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Hoffmann O, Salih F, Masuhr F. Computed tomography angiography in the diagnosis of brain death: Implementation and results in Germany. Eur J Neurol 2024; 31:e16209. [PMID: 38217344 DOI: 10.1111/ene.16209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/06/2023] [Accepted: 12/28/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Computed tomography angiography (CTA) has been investigated as a confirmatory study (CS) for the diagnosis of brain death (BD). International consensus regarding its use, study parameters, and evaluation criteria is lacking. In the German BD guideline, a CTA protocol was first introduced in 2015. METHODS The authors obtained a comprehensive dataset of all BD examinations in adults from the German organ procurement organization to investigate implementation, results, and impact of CTA on BD determination during the first 4 years. RESULTS In 5152 patients with clinically absent brain function, 1272 CTA were reported by 676 hospitals. Use of CTA increased from 17.2% of patients in the first year to 29.7% in the final year. CTA replaced other CS such as electroencephalography without increasing overall CS frequency. Technical failure was rare (0.9%); 89.3% of studies were positive. Negative results (9.8%) were more frequent with secondary brain injury, longer duration of the clinical BD syndrome, or unreliable clinical assessment. Median time to diagnosis was longer with CTA (2.6 h) versus other CS (1.6 h). CTA had no differential impact on the rate of confirmed BD and did not improve access of small hospitals to CS for BD determination. CONCLUSIONS CTA expands the range of available CS for the diagnosis of BD in adults. Real-world evidence from a large cohort confirms usability of the German CTA protocol within the guideline-specified context.
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Affiliation(s)
- Olaf Hoffmann
- Department of Neurology, Alexianer St. Josefs Hospital, Potsdam, Germany
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Germany
| | - Farid Salih
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Masuhr
- Klinik für Neurologie, Bundeswehrkrankenhaus Berlin, Berlin, Germany
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Aziz Rizk A, Farhani N, Shankar J. Computed Tomography Perfusion for the Diagnosis of Brain Death: A Technical Review. Can J Neurol Sci 2024; 51:173-178. [PMID: 37462465 DOI: 10.1017/cjn.2023.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Timely diagnosis of brain death (BD) is critical as it prevents unethical and futile continuation of support of vital organ functions when the patient has passed. Furthermore, it helps with avoiding the unnecessary use of resources and provides early opportunity for precious organ donation. The diagnosis of BD is mainly based on careful neurological assessment of patients with an established underlying diagnosis of neurological catastrophe capable of causing BD.Ancillary testing, however, is tremendously helpful in situations when the presence of confounders prevents or delays comprehensive neurological assessment. Traditionally, four-vessel digital subtraction angiography and computed tomography angiography have been used for blood flow (BF) examinations of the brain. The lack of BF in the intracranial arteries constitutes conclusive evidence that the brain is dead. However, there is an apparent discrepancy between the BF and sufficient cerebral perfusion; several studies have shown that in 15% of patients with confirmed clinical diagnosis of BD, BF is still preserved. In these patients, cerebral perfusion is significantly impaired. Hence, measurement of cerebral perfusion rather than BF will provide a more precise assessment of the brain function.In this review article, we discuss a brief history of BD, our understanding of its complex pathophysiology, current Canadian guidelines for the clinical diagnosis of BD, and the ancillary tests-specifically CT perfusion of the brain that help us with the prompt and timely diagnosis of BD.
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Affiliation(s)
| | - Nahal Farhani
- Department of Internal Medicine, Division of Neurology, University of MB, Winnipeg, MB, Canada
| | - Jai Shankar
- Department of Radiology, University of Manitoba, Winnipeg, MB, Canada
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3
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Chen J, Zhao W, Zhu X, Yang L, Geng C, Zhang X, Wang Y. The value of computed tomography angiography in predicting the surgical effect and prognosis of severe traumatic brain injury. Sci Rep 2024; 14:1819. [PMID: 38245634 PMCID: PMC10799957 DOI: 10.1038/s41598-024-52385-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 01/18/2024] [Indexed: 01/22/2024] Open
Abstract
It is difficult to predict the surgical effect and outcome of severe traumatic brain injury (TBI) before surgery. This study aims to approve an evaluation method of computed tomography angiography (CTA) to predict the effect of surgery and outcome in severe TBI. Between January 2010 and January 2020, we retrospectively reviewed 358 severe TBI patients who underwent CTA at admission and reexamination. CTA data were evaluated for the presence of cerebrovascular changes, including cerebrovascular shift (CS), cerebral vasospasm (CVS), large artery occlusion (LAO), and deep venous system occlusion (DVSO). Medical records were reviewed for baseline clinical characteristics and the relationship between CTA changes and outcomes. Cerebrovascular changes were identified in 247 (69.0%) of 358 severe TBI patients; only 25 (10.12%) of them had poor outcomes, and 162 (65.6%) patients had a good recovery. Eighty-three (23.18%) patients were diagnosed with CVS, 10 (12.05%) had a good outcome, 57 (68.67%) had severe disability and 16 (19.28%) had a poor outcome. There were twenty-six (7.3%) patients who had LAO and thirty-one (8.7%) patients who had DVSO; no patients had good recovery regardless of whether they had the operation or not. Cerebrovascular injuries and changes are frequent after severe TBI and correlate closely with prognosis. CTA is an important tool in evaluating the severity, predicting the operation effect and prognosis, and guiding therapy for severe TBI. Well-designed, multicenter, randomized controlled trials are needed to evaluate the value of CTA for severe TBI in the future.
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Affiliation(s)
- Junhui Chen
- Department of Neurosurgery, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Xingyuan North Road No. 101, Liangxi District, Wuxi, 214044, Jiangsu Province, China
- Department of Human Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha, Hunan Province, China
| | - Wei Zhao
- Department of Neurosurgery, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Xingyuan North Road No. 101, Liangxi District, Wuxi, 214044, Jiangsu Province, China
| | - Xiaoming Zhu
- Department of Neurosurgery, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Xingyuan North Road No. 101, Liangxi District, Wuxi, 214044, Jiangsu Province, China
| | - Likun Yang
- Department of Neurosurgery, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Xingyuan North Road No. 101, Liangxi District, Wuxi, 214044, Jiangsu Province, China
| | - Chengjun Geng
- Department of Imaging, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu Province, China
| | - Xu Zhang
- Department of Neurosurgery, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Xingyuan North Road No. 101, Liangxi District, Wuxi, 214044, Jiangsu Province, China
| | - Yuhai Wang
- Department of Neurosurgery, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Xingyuan North Road No. 101, Liangxi District, Wuxi, 214044, Jiangsu Province, China.
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4
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Neves Briard J, Nitulescu R, Lemoine É, Titova P, McIntyre L, English SW, Knoll G, Shemie SD, Martin C, Turgeon AF, Lauzier F, Fergusson DA, Chassé M. Diagnostic accuracy of ancillary tests for death by neurologic criteria: a systematic review and meta-analysis. Can J Anaesth 2023; 70:736-748. [PMID: 37155120 PMCID: PMC10202988 DOI: 10.1007/s12630-023-02426-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 05/10/2023] Open
Abstract
PURPOSE Ancillary tests are frequently used in death determination by neurologic criteria (DNC), particularly when the clinical neurologic examination is unreliable. Nevertheless, their diagnostic accuracy has not been extensively studied. Our objective was to synthesize the sensitivity and specificity of commonly used ancillary tests for DNC. SOURCE We performed a systematic review and meta-analysis by searching MEDLINE, EMBASE, Cochrane databases, and CINAHL Ebsco from their inception to 4 February 2022. We selected cohort and case-control studies including patients with 1) clinically diagnosed death by neurologic criteria or 2) clinically suspected death by neurologic criteria who underwent ancillary testing for DNC. We excluded studies without a priori diagnostic criteria and studies conducted solely on pediatric patients. Accepted reference standards were clinical examination, four-vessel conventional angiography, and radionuclide imaging. Data were directly extracted from published reports. We assessed the methodological quality of studies with the QUADAS-2 tool and estimated ancillary test sensitivities and specificities using hierarchical Bayesian models with diffuse priors. PRINCIPAL FINDINGS Overall, 137 records met the selection criteria. One study (0.7%) had a low risk of bias in all QUADAS-2 domains. Among clinically diagnosed death by neurologic criteria patients (n = 8,891), ancillary tests had similar pooled sensitivities (range, 0.82-0.93). Sensitivity heterogeneity was greater within (σ = 0.10-0.15) than between (σ = 0.04) ancillary test types. Among clinically suspected death by neurologic criteria patients (n = 2,732), pooled ancillary test sensitivities ranged between 0.81 and 1.00 and specificities between 0.87 and 1.00. Most estimates had high statistical uncertainty. CONCLUSION Studies assessing ancillary test diagnostic accuracy have an unclear or high risk of bias. High-quality studies are required to thoroughly validate ancillary tests for DNC. STUDY REGISTRATION PROSPERO (CRD42013005907); registered 7 October 2013.
