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Suthar PP, Jhaveri MD, Kounsal A, Pierce LD, Singh JS. Role of Clinical and Multimodality Neuroimaging in the Evaluation of Brain Death/Death by Neurologic Criteria and Recent Highlights from 2023 Updated Guidelines. Diagnostics (Basel) 2024; 14:1287. [PMID: 38928702 PMCID: PMC11202462 DOI: 10.3390/diagnostics14121287] [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: 05/09/2024] [Revised: 06/04/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Purpose of Review: This review aims to provide a comprehensive overview of the diagnosis of brain death/death by neurologic criteria (BD/DNC) by emphasizing the clinical criteria established by the American Academy of Neurology (AAN) in light of their updated guidelines released in 2023. In this review, we will focus on the current implementation of ancillary tests including the catheter cerebral angiogram, nuclear scintigraphy, and transcranial Doppler, which provide support in diagnoses when clinical examination and apnea tests are inconclusive. Finally, we will also provide examples to discuss the implementation of certain imaging studies in the context of diagnosing BD/DNC. Recent Findings: Recent developments in the field of neurology have emphasized the importance of clinical criteria for diagnosing BD/DNC, with the AAN providing clear updated guidelines that include coma, apnea, and the absence of brainstem reflexes. Current ancillary tests, including the catheter cerebral angiogram, nuclear scintigraphy, and transcranial Doppler play a crucial role in confirming BD/DNC when the clinical assessment is limited. The role of commonly used imaging studies including computed tomography and magnetic resonance angiographies of the brain as well as CT/MR perfusion studies will also be discussed in the context of these new guidelines. Summary: BD/DNC represents the permanent cessation of brain functions, including the brainstem. This review article provides the historical context, clinical criteria, and pathophysiology that goes into making this diagnosis. Additionally, it explores the various ancillary tests and selected imaging studies that are currently used to diagnose BD/DNC under the newly updated AAN guidelines. Understanding the evolