Vascular
Transcranial Doppler Sonography
Pulsatility Index (PI) Reflects
Intracranial Pressure (ICP)
Johan Bellner, M.D.,* Bertil Romner, M.D., Ph.D.,* Peter Reinstrup, M.D., Ph.D.,*
Karl-Axel Kristiansson, M.L.T.,† Erik Ryding, M.D., Ph.D.,† and
Lennart Brandt, M.D., Ph.D.†
*Department of Neurosurgery, Department of Anesthesiology & Intensive Care and
†Department of Neurophysiology, University Hospital of Lund, Lund, Sweden
Bellner J, Romner B, Reinstrup P, Kristiansson K-A, Ryding E,
Brandt L. Transcranial Doppler sonography pulsatility index (PI)
reflects intracranial pressure (ICP). Surg Neurol 2004;62:45–51.
BACKGROUND
In patients with intracranial pathology, especially when
comatose, it is desirable to have knowledge of the intra-
cranial pressure (ICP). To investigate the relationship
between ICP and transcranial Doppler (TCD) derived pul-
satility index (PI) in neurosurgical patients, a prospective
study was performed on patients admitted to our neu-
rointensive care unit.
METHODS
Daily TCD mean flow velocity (mFV) measurements were
made. TCD measurements were routinely performed bi-
laterally on the middle cerebral artery (MCA). PI (peak
systolic-end diastolic velocities/mean flow velocity) was
calculated.
RESULTS
Eighty-one patients with various intracranial disorders
who had an intraventricular catheter for registration of
the ICP were investigated: 46 (57%) patients had sub-
arachnoid hemorrhage, 21 (26%) patients had closed
head injury, and 14 (18%) patients had other neurosurgi-
cal disorders. A total of 658 TCD measurements were
made. ICP registrations were made parallel with all TCD
measurements. A significant correlation (p ⬍ 0.0001) was
found between the ICP and the PI with a correlation
coefficient of 0.938: ICP ⫽ 10.93 ⫻ PI – 1.28.
In the ICP interval between 5 to 40 mm Hg the correla-
tion between ICP and PI enabled an estimation of ICP from
the PI values with an SD of 2.5. The correlation between
the cerebral perfusion pressure (CPP) and PI was signif-
icant (p ⬍ 0.0001) with a correlation coefficient of ⫺0.493.
When separating the measurements in severely elevated
(⬎120 cm/s) and subnormal (⬍50 cm/s) TCD mFV values,
the correlation coefficient between ICP and PI was 0.828
(p ⬍ 0.002) and 0.942 (p ⬍ 0.638), respectively.
Address reprint requests to: Johan Bellner, M.D., Department of Neu-
rosurgery, University Hospital, S-221 85 LUND, Sweden.
Received June 6, 2001; accepted December 15, 2003.
© 2004 Elsevier Inc. All rights reserved.
360 Park Avenue South, New York, NY 10010 –1710
CONCLUSIONS
Independent of the type of intracranial pathology, a
strong correlation between PI and ICP was demonstrated.
Therefore, PI may be of guiding value in the invasive ICP
placement decision in the neurointensive care
patient. © 2004 Elsevier Inc. All rights reserved.
KEY WORDS
Transcranial Doppler, pulsatility index, intracranial pres-
sure, head injury, subarachnoid hemorrhage.
ranscranial Doppler sonography (TCD) was
T primarily established as a sensitive method
for detection of changes in cerebral blood flow ve-
locities in patients with aneurysmal subarachnoid
hemorrhage (SAH) indicating vasospasm [2]. The
TCD technique is noninvasive and can easily be
repeated bedside without any risk for the patient.
The agility of the TCD equipment has also raised
hopes for ultra early assessment of intracranial dy-
namics following head injury [13]. The value of TCD
recordings in patients with head injury is, however,
controversial even though changes in flow veloci-
ties may enable early detection of potentially treat-
able cerebral blood flow (CBF) disturbances.
In patients with intracranial pathology, especially
when comatose, it is often paramount to have con-
tinuing knowledge of the intracranial pressure
(ICP). Exact ICP measurement is obtainable only by
an invasive intracranial pressure device [7,11].
