Transcranial Doppler ultrasonography in geriatric anesthesia: moving toward personalized brain protection strategies

The increasing volume of geriatric surgical procedures presents a critical challenge: protecting the aging brain from perioperative complications such as postoperative delirium and postoperative cognitive dysfunction. Conventional anesthetic management, which relies primarily on systemic parameters like blood pressure, often overlooks age-related vulnerabilities, including impaired cerebral autoregulation and reduced cerebrovascular reserve. Transcranial Doppler ultrasonography (TCD) offers a valuable solution by providing real-time, noninvasive assessment of cerebral hemodynamics. This modality enables dynamic monitoring of key indicators, such as mean flow velocity and pulsatility index, to detect cerebral hypoperfusion, microembolic events, and blood flow variability-all of which represent significant risk factors for neurological injury. A major advantage of TCD lies in its capacity to guide individualized blood pressure management. By determining each patient's optimal mean arterial pressure, TCD assists clinicians in preventing both hypotension and hypertension, thereby surpassing the limitations of a one-size-fits-all approach. Despite remaining challenges-such as operator dependence and the need for larger-scale validation studies-the future of TCD appears promising. Integration with robotic systems and artificial intelligence is expected to improve automation and reliability. Ultimately, TCD is likely to become an integral component of multimodal intraoperative monitoring, facilitating a data-driven, brain-centered anesthetic strategy that enhances the safety and well-being of elderly surgical patients.