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Affiliation(s)
- Joel Neves Briard
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue Saint-Denis, Montreal, QC, H2X 3H8, Canada
| | - Roy Nitulescu
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue Saint-Denis, Montreal, QC, H2X 3H8, Canada
| | - Émile Lemoine
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
| | - Polina Titova
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue Saint-Denis, Montreal, QC, H2X 3H8, Canada
| | - Lauralyn McIntyre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Shane W English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Greg Knoll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sam D Shemie
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Claudio Martin
- Department of Medicine, Schulich School of Medicine and Dentistry, London, ON, Canada
| | - Alexis F Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Center, Quebec City, QC, Canada
| | - François Lauzier
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Center, Quebec City, QC, Canada
- Department of Medicine, Université Laval, Quebec City, QC, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Michaël Chassé
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue Saint-Denis, Montreal, QC, H2X 3H8, Canada.
- Department of Medicine, Université de Montréal, Montreal, QC, Canada.
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Dineen RA, Thomas EO, Mortimer A, Summers DM, Manara A, Gardiner D. Cerebral CT angiography as an ancillary investigation in the diagnosis of death using neurological criteria: a new UK guideline. Clin Radiol 2023; 78:e166-e168. [PMID: 36759073 DOI: 10.1016/j.crad.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023]
Affiliation(s)
- R A Dineen
- Radiological Sciences, School of Medicine, University of Nottingham, Nottingham, UK; Department of Radiology, Nottingham University Hospital NHS Trust, Nottingham, UK.
| | - E O Thomas
- Department of Intensive Care Medicine, University Hospitals NHS Trust Plymouth, Plymouth, UK
| | - A Mortimer
- Department of Radiology, North Bristol NHS Trust, Bristol, UK
| | - D M Summers
- Department of Neuroradiology, NHS Lothian, Edinburgh, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - A Manara
- Department of Intensive Care Medicine, North Bristol NHS Trust, Bristol, UK
| | - D Gardiner
- Department of Intensive Care Medicine, Nottingham University Hospital NHS Trust, Nottingham, UK
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Haggenmüller B, Kreiser K, Sollmann N, Huber M, Vogele D, Schmidt SA, Beer M, Schmitz B, Ozpeynirci Y, Rosskopf J, Kloth C. Pictorial Review on Imaging Findings in Cerebral CTP in Patients with Acute Stroke and Its Mimics: A Primer for General Radiologists. Diagnostics (Basel) 2023; 13:diagnostics13030447. [PMID: 36766552 PMCID: PMC9914845 DOI: 10.3390/diagnostics13030447] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 01/28/2023] Open
Abstract
The imaging evaluation of computed tomography (CT), CT angiography (CTA), and CT perfusion (CTP) is of crucial importance in the setting of each emergency department for suspected cerebrovascular impairment. A fast and clear assignment of characteristic imaging findings of acute stroke and its differential diagnoses is essential for every radiologist. Different entities can mimic clinical signs of an acute stroke, thus the knowledge and fast identification of stroke mimics is important. A fast and clear assignment is necessary for a correct diagnosis and a rapid initiation of appropriate therapy. This pictorial review describes the most common imaging findings in CTP with clinical signs for acute stroke or other acute neurological disorders. The knowledge of these pictograms is therefore essential and should also be addressed in training and further education of radiologists.
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Affiliation(s)
- Benedikt Haggenmüller
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany
- Correspondence:
| | - Kornelia Kreiser
- Department of Radiology and Neuroradiology, RKU—Universitäts- und Rehabilitationskliniken Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Nico Sollmann
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Magdalena Huber
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Daniel Vogele
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Stefan A. Schmidt
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Meinrad Beer
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Bernd Schmitz
- Department of Neuroradiology, Bezirkskrankenhaus Günzburg, Lindenallee 2, 89312 Günzburg, Germany
| | - Yigit Ozpeynirci
- Institute of Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Johannes Rosskopf
- Department of Neuroradiology, Bezirkskrankenhaus Günzburg, Lindenallee 2, 89312 Günzburg, Germany
| | - Christopher Kloth
- Department of Diagnostic and Interventional Radiology, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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7
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Cerebral blood vessels and perfusion in the pediatric brain death: five cases studied by neuroimaging. Neuroradiology 2022; 64:1661-1669. [PMID: 35511244 DOI: 10.1007/s00234-022-02955-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/11/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE To detect the cerebral blood vessels and perfusion using neuroimaging modalities including computed tomography angiography (CTA), computed tomography perfusion (CTP), and arterial spin labeling (ASL) in children with brain death (BD). METHODS According to the current children's BD criteria, 5 children (3 males, 2 females, mean age of 5.65 years) with BD were enrolled from January 2019 to December 2020. The imaging features of CTA, CTP, and ASL were evaluated to analyze the visualization of important intracranial blood vessels and the states of the cerebral blood flow (CBF) and cerebral blood volume (CBV) related to the region of interest (ROI) brain tissue during the two clinical assessments for BD. RESULTS The "4-point scale" scoring system of CTA was applied to evaluate BD and no negative results were detected. The CTP results of the 5 children suggested the cessation of cerebral circulation with 100% positive results. The ranges of CBF and CBV were 0.00-9.52 ml/100 g/min (mean value 4.95 ± 1.69 ml/100 g/min) and 0.00-1.34 ml/100 g (mean value 0.36 ± 0.20 ml/100 g), respectively. One patient also underwent ASL examination, which demonstrated a significant reduction in whole brain perfusion, indicating the absence of cerebral circulation. The CBF values of the brainstem, basal ganglia, and prefrontal lobe were 11.61 ± 1.49 ml/100 g/min, 7.81 ± 2.42 ml/100 g/min, and 9.94 ± 2.01 ml/100 g/min, respectively. CONCLUSION Neuroimaging examinations particularly CTA and CTP reveal well the hemodynamic and cerebral blood vessels changes of BD, which can be used as supplementary supportive evidence for the declaration of brain death in children.
