Skip to main content Accessibility help
×
Hostname: page-component-76fb5796d-vfjqv Total loading time: 0 Render date: 2024-04-26T11:39:36.326Z Has data issue: false hasContentIssue false

Chapter 10 - The Role of Transcranial Doppler as a Monitoring Tool in the Neurocritical Care Unit

Published online by Cambridge University Press:  24 July 2019

Michel T. Torbey
Affiliation:
Ohio State University
Get access

Summary

Transcranial Doppler (TCD) has been increasingly utilized as a monitoring tool in the neurocritical care unit (NCCU) since it is a noninvasive tool and can be brought to the bedside.

Type
Chapter
Information
Neurocritical Care , pp. 92 - 102
Publisher: Cambridge University Press
Print publication year: 2019

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Moehring, MA, Spencer, MP (2002). Power m-mode doppler (pmd) for observing cerebral blood flow and tracking emboli. Ultrasound Med Biol 28: 4957.Google Scholar
Weir, B, Grace, M, Hansen, J, Rothberg, C (1978). Time course of vasospasm in man. J Neurosurg 48: 173178.Google Scholar
Sloan, M (1994). Cerebral vasoconstriction: physiology, patho-physiology and occurrence in selected cerebrovascular disorder. In Caplan, LR, ed. Brain Ischemia: Basic Concept and their Clinical Relevance. London: Springer-Verlag, 151172.Google Scholar
Reynolds, AF, Shaw, CM (1981). Bleeding patterns from ruptured intracranial aneurysms: An autopsy series of 205 patients. Surg Neurol 15: 232235.Google Scholar
Bleck, TP (1997). Rebleeding and vasospasm after sah: New strategies for improving outcome. J Crit Illn 12: 572582.Google Scholar
Ecker, A, Riemenschneider, PA (1951). Arteriographic demonstration of spasm of the intracranial arteries, with special reference to saccular arterial aneurysms. J Neurosurg 8: 660667.Google Scholar
Cloft, HJ, Joseph, GJ, Dion, JE (1999). Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a meta-analysis. Stroke 30: 317320.CrossRefGoogle ScholarPubMed
Aaslid, R, Huber, P, Nornes, H (1984). Evaluation of cerebrovascular spasm with transcranial doppler ultrasound. J Neurosurg 60: 3741.Google Scholar
Seiler, R, Grolimund, P, Huber, P (1986). Transcranial Doppler sonography: an alternative to angiography in the evaluation of vasospasm after subarachnoid hemorrhage. Acta Radiol Suppl 369: 99102.Google Scholar
Lindegaard, KF, Nornes, H, Bakke, SJ, Sorteberg, W, Nakstad, P (1989). Cerebral vasospasm diagnosis by means of angiography and blood velocity measurements. Acta Neurochir (Wien) 100: 1224.Google Scholar
Lindegaard, KF, Nornes, H, Bakke, SJ, Sorteberg, W, Nakstad, P (1988). Cerebral vasospasm after subarachnoid haemorrhage investigated by means of transcranial Doppler ultrasound. Acta Neurochir Suppl (Wien): 81–84.Google Scholar
Naval, NS, Thomas, CE, Urrutia, VC (2005). Relative changes in flow velocities in vasospasm after subarachnoid hemorrhage: a transcranial Doppler study. Neurocrit Care 2: 133140.CrossRefGoogle ScholarPubMed
Akhtar, N, Saqqur, M, Roy, J, et al. (2004). Developing criteria on power m mode transcranial doppler ultrasound for angiographic proven cerebral vasospasm in aneurysmal subarachnoid hemorrhage patients. World Stroke Congress (abstract).Google Scholar
Yonas, H, Sekhar, L, Johnson, DW, Gur, D (1989). Determination of irreversible ischemia by xenon-enhanced computed tomographic monitoring of cerebral blood flow in patients with symptomatic vasospasm. Neurosurgery 24: 368372.Google Scholar