However, a relationship between ICP and the pul-
satility index (PI) in head injured patients has been
described [8,14]. These findings have been further
evaluated in an experimental mathematical model
[21]. No prospective study on the possible relation-
ship between ICP and PI has, to our knowledge,
been performed on patients with intracranial pa-
thology equipped with intraventricular ICP moni-
0090-3019/04/$–see front matter
doi:10.1016/j.surneu.2003.12.007
46 Surg Neurol
2004;62:45–51
toring. Presently, such a study was carried out on
the postulation that increased ICP is paralleled by
an increase in PI.
Materials and Methods
PATIENT POPULATION
Eighty-one patients were included with the follow-
ing types of intracranial disorders, verified by com-
puterized tomography (CT): 46 (57%) had aneurys-
mal subarachnoid hemorrhage, 21 (26%) severe
head injury, 7 (9%) spontaneous intracerebral hem-
orrhage, and 7 (9%) had other neurologic disorders
[encephalitis (n ⫽ 1), meningitis (n ⫽ 3), meningi-
oma (n ⫽ 1), idiopathic intracranial hypertension (n
⫽ 1), and sagittal sinus thrombosis (n ⫽ 1)].
INTRACRANIAL PRESSURE
MONITORING
All patients received an intraventricular catheter
for continuous recording of the intracranial pres-
sure (HanniKath, 7F, pvb Medizintechnik Gmbh &
Co. kg, Kirchseeon, Germany).
TCD
One investigator conducted all TCD examinations.
TCD measurements were performed parallel to the
ICP registration.
The daily TCD measurements were conducted
transtemporally using a traditional 2-MHz trans-
ducer (EME TC-64 Eden medical records, Uberlin-
gen, Germany). The TCD measurements were rou-
tinely performed bilaterally on the middle cerebral
artery (MCA). Recordings were documented on a
videographic printer for later analysis (Sony VP
850). The depth and angle of insonation giving the
highest mean flow velocity (mFV) in MCA was al-
ways chosen. Normal mFV in MCA was defined as 62
⫾ 12 cm/s [1]. Consequently, mFVs were consid-
ered subnormal when below 50 cm/s and supernor-
mal when above 74 cm/s. mFVs above 120 cm/s
were considered severely elevated indicating vaso-
spasm or hyperemia [2,16]. Normal values for PI are
0.7 ⫾ 0.3 [20].
CALCULATIONS AND STATISTICAL
METHODS
PI was calculated according to the method of Gos-
ling [6]. PI is derived from the difference in the
systolic and diastolic flow velocity divided by the
mFV.
The PI data were correlated to ICP and CPP and
the correlation coefficient calculated. To control
the linear correlation, the residuals were tested for
normal distribution around the regression line with
Bellner et al
Kolmogorov-Smirnof’s test. An estimated ICP from
PI was determined from the regression equation.
The validity of the TCD(PI) method for ICP measur-
ing was tested by a Bland & Altman plot [3]. Sensi-
tivity and specificity for ICP(PI) were calculated in
the ICP range of 0 to 20 and 0 to 40 mm Hg.
Results
Eighty-one patients (37 males and 44 females) aged
2 to 79 years (mean 52 years) were investigated
daily with a total of 658 PI measurements. The pa-
tients had a mean (⫾ SD) arterial partial pressure of
carbon dioxide (PCO2) of 4.84 ⫾ 0.64 (range 3.25–
7.5) kPa, a heart frequency of 79 ⫾ 17 (range 47–
142), 97.3% with regular sinus rhythm, and a mean
arterial blood pressure (MAP) of 92 ⫾ 16 mm Hg
(range 48 –162) at the time of investigation.
The correlation between the cerebral perfusion
pressure (CPP) and PI was significant (p ⬍ 0.0001)
with a correlation coefficient of ⫺0.493 (Figure 1).
This finding was paralleled by a similar significant
correlation (p ⬍ 0.0001) between CPP and ICP
where the similar correlation coefficient was
⫺0.477.
In the overall results there was a significant cor-
relation (p ⬍ 0.0001) between the ICP and the PI
with a correlation coefficient of 0.938 (Figure 2).
