REVIEW ARTICLE

Melanie Wielicka* , Jolanta Neubauer-Geryk* , Grzegorz Kozera , Leszek Bieniaszewski

*Both authors had an equal authorship in the study
Clinical Physiology Unit, Medical Simulation Centre, Medical University of Gdansk, Gdansk, Poland

Clinical application of pulsatility index

Corresponding author: ABSTRACT
Jolanta Neubauer-Geryk, Clinical Pulsatility index (PI) is defined as the difference between the peak systolic flow and minimum diastolic flow
Physiology Unit, Medical Simulation
Centre, Medical University of Gdansk, velocity, divided by the mean velocity recorded throughout the cardiac cycle. It is a non-invasive method
Gdansk, Poland, Dębowa 25 Str., of assessing vascular resistance with the use of Doppler ultrasonography. It was first introduced in 1974
80-204 Gdansk, Poland, by Gosling and King and is also known as the Gosling Index. PI as a method of examining macrocircula-
e-mail: jolaneub@gumed.edu.pl
tion has a variety of clinical applications. For instance, in diabetic patients, it has been measured on the
common carotid, middle cerebral or renal arteries to help predict complications such as cerebrovascular
disease or nephropathy. In hypertensive patients, it has been used to assess complications and assess
the chronicity of the disease. To our knowledge, despite the diverse use of this ultrasonographic parameter,
there is a deficiency in reports that would comprehensively summarize its clinical applications.
Based on our extensive review of the literature and the gathered information, we conclude that pulsatility
index (PI) is an easy to obtain parameter with a broad range of both, research and clinical applications.
Medical Research Journal 2020; It has been widely used in the assessment of macrocirculation in highly prevalent chronic medical condi-
Volume 5, Number 3, 201–210 tions, such as hypertension, both type 1 and type 2 diabetes and thyroid disorders.
10.5603/MRJ.a2020.0016
Copyright © 2020 Via Medica Key words: pulsatility index, clinical application, cerebral artery, carotid artery, renal artery
ISSN 2451–2591 Med Res J 2020; 5 (3): 201–210

Introduction tions, including increased stress on the left ventricle,

a gradual increase in blood pressure and, eventually,
Macrovascular complications, such as cardiovascu- even end-organ damage through the transmission of
lar and cerebrovascular events, are the leading cause harmful pulsation into the microcirculation. Thus, the
of mortality in patients with common vascular risk fac- increase in pulsatility associated with loss of elastic
tors, such as diabetes or hypertension. It is estimated recoil in large blood vessels has detrimental effects on
that, globally, approximately 32.2% of type 2, 30.3% of global cardiovascular health.
type 1 diabetic and 30% hypertensive patients suffer Pulsatility index (PI) is defined as the difference
from cardiovascular complications [1–5]. between the peak systolic flow and minimum diastolic
Pulsatility is an intrinsic property and an integral flow velocity, divided by the mean velocity recorded
aspect of the cardiovascular system, strongly related to throughout the cardiac cycle. It is a non-invasive
elasticity of arteries. The natural pulsations in pressure method of assessing vascular resistance with the use
caused by each contraction of the left ventricle are large- of doppler ultrasonography. It was first introduced in
ly diminished thanks to elasticity of large arteries. As the 1974 by Gosling and King, thus is also known as the
aorta expands, it stores a portion of the stroke volume, Gosling Index [7, 8]. Due to the vast applications of this
so that the microvasculature is less exposed to pulsatile parameter, we comprehensively discuss PI use and its
stress [6]. Thus, the elasticity of blood vessels allows clinical significance in the assessment of microcircula-
for blunting down harmful pulsations in the large arter- tory system (Fig. 1).
ies before they reach end-organ microcirculation [6].
However, from early on in childhood, arterial walls con-
tinually increase in stiffness through the loss of elastic Macrocirculation and pulsatility
fibers. This process is further augmented by disorders
of metabolism such as hyperlipidemia or diabetes The great physiological and clinical significance
mellitus through a variety of mechanisms. A decrease of arterial pulsatility is related to how the large, elastic
in elasticity is associated with a multitude of complica- arteries serve as a type of reservoir that functions to