Clyde, BL, Resnick, DK, Yonas, H, Smith, HA, Kaufmann, AM (1996). The relationship of blood velocity as measured by transcranial doppler ultrasonography to cerebral blood flow as determined by stable xenon computed tomographic studies after aneurysmal subarachnoid hemorrhage. Neurosurgery 38: 896904; discussion 904–895.Google Scholar
Romner, B, Brandt, L, Berntman, L, et al. (1991). Simultaneous transcranial doppler sonography and cerebral blood flow measurements of cerebrovascular CO2-reactivity in patients with aneurysmal subarachnoid haemorrhage. Br J Neurosurg 5: 3137.Google Scholar
Yahia, AM, Kirmani, JF, Qureshi, AI, Guterman, LR, Hopkins, LN (2005). The safety and feasibility of continuous intravenous magnesium sulfate for prevention of cerebral vasospasm in aneurysmal subarachnoid hemorrhage. Neurocrit Care 3: 1623.Google Scholar
Pachl, J, Haninec, P, Tencer, T, et al. (2005). The effect of subarachnoid sodium nitroprusside on the prevention of vasospasm in subarachnoid haemorrhage. Acta Neurochir Suppl 95: 141145.Google Scholar
Newell, DW, Eskridge, JM, Mayberg, MR, Grady, MS, Winn, HR (1989). Angioplasty for the treatment of symptomatic vasospasm following subarachnoid hemorrhage. J Neurosurg 71: 654660.Google ScholarPubMed
Hurst, RW, Schnee, C, Raps, EC, Farber, R, Flamm, ES (1993). Role of transcranial doppler in neuroradiological treatment of intracranial vasospasm. Stroke 24: 299303.Google Scholar
Torbey, MT, Hauser, TK, Bhardwaj, A, et al. (2001). Effect of age on cerebral blood flow velocity and incidence of vasospasm after aneurysmal subarachnoid hemorrhage. Stroke 32: 20052011.CrossRefGoogle ScholarPubMed
Kantelhardt, SR, Greke, C, Keric, N, et al. (2011). Image guidance for transcranial doppler ultrasonography. Neurosurgery 68: 257266; discussion 266.Google Scholar
Burch, CM, Wozniak, MA, Sloan, MA, et al. (1996). Detection of intracranial internal carotid artery and middle cerebral artery vasospasm following subarachnoid hemorrhage. J Neuroimaging 6: 815.CrossRefGoogle ScholarPubMed
Kyoi, K, Hashimoto, H, Tokunaga, H, et al. (1989). [Time course of blood velocity changes and clinical symptoms related to cerebral vasospasm and prognosis after aneurysmal surgery]. No Shinkei Geka 17: 2130.Google Scholar
Langlois, O, Rabehenoina, C, Proust, F, et al. (1992). [Diagnosis of vasospasm: comparison between arteriography and transcranial Doppler. A series of 112 comparative tests]. Neurochirurgie 38: 138140.Google Scholar
Lennihan, L, Petty, GW, Fink, ME, Solomon, RA, Mohr, JP (1993). Transcranial doppler detection of anterior cerebral artery vasospasm. J Neurol Neurosurg Psychiatry 56: 906909.Google Scholar
Sloan, MA, Haley, EC Jr, Kassell, NF, et al. (1989). Sensitivity and specificity of transcranial doppler ultrasonography in the diagnosis of vasospasm following subarachnoid hemorrhage. Neurology 39: 15141518.Google Scholar
Vora, YY, Suarez-Almazor, M, Steinke, DE, Martin, ML, Findlay, JM (1999). Role of transcranial doppler monitoring in the diagnosis of cerebral vasospasm after subarachnoid hemorrhage. Neurosurgery 4: 12371247; discussion 1247–1238.Google Scholar
Hutchison, K, Weir, B (1989). Transcranial Doppler studies in aneurysm patients. Can J Neurol Sci 16: 411416.Google Scholar
Aaslid, R, Markwalder, TM, Nornes, H (1982). Noninvasive transcranial doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 57: 769774.Google Scholar
Sebastian, J, Derksen, C, Khan, K, et al. (2013). Derivation of transcranial doppler criteria for angiographically proven middle cerebral artery vasospasm after aneurysmal subarachnoid hemorrhage. J Neuroimaging 23: 489494.Google Scholar
