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Deana C, Biasucci DG, Aspide R, Brasil S, Vergano M, Leonardis F, Rica E, Cammarota G, Dauri M, Vetrugno G, Longhini F, Maggiore SM, Rasulo F, Vetrugno L. Transcranial Doppler and Color-Coded Doppler Use for Brain Death Determination in Adult Patients: A Pictorial Essay. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:979-992. [PMID: 38279568 DOI: 10.1002/jum.16421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 01/28/2024]
Abstract
Transcranial Doppler (TCD) is a repeatable, at-the-bedside, helpful tool for confirming cerebral circulatory arrest (CCA). Despite its variable accuracy, TCD is increasingly used during brain death determination, and it is considered among the optional ancillary tests in several countries. Among its limitations, the need for skilled operators with appropriate knowledge of typical CCA patterns and the lack of adequate acoustic bone windows for intracranial arteries assessment are critical. The purpose of this review is to describe how to evaluate cerebral circulatory arrest in the intensive care unit with TCD and transcranial duplex color-coded doppler (TCCD).
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Affiliation(s)
- Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Daniele G Biasucci
- Department of Clinical Science and Translational Medicine, "Tor Vergata" University, Rome, Italy
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
- Catholic University of the Sacred Heart (UCSC), Rome, Italy
| | - Raffaele Aspide
- Anesthesia and Neurointensive Care Unit, Istituto delle Scienze Neurologiche IRCCS, Bologna, Italy
| | - Sergio Brasil
- Neurosurgical Division, Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Francesca Leonardis
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
- Department of Surgical Science, "Tor Vergata" University, Rome, Italy
| | - Ermal Rica
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Gianmaria Cammarota
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, "Tor Vergata" University, Rome, Italy
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
| | - Giuseppe Vetrugno
- Catholic University of the Sacred Heart (UCSC), Rome, Italy
- Risk Management, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Salvatore Maurizio Maggiore
- Department of Innovative Technologies in Medicine & Dentistry, Section of Anesthesia and Intensive Care, "G. D'Annunzio" University, "SS. Annunziata" Hospital, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, "SS. Annunziata" Hospital, Chieti, Italy
| | - Frank Rasulo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency, "SS. Annunziata" Hospital, Chieti, Italy
- Department of Medical, Oral and Biotechnological Science, "G. d'Annunzio" Chieti-Pescara University, Chieti, Italy
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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 PMCID: PMC11235910 DOI: 10.1111/ene.16209] [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] [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 NeurologyAlexianer St. Josefs HospitalPotsdamGermany
- Medizinische Hochschule Brandenburg Theodor FontaneNeuruppinGermany
| | - Farid Salih
- Department of Neurology and Experimental NeurologyCharité‐Universitätsmedizin BerlinBerlinGermany
| | - Florian Masuhr
- Klinik für NeurologieBundeswehrkrankenhaus BerlinBerlinGermany
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Viski S, Olah L. Use of Transcranial Doppler in Intensive Care Unit. ACTA ACUST UNITED AC 2017; 3:99-104. [PMID: 29967879 PMCID: PMC5769900 DOI: 10.1515/jccm-2017-0021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 07/21/2017] [Indexed: 11/25/2022]
Abstract
Use of transcranial Doppler has undergone much development since its introduction in 1982, making the technique suitable for general use in intensive care units. The main application in intensive care units is to assess intracranial pressure, confirm the lack of cerebral circulation in brain death, detect vasospasm in subarachnoid haemorrhage, and monitor the blood flow parameters during thrombolysis and carotid endarterectomy, as well as measuring stenosis of the main intracranial arteries in sickle cell disease in children. This review summarises the use of transcranial Doppler in intensive care units.