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The impact of aging on arterial stiffness and

Velocity pulsatility has been demonstrated in several stud-
V max– V min ies. Zarrinkoob et al [12] investigated how age and
PI =
V mean sex impacts the dampening of the pulsatile flow
V max
from the proximal to the distal cerebral arteries. The
study groups consisted of 45 healthy elderly, with
a mean are of 71 years, and 49 young healthy
subjects, with a mean age of 25 years. The authors
V mean found that especially cerebral pulsatile flow was
dampened from proximal to distal parts of the ce-
rebral arterial system and that this dampening was
V min more pronounced in the younger studied group.
This demonstrates how aging impacts the ability of
Time
larger, more elastic arteries to diminish delivery of
harmful pulsations to smaller blood vessels. Several
Figure 1. Calculation of the Pulsatility (Gosling) Index (PI).
other authors have also shown an increase in PI of
V max — maximal flow velocity, V min — minimal flow
the cerebrovascular circulation with an increase in
velocity, V mean — mean flow velocity
age [13, 14]. Additionally, Schoning et al [15, 16]
used ultrasound examination to establish PI at the
common carotid artery in healthy children, adoles-
store blood during systole and expel it to the peripheral cents and adults. They were able to demonstrate how
circulation during diastole within each contraction of arterial hemodynamics change with age and show
the left ventricle [4, 5]. This provides a constant flow that PI is an age-dependent parameter.
of blood into the microvascular beds throughout the It is also worth mentioning how an increase in arterial
cardiac cycle, allowing for continuous exchange of diameter affects PI. It has been described that in arterial
substances between tissues and plasma. Loss of this aneurysms, a Windkessel effect takes place, where the
elastic reservoir has several negative effects on the aneurysm acts as a reservoir for blood during systole
cardiovascular system and has the potential to damage and releases it during diastole. This results in lower
end-organ circulation. With the loss of elasticity, there pulse pressure, because of increased vascular resis-
is an increase in pulsatile load of the heart, which has tance distally [9, 10]. This was supported by a study
detrimental effects on the left ventricle through increas- by Hussein et al [9], where the authors demonstrated
ing its mass and thus the myocardial oxygen demand the relationship between the size of internal carotid
[9]. Additionally, the increased pulsations resulting artery aneurysms and distal intracranial hemodynam-
from the stiffness of large vessels are believed to af- ics. They have measured flow and pulsatility index within
fect the capillary networks, resulting in microvascular bilateral middle cerebral arteries and internal carotid
complications, as they allow the harmful pulsations to arteries prior to initiating any treatment. They found
be conducted into end-organ microcirculation [10]. that larger aneurysmal size (>10mm) had a significant
This is particularly important when it comes to organs correlation with higher ipsilateral middle cerebral artery
characterized by high flow and low resistance, such as PI. Conversely, a decrease in aortic diameter causes
the brain and the kidneys [6]. an increase in vascular resistance. An increase in
The complex elastic fiber mesh in large blood pulsatility index is a reliable marker of distal resistance
vessels begins its synthesis development in early em- in the examined blood vessel [11]. Pulsatility index as
bryogenesis, a process which continues up until early a measure of vascular resistance has also been used
childhood. As a result, adults have a relatively fixed in examining patients with carotid artery stenosis as
amount of elastic fibers in their aorta, which slowly well as aortic stenosis, helping in assessment of the
stretch out, degenerate and become replaced by much efficacy of treatment.
less compliant collagen fibers [9]. As shown by Eberth PI as a method of examining macrocirculation has
et al increasing pulsatile pressure and continuous a wide range of clinical applications. For instance, in
flow injury on the vascular wall result in a significant diabetic patients it has been measured on the common
increase in the number of cells and an increased col- carotid, middle cerebral or renal arteries to help predict
lagen-to-elastin ratio with further aortic wall thickening complications such as cerebrovascular disease or
and luminal narrowing [11]. The progression of arterial nephropathy [12, 13]. In hypertensive patients, it has
stiffening and the increase in flow pulsatility in the el- been used to assess complications and assess the
derly occurs due to the fact that the less elastic vessels chronicity of disease [14]. To our knowledge, despite
are no longer capable of buffering the flow pulsations the diverse use of this ultrasonographic parameter,
generated with each ventricular contraction. there is a deficiency in reports that would comprehen-