Grolimund, P, Seiler, RW, Aaslid, R, Huber, P, Zurbruegg, H (1987). Evaluation of cerebrovascular disease by combined extracranial and transcranial doppler sonography. Experience in 1,039 patients. Stroke 18: 10181024.Google Scholar
Wozniak, MA, Sloan, MA, Rothman, MI, et al. (1996). Detection of vasospasm by transcranial doppler sonography. The challenges of the anterior and posterior cerebral arteries. J Neuroimaging 6: 8793.Google Scholar
Creissard, P, Proust, F (1994). Vasospasm diagnosis: theoretical sensitivity of transcranial Doppler evaluated using 135 angiograms demonstrating vasospasm. Practical consequences. Acta Neurochir (Wien) 131: 1218.Google Scholar
Soustiel, JF, Bruk, B, Shik, B, Hadani, M, Feinsod, M (1998). Transcranial doppler in vertebrobasilar vasospasm after subarachnoid hemorrhage. Neurosurgery 43: 282291; discussion 291–283.CrossRefGoogle ScholarPubMed
Sloan, MA, Burch, CM, Wozniak, MA, et al. (1994). Transcranial doppler detection of vertebrobasilar vasospasm following subarachnoid hemorrhage. Stroke 25: 21872197.CrossRefGoogle ScholarPubMed
Soustiel, JF, Shik, V, Shreiber, R, Tavor, Y, Goldsher, D (2002). Basilar vasospasm diagnosis: investigation of a modified “Lindegaard Index” based on imaging studies and blood velocity measurements of the basilar artery. Stroke 33: 7277.Google Scholar
Newell, DW, Grady, MS, Eskridge, JM, Winn, H (1990). Distribution of angiographic vasospasm after subarachnoid hemorrhage: implications for diagnosis by transcranial doppler ultrasonography. Neurosurgery 27: 574577.Google Scholar
Grosset, DG, Straiton, J, du Trevou, M, Bullock, R (1992). Prediction of symptomatic vasospasm after subarachnoid hemorrhage by rapidly increasing transcranial doppler velocity and cerebral blood flow changes. Stroke 23: 674679.Google Scholar
The Brain Trauma Foundation; The American Association of Neurological Surgeons; The Joint Section on Neurotrauma and Critical Care (2000). Indications for intracranial pressure monitoring. J Neurotrauma 17: 479491.Google Scholar
The Brain Trauma Foundation; The American Association of Neurological Surgeons; The Joint Section on Neurotrauma and Critical Care (2000). Guidelines for cerebral perfusion pressure. J Neurotrauma 17: 507511.CrossRefGoogle Scholar
Chan, KH, Miller, JD, Dearden, NM, Andrews, PJ, Midgley, S (1992). The effect of changes in cerebral perfusion pressure upon middle cerebral artery blood flow velocity and jugular bulb venous oxygen saturation after severe brain injury. J Neurosurg 77: 5561.Google Scholar
Klingelhofer, J, Conrad, B, Benecke, R, Sander, D (1987). Intracranial flow patterns at increasing intracranial pressure. Klin Wochenschr 65: 542545.Google Scholar
Klingelhofer, J, Conrad, B, Benecke, R, Sander, D, Markakis, E (1988). Evaluation of intracranial pressure from transcranial doppler studies in cerebral disease. J Neurol 235: 159162.Google Scholar
Homburg, AM, Jakobsen, M, Enevoldsen, E (1993). Transcranial doppler recordings in raised intracranial pressure. Acta Neurol Scand 87: 488493.Google Scholar
Czosnyka, M, Matta, BF, Smielewski, P, Kirkpatrick, PJ, Pickard, JD (1998). Cerebral perfusion pressure in head-injured patients: a noninvasive assessment using transcranial doppler ultrasonography. J Neurosurg 88: 802808.CrossRefGoogle ScholarPubMed