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Arsava EM, Ayvacioglu Cagan C, Gumeler E, Parlak S, Oguz KK, Topcuoglu MA. Comparison of early- and late-phase CT angiography findings in brain death. J Neurol 2022; 269:5973-5980. [PMID: 35842546 DOI: 10.1007/s00415-022-11281-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/05/2022] [Accepted: 07/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Late-phase images on computed tomography angiography (CTA), traditionally used for assessing cerebral circulatory arrest in brain death, suffer from suboptimal diagnostic yield due to stasis filling. Herein, we assessed contrast filling in individual intracranial arteries and veins in the early and late phases of CTA in patients with clinically confirmed brain death. METHODS Contrast opacification within 28 arterial/venous segments was evaluated in both phases of CTA in 79 patients. This information was combined with reports in the literature to calculate prevalence of contrast filling in different intracranial vessels. Additionally, diagnostic sensitivity of 4-point, 7-point, and 10-point scores defined for brain death were compared among ratings based on early, late, and both phases (arteries rated on early, veins rated on late phase) of imaging. RESULTS The median (IQR) number of vessel segments with contrast opacification was 0 (0-2) in early phase and 6 (0-10) in late phase. All segments showed increased prevalence of opacification when evaluated in late phase (p < 0.05). The M4 segments of MCA, internal cerebral veins, and vein of Galen had the lowest percentage of opacification in both phases. The sensitivity of 4-, 7-, and 10-point scoring algorithms increased from 59-91% to 94-99% when ratings were performed using early-phase images rather than based solely on late-phase images. CONCLUSIONS The incorporation of early-phase images might be considered as a strategy to improve the sensitivity of CTA as an ancillary test in confirming brain death, especially in patients without missing or questionable elements in clinical examination.
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Affiliation(s)
- Ethem Murat Arsava
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
| | | | - Ekim Gumeler
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Safak Parlak
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kader Karli Oguz
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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9
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Spears W, Mian A, Greer D. Brain death: a clinical overview. J Intensive Care 2022; 10:16. [PMID: 35292111 PMCID: PMC8925092 DOI: 10.1186/s40560-022-00609-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/06/2022] [Indexed: 01/01/2023] Open
Abstract
Brain death, also commonly referred to as death by neurologic criteria, has been considered a legal definition of death for decades. Its determination involves many considerations and subtleties. In this review, we discuss the philosophy and history of brain death, its clinical determination, and special considerations. We discuss performance of the main clinical components of the brain death exam: assessment of coma, cranial nerves, motor testing, and apnea testing. We also discuss common ancillary tests, including advantages and pitfalls. Special discussion is given to extracorporeal membrane oxygenation, target temperature management, and determination of brain death in pediatric populations. Lastly, we discuss existing controversies and future directions in the field.
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Affiliation(s)
- William Spears
- Department of Neurology, Boston University, Boston Medical Center, 85 East Concord Street, Room 1145, Boston, MA, 02118, USA
| | - Asim Mian
- Department of Radiology, Boston University, Boston Medical Center, 820 Harrison Avenue FGH, 3rd floor, Boston, USA
| | - David Greer
- Department of Neurology, Boston University, Boston Medical Center, 85 East Concord Street, Room 1145, Boston, MA, 02118, USA.
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Zampakis P, Panagiotopoulos V, Kalogeropoulou C, Karachaliou M, Aretha D, Sioulas N, Dimoulia S, Karnabatidis D, Fligou F. Computed tomography angiography scoring systems and the role of skull defects in the confirmation of brain death. Sci Rep 2021; 11:15081. [PMID: 34302043 PMCID: PMC8302591 DOI: 10.1038/s41598-021-94763-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 07/15/2021] [Indexed: 01/07/2023] Open
Abstract
To assess and compare all current computed tomography angiography (CTA) scoring systems for the diagnostic workup of brain death (BD) to digital subtraction angiography (DSA) and clinical tests. Fifty-two patients with a clinical suspicion of BD underwent CTA and subsequently DSA. The diagnostic performance of all current CTA scoring systems was compared to that of DSA, in all patients with a suspicion of BD. A comparison to clinical tests was made only in DSA-positive for BD patients (n = 49), since in DSA-negative BD patients (n = 3) clinical tests were not performed. Further subgroup analysis was performed in relation to skull defects (SDs) stratification. Statistical analysis was conducted by applying statistics-contingency tables, Cochran's-Q test and McNemar's test. The CTA -10, and -7- and all 4-point scoring systems, showed overall sensitivities of 81,6%, 87.8% and 95.9% respectively and 100% specificity, when compared to DSA. In patients with a clinical verification of BD, the CTA -10 and -7-point scoring systems were significantly inferior to clinical tests (p = 0.004 and p = 0.031), while the 4-point scoring systems showed no such difference (p = 0.5). All 4-point scoring systems showed 100% sensitivity in patients with a minor SD or no SD. In patients with a major SD, all CTA scoring systems (- 10, - 7- and all 4-point) were less sensitive (62.5%, 62.5% and 75% respectively). The presence of a major SD was associated with an 8 × relative risk for false negative results in all 4-point scoring systems. CTA showed excellent diagnostic performance in patients with a suspicion of BD. The 4-point CTA scoring systems are the most sensitive for the diagnosis of BD, although in patients with a major SD patient, the role of CTA is ambiguous.
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Affiliation(s)
- Petros Zampakis
- Department of Radiology, University Hospital of Patras GR, 265 04, Patras, Greece.
| | | | | | - Maria Karachaliou
- Department of Radiology, University Hospital of Patras GR, 265 04, Patras, Greece
| | - Diamanto Aretha
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras. GR, 265 04, Patras, Greece
| | - Nektarios Sioulas
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras. GR, 265 04, Patras, Greece
| | - Sofia Dimoulia
- Department of Radiology, University Hospital of Patras GR, 265 04, Patras, Greece
| | | | - Fotini Fligou
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras. GR, 265 04, Patras, Greece
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11
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Alcock S, Batoo D, Ande SR, Grierson R, Essig M, Martin D, Trivedi A, Sinha N, Leeies M, Zeiler FA, Shankar JJS. Early diagnosis of mortality using admission CT perfusion in severe traumatic brain injury patients (ACT-TBI): protocol for a prospective cohort study. BMJ Open 2021; 11:e047305. [PMID: 34108167 PMCID: PMC8191612 DOI: 10.1136/bmjopen-2020-047305] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Severe traumatic brain injury (TBI) is a catastrophic neurological condition with significant economic burden. Early in-hospital mortality (<48 hours) with severe TBI is estimated at 50%. Several clinical examinations exist to determine brain death; however, most are difficult to elicit in the acute setting in patients with severe TBI. Having a definitive assessment tool would help predict early in-hospital mortality in this population. CT perfusion (CTP) has shown promise diagnosing early in-hospital mortality in patients with severe TBI and other populations. The purpose of this study is to validate admission CTP features of brain death relative to the clinical examination outcome for characterizing early in-hospital mortality in patients with severe TBI. METHODS AND ANALYSIS The Early Diagnosis of Mortality using Admission CT Perfusion in Severe Traumatic Brain Injury Patients study, is a prospective cohort study in patients with severe TBI funded by a grant from the Canadian Institute of Health Research. Adults aged 18 or older, with evidence of a severe TBI (Glasgow Coma Scale score ≤8 before initial resuscitation) and, on mechanical ventilation at the time of imaging are eligible. Patients will undergo CTP at the time of first imaging on their hospital admission. Admission CTP compares with the reference standard of an accepted bedside clinical assessment for brainstem function. Deferred consent will be used. The primary outcome is a binary outcome of mortality (dead) or survival (not dead) in the first 48 hours of admission. The planned sample size for achieving a sensitivity of 75% and a specificity of 95% with a CI of ±5% is 200 patients. ETHICS AND DISSEMINATION This study has been approved by the University of Manitoba Health Research Ethics Board. The findings from our study will be disseminated through peer-reviewed journals and presentations at local rounds, national and international conferences. The public will be informed through forums at the end of the study. TRIAL REGISTRATION NUMBER NCT04318665.