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Affiliation(s)
- Sandor Viski
- Department of Family and Occupational Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Laszlo Olah
- Department of Neurology, University of Debrecen, Móricz Zs. krt. 22, H-4032, Debrecen, Hungary
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Obeidat N, Sallout B, Albaqawi B, Al AlAali W. The impact of fetal middle cerebral artery Doppler on the outcome of congenital hydrocephalus. J Matern Fetal Neonatal Med 2017; 31:413-417. [DOI: 10.1080/14767058.2017.1286318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Nail Obeidat
- Department of Obstetrics and Gynecology, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
- Department of Fetal Medicine and Ultrasound, Women’s’ Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Bahauddin Sallout
- Department of Fetal Medicine and Ultrasound, Women’s’ Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Badi Albaqawi
- Department of Fetal Medicine and Ultrasound, Women’s’ Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Wajeih Al AlAali
- Department of Fetal Medicine and Ultrasound, Women’s’ Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
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Chang JJ, Tsivgoulis G, Katsanos AH, Malkoff MD, Alexandrov AV. Diagnostic Accuracy of Transcranial Doppler for Brain Death Confirmation: Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2016; 37:408-14. [PMID: 26514611 DOI: 10.3174/ajnr.a4548] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/11/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Transcranial Doppler is a useful ancillary test for brain death confirmation because it is safe, noninvasive, and done at the bedside. Transcranial Doppler confirms brain death by evaluating cerebral circulatory arrest. Case series studies have generally reported good correlations between transcranial Doppler confirmation of cerebral circulatory arrest and clinical confirmation of brain death. The purpose of this study is to evaluate the utility of transcranial Doppler as an ancillary test in brain death confirmation. MATERIALS AND METHODS We conducted a systematic review of the literature and a diagnostic test accuracy meta-analysis to compare the sensitivity and specificity of transcranial Doppler confirmation of cerebral circulatory arrest, by using clinical confirmation of brain death as the criterion standard. RESULTS We identified 22 eligible studies (1671 patients total), dating from 1987 to 2014. Pooled sensitivity and specificity estimates from 12 study protocols that reported data for the calculation of both values were 0.90 (95% CI, 0.87-0.92) and 0.98 (95% CI, 0.96-0.99), respectively. Between-study differences in the diagnostic performance of transcranial Doppler were found for both sensitivity (I(2) = 76%; P < .001) and specificity (I(2) = 74.3%; P < .001). The threshold effect was not significant (Spearman r = -0.173; P = .612). The area under the curve with the corresponding standard error (SE) was 0.964 ± 0.018, while index Q test ± SE was estimated at 0.910 ± 0.028. CONCLUSIONS The results of this meta-analysis suggest that transcranial Doppler is a highly accurate ancillary test for brain death confirmation. However, transcranial Doppler evaluates cerebral circulatory arrest rather than brain stem function, and this limitation needs to be taken into account when interpreting the results of this meta-analysis.
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Affiliation(s)
- J J Chang
- From the Department of Neurology (J.J.C., G.T., M.D.M., A.V.A.), University of Tennessee Health Science Center, Memphis, Tennessee
| | - G Tsivgoulis
- From the Department of Neurology (J.J.C., G.T., M.D.M., A.V.A.), University of Tennessee Health Science Center, Memphis, Tennessee Second Department of Neurology (G.T., A.H.K.), Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - A H Katsanos
- Second Department of Neurology (G.T., A.H.K.), Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece Department of Neurology (A.H.K.), University of Ioannina, School of Medicine, Ioannina, Epirus, Greece
| | - M D Malkoff
- From the Department of Neurology (J.J.C., G.T., M.D.M., A.V.A.), University of Tennessee Health Science Center, Memphis, Tennessee
| | - A V Alexandrov
- From the Department of Neurology (J.J.C., G.T., M.D.M., A.V.A.), University of Tennessee Health Science Center, Memphis, Tennessee
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Lange MC, Zétola VHF, Miranda-Alves M, Moro CHC, Silvado CE, Rodrigues DLG, Gregorio EGD, Silva GS, Oliveira-Filho J, Perdatella MTA, Pontes-Neto OM, Fábio SRC, Avelar WM, Freitas GRD. Brazilian guidelines for the application of transcranial ultrasound as a diagnostic test for the confirmation of brain death. ARQUIVOS DE NEURO-PSIQUIATRIA 2012; 70:373-80. [PMID: 22618790 DOI: 10.1590/s0004-282x2012000500012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 01/05/2012] [Indexed: 11/22/2022]
Abstract
Neurosonological studies, specifically transcranial Doppler (TCD) and transcranial color-coded duplex (TCCD), have high level of specificity and sensitivity and they are used as complementary tests for the diagnosis of brain death (BD). A group of experts, from the Neurosonology Department of the Brazilian Academy of Neurology, created a task force to determine the criteria for the following aspects of diagnosing BD in Brazil: the reliability of TCD methodology; the reliability of TCCD methodology; neurosonology training and skills; the diagnosis of encephalic circulatory arrest; and exam documentation for BD. The results of this meeting are presented in the current paper.