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 Melanie Wielicka et al., Pulsatility index

sively summarize its clinical applications. Thus, we Pulsatility index in atherosclerosis and arterial
would like to discuss the value of pulsatility index in the stenosis
macrovascular examination.
Several studies report a relationship between pul-
satility and atherosclerotic disease. Pulsatility index
Clinical applications of PI has been studied as an additional parameter when
assessing arterial wall shear stress, an important
Pulsatility index in hypertension and heart disease predictor of cardiovascular risk and atherosclerosis
development. Avrahami et al have studied pulsating
Many available reports discuss the association flow waveforms in a straight, rigid tube, with and without
between the loss of arterial elasticity and hypertension. flow reversals. Their results had indicated that adding
A study by Clime et al explains that increased blood PI to the already widely used average flow rate and
pressure values are associated with an increase in inti- heart rate measurements improve diagnostic evaluation
mal-media thickness, lumen enlargement and increased [20]. Jotoku et al. have shown a significant association
stiffness of proximal elastic arteries [6]. Conversely, between pulsatility index of the common carotid artery
Mitchell discusses several publications that have shown with cardiovascular risk factors, namely homocysteine
that the arterial stiffness precedes and strongly contrib- and monocyte levels. Both of the latter parameters
utes to the development of hypertension [9]. have been shown to be related to coronary plaque
In hypertensive patients, the pulsatility index can development and progression in acute myocardial
be used as a predictor of complications and help infarction [21].
assess chronicity of disease. Cho et al measured flow As per Poiseuille’s Law, a decrease in vascular diam-
velocities and Gosling Index of the middle cerebral and eter, such as in the case of arterial stenosis, leads to an
internal carotid arteries in 94 hypertensive patients. They increase in vascular resistance [22]. An increase in PI
demonstrated a significant decrease in flow velocities, is a reliable marker of distal resistance in the examined
and an increase in the Gosling index in patients who blood vessel [11], which is why it can be useful in as-
had hypertension for over five years. These differences sessing the distal parts of examined vessels that are not
were not present in patients with a shorter duration of as easily accessible with ultrasound techniques. Thus,
the disease [14]. the pulsatility index as a measure of vascular resistance
PI has also been studied in patients with renovas- has been utilized in assessing arterial narrowing and
cular hypertension, and hypertension associated with efficacy of treatment in carotid artery stenosis. Heyer
renal failure. A report by Bardelli et al discusses the et al [23] studied PI of the middle cerebral artery in
possible use of the pulsatility index of renal arteries as patients with carotid artery stenosis and its correla-
an indicator of bilateral renal artery stenosis in hyper- tion with cerebral blood flow and cognitive function
tensive patients. They were able to correctly diagnose post carotid endarterectomy. The authors explained
renovascular hypertension in 84% of patients, while the that those patients frequently have reduced cerebral
presence of renal artery stenosis was established in 94% vascular resistance, likely through autoregulation, to
of patients [16]. Renal artery PI and resistive index have compensate for decreased cerebral blood flow, with PI
also been demonstrated to be associated with renal values in symptomatic patients typically documented
function parameters, such as creatinine clearance, in to be < 1.0. They found that symptomatic patients with
patients with renal failure and hypertension [17]. Addi- a low baseline PI (=< 0.80) are likely to have increased
tionally, Okuma et al studied intrarenal PI and resistive cerebral blood flow and improved cognitive function
index in patients with hypertension and showed that even 1 day after carotid endarterectomy.
they are positively correlated with carotid intima-media Wada et al [24] investigated whether carotid ultra-
thickness, suggesting that those measurements could sonography indices could help detect the progression
be used in the evaluation of arterial stiffness in hyper- of arterial stenosis in patients with vertebral artery (VA)
tensive patients [18]. dissection. In patients admitted with intracranial VA
In a recently published study from 2019, Sasaki dissection, an MR angiography (MRA) was performed at
et al have shown that common carotid artery PI, as admission and after a median of 20 days, while the base-
well as resistance index measurements, are associ- line peak systolic velocity, end-diastolic velocity, mean
ated with the log NT-pro-BNP levels in hypertensive velocity and pulsatility index were measured at admis-
patients, suggesting that PI could be a useful marker sion and followed up after a median of 22 days. A follow
of hemodynamic stress on the left ventricle, while up to baseline ratio was then calculated. The PI ratio
mean intima-media thickness, number of plaques was significantly higher in patients with stenosis pro-
and plaque score had no association with log gression, while there were no significant differences in
NT-proBNP [19]. the other measured parameters. The authors concluded