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Affiliation(s)
- Susan Alcock
- Department of Radiology, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Divjeet Batoo
- Department of Radiology, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Sudharsana Rao Ande
- Department of Radiology, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Rob Grierson
- Department of Emergency Medicine, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Marco Essig
- Department of Radiology, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Douglas Martin
- Department of Emergency Medicine, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Anurag Trivedi
- Section of Neurology, Department of Internal Medicine, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Namita Sinha
- Section of Neuropathology, Department of Pathology, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Murdoch Leeies
- Department of Emergency Medicine & Section of Critical Care Medicine, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Jai Jai Shiva Shankar
- Department of Radiology, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
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Ozpar R, Tonkaz M, Girgin NK, Bodur M, Dinc Y, Kocaeli H, Hakyemez B. Reliability of CT angiography scoring systems used for brain death and the effect of cranial interventions on the results. Clin Imaging 2021; 79:142-147. [PMID: 33945904 DOI: 10.1016/j.clinimag.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/09/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To assess vascular opacifications, the efficiency, and interobserver agreement (IOA) of five different computed tomography angiography (CTA) brain death (BD) scoring systems in patients with and without cranial interventions, for determining alternative findings correctly supporting BD diagnosis by CTA even in cranial intervention presence. METHODS 45 patients clinically identified with BD and evaluated with CTA were included. IOA of five different scoring systems used for CTA BD diagnosis, the effect of intracranial interventions on scoring systems, and vascular opacification were evaluated. RESULTS IOA was almost perfect (κ = 0.843-0.911, p < 0.05) and substantial (κ = 0.771-0.776, p < 0.05) in all scoring systems. Significant relationships were observed between craniectomy presence and middle cerebral artery M4 segment and internal cerebral vein (ICV) opacification. No opacification was observed in straight sinus (SS) by observers in any of the craniectomized patients. CONCLUSION IOA of CTA scoring systems is adequate. But a significant degree of false-negative results is observed due to ICV filling in craniectomy cases. Opacification presence in SS can give an idea of BD in these cases.
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Affiliation(s)
- Rifat Ozpar
- Department of Radiology, Bursa Uludag University Faculty of Medicine, Bursa, Turkey.
| | - Mehmet Tonkaz
- Department of Radiology, Bursa Uludag University Faculty of Medicine, Bursa, Turkey
| | - Nermin Kelebek Girgin
- Department of Anesthesiology and Reanimation, Bursa Uludag University Faculty of Medicine, Bursa, Turkey
| | - Muhittin Bodur
- Department of Pediatric Neurology, Bursa Uludag University Faculty of Medicine, Bursa, Turkey
| | - Yasemin Dinc
- Department of Neurology, Bursa Uludag University Faculty of Medicine, Bursa, Turkey
| | - Hasan Kocaeli
- Department of Neurosurgery, Bursa Uludag University Faculty of Medicine, Bursa, Turkey
| | - Bahattin Hakyemez
- Department of Radiology, Bursa Uludag University Faculty of Medicine, Bursa, Turkey
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Outcomes, Time-Trends, and Factors Associated With Ancillary Study Use for the Determination of Brain Death. Crit Care Med 2021; 49:e840-e848. [PMID: 33852444 DOI: 10.1097/ccm.0000000000005035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Brain death determination often requires ancillary studies when clinical determination cannot be fully or safely completed. We aimed to analyze the results of ancillary studies, the factors associated with ancillary study performance, and the changes over time in number of studies performed at an academic health system. DESIGN Retrospective cohort. SETTING Multihospital academic health system. PATIENTS Consecutive adult patients declared brain dead between 2010 and 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 140 brain death patients, ancillary studies were performed in 84 (60%). The false negative rate of all ancillary studies was 4% (5% of transcranial Doppler ultrasounds, 4% of nuclear studies, 0% of electroencephalograms, and 17% of CT angiography). In univariate analysis, ancillary study use was associated with female sex (odds ratio, 2.4; 95% CI, 1.21-5.01; p = 0.013) and the etiology of brain death being hypoxic-ischemic brain injury (odds ratio, 2.9; 95% CI, 1.43-5.88; p = 0.003), nontraumatic intracranial hemorrhage (odds ratio, 0.45; 95% CI, 0.21-0.96; p = 0.039), or traumatic brain injury (odds ratio, 0.22; 95% CI, 0.04-0.8; p = 0.031). In multivariable analysis, female sex (odds ratio, 5.7; 95% CI, 2.56-15.86; p = 0.004), the etiology of brain death being hypoxic-ischemic brain injury (odds ratio, 3.2; 95% CI, 1.3-8.8; p = 0.015), and the neurologists performing brain death declaration (odds ratio, 0.08; 95% CI, 0.004-0.64; p = 0.034) were factors independently associated with use of ancillary studies. Over the study period, the total number of ancillary studies performed each year did not significantly change; however, the number of electroencephalograms significantly decreased with time (odds ratio per 1-yr increase, 0.67; 95% CI, 0.49-0.90; p = 0.014). CONCLUSIONS A large number of ancillary studies were performed despite a clinical determination of brain death; patients with hypoxic-ischemic brain injury are more likely to undergo ancillary studies for brain death determination, and neurologists were less likely to use ancillary studies for brain death. Recently, the use of electroencephalograms for brain death determination has decreased, likely reflecting significant concerns regarding its validity and reliability.
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Brain Death in Patients With "Isolated" Brainstem Lesions: A Case Against Controversy. J Neurosurg Anesthesiol 2020; 31:171-173. [PMID: 30540618 DOI: 10.1097/ana.0000000000000568] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Sayan HE. Retrospective analysis of the apnea test and ancillary test in determining brain death. Rev Bras Ter Intensiva 2020; 32:405-411. [PMID: 33053030 PMCID: PMC7595719 DOI: 10.5935/0103-507x.20200069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/17/2020] [Indexed: 12/02/2022] Open
Abstract
Objective We investigated the frequency of apnea tests, and the use of ancillary tests in the diagnosis of brain death in our hospital, as well as the reasons for not being able to perform apnea testing and the reasons for using ancillary tests. Methods In this retrospective study, the files of patients diagnosed with brain death between 2012 - 2018 were examined. The preferred test was determined if an ancillary test was performed in the diagnosis of brain death. The rate and frequency of use of these tests were analyzed. Results During the diagnosis of brain death, an apnea test was performed on 104 (61.5%) patients and was not or could not be performed on 65 (38.5%) patients. Ancillary tests were performed on 139 (82.8%) of the patients. The most common ancillary test was computed tomography angiography (79 patients, 46.7%). Approval for organ donation was received in the meetings with the family following the diagnosis of brain death for 55 (32.5%) of the 169 patients. Conclusion We found an increase in the rate of incomplete apnea tests and concordantly, an increase in the use of ancillary tests in recent years. Ancillary tests should be performed on patients when there is difficulty in reaching a decision of brain death, but it should not be forgotten that there is no worldwide consensus on the use of ancillary tests.
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Affiliation(s)
- Halil Erkan Sayan
- Department of Anesthesiology and Reanimation, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences - Bursa, Turkey
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16
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Akdogan AI, Pekcevik Y, Sahin H, Pekcevik R. Assessment of Cerebral Circulatory Arrest via CT Angiography and CT Perfusion in Brain Death Confirmation. Korean J Radiol 2020; 22:395-404. [PMID: 32932559 PMCID: PMC7909855 DOI: 10.3348/kjr.2019.0859] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 05/17/2020] [Accepted: 06/17/2020] [Indexed: 01/04/2023] Open
Abstract
Objective To compare the utility of computed tomography perfusion (CTP) and three different 4-point scoring systems in computed tomography angiography (CTA) in confirming brain death (BD) in patients with and without skull defects. Materials and Methods Ninety-two patients clinically diagnosed as BD using CTA and/or CTP for confirmation were retrospectively reviewed. For the final analysis, 86 patients were included in this study. Images were re-evaluated by three radiologists according to the 4-point scoring systems that consider the vessel opacification on 1) the venous phase for both M4 segments of the middle cerebral arteries (MCAs-M4) and internal cerebral veins (ICVs) (A60-V60), 2) the arterial phase for the MCA-M4 and venous phase for the ICVs (A20-V60), 3) the venous phase for the ICVs and superior petrosal veins (ICV-SPV). The CTP images were independently reviewed. The presence of an open skull defect and stasis filling was noted. Results Sensitivities of the ICV-SPV, A20-V60, A60-V60 scoring systems, and CTP in the diagnosis of BD were 89.5%, 82.6%, 67.4%, and 93.3%, respectively. The sensitivity of A20-V60 scoring was higher than that of A60-V60 in BD patients (p < 0.001). CTP was found to be the most sensitive method (86.5%) in patients with open skull defect (p = 0.019). Interobserver agreement was excellent in the diagnosis of BD, in assessing A20-V60, A60-V60, ICV-SPV, CTP, and good in stasis filling (κ: 0.84, 0.83, 0.83, 0.83, and 0.67, respectively). Conclusion The sensitivity of CTA confirming brain death differs between various proposed 4-point scoring systems. Although the ICV-SPV is the most sensitive, evaluation of the SPV is challenging. Adding CTP to the routine BD CTA protocol, especially in cases with open skull defect, could increase sensitivity as a useful adjunct.