Aaslid, R, Lundar, T, Lindegaard, KF (1986). Estimation of cerebral perfusion pressure from arterial blood pressure and transcranial doppler recordings. In Miller, JD, Teasdale, GM, Rowan, JO, eds. Intracranial Pressure VI. Berlin: Springer-Verlag, 226229.Google Scholar
Schmidt, EA, Czosnyka, M, Gooskens, I, et al. (2001). Preliminary experience of the estimation of cerebral perfusion pressure using transcranial doppler ultrasonography. J Neurol Neurosurg Psychiatry 70: 198204.Google Scholar
Ragauskas, A, Daubaris, G, Dziugys, A, Azelis, V, Gedrimas, V (2005). Innovative non-invasive method for absolute intracranial pressure measurement without calibration. Acta Neurochir Suppl 95: 357361.Google Scholar
Bellner, J, Romner, B, Reinstrup, P, et al. (2004). Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP). Surg Neurol 62: 4551; discussion 51.Google Scholar
Kramer, DR, Winer, JL, Pease, BA, Amar, AP, Mack, WJ (2013). Cerebral vasospasm in traumatic brain injury. Neurol Res Int 2013: 415813.CrossRefGoogle ScholarPubMed
Razumovsky, A, Tigno, T, Hochheimer, SM, et al. (2013). Cerebral hemodynamic changes after wartime traumatic brain injury. Acta Neurochir Suppl 115: 8790.Google Scholar
de Freitas, GR, Andre, C (2006). Sensitivity of transcranial Doppler for confirming brain death: a prospective study of 270 cases. Acta Neurol Scand 113: 426432.Google Scholar
Kuo, JR, Chen, CF, Chio, CC, et al. (2006). Time dependent validity in the diagnosis of brain death using transcranial doppler sonography. J Neurol Neurosurg Psychiatry 77: 646649.Google Scholar
Dosemeci, L, Dora, B, Yilmaz, M, et al. (2004). Utility of transcranial doppler ultrasonography for confirmatory diagnosis of brain death: two sides of the coin. Transplantation 77: 7175.Google Scholar
Steiner, LA, Balestreri, M, Johnston, AJ, et al. (2004). Sustained moderate reductions in arterial CO2 after brain trauma time-course of cerebral blood flow velocity and intracranial pressure. Intensive Care Med 30: 21802187.Google Scholar
Lee, JH, Kelly, DF, Oertel, M, et al. (2001). Carbon dioxide reactivity, pressure autoregulation, and metabolic suppression reactivity after head injury: a transcranial doppler study. J Neurosurg 95: 222232.Google Scholar
Bishop, CC, Powell, S, Rutt, D, Browse, NL (1986). Transcranial doppler measurement of middle cerebral artery blood flow velocity: a validation study. Stroke 17: 913915.Google Scholar
Obrist, WD, Langfitt, TW, Jaggi, JL, Cruz, J, Gennarelli, TA (1984). Cerebral blood flow and metabolism in comatose patients with acute head injury: relationship to intracranial hypertension. J Neurosurg 61: 241253.Google Scholar
Marion, DW, Bouma, GJ (1991). The use of stable xenon-enhanced computed tomographic studies of cerebral blood flow to define changes in cerebral carbon dioxide vasoresponsivity caused by a severe head injury. Neurosurgery 29: 869873.CrossRefGoogle ScholarPubMed
Klingelhofer, J, Sander, D (1992). Doppler CO2 test as an indicator of cerebral vasoreactivity and prognosis in severe intracranial hemorrhages. Stroke 23: 962966.Google Scholar
Czosnyka, M, Smielewski, P, Kirkpatrick, P, Menon, DK, Pickard, JD (1996). Monitoring of cerebral autoregulation in head-injured patients. Stroke 27: 18291834.Google Scholar
Lam, JM, Hsiang, JN, Poon, WS (1997). Monitoring of autoregulation using laser doppler flowmetry in patients with head injury. J Neurosurg 86: 438445.CrossRefGoogle ScholarPubMed
Poon, WS, Ng, SC, Chan, MT, Lam, JM, Lam, WW (2005). Cerebral blood flow (cbf)-directed management of ventilated head-injured patients. Acta Neurochir Suppl 95: 911.Google Scholar