When separating severely elevated (⬎120 cm/s)
and subnormal (⬍50 cm/s) TCD mFV values, the
correlation coefficient between ICP and PI was 0.828
(p ⬍ 0.002) and 0.942 (p ⬍ 0.638 because of a low
number of measurements), respectively (Figures 3
and 4). Only in one of 658 measurements (0.15%),
the mFV exceeded 120 cm/s in conjunction with an
ICP above 20 mm Hg (Figure 3). However, only in the
ICP interval 5 to 40 mm Hg were the data normal
distributed around the regression line. Omitting re-
peated measurements, and only considering the ini-
tial TCD-ICP recording in each subject (n ⫽ 81) for
the interval, 5 to 40 mm Hg R2 was 0.733 (p ⬍ 0.0001)
with a SD 2.5. The regression line is ICP(PI) ⫽ 11.1
⫻ PI – 1.43. Using the regression equation we get
ICP(PI) ⫽ ICP ⫾ 2.5 (SD) with a 95% confidence
interval of ⫾4.2.
A Bland and Altman plot of all measurements
confirmed that the difference between the observed
ICP and the ICP predicted from the PI was within the
⫾4.2 of the observed ICP (Figure 5).
In an ICP span between 0 and 20 mm Hg, the
method had for all measurements a sensitivity of
0.88 and a specificity of 0.69, and for the first mea-
surement only a sensitivity of 0.91 and a specificity
of 0.79, for detecting an ICP ⬎10 mm Hg. To detect
Pulsatility Index Reflects Intracranial Pressure Surg Neurol 47
2004;62:45–51

Graph demonstrating a significant correlation between the CPP and PI with a correlation coefficient of ⫺0.493 (p
1 ⬍ 0.0001) and a correlation formula of: CPP ⫽ 89.646 – 8.258 ⫻ PI. The correlation between CPP and PI is mainly
when PI ⬎3. The dotted lines are the 95% confidence interval for the regression line, which can be significantly affected
by outliers when PI is large.

an ICP ⬎ 20 in a population with ICP between 10 and
40, the method had for all measurements a sensi-
tivity of 0.83 and a specificity of 0.99, and for the
first measurement only a sensitivity of 0.89 and a
specificity of 0.92.
Discussion
TRANSCRANIAL DOPPLER IN
NEUROINTENSIVE CARE
The mobility of the equipment, the possibility of
repeated bedside investigations together with the
noninvasive nature of the technique, makes TCD
measurements attractive in the attempt to estimate
CBF in acute care settings. The basic technical lim-
itation, i.e., measuring cerebral blood flow velocity
and not true volume flow, has triggered further
development in the utilization of acquired data
from the TCD investigations.
In neurointensive care, knowledge of ICP is often
essential. When measuring ICP the use of an intra-
ventricular catheter has for decades been consid-
ered as gold standard [11].
In the present study, we found independent of
intracranial pathology, a significantly strong posi-
tive correlation between PI and intraventricular ICP
monitoring. Notably, the correlation was still strong
in the patient subgroup demonstrating mFV values
above and below normal interval.
A less clear correlation (⫺0.493) between PI and
CPP was seen. In head injured patients, Chan et al
[4], reported a correlation (⫺0.725) between PI and

Graph demonstrating a significant correlation between the ICP and the PI with a correlation coefficient of 0.938 (p
2 ⬍ 0.0001) and a correlation formula of: ICP ⫽ 10.927 ⫻ PI – 1.284. The dotted lines are the 95% confidence interval
for the regression line, which can be significantly affected by outliers when PI is large.
48 Surg Neurol Bellner et al
2004;62:45–51

Graph demonstrating a significant correlation between the ICP and PI in measurements when TCD mFV exceed 120
3 cm/s. The correlation coefficient between ICP and PI was 0.828 (p ⬍ 0.002). The dotted lines are the 95% confidence
interval for the regression line, which can be significantly affected by outliers when PI is large.

CPP with an even better correlation (⫺0.942) as
CPP decreased below a critical value of 70 mm Hg.
In an experimental mathematical model study,
Ursino et al [21], described relationships between
perfusion pressure, autoregulation and TCD wave-
form during various settings in cerebrovascular he-
modynamics. These theoretical models indicate
that during normoventilation within normal blood
pressure range, sudden increases in PI are only
attainable with a rise in ICP. Our clinical results are
in agreement with these findings. However, to rely
on PI in daily practice one has to determine the
sensitivity and specificity of the method. In the
acceptable ICP interval of 0 to 20 mm Hg, the TCD is
highly sensitive with a medium high specificity. In
the supranormal ICP range between 10 and 40 mm
Hg the sensitivity decreases while the specificity
increases. Consequently, the TCD-PI measurement
gives a fairly good estimation of the ICP, which
might be of value in unconscious patients.