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Affiliation(s)
- Asli Irmak Akdogan
- Department of Radiology, Buca Women Birth and Child Diseases Hospital, Izmir, Turkey.
| | - Yeliz Pekcevik
- Department of Radiology, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Hilal Sahin
- Department of Radiology, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Ridvan Pekcevik
- Department of Radiology, Katip Çelebi University, Ataturk Training and Research Hospital, Izmir, Turkey
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Manara AR, Thomas I. Current status of organ donation after brain death in the UK. Anaesthesia 2020; 75:1205-1214. [DOI: 10.1111/anae.15038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 01/07/2023]
Affiliation(s)
- A. R. Manara
- Department of Intensive Care Medicine and Anaesthesia Southmead Hospital Bristol UK
| | - I. Thomas
- Department of Intensive Care Medicine and Anaesthesia Southmead Hospital Bristol UK
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Admission Perfusion CT for Classifying Early In-Hospital Mortality of Patients With Severe Traumatic Brain Injury: A Pilot Study. AJR Am J Roentgenol 2020; 214:872-876. [PMID: 31990213 DOI: 10.2214/ajr.19.21599] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purposes of this study were to assess the feasibility and safety of perfusion CT of patients with severe traumatic brain injury (TBI) at hospital admission and to examine whether early in-hospital mortality could be characterized with perfusion CT (PCT). The hypothesis was that PCT can be used to characterize brain death, when present, in patients with severe TBI at hospital admission. SUBJECTS AND METHODS. In this prospective cohort pilot study, PCT was performed on patients with severe TBI at first imaging workup at hospital admission. PCT images were processed at the end of the study and assessed for features of brain death. The PCT features were then compared with the clinical outcome of in-hospital mortality. RESULTS. A total of 19 patients (13 men [68.4%]; six women [31.6%]; mean age, 36.4 years; median, 27.5 years) had a mean hospital stay longer than 1 month. No complications of PCT were found. In the first 48 hours after admission, four patients (21%) died. Admission PCT changes suggesting brainstem death were sensitive (75%) and specific (100%) and had high positive (100%) and negative (93.75%) predictive value for correct classification early in-hospital mortality. CONCLUSION. Admission PCT of patients with severe TBI was feasible and safe. Admission PCT findings helped in correctly classifying early in-hospital mortality in the first 48 hours of hospital admission.
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Pant M, Pant J, Pandey SK, Shukla RC. Study of pattern of origin of central branches of middle cerebral artery by using 64-slice computed tomography angiography. NATIONAL JOURNAL OF CLINICAL ANATOMY 2020. [DOI: 10.4103/njca.njca_3_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Gastala J, Fattal D, Kirby PA, Capizzano AA, Sato Y, Moritani T. Brain death: Radiologic signs of a non-radiologic diagnosis. Clin Neurol Neurosurg 2019; 185:105465. [DOI: 10.1016/j.clineuro.2019.105465] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/30/2019] [Accepted: 08/06/2019] [Indexed: 11/13/2022]
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Brasil S, Bor-Seng-Shu E, de-Lima-Oliveira M, Taccone FS, Gattás G, Nunes DM, Gomes de Oliveira RA, Martins Tomazini B, Tierno PF, Becker RA, Bassi E, Sá Malbouisson LM, da Silva Paiva W, Teixeira MJ, de Carvalho Nogueira R. Computed tomography angiography accuracy in brain death diagnosis. J Neurosurg 2019; 133:1220-1228. [PMID: 31561215 DOI: 10.3171/2019.6.jns191107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/18/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The present study was designed to answer several concerns disclosed by systematic reviews indicating no evidence to support the use of computed tomography angiography (CTA) in the diagnosis of brain death (BD). Therefore, the aim of this study was to assess the effectiveness of CTA for the diagnosis of BD and to define the optimal tomographic criteria of intracranial circulatory arrest. METHODS A unicenter, prospective, observational case-control study was undertaken. Comatose patients (Glasgow Coma Scale score ≤ 5), even those presenting with the first signs of BD, were included. CTA scanning of arterial and venous vasculature and transcranial Doppler (TCD) were performed. A neurological determination of BD and consequently determination of case (BD group) or control (no-BD group) was conducted. All personnel involved with assessing patients were blinded to further tests results. Accuracy of BD diagnosis determined by using CTA was calculated based on the criteria of bilateral absence of visualization of the internal cerebral veins and the distal middle cerebral arteries, the 4-point score (4PS), and an exclusive criterion of absence of deep brain venous drainage as indicated by the absence of deep venous opacification on CTA, the venous score (VS), which considers only the internal cerebral veins bilaterally. RESULTS A total of 106 patients were enrolled in this study; 52 patients did not have BD, and none of these patients had circulatory arrest observed by CTA or TCD (100% specificity). Of the 54 patients with a clinical diagnosis of BD, 33 met the 4PS (61.1% sensitivity), whereas 47 met the VS (87% sensitivity). The accuracy of CTA was time related, with greater accuracy when scanning was performed less than 12 hours prior to the neurological assessment, reaching 95.5% sensitivity with the VS. CONCLUSIONS CTA can reliably support a diagnosis of BD. The criterion of the absence of deep venous opacification, which can be assessed by use of the VS criteria investigated in this study, can confirm the occurrence of cerebral circulatory arrest.Clinical trial registration no.: 12500913400000068 (clinicaltrials.gov).
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Affiliation(s)
| | | | | | | | | | | | | | - Bruno Martins Tomazini
- 3Trauma Intensive Care Unit, Hospital das Clinicas, School of Medicine, São Paulo, Brazil; and
| | - Paulo Fernando Tierno
- 3Trauma Intensive Care Unit, Hospital das Clinicas, School of Medicine, São Paulo, Brazil; and
| | - Rafael Akira Becker
- 3Trauma Intensive Care Unit, Hospital das Clinicas, School of Medicine, São Paulo, Brazil; and
| | - Estevão Bassi
- 3Trauma Intensive Care Unit, Hospital das Clinicas, School of Medicine, São Paulo, Brazil; and
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Abstract
PURPOSE OF REVIEW This article discusses the diagnostic and therapeutic approach to patients who are comatose and reviews the current knowledge on prognosis from various causes of coma. This article also provides an overview of the principles for determination of brain death as well as advice on how to avoid common pitfalls. RECENT FINDINGS Technologic advances have refined our understanding of the physiology of consciousness and the spectrum of disorders of consciousness; they also promise to improve our prognostic accuracy. Yet the clinical principles for the evaluation and treatment of coma remain unaltered. The clinical standards for determination of death by neurologic criteria (ie, brain death) are also well established, although variabilities in local protocols and legal requirements remain a problem to be resolved. SUMMARY Effective evaluation of coma demands a systematic approach relying on clinical information to ensure rational use of laboratory and imaging tests. When the cause of coma is deemed irreversible in the setting of a catastrophic brain injury and no clinical evidence exists for brain and brainstem function, patients should be evaluated for the possibility of brain death by following the clinical criteria specified in the American Academy of Neurology guidelines.