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Figure 2. Extra-cranial Doppler Duplex examination of vertebral artery. A — normal flow pulsatility; B — increased
pulsatility due to distal occlusion with preserved collateralization by Posterior Inferior Cerebellar Artery; C — increased
pulsatility due to distal occlusion without preserved collateralization by Posterior Inferior Cerebellar Artery. AC — angle
correction [The exam performed at the Laboratory of Neurosonology of the Department of Neurology, Collegium
Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, head of the clinic dr. hab. G. Kozera, ESAOTE MyLab
Class C apparatus with a 5.5 MHz (A) linear probe and in the Laboratory of Neurosonology of the Clinic of Neurology,
Medical University of Gdańsk, head of the clinic prof. W. M. Nyka, GE Vivid I device with 5.5 MHz linear probe (B–C)]

that PI might be a useful index in the detection of arterial vessels and that PI and RI are reliable in diagnosing
stenosis progression. Thus, an increase in PI may be cerebrovascular malformations [27].
currently used as an ultrasonographic marker of distal Kaspera et al. studied the impact of treatment on
stenosis or occlusion and help to predict its site (Fig. 2). hemodynamic parameters of AVMs using color-coded
PI has also been used in patients with age-related doppler sonography. They assessed mean flow velocity,
aortic stenosis. Cay et al investigated the association pulsatility index and vasomotor reactivity in the major
between ascending aortic pressure-derived indices and cerebral vessels in 46 adult patients who were all diag-
hemodynamic characteristics of calcific aortic stenosis nosed with AVMs. These parameters were recorded at
(AS) [25]. They measured fractional pulse pressure admission, within 24 hours after the first embolization or
(FFP) and pulsatility index in the ascending aorta in surgical resection, and before the second embolization.
a group of patients with aortic stenosis and healthy The authors found a decrease in mean flow velocity and
controls. Both values were significantly higher in the AS an increase in PI in the embolized feeding vessels [28].
group. The authors suggested future studies could po-
tentially evaluate the prognostic value of both FFP and Pulsatility index in diabetes
PI in determining the severity of calcific aortic stenosis.
According to the CDC statistics, there were in total of
Pulsatility index in vascular malformations 26.9 million diagnosed cases of diabetes in the United
States in 2018 alone, with only 5.2% of these cases ac-
In neurosurgery, PI is helpful in the evaluation of counted for by type 1 diabetes [29]. Long-standing hy-
cerebral arteriovenous malformations (AVMs). The feed- perglycemia in diabetic patients is known to damage the
ing arterioles in AVMs empty directly into a vein with no vascular endothelium, and correlates with an increase
capillary network in between to increase resistance. This in vascular stiffness [30], increasing pulsations. The
has been associated with high-flow and low resistance increased pulsations resulting from the stiffness of
within the ACMs, with a decrease in PI values [26]. large vessels are also believed to affect the capillary
Burkhardt et al. have analyzed hemodynamic profiles, networks, resulting in microvascular complications [31].
measured flow velocities, resistance index and pulsatil- Thus, several studies have shown a possible application
ity index of feeding and draining arteries in 32 patients for the pulsatility index in examining the larger blood
with AVMs with the use of intraoperative micro-Doppler vessels to predict and prevent microvascular compli-
(IOMD). They concluded that IOMD is a safe and useful cations in diabetic patients, especially in the renal and
tool which helps in eliminating only the necessary blood cerebral circulation.