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Affiliation(s)
- Marcos C Lange
- Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
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Conti A, Iacopino DG, Spada A, Cardali SM, Giusa M, La Torre D, Campennì A, Penna O, Baldari S, Tomasello F. Transcranial Doppler ultrasonography in the assessment of cerebral circulation arrest: improving sensitivity by transcervical and transorbital carotid insonation and serial examinations. Neurocrit Care 2009; 10:326-35. [PMID: 19238589 DOI: 10.1007/s12028-009-9199-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2008] [Accepted: 01/29/2009] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Transcranial Doppler (TCD) can detect the cerebral circulation arrest (CCA) in brain death. TCD is highly specific, but less sensitive because of false-negatives accounting for up to 10%. The aim of the study was to explore the diagnostic accuracy of TCD and to determine whether it can be augmented by strategies such as the insonation of the extracranial internal carotid artery (ICA) and sequential examinations. METHODS Data of 184 patients, who met clinical criteria of brain death, observed from 1998 through 2006, were retrospectively reviewed. The study of cerebral arteries was performed through the transtemporal approach, suboccipital insonation of the vertebro-basilar system, transorbital insonation of the ICA and ophthalmic artery, and transcervical insonation of the extracranial ICA. Repeated exams were performed in cases of persistent diastolic flow. RESULTS The specificity of the testing was 100%, no false-positive cases were recorded. The sensitivity of conventional TCD examination was 82.1%. The insonation of the extracranial ICA increased sensitivity to 88% allowing the detection of CCA in those patients lacking temporal windows; serial examinations further increased sensitivity to 95.6%. CONCLUSIONS The addition of insonation of the cervical ICA and of the siphon increased sensitivity of TCD. Nevertheless, a CCA flow patterns may appear later on those segments. Serial examinations, may be needed in those cases.
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Affiliation(s)
- Alfredo Conti
- Department of Neurosurgery, University of Messina, Policlinico Universitario, Via Consolare Valeria 1, 98125, Messina, Italy.
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de Freitas GR, André C. Sensitivity of transcranial Doppler for confirming brain death: a prospective study of 270 cases. Acta Neurol Scand 2006; 113:426-32. [PMID: 16674610 DOI: 10.1111/j.1600-0404.2006.00645.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The reported sensitivity of transcranial Doppler ultrasonography (TCD) for confirming brain death (BD) ranges from 91% to 100%. We assessed the frequency and causes of false-negative results in TCD examination in a series of patients with BD and in the literature. METHODS We carried out a prospective TCD examination of consecutive patients with the clinical diagnosis of BD. RESULTS In 204 (75.5%) of 270 patients, TCD showed a pattern compatible with BD. The causes of the false-negative results were persistent flow in the intracranial arteries in 47 (17.4%) patients and a lack of signal in 19 (7%). Absence of sympathomimetic drug use [odds ratio (OR) 5.4, 95% confidence interval (CI) 1.8-16.0, P = 0.003) and female gender (OR 3.7, 95% CI 1.1-12.5, P = 0.03) were associated with false-negative results. A review of 16 studies showed a sensitivity of 88% and a specificity of 98% of TCD for confirming BD. CONCLUSIONS The sensitivity of TCD for confirming BD may be lower than previously reported, but is probably similar to that of other non-invasive methods. The specificity of TCD is close to 100%. Uniform criteria are needed for the routine use of TCD as a confirmatory test for BD.
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Affiliation(s)
- G R de Freitas
- Department of Neurology, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
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White H, Venkatesh B. Applications of transcranial Doppler in the ICU: a review. Intensive Care Med 2006; 32:981-94. [PMID: 16791661 DOI: 10.1007/s00134-006-0173-y] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2005] [Accepted: 03/16/2006] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Transcranial Doppler (TCD) ultrasonography is a technique that uses a hand-held Doppler transducer (placed on the surface of the cranial skin) to measure the velocity and pulsatility of blood flow within the intracranial and the extracranial arteries. This review critically evaluates the evidence for the use of TCD in the critical care population. DISCUSSION TCD has been frequently employed for the clinical evaluation of cerebral vasospasm following subarachnoid haemorrhage (SAH). To a lesser degree, TCD has also been used to evaluate cerebral autoregulatory capacity, monitor cerebral circulation during cardiopulmonary bypass and carotid endarterectomies and to diagnose brain death. Technological advances such as M mode, colour Doppler and three-dimensional power Doppler ultrasonography have extended the scope of TCD to include other non-critical care applications including assessment of cerebral emboli, functional TCD and the management of sickle cell disease. CONCLUSIONS Despite publications suggesting concordance between TCD velocity measurements and cerebral blood flow there are few randomized controlled studies demonstrating an improved outcome with the use of TCD monitoring in neurocritical care. Newer developments in this technology include venous Doppler, functional Doppler and use of ultrasound contrast agents.
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Affiliation(s)
- Hayden White
- Queen Elizabeth II Hospital, Department of Anaesthesia, Coopers Plains, QLD, Australia
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