PI IN ANEURYSMAL SUBARACHNOID
HEMORRHAGE
The correlation between ICP and PI was still intact
in SAH patients suffering vasospasm detected by
TCD (Figure 3). Cerebral vasospasm in SAH is char-
acterized by a high mFV through the vasospastic
artery, often exceeding 120 cm/s [2]. In such cases
there will be a decrease in CBF because of an in-
crease in cerebrovascular resistance through the
artery [17]. The high flow velocity is only obtain-
able if the peripheral vascular resistance remains at
a relatively low level. As a result a high mFV is
usually not found in patients with high ICP as they

Graph demonstrating the correlation between the ICP and PI in measurements with TCD mFV below 50 cm/s. The
4 correlation coefficient between ICP and PI was 0.942 (p ⬍ 0.638). The dotted lines are the 95% confidence interval
for the regression line, which can be significantly affected by outliers when PI is large.
Pulsatility Index Reflects Intracranial Pressure
In the ICP interval 5 to 40 mm Hg was the data
5 normal distributed around the regression line. The
correlation formula in this interval is: ICP(PI) ⫽ 11.5 ⫻ PI
– 2.23 and R2 ⫽ 0.732, p ⬍ 0.0001. Using the regression
equation we get ICP(PI) ⫽ ICP ⫾ 2.5 (SD) with a 95%
confidence interval of ⫾4.2. The Bland and Altman plot
confirmed that 95% of the ICP (PI) data are within the
⫾4.2 limit Bland and Altman plot showing ICP(PI)-ICP and
mean ICP.
have a concomitant increase in small vessel resis-
tance [9]. In the present study, only once in 658
measurements was an mFV exceeding 120 cm/s ob-
served in conjunction with an ICP above 20 mm Hg
(Figure 3).
PI IN HEAD INJURY
With repeated carotid Doppler sonograms, Steiger
[19] investigated PI in patients with severe head
injury as compared to healthy volunteers. This ex-
tracranial utilization of PI revealed values between
1.5 to 2.0 in control subjects with a gradual increase
in cases with posttraumatic brain edema. PI values
⬎3 were associated with severe intracranial hyper-
tension, and in cases of angiographically demon-
strated cerebral circulatory arrest, PI values in the
range of 6 to 8 were found.
Presently a significant correlation between PI and
ICP was found, the correlation being stronger as
compared to previous studies. Homburg et al [8],
investigated 10 head injured patients and demon-
strated a positive exponential correlation between
PI and the epidural pressure (r ⫽ 0.82). McQuire
and colleagues [13] performed TCD measurements
within 3 hours after injury on 22 head injured pa-
tients. Thirteen of the patients had either computed
tomography verified space-occupying hematomas
or brain swelling. Among these cases 10 had an
increased PI in this ultra-early phase. Recently,
Moreno et al [14] correlated TCD measurements
with ICP and CPP values in 125 patients with severe
head injury. They found that an elevated PI predicts
poor outcome (PI 1.56), and furthermore, a corre-
Surg Neurol 49
2004;62:45–51
lation between ICP and PI (R2 ⫽ 0.69) was found. In
severe head injured patients, Martin et al [12] re-
ported significantly higher PI values on Day 0, com-
pared to Days 1 through 3 and Days 4 through 14
post-trauma. These findings strongly suggest the
presence of high distal vascular resistance in the
early phase after head injury. The authors also
showed that one-third of patients with severe head
injuries have vasospasm, and that vasospasm will
significantly change both mFV and PI. In our study
we found that PI reflected ICP even when mFV was
above 120 in the ICP range of 0 to 20 mm Hg, but
with only one reading above 20 mm Hg.