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 Melanie Wielicka et al., Pulsatility index

In a study from 2006, pulsatility index at the internal the presence of asymptomatic brain injury (white matter
carotid artery was used to indicate presence of mi- lesions, WML) may be related to higher PI in the pres-
croangiopathy by showing its strong correlation with ence of additional confounders, such as type 2 diabetes
microalbuminuria in type 2 diabetic patients [32]. A dif- and ACE inhibitor or statin use [37].
ferent, more recent study from 2018, has determined the The decline in peripheral vascular function is also an
relationship between renal resistivity index, pulsatility important complication of diabetes. In 2005, Janssen
index and renal function parameters, namely urinary suggested pulsatility index as a non-invasive method
albumin secretion rate, serum creatinine levels and of evaluation of critical limb ischemia in patients with
eGFR (estimated glomerular filtration rate). The positive diabetic neuropathy. This study even compares PI to
correlation between PI, albuminuria and serum creati- ankle-brachial doppler index and the systolic ankle
nine, combined with a negative correlation with eGFR, pressure, and shows that it is superior to the other
suggest that PI may be a useful parameter in predicting methods when assessing critical limb ischemia in this
renal dysfunction in type 2 diabetic patients [13]. group of patients [38]. In a study by Zou et al, the
Lee at al. have shown that pulsatility index at the authors explored the clinical value of ultrasound exam-
middle cerebral artery and at the internal carotid artery ination combined with a warm bath in the assessment
was significantly higher in patients with microvascular of the microcirculation in diabetic patients. Several
complications such as retinopathy, nephropathy and Doppler parameters were used, including pulsatility
neuropathy than those with no complications and and resistivity indices at the dorsalis pedis artery and
healthy controls. Their study population consisted of plantar digital artery. They suggested that color dop-
56 types 2 diabetic patients, with a mean age of 59, pler combined with a warm bath test could potentially
and 70 age-and gender-matched controls [33]. Agha be used when assessing the differences in reactivity
et al have measured pulsatility index along with flow of distal limb microvasculature in patients with type
velocity at the middle cerebral, basilar and intracranial 2 diabetes [13].
portion of the internal carotid artery in a large sample of Additionally, the pulsatility index has been used to
141 of diabetic patients and 131 age and sex-matched help assess the effects of certain therapies in diabetic
controls. Their results have demonstrated a statistical- patients. A study from 2016 used PI to analyze the
ly significant difference between these values when effect of Naoxitong Capsules on vascular remodelling
they compared patients with diabetes to healthy con- of carotid artery in type 2 diabetic patients [39]. In
trols. When dividing the diabetic group into patients another report by Park et al. the effect of pioglitazone
with or without complications, they were also able to on the pulsatility index of cerebral arteries and carotid
demonstrate significant differences between those two intima thickness in type 2 diabetic patients was studied.
sub-groups. They had concluded that arterial pulsatility The study group involved 40 types 2 diabetic patients,
index can be used as an indicator of the presence of divided into two groups: one treated with pioglitazone
cerebral microangiopathy in type 2 diabetic patients and one treated with gliclazide. Pulsatility index was
[34]. A different study on cerebrovascular pulsatility in calculated for each group based on transcranial Dop-
diabetes investigated the relationship between insulin pler examination and was found to be significantly
resistance and pulsatility index in diabetic patients by decreased in the pioglitazone treated group. Through
measuring the PI at middle cerebral artery [35]. The obtaining the PI measurements, the authors were able
authors found that pulsatility index was significantly to conclude that pioglitazone improved cerebrovascular
higher in diabetic patients when compared to healthy resistance in type 2 diabetic patients [40].
controls, and additionally, was also higher in patients
who had insulin resistance confirmed with a short Pulsatility index in children
insulin tolerance test, than in patients with diabetes
alone. However, it is important to note that the age and In healthy subjects, PI is an age-dependent param-
duration of diabetes independently contributed to the eter. This fact was described by Schoning et al [41, 42]
changes in PI between the subgroups. Kozera et al. in their studies applying ultrasound examination of PI for
studied the presence of cerebral and skin angiopathy in common carotid artery in healthy children, adolescents
adult patients with type 1 diabetes mellitus. In a group and adults. They showed that PI changes from value
of adult patients with type 1 diabetes mellitus, authors 1.73 ± 0.31 for children under 10 years of age through
found no significant association between cerebral and 1.97 ± 0.42 in children and adolescents over 10 years of
skin microvasculature function despite the simultane- age [41] to 1.72 ± 0.5 for adults [41, 42]. The significant
ous presence of cerebral microangiopathy reflected differences of PI between groups were shown. It is worth
by increased PI of the middle cerebral artery and skin noticing that according to Shoning et al., pulsatility
microangiopathy (reflected in by increased COVERAGE index at common carotid in adults artery significantly
of skin capillaries)[36]. Kozera et al. also showed that decreases with age (r = -0,52, p = 0.001) [42].