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The observation period after clinical brain death diagnosis according to ancillary tests: differences between supratentorial and infratentorial brain injury. J Neurol 2019; 266:1859-1868. [DOI: 10.1007/s00415-019-09338-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/21/2019] [Accepted: 04/23/2019] [Indexed: 12/23/2022]
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Manara AR. All human death is brain death: The legacy of the Harvard criteria. Resuscitation 2019; 138:210-212. [DOI: 10.1016/j.resuscitation.2019.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/03/2019] [Accepted: 03/06/2019] [Indexed: 12/16/2022]
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Manara A, Varelas P, Smith M. Neurological determination of death in isolated brainstem lesions: A case report to highlight the issues involved. J Intensive Care Soc 2019; 21:269-273. [PMID: 32782467 DOI: 10.1177/1751143719832169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The neurological determination of death in patients with isolated brainstem lesions or by disruption of the posterior cerebral circulation is uncommon and many intensivists may never see such a case in their career. It is also the only major difference between the "whole brain" and "brain stem" formulations for the neurological determination of death. We present a case of a patient with infarction of the structures supplied by the posterior cerebral circulation in whom death was diagnosed using neurological criteria, to illustrate the issues involved. We also suggest that international consensus may be achieved if ancillary tests, such as CT angiography, are made mandatory in this situation o demonstrate loss of blood flow in the anterior cerebral circulation as well the posterior circulation.
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Affiliation(s)
- Alex Manara
- The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Martin Smith
- National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK
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Ramachandran S, Venkatesh H, Foley RW. How should we use imaging in the determination of brainstem death? BJR Open 2018; 1:20180013. [PMID: 33178909 PMCID: PMC7592410 DOI: 10.1259/bjro.20180013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/03/2018] [Indexed: 11/05/2022] Open
Abstract
Brainstem death is defined as the "irreversible cessation of brainstem function", either due to primary intracranial events or extracranial factors such as hypoxia. The importance of accurate and timely diagnosis of brainstem death in critical care should not be understated, as it allows the withdrawal of treatment when it is no longer deemed to beneficial. Additionally, it may facilitate the process of organ donation. Overall, the diagnosis of brainstem death has four common principles across the world: (1) neurological criteria based on clinical assessment; (2) evidence of irreversible brain damage from known aetiology; (3) demonstrating an absence of a reversible cause; and (4) the use of ancillary studies. The latter in particular has been a controversial issue, with much debate continuing on how imaging should be used. We discuss three key questions surrounding the role of imaging in the diagnosis of brainstem death as well as important issues the radiology community should consider.
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The role of cervical color Doppler ultrasound in the diagnosis of brain death. Neuroradiology 2018; 61:137-145. [DOI: 10.1007/s00234-018-2111-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/04/2018] [Indexed: 10/28/2022]
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Rizvi T, Batchala P, Mukherjee S. Brain Death: Diagnosis and Imaging Techniques. Semin Ultrasound CT MR 2018; 39:515-529. [DOI: 10.1053/j.sult.2018.01.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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MacDonald D, Stewart-Perrin B, Shankar JJS. The Role of Neuroimaging in the Determination of Brain Death. J Neuroimaging 2018; 28:374-379. [PMID: 29749664 PMCID: PMC6055878 DOI: 10.1111/jon.12516] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/06/2018] [Accepted: 04/08/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Brain death determination (BDD) is primarily a clinical diagnosis, where death is defined as the permanent loss of brainstem function. In scenarios where clinical examinations are inaccurate, ancillary imaging tests are required. The choice of ancillary imaging test is variable, but the common denominator for all of them is to establish a lack of cerebral blood flow. The purpose of this study was to compare the diagnostic accuracy and interrater reliability of different ancillary imaging tests used for BDD. METHODS Archival data were retrospectively analyzed for all patients who underwent any ancillary imaging test for BDD at our institution. The results of ancillary imaging tests were compared with, the reference standard, the clinical checklist for declaration of brain death. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of different ancillary imaging tests for BDD were performed. Interobserver agreement between two observers was measured using kappa statistics for each of the imaging modalities. RESULTS A total of 74 patients underwent 41 computer tomography perfusion (CTP), 54 CT angiogram, 15 radionuclide scans, 1 cerebral angiogram, 3 magnetic resonance imaging, and 71 nonenhanced CT (NECT) head for BDD. All ancillary tests (except NECT head) showed 100% specificity and PPV. CTP had the highest sensitivity and NPV. All ancillary imaging tests demonstrated very high interrater reliability. CONCLUSIONS The uses of ancillary imaging tests for BDD are increasing. Within this study's limitations, CTP followed by radionuclide scan were found to be the most accurate and reliable ancillary imaging test for BDD.
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Affiliation(s)
- Derek MacDonald
- Department of Diagnostic Imaging, QE II Health Sciences, Halifax, NS, Canada
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Sawicki M, Sołek-Pastuszka J, Chamier-Ciemińska K, Walecka A, Bohatyrewicz R. Accuracy of Computed Tomographic Perfusion in Diagnosis of Brain Death: A Prospective Cohort Study. Med Sci Monit 2018; 24:2777-2785. [PMID: 29727439 PMCID: PMC5957092 DOI: 10.12659/msm.906304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background This study was designed to determine diagnostic accuracy of computed tomographic perfusion (CTP) compared to computed tomographic angiography (CTA) for the diagnosis of brain death (BD). Material/Methods Whole-brain CTP was performed in patients diagnosed with BD and in patients with devastating brain injury with preserved brainstem reflexes. CTA was derived from CTP datasets. Cerebral blood flow (CBF) and volume (CBV) were calculated in all brain regions. CTP findings were interpreted as confirming diagnosis of BD (positive) when CBF and CBV in all ROIs were below 10 mL/100 g/min and 1.0 mL/100 g, respectively. CTA findings were interpreted using a 4-point system. Results Fifty brain-dead patients and 5 controls were included. In brain-dead patients, CTP results revealed CBF 0.00–9.98 mL/100 g/min and CBV 0.00–0.99 mL/100 g, and were thus interpreted as positive in all patients. CTA results suggested 7 negative cases, providing 86% sensitivity. In the non-brain-dead group, CTP results revealed CBF 2.37–37.59 mL/100 g/min and CBV 0.73–2.34 mL/100 g. The difference between values of CBF and CBV in the brain-dead and non-brain-dead groups was statistically significant (p=0.002 for CBF and p=0.001 for CBV). CTP findings in all non-brain-dead patients were interpreted as negative. This resulted in a specificity of 100% (95% CI, 0.31–1.00) for CTP in the diagnosis of BD. In all non-brain-dead patients, CTA revealed preserved intracranial filling and was interpreted as negative. This resulted in a specificity of 100% (95% CI, 0.31–1.00) for CTA in diagnosis of BD. Conclusions Whole-brain CTP seems to be a highly sensitive and specific method in diagnosis of BD.
