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Taran S, Gros P, Gofton T, Boyd G, Briard JN, Chassé M, Singh JM. The reticular activating system: a narrative review of discovery, evolving understanding, and relevance to current formulations of brain death. Can J Anaesth 2023; 70:788-795. [PMID: 37155119 PMCID: PMC10203024 DOI: 10.1007/s12630-023-02421-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 05/10/2023] Open
Abstract
A series of landmark experiments conducted throughout the 20th century progressively localized the regions involved in consciousness to the reticular activating system (RAS) and its ascending projections. The first description of the RAS emerged in 1949 through seminal experiments performed by Moruzzi and Magoun in feline brainstems; additional experiments in the 1950s revealed connections between the RAS and the thalamus and neocortical structures. This knowledge has allowed for the explanation of disorders of consciousness with exquisite anatomic precision. The clinical relevance of the RAS is further apparent in modern definitions of brain death/death by neurologic criteria (BD/DNC), which require demonstration of the complete and permanent loss of capacity for consciousness as one of their core criteria. BD/DNC is currently understood across jurisdictions in terms of "whole brain" and "brainstem" formulations. Although their clinical examination between formulations is indistinguishable, policies for BD/DNC declaration may differ in the rare scenario of patients with isolated infratentorial brain injuries, in which ancillary testing is advised in the whole brain formulation but not the brainstem formulation. Canadian guidelines acknowledge that the distinction between whole brain and brainstem formulations is unclear with respect to clinical implications for patients with isolated infratentorial injuries. This has led to variability in Canadian clinicians' use of ancillary testing when the mechanism of BD/DNC is suspected to be an isolated infratentorial injury. The present narrative review highlights these concepts and explores implications for determination of BD/DNC in Canada, with specific emphasis on the RAS and its relevance to both formulations.
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Affiliation(s)
- Shaurya Taran
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Western Hospital, Office 411-L, 2nd Floor McLaughlin, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Priti Gros
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Division of Neurology, University Health Network, Toronto, ON, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Gordon Boyd
- Department of Medicine (Neurology) and Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Joel Neves Briard
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
| | - Michaël Chassé
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Université de Montréal Hospital Research Centre, Montreal, QC, Canada
| | - Jeffrey M Singh
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Ontario Health - Trillium Gift of Life Network, Toronto, ON, Canada
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Neves Briard J, Plourde G, Nitulescu R, Boyd JG, Carrier FM, Couillard P, Keezer MR, Kramer AH, Shemie SD, Stapf C, Chassé M. Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria: A Systematic Review and Meta-analysis. Neurology 2023; 100:e443-e453. [PMID: 36220596 DOI: 10.1212/wnl.0000000000201449] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/08/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There is a paucity of data on the frequency and prognosis of infratentorial brain injury among patients suspected of death by neurologic criteria (DNC), which likely contributes to scientific uncertainty regarding the role of isolated brainstem death in DNC determination. Our aim was to synthesize the prevalence, characteristics, and evolution of infratentorial brain injury, including isolated brainstem death, among patients suspected of DNC. METHODS We conducted a systematic review by searching Medline, Embase, EBM Reviews, CINAHL Complete, and the gray literature from inception to March 26, 2021. We selected cohort and cross-sectional studies, case reports, and case series that included patients suspected of DNC. Two study investigators independently performed study selection, data collection, and risk of bias assessment. Our primary outcomes were the respective prevalence of infratentorial brain injury and isolated brainstem death, which we meta-analyzed using mixed-effects Bayesian hierarchical models with diffuse priors. Our secondary outcomes were the characteristics and evolution of patients with infratentorial brain injury and isolated brainstem death. RESULTS Twenty-one studies met the selection criteria, most of which were of moderate to high risk of bias. Among patients suspected of DNC, the prevalence of infratentorial brain injury ranged from 2% to 16% (n = 3,602, mean prevalence: 6.3%, 95% highest density interval [2.4%-14.2%]), whereas the prevalence of isolated brainstem death ranged from 1% to 4% (n = 3,692, mean prevalence: 1.5%, 95% highest density interval [0.5%-3.9%]). A total of 38 isolated brainstem death cases with data on clinical characteristics and/or evolution were included. All had infratentorial strokes. Twenty patients had EEG background activity in the α or θ frequencies, 19 had preserved cerebral blood flow, 2 had preserved supratentorial cerebral perfusion, 2 had cortical responses to visual evoked potentials, and 1 had cortical responses to somatosensory evoked potentials. At the latest follow-up, 28 had progressed to whole-brain death. DISCUSSION Studies with moderate to high risk of bias suggest that infratentorial brain injury is relatively uncommon among patients suspected of DNC. Isolated brainstem death is rarer and seems to carry a high risk of progression to whole-brain death. These findings require further high-quality investigation.
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Affiliation(s)
- Joel Neves Briard
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Guillaume Plourde
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Roy Nitulescu
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - J Gordon Boyd
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - François Martin Carrier
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Philippe Couillard
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Mark R Keezer
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Andreas H Kramer
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Sam D Shemie
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Christian Stapf
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Michaël Chassé
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada.
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