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Pulsatility index, being a fast, simple and non-in- disease. The thyroid arteries, although significantly
vasive test that does not require a lot of cooperation, smaller than the main pulsatile arteries of the cardio-
has many applications in the pediatric population. For vascular system, such as the aorta, the carotid arteries
instance, it has been used to evaluate renal vascula- or the renal arteries, still play a significant role in diag-
ture in type 1 diabetic children. A study from 2010 has nostics. Thus, several studies have investigated the use
investigated renal resistive index as well as pulsatility of measuring the pulsatility index in thyroid vessels.
index in a large sample of 100 diabetic children, aged A study from 2018 evaluated a large group of
13.4 ± 2.9 years, with an average diabetes duration 208 patients with a mean age of 37.7 years to establish
7.2 ± 2.5 years, as well as in 30 healthy controls. Both the mean values in euthyroid adults of pulsatility index,
pulsatility Index (mean PI left/right in diabetic patients along with RI and PSV, of the superior thyroid arteries
1.15 ± 0.2, mean PI left/right in healthy controls in euthyroid adults. The mean PI obtained in this study
1.0 ± 0.1, p = 0.04) and Resistivity Index (mean RI was 0.93 ± 0.31, and no significant differences were
left/right in diabetic children 0.72 ± 0.1, mean RI found between males and females [47].
left/right in healthy controls 0.6 ± 0.045, p = 0.001) A case-control study from 2015 investigated carotid
were significantly higher in children with type 1 diabetes, artery hemodynamics and cardiovascular risk factors in
particularly in those who had additionally been diag- 31 women with Hashimoto thyroiditis on levothyroxine
nosed with insulin resistance syndrome, hypertension treatment and 26 euthyroid women with Hashimoto
or obesity. The authors concluded that these doppler thyroiditis without levothyroxine treatment. They mea-
parameters should be added to the routine workup in sured carotid intima-media thickness, carotid extra-me-
diabetic children, especially with these additional risk dia thickness and pulsatility indexes in the common
factors, as they could potentially help diagnose diabetic carotid artery and internal carotid artery. PI CCA and
nephropathy before the appearance of albuminuria. PI ICA were both increased in the study group when
This study also shows that the results obtained through compared to the controls (p = 0.02 and p = 0.047),
PI measurements may also be supported by other while CIMT and CEMT were similar in both groups. The
parameters - in this specific case, resistivity index [43]. authors concluded, that it was the hormonal imbalance
Sawires et al. have also suggested PI as one of the of hypothyroidism that influences arterial stiffness, and
Doppler markers of renal dysfunction in children. They not the autoimmune disease process itself, that causes
have shown a significant difference in PI (p = 0.02), arterial stiffness [48]. In a more recent study by Kalantari
amongst other tested parameters, when comparing [49], he investigated the use of color doppler and gray
a group of 42 children with chronic kidney disease scale ultrasound on predicting thyroid nodule malignan-
(1.05 ± 0.36) with 42 healthy controls (0.89 ± 0.23) [44]. cy. All of the 63 participants had a thyroid ultrasound
Additionally, PI in children appears to have sever- done, which was followed by fine-needle aspiration and
al applications in Pediatric Neurology. A study from surgery. Out of the doppler parameters obtained in this
2015 suggests that PI could be used as a simple, study, pulsatility index was the most predictive factor
non-invasive method of assessing raised intracranial of thyroid malignancy, with a positive predictive value
pressure in children who are at risk but do not meet all (PPV) of 62% and a negative predictive value (NPV) of
the criteria for invasive monitoring. The PI measured 100%. The author concluded that a combination of the
at the middle cerebral artery had good specificity and presence of calcifications, a resistive index at or above
sensitivity in predicting increased intracranial pressure 0.715 and a PI at or above 0.945 was strongly diagnostic
in children with early acute brain injury [45]. of malignancy (PPV = 66.6%, NPV 98.4%).