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Affiliation(s)
- Marcin Sawicki
- Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Joanna Sołek-Pastuszka
- Clinic of Anesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Katarzyna Chamier-Ciemińska
- Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Anna Walecka
- Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Romuald Bohatyrewicz
- Clinic of Anesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, Szczecin, Poland
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Brasil S, de-Lima-Oliveira M, Bor-Seng-Shu E, Teixeira MJ. Letter to the Editor. Determining brain death using computed tomography angiography. J Neurosurg 2018; 128:653-654. [DOI: 10.3171/2017.6.jns171335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Garrett MP, Williamson RW, Bohl MA, Bird CR, Theodore N. Computed tomography angiography as a confirmatory test for the diagnosis of brain death. J Neurosurg 2018; 128:639-644. [DOI: 10.3171/2016.10.jns161042] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEFor a diagnosis of brain death (BD), ancillary testing is performed if patient factors prohibit a complete clinical examination and apnea test. The American Academy of Neurology (AAN) guidelines identify cerebral angiography (CA), cerebral scintigraphy, electroencephalography, and transcranial Doppler ultrasonography as accepted ancillary tests. CA is widely considered the gold standard of these, as it provides the most reliable assessment of intracranial blood flow. CT angiography (CTA) is a noninvasive and widely available study that is also capable of identifying absent or severely diminished intracranial blood flow, but it is not included among the AAN's accepted ancillary tests because of insufficient evidence demonstrating its reliability. The objective of this study was to assess the statistical performance of CTA in diagnosing BD, using clinical criteria alone or clinical criteria plus CA as the gold-standard comparisons.METHODSThe authors prospectively enrolled 22 adult patients undergoing workup for BD. All patients had cranial imaging and clinical examination results consistent with BD. In patients who met the AAN clinical criteria for BD, the authors performed CA and CTA so that both tests could be compared with the gold-standard clinical criteria. In cases that required ancillary testing, CA was performed as a confirmatory study, and CTA was then performed to compare against clinical criteria plus CA. Radiographic data were evaluated by an independent neuroradiologist. Test characteristics for CTA were calculated.RESULTSFour patients could not complete the standard BD workup and were excluded from analysis. Of the remaining 18 patients, 16 met AAN criteria for BD, 9 of whom required ancillary testing with CA. Of the 16 patients, 2 who also required CA ancillary testing were found to have persistent intracranial flow and were not declared brain dead at that time. These patients also underwent CTA; the results were concordant with the CA results. Six patients who were diagnosed with BD on the basis of clinical criteria alone also underwent CA, with 100% sensitivity. For all 18 patients included in the study, CTA had a sensitivity of 75%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 33%.CONCLUSIONSClinical examination with or without CA remains the gold standard in BD testing. Studies assessing the statistical performance of CTA in BD testing should compare CTA to these gold standards. The statistical performance of CTA in BD testing is comparable to several of the nationally accepted ancillary tests. These data add to the growing medical literature supporting the use of CTA as a reliable ancillary test in BD testing.
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Affiliation(s)
| | | | | | - C. Roger Bird
- 2Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Sawicki M, Sołek-Pastuszka J, Chamier-Ciemińska K, Walecka A, Walecki J, Bohatyrewicz R. Computed Tomography Perfusion is a Useful Adjunct to Computed Tomography Angiography in the Diagnosis of Brain Death. Clin Neuroradiol 2017; 29:101-108. [PMID: 29150710 PMCID: PMC6394546 DOI: 10.1007/s00062-017-0631-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 09/18/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND In the diagnosis of brain death (BD), computed tomography angiography (CTA) results in some cases show intracranial filling, leading to diagnostic confusion. Because cerebral circulatory arrest commences at the capillary level, we hypothesized that computed tomography perfusion (CTP) would be a more sensitive approach than CTA; therefore, the aim of the study was to compare the sensitivities of CTP and CTA in the diagnosis of BD. MATERIAL AND METHODS Whole brain CTP was performed in patients in the intensive care unit diagnosed with BD and CTA was derived from CTP datasets. Cerebral blood flow (CBF) and volume (CBV) were calculated in all brain regions. The CTP findings were interpreted as being consistent with a diagnosis of BD (positive) when CBF and CBV in all regions of interest (ROIs) were below 10 ml/100 g/min and 1.0 ml/100 g, respectively. The CTA findings were interpreted using a 4-point grading system. RESULTS A total of 50 patients were included in the study. The CTP results revealed CBF from 0.00 to 9.98 ml/100 g/min (mean, 1.98 ± 1.68 ml/100 g/min) and CBV from 0.00 to 0.99 ml/100 g (mean, 0.14 ± 0.12 ml/100 g) and were thus interpreted as positive in all 50 patients. In contrast, the CTA results suggested 7 negative cases, providing a sensitivity of 86%. The difference between the CTP and CTA sensitivity results for the diagnosis of BD was statistically significant (p = 0.006). CONCLUSION Whole brain CTP may potentially be a feasible and highly sensitive test for diagnosing BD: therefore, performing CTP in combination with CTA in cases when CTA results are negative for BD could increase the sensitivity of CTA.
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Affiliation(s)
- M Sawicki
- Dept. of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University, Szczecin, Poland
| | - J Sołek-Pastuszka
- Clinic of Anesthesiology and Intensive Care, Pomeranian Medical University, Clinical Hospital No1, Unii Lubelskiej 1, 71252, Szczecin, Poland.
| | - K Chamier-Ciemińska
- Dept. of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University, Szczecin, Poland
| | - A Walecka
- Dept. of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University, Szczecin, Poland
| | - J Walecki
- The Centre of Postgraduate Medical Education, Warsaw, Poland
| | - R Bohatyrewicz
- Clinic of Anesthesiology and Intensive Care, Pomeranian Medical University, Clinical Hospital No1, Unii Lubelskiej 1, 71252, Szczecin, Poland
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Henderson N, McDonald MJ. Ancillary Studies in Evaluating Pediatric Brain Death. J Pediatr Intensive Care 2017; 6:234-239. [PMID: 31073456 DOI: 10.1055/s-0037-1604015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/28/2017] [Indexed: 12/18/2022] Open
Abstract
When confounding variables exist that inhibit the ability to diagnose brain death clinically in pediatric patients, ancillary tests may provide additional information for the practitioner in evaluating for the presence or absence of brain death. Multiple options exist but differ in availability, ease of administration, cost, safety profile, and reliability to accurately diagnose brain death. An important desirable quality of an ancillary test is eliminating false positives, which imply brain death when brain death is in fact not present. More commonly available ancillary studies include electroencephalograms, brain angiography through various modalities, brain stem auditory evoked potentials, and transcranial Doppler ultrasound. At this time, there is not an ancillary test with 100% reliability in diagnosing brain death that can replace the clinical brain death exam. Therefore, practitioners need to understand the strengths and limitations of the ancillary studies available at their hospital.
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Affiliation(s)
- Natalie Henderson
- Division of Pediatric Critical Care, Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - Mark J McDonald
- Division of Pediatric Critical Care, Department of Pediatrics, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky, United States
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Chakraborty S, Dhanani S. Guidelines for Use of Computed Tomography Angiogram as an Ancillary Test for Diagnosis of Suspected Brain Death. Can Assoc Radiol J 2017; 68:224-228. [PMID: 28245959 DOI: 10.1016/j.carj.2016.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/24/2016] [Accepted: 12/06/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
- Santanu Chakraborty
- Department of Medical Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Sonny Dhanani
- Department of Critical Care, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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Abstract
Organ transplantation improves survival and quality of life in patients with end-organ failure. Waiting lists continue to grow across the world despite remarkable advances in the transplantation process, from the creation of public engagement campaigns to the development of critical pathways for the timely identification, referral, approach, and treatment of the potential organ donor. The pathophysiology of dying triggers systemic changes that are intimately related to organ viability. The intensive care management of the potential organ donor optimizes organ function and improves the donation yield, representing a significant step in reducing the mismatch between organ supply and demand. Different beliefs and cultures reflect diverse legislations and donation practices amongst different countries, creating a challenge to standardized practices. Maintaining public trust is necessary for continued progress in organ donation and transplantation, hence the urge for a joint effort in creating uniform protocols that ensure transparent practices within the medical community.