With data obtained by TCD, Czosnyka and asso-
ciates [5] made estimations of CPP after head injury
and concluded that such measurements may be of
value in situations where direct measurements of
CPP are not readily available. Moreno et al [14]
found a positive correlation of 0.60 between PI and
CPP. This correlation is probably dominated by the
ICP. In our experience, reduced mFV after head
injury always indicates reduced volume flow in the
insonated artery, and can hence be helpful to indi-
cate compromised cerebral perfusion, and a low
mFV postinjury should guide the choice of blood
pressure targets that should be used during the
cerebral resuscitation [16]. An example of this is
our findings of frequently reduced mFV in measure-
ments where ICP exceeded 20 mm Hg with a corre-
sponding rise in PI.
PI IN HYDROCEPHALUS
In hydrocephalic children a decrease of PI in the
postshunting test as compared with the preshunt-
ing test has been shown [15]. Furthermore, after
endoscopic third ventriculostomy for the treatment
of obstructive hydrocephalus, pre- and postopera-
tive PI measurements have been shown useful for
evaluation of fenestration patency [22]. Recently,
the value of PI measurements was confirmed in a
study of 21 hydrocephalic patients [18].
FACTORS THAT INFLUENCE PI
Flow velocity, the velocity pattern, and thereby the
PI may be influenced by different factors, like hemo-
dynamic, respiratory, and hematologic parameters,
and, in the case of brain vessels, tissue compliance.
For this reason, the absolute value of this index is,
in general, not considered sufficient to characterize
overall intracranial hemodynamic conditions if no
other information is simultaneously provided. The
main advantage of PI is that, being a ratio; it is not
affected by the angle of insonation.
The arterial pressure in large and medium sized
cerebral arteries is only slightly reduced compared
50 Surg Neurol
2004;62:45–51
to the pressure created by the heart, but in the
arterioles the normal mean pressure drops. During
elevated intracranial pressure, the arterioles are
easily compressed creating a high peripheral vas-
cular resistance reducing the flow, and thereby, the
denominator of the PI. The numerator of the PI
derives from the difference between systolic and
diastolic flow velocities. The elasticity of the normal
vascular system dampens the flow and flow velocity
fluctuations because of blood pressure changes,
which is in contrast to a rigid tube where the pres-
sure is directly proportional to the flow velocity
[21]. A clinical setting where this is apparent is the
elevation of PI in diabetic patients with cerebral
microangiopathy and hence depressed vessel com-
pliance [10]. An increased intracranial pressure al-
ways results in reduced compliance of the entire
brain tissue including increased rigidity of the brain
arteries augmenting the velocity variations, which
in turn increases the denominator of the PI. Conse-
quently, this index is sensitive to ICP changes.
The flow velocity pattern in cerebral arteries is
affected both by cerebrospinal fluid pulsatility and
the action of cerebrovascular control mechanisms.
In a situation with severely raised ICP one might
expect not only a decrease in mFV, but in particular
an effect on velocity pattern during diastole. The
reduction in mFV during this phase is more pro-
nounced and rapid. These factors will thus, accord-
ing to the equation, increase the PI. This pattern is,
to the most extreme, seen when total brain infarc-
tion is present. Then mFV approaches zero and the
calculated PI thus reaches extreme values.
Conclusion
Our data shows a highly significant correlation be-
tween PI and ICP independent of intracranial pa-
thology. Accordingly, in patients with suspected
increase in ICP or where an increased ICP has to be
excluded, PI may be of guidance and repeated PI
measurements might prove a useful tool in neuroin-
tensive care settings.
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COMMENTARY
Bellner et al have added to the growing body of
knowledge regarding transcranial Doppler sonogra-
phy and its use in various neurosurgical clinical
problems. This study has the advantage of being
prospective with a good statistical analysis of the
data. Although they are able to describe the results
of the technique in several different pathologies, it
is important to realize that the intracranial dynam-
ics and the cause of increased intracranial pressure
Surg Neurol 51
2004;62:45–51
would vary with pathology type, e.g., between sub-
arachnoid hemorrhage and traumatic brain injury.
Although the correlation between pulsatility index
and intracranial pressure was strong, the transcra-
nial Doppler study can only be done intermittently.
Obviously, in the pathology described, intracranial
pressure is a moving target. This limits its clinical
applicability significantly. However, as the authors
point out, I think it could be a useful technique in
patients in whom elevated intracranial pressure
was suspected or in those patients in whom it
would be important to exclude.
Gaylan L. Rockswold, M.D.
Professor of Neurosurgery
University of Minnesota
Minneapolis, Minnesota