Pulsatility index and thyroid disease Pulsatility index as a marker of brain edema

Hypothyroidism, which affects between 4–10 % of Published reports indicate that increased flow
the population, is known to have many negative effects pulsatility in main cerebral arteries may reflect raised
on the cardiovascular system. It is associated with im- intracranial pressure (ICP) in brain edema. Asil et al
paired relaxation of the vascular smooth muscle and [50] showed that in patients with ICP progression in
release of nitric oxide, arterial stiffness and increased malignant middle cerebral artery (MCA) infarction the
vascular resistance. It also impacts the renal-angio- pulsatility indices of MCA were higher on the third hospi-
tensin-aldosterone system, as hepatic renin synthesis tal day than on the first day, and PI were correlated with
is stimulated by triiodothyronine. Additionally, it has the midline shift measured on the third day after stroke.
a strong effect on lipid metabolism, resulting in elevated They also showed worse prognoses in patients with
total cholesterol, LDL and apolipoprotein B [46]. PI > 1.5 than PI < 1.5. Bor-Seng-Shu [51] reported that
Ultrasonography of the thyroid gland is one of the PI values decrease significantly after decompressive
most common tests performed in diagnosing thyroid craniectomy. On the other hand, some authors indicate,

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 Melanie Wielicka et al., Pulsatility index

that PI-based methods can not predict ICP reliably, index (PI) is an easy to obtain parameter with a broad
as some studies show poor or inexistent correlations range of both, research and clinical applications. It has
between both parameters. Nevertheless, flow spectra been widely used in the assessment of macrocirculation
analysis with the use of Transcranial Doppler is applied in highly prevalent chronic medical conditions, such
as a supportive method in the procedure of the brain as hypertension, both type 1 and type 2 diabetes and
death confirmation [50, 52] (Fig. 3, Tab. 1). thyroid disorders. For instance, in diabetic patients, it
has been found to be of great value in prediction and
early diagnosis of microvascular complications.
Conclusion Amongst the cited articles, PI has mainly been mea-
sured at carotid arteries and middle cerebral arteries,
Based on our extensive review of the literature and but also at renal arteries, peripheral limb vasculature or
the gathered information, we conclude that pulsatility thyroid vessels. Because it is non-invasive and requires

Figure 3. Transcranial Doppler examination of Middle Cerebral Artery. Left picture — normal flow with low pulsatility (PI
0,62); right picture — increased pulsatility (PI 1,18) due to raised intracranial pressure (Exam performed Laboratory of
Neurosonology, Department of Neurology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń,
head of the clinic dr. hab. G. Kozera, using a Viasys Companion III camera with a PW 2MHz probe

Table 1. Clinical applications of Pulsatility Index (PI)

Clinical Reference/year Study group Method and study area
application
Hypertension and Cho [14]/1997 94 stroke-free, hypertensive patients PI in middle cerebral artery/internal carotid
heart disease divided into two groups based on artery
hypertension duration and controls, 81 y
Bardelli [16]/1992 49 hypertensive patients, with and without PI in renal arteries
renal artery stenosis, and 20 normotensive
controls
Petersen [17]/1995 25 hypertensive patients with a GFR of < PI and RI in renal arteries
50mL/min and blood pressure > 140/95,
and 10 healthy, normotensive volunteers
Okura [18]/2004 51 patients with essential hypertension Intrarenal PI and resistive index, carotid
intimal-media thickness
Sasaki [19]/2019 1313 participants 70 years or older without PI and resistance index in Common carotid
cardiovascular disease. artery, log NT-pro-BNP levels
Atherosclerosis Jotoku [21]/2015 67 hypertensive patients PI in common carotid artery, homocysteine
and arterial and monocyte levels
stenosis
Heyer [23]/2014 53 patients who underwent carotid artery PI in carotid artery
endarectomy
Wada [24]/2019 42 patients with intracranial vertebral artery PI in carotid ultrasonography
dissection
Cay [25]/2010 45 patients with aortic stenosis / 45 healthy Fractional pulse pressure (FFP) and PI at
controls the ascending aorta