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Affiliation(s)
- C B Maciel
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - D Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - D M Greer
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
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Polish Guidelines on Diagnosing Brain Death in Adults vs the International Perspective: Are We in Need of an Update? Transplant Proc 2016; 48:1394-8. [DOI: 10.1016/j.transproceed.2016.01.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 01/21/2016] [Indexed: 11/17/2022]
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Dead or alive? New confirmatory test using quantitative analysis of computed tomographic angiography. J Trauma Acute Care Surg 2015; 79:995-1003; discussion 1003. [DOI: 10.1097/ta.0000000000000831] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Brasil S, Bor-Seng-Shu E, de-Lima-Oliveira M, K Azevedo M, J Teixeira M, Bernardo L, M Bernardo W. Role of computed tomography angiography and perfusion tomography in diagnosing brain death: A systematic review. J Neuroradiol 2015; 43:133-40. [PMID: 26542968 DOI: 10.1016/j.neurad.2015.07.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/22/2015] [Accepted: 07/20/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Several complications make the diagnosis of brain death (BD) medically challenging and a complimentary method is needed for confirmation. In this context, computed tomography angiography (CTA) and computed tomography perfusion (CTP) could represent valuable alternatives; however, the reliability of CTA and CTP for confirming brain circulatory arrest remains unclear. METHODS A systematic review was performed to identify relevant studies regarding the use of CTA and CTP as ancillary tests for BD confirmation. RESULTS Three hundred twenty-two patients were eligible for the meta-analysis, which exhibited 87.5% sensitivity. CTA image evaluation protocol exhibited variations between medical institutions regarding which intracranial vessels should be considered to determine positive or negative test results. CONCLUSIONS For patients who were previously diagnosed with BD according to clinical criteria, CTA demonstrated high sensitivity to provide radiologic confirmation. The current evidence that supports the use of CTA in BD diagnosis is comparable to other methods applied worldwide.
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Affiliation(s)
- Sérgio Brasil
- University of São Paulo, School of Medicine, Hospital das Clínicas, Division of Neurological Surgery, São Paulo, Brazil.
| | - Edson Bor-Seng-Shu
- University of São Paulo, School of Medicine, Hospital das Clínicas, Division of Neurological Surgery, São Paulo, Brazil.
| | - Marcelo de-Lima-Oliveira
- University of São Paulo, School of Medicine, Hospital das Clínicas, Division of Neurological Surgery, São Paulo, Brazil
| | - Milena K Azevedo
- University of São Paulo, School of Medicine, Hospital das Clínicas, Division of Neurological Surgery, São Paulo, Brazil
| | - Manoel J Teixeira
- University of São Paulo, School of Medicine, Hospital das Clínicas, Division of Neurological Surgery, São Paulo, Brazil
| | - Luca Bernardo
- University of São Paulo, School of Medicine, São Paulo, Brazil
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Wojak JC, Abruzzo TA, Bello JA, Blackham KA, Hirsch JA, Jayaraman MV, Dariushnia SR, Meyers PM, Midia M, Russell EJ, Walker TG, Nikolic B. Quality Improvement Guidelines for Adult Diagnostic Cervicocerebral Angiography: Update Cooperative Study between the Society of Interventional Radiology (SIR), American Society of Neuroradiology (ASNR), and Society of NeuroInterventional Surgery (SNIS). J Vasc Interv Radiol 2015; 26:1596-608. [DOI: 10.1016/j.jvir.2015.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 07/07/2015] [Accepted: 07/07/2015] [Indexed: 12/19/2022] Open
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Markert L, Bockholdt B, Verhoff MA, Heinze S, Parzeller M. Renaissance of criticism on the concept of brain death--the role of legal medicine in the context of the interdisciplinary discussion. Int J Legal Med 2015; 130:587-95. [PMID: 26174445 DOI: 10.1007/s00414-015-1224-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 06/22/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND In the practice of legal medicine in Germany, the assessment of brain death is of minor importance and attracts little attention. However, since several years, international criticism on the concept of brain death has culminated. By reviewing literature and the results of a questionnaire distributed among the participants of the 93rd Annual Congress of the Germany Society of Legal Medicine, the state of knowledge and the current views on brain death were evaluated. MATERIALS AND METHODS Literature search of recent publications regarding brain death was performed (PubMed database, references of legal medicine, Report of the President's Council on Bioethics, USA 2008). A questionnaire was developed and distributed among the participants of the Congress. RESULTS The assumption that individual and brain death are synonymous is criticized. Internationally, there are trends to harmonize the very different clinical criteria to assess brain death. The diagnostic advantage of novel techniques such as CT angiography is controversially discussed. It becomes apparent that procedures which record the blood flow and perfusion of the brain will be applied more in the future. Regrettably, these developments are not described in the literature of legal medicine. Moreover, among German forensic scientists, different views concerning brain death exist. The majority favors its equivalent treatment with individual death. The thanatological background can be improved concerning certain aspects of brain death as well as its legal implications. CONCLUSION Teaching and research in legal medicine should include the subject brain death. Expertise in forensic science may contribute to the interdisciplinary discussion on brain death. The transfer of actual knowledge, also on disputed ethical aspects of thanatology, to physicians of all disciplines is of great importance.
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Affiliation(s)
- L Markert
- Institute of Legal Medicine, University Hospital, Goethe University of Frankfurt, Frankfurt, Germany.
| | - B Bockholdt
- Institute of Legal Medicine, Ernst Moritz Arndt University of Greifswald, University Medicine Greifswald, Greifswald, Germany
| | - M A Verhoff
- Institute of Legal Medicine, University Hospital, Goethe University of Frankfurt, Frankfurt, Germany
| | - S Heinze
- Institute of Legal Medicine, Johannes Gutenberg University of Mainz, Mainz, Germany.,Department of Radiology, St. Marienkrankenhaus, Ludwigshafen am Rhein, Germany
| | - M Parzeller
- Institute of Legal Medicine, University Hospital, Goethe University of Frankfurt, Frankfurt, Germany.
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Şahin H, Pekçevik Y. CT angiography as a confirmatory test in diagnosis of brain death: comparison between three scoring systems. Diagn Interv Radiol 2015; 21:177-83. [PMID: 25698093 PMCID: PMC4463321 DOI: 10.5152/dir.2014.14241] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Revised: 09/08/2014] [Accepted: 09/28/2014] [Indexed: 12/27/2022]
Abstract
PURPOSE Computed tomography (CT) angiography emerges as a viable alternative technique for confirmation of brain death. However, evaluation criteria are not well established for demonstration of cerebral circulatory arrest. This retrospective study aimed to evaluate CT angiography scoring systems in diagnosis of brain death, review the literature, and compare interobserver agreement between different scales for the diagnosis of brain death. METHODS CT angiography examinations of 25 patients with a clinical diagnosis of brain death were reevaluated according to 10-, 7-, and 4-point scales. Exams were performed with a 64-slice CT scanner including unenhanced, arterial (20 s) and venous phase (60 s) scans. Subtraction images of both phases were obtained. Interobserver agreement was evaluated for the assessment of vessel opacification and diagnosis of brain death. RESULTS According to 10-, 7-, and 4-point scales; 13, 16, and 22 of 25 patients had full score, respectively. Using the clinical exam as the reference standard, sensitivities obtained for 10-, 7-, and 4-point scales were 52%, 64%, and 88%, respectively. Percent agreement between readers was 100% for 10- and 7-point scales and 88% for 4-point scale. Percent agreement for opacification of scale vessels was equally high for all three scales (93.6%, 93.7%, 91% for 10-, 7-, and 4-point scales, respectively). CONCLUSION The 4-point scale appears to be more sensitive than the 10- and 7-point scales in CT angiography evaluation for brain death. Interobserver agreement is high for all three scales when subtraction images are used.
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Affiliation(s)
- Hilal Şahin
- From the Department of Radiology (H.Ş. ), Tepecik Training and Research Hospital, Izmir, Turkey
| | - Yeliz Pekçevik
- From the Department of Radiology (H.Ş. ), Tepecik Training and Research Hospital, Izmir, Turkey
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