Caplan, LR, Mohr, JP, Kistler, JP, Koroshetz, W (1997). Should thrombolytic therapy be the first-line treatment for acute ischemic stroke?: thrombolysis--not a panacea for ischemic stroke. New Engl J Med 337: 13091310; discussion 1313.Google Scholar
Barber, PA, Demchuk, AM, Hudon, ME,et al. (2001). Hyperdense sylvian fissure MCA “dot” sign: A CT marker of acute ischemia. Stroke 32: 8488.CrossRefGoogle Scholar
Wildermuth, S, Knauth, M, Brandt, T, et al. (1998). Role of CT angiography in patient selection for thrombolytic therapy in acute hemispheric stroke. Stroke 29: 935938.Google Scholar
Kenton, AR, Martin, PJ, Abbott, RJ, Moody, AR (1997). Comparison of transcranial color-coded sonography and magnetic resonance angiography in acute stroke. Stroke 28: 16011606.Google Scholar
Fieschi, C, Argentino, C, Lenzi, GL, et al. (1989). Clinical and instrumental evaluation of patients with ischemic stroke within the first six hours. J Neurol Sci 91: 311321.Google Scholar
Zanette, EM, Fieschi, C, Bozzao, L, et al. (1989). Comparison of cerebral angiography and transcranial doppler sonography in acute stroke. Stroke 20: 899903.Google Scholar
Razumovsky, AY, Gillard, JH, Bryan, RN, Hanley, DF, Oppenheimer, SM (1999). TCD, MRA and MRI in acute cerebral ischemia. Acta Neurol Scand 99: 6576.Google Scholar
Demchuk, AM, Christou, I, Wein, TH, et al. (2000). Accuracy and criteria for localizing arterial occlusion with transcranial Doppler. J Neuroimaging 10: 112.Google Scholar
Demchuk, AM, Christou, I, Wein, TH, et al. (2000). Specific transcranial doppler flow findings related to the presence and site of arterial occlusion. Stroke 31: 140146.CrossRefGoogle Scholar
Alexandrov, AV, Demchuk, AM, Burgin, WS (2002). Insonation method and diagnostic flow signatures for transcranial power motion (M-mode) Doppler. J Neuroimaging 12: 236244.Google ScholarPubMed
Barnett, SB, Ter Haar, GR, Ziskin, MC, et al. (2000). International recommendations and guidelines for the safe use of diagnostic ultrasound in medicine. Ultrasound Med Biol 26: 355366.CrossRefGoogle ScholarPubMed
Demchuk, AM, Wein, TH, Felberg, RA, Christou, I, Alexandrov, AV (1999). Images in cardiovascular medicine. Evolution of rapid middle cerebral artery recanalization during intravenous thrombolysis for acute ischemic stroke. Circulation 100: 22822283.Google Scholar
Alexandrov, AV, Burgin, WS, Demchuk, AM, El-Mitwalli, A, Grotta, JC (2001). Speed of intracranial clot lysis with intravenous tissue plasminogen activator therapy: sonographic classification and short-term improvement. Circulation 103: 28972902.Google Scholar
Christou, I, Burgin, WS, Alexandrov, AV, Grotta, JC (2001). Arterial status after intravenous tpa therapy for ischaemic stroke: a need for further interventions. Int Angiol 20: 208213.Google Scholar
Kim, YS, Garami, Z, Mikulik, R, et al. (2005). Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion. Stroke 36: 869871.Google Scholar
Christou, I, Alexandrov, AV, Burgin, WS, et al. (2000). Timing of recanalization after tissue plasminogen activator therapy determined by transcranial doppler correlates with clinical recovery from ischemic stroke. Stroke 31: 18121816.Google Scholar
Molina, CA, Alexandrov, AV, Demchuk, AM, et al. (2004). Improving the predictive accuracy of recanalization on stroke outcome in patients treated with tissue plasminogen activator. Stroke 35: 151156.CrossRefGoogle ScholarPubMed
Alexandrov, AV, Grotta, JC (2002). Arterial reocclusion in stroke patients treated with intravenous tissue plasminogen activator. Neurology 59: 862867.Google Scholar