Æ
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Table 1. cont. Clinical applications of Pulsatility Index (PI)

Clinical Reference/year Study group Method and study area

application
Vascular Burkhardt [27]/2015 32 patients with arteriovenous PI and RI measured on AVM feeding
malformations malformations (AVMs) arteries
Kaspera [28]/2014 46 adult patients diagnosed with AVMs PI in the embolized feeding vessels
Fukuhara [32]/2006 159 patients hospitalized for controlling PI at the internal carotid artery
type 2 diabetes mellitus
Soyoye [12]/2018 80 adults with type 2 diabetes mellitus PI in renal artery
Lee [33]/2000 56 type 2 diabetic patients with a mean age PI in middle cerebral artery/internal carotid
of 59, and 70 age- and gender-matched artery
healthy controls

Agha [34]/2014 141 diabetic patients and 131 sex and age- PI and flow velocity at middle cerebral,
matched controls basilar and intracranial portion of the
internal carotid artery
Park [35]/2008 90 patients with stroke-free type 2 diabetes PI in middle cerebral artery
and 45 healthy age- and sex-matched
controls
Kozera [36]/2019 51 patients with type 1 diabetes mellitus, PI in middle cerebral artery
with a median age of 37.5 years
Kozera [37]/2010 54 men with hypertension, all 60 years of PI in middle cerebral artery, Magnetic
age resonance imaging
Janssen [38]/2005 106 diabetic patients who presented with PI in ankle artery, digital subtraction
polyneuropathy arteriography, ankle-brachial Doppler
index, systolic ankle blood pressure
Zou [13] /2017 56 type 2 diabetic patients and 50 healthy PI and RI at the dorsalis pedis artery and
controls plantar digital artery, a warm bath test
Park [40]/2007 40 type 2 diabetic patients divided into two PI in middle cerebral artery and basilar
groups: one treated with pioglitazone, one artery, carotid intima-media thickness
treated with gliclazide
Pediatrics Schoning [41]/1998 48 adults, 94 healthy children and PI in common carotid artery
adolescents
Abd El Ghaffar 100 diabetic children, aged 13.4 ± 2.9, Renal PI and RI
[43]/2010 with an average diabetes duration 7.2 ±
2.5 years, and 30 healthy controls
Sawires [44]/2018 42 children with chronic kidney disease PI in renal arteries
and 42 healthy controls
O’Brian [45]/2020 36 children admitted to intensive care units PI in middle cerebral artery
with a diagnosis of severe traumatic brain
injury (GCS =< 8)
Thyroid disease Joish [47]/2018 208 patients with a mean age of 37.7 PI, RI and PSV of the superior thyroid artery
Owecki [48]/2015 31 women with Hashimoto thyroiditis on PI in common carotid artery and PI in
levothyroxine treatment and 26 euthyroid internal carotid artery
women with Hashimoto thyroiditis without
levothyroxine treatment.
Kalantari [49] /2018 63 patients with thyroid nodules. PI and RI at  thyroid nodules
Brain edema Asil [50]/2003 18 patients with first-ever strokes and large PI in middle cerebral artery
MCA (middle cerebral artery) infarction
Bor-Sheng-Shu 19 patients presenting with traumatic brain PI in transcranial ultrasonography
[51]/2013 swelling

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 Melanie Wielicka et al., Pulsatility index

little cooperation, it has also been widely used in pedia­ angiography. Interventional Neuroradiology. 2017; 23(4): 357–361, doi:
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Statement of competing interests: The authors de- patients with essential hypertension. Clinical and Experimental Hyper-
clared no potential conflicts of interest with respect to the tension. 2014; 37(5): 358–363, doi: 10.3109/10641963.2014.972563.
22. Norouzpour A, Hooshyar Z, Mehdizadeh A. Autoregulation of blood
research, authorship, and/or publication of this article. flow: Vessel diameter changes in response to different temperatures. J
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