .05). Conclusions. Low pulsatility index and resistive index values for cerebral blood flow were observed in the early stage of critical enteroviral infection. This characteristic finding of cerebral blood flow might be associated with the increased sympathetic discharge induced by a brain stem–involved systemic inflammatory response and dysfunction of autoregulation caused by the infection or other disorders of autoregulation that might cause severe or fatal complications.

Key Words: enteroviral infection • Gosling pulsatility index • Pourcelot resistive index • transcranial Doppler sonography

Abbreviations: ACA, anterior cerebral artery • CNS, central nervous system • CSF, cerebrospinal fluid • HFMD, hand-foot-and-mouth disease • LMCA, left middle cerebral artery • PI, pulsatility index • PICU, pediatric intensive care unit • RI, resistive index • RMCA, right middle cerebral artery • TCD, transcranial Doppler

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