Rubiera, M, Alvarez-Sabin, J, Ribo, M, et al. (2005). Predictors of early arterial reocclusion after tissue plasminogen activator-induced recanalization in acute ischemic stroke. Stroke 36: 14521456.Google Scholar
Russell, D, Madden, KP, Clark, WM, Sandset, PM, Zivin, JA (1991). Detection of arterial emboli using doppler ultrasound in rabbits. Stroke 22: 253258.CrossRefGoogle ScholarPubMed
Sliwka, U, Lingnau, A, Stohlmann, WD, et al. (1997). Prevalence and time course of microembolic signals in patients with acute stroke: a prospective study. Stroke 28: 358363.Google Scholar
Valton, L, Larrue, V, le Traon, AP, Massabuau, P, Geraud, G (1998). Microembolic signals and risk of early recurrence in patients with stroke or transient ischemic attack. Stroke 29: 21252128.Google Scholar
Forteza, AM, Babikian, VL, Hyde, C, Winter, M, Pochay, V (1996). Effect of time and cerebrovascular symptoms of the prevalence of microembolic signals in patients with cervical carotid stenosis. Stroke 27: 687690.Google Scholar
Babikian, VL, Wijman, CA, Hyde, C, et al. (1997). Cerebral microembolism and early recurrent cerebral or retinal ischemic events. Stroke 28: 13141318.CrossRefGoogle ScholarPubMed
Levi, CR, Stork, JL, Chambers, BR, et al. (2001). Dextran reduces embolic signals after carotid endarterectomy. Ann Neurol 50: 544547.Google Scholar
Schmidt, A, Diederich, KW, Scheinert, S, et al. (2004). Effect of two different neuroprotection systems on microembolization during carotid artery stenting. J Am Coll Cardiol 44: 19661969.Google Scholar
Goertler, M, Blaser, T, Krueger, S, et al. (2002). Cessation of embolic signals after antithrombotic prevention is related to reduced risk of recurrent arterioembolic transient ischaemic attack and stroke. J Neurol Neurosurg Psychiatry 72: 338342.Google Scholar
Goertler, M, Baeumer, M, Kross, R, et al. (1999). Rapid decline of cerebral microemboli of arterial origin after intravenous acetylsalicylic acid. Stroke 30: 6669.Google Scholar
Markus, HS, Droste, DW, Kaps, M, et al. (2005). Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation 111: 22332240.Google Scholar
Junghans, U, Siebler, M (2003). Cerebral microembolism is blocked by tirofiban, a selective nonpeptide platelet glycoprotein IIb/IIIa receptor antagonist. Circulation 107: 27172721.Google Scholar
Visser, GH, Wieneke, GH, van Huffelen, AC, Eikelboom, BC (2000). The use of preoperative transcranial Doppler variables to predict which patients do not need a shunt during carotid endarterectomy. Eur J Vasc Endovasc Surg 19: 226232.CrossRefGoogle ScholarPubMed
Tamaschke, C, Kehl, K, Chaoui, Z, Heyn, G (1996). [Transcranial Doppler ultrasound as monitoring during carotid operation]. Zentralbl Chir 121: 10361040.Google ScholarPubMed
Yun, WS (2017). Cerebral monitoring during carotid endarterectomy by transcranial doppler ultrasonography. Ann Surg Treat Res 92: 105109.CrossRefGoogle ScholarPubMed
van Zuilen, EV, Moll, FL, Vermeulen, FE, et al. (1995). Detection of cerebral microemboli by means of transcranial doppler monitoring before and after carotid endarterectomy. Stroke 26: 210213.Google Scholar
Antonius Carotid Endarterectomy, Angioplasty, and Stenting Study Group, Ackerstaff, RG, Vos, JA (2004). TCD-detected cerebral embolism in carotid endarterectomy versus angioplasty and stenting of the carotid bifurcation. Acta Chir Belg 104: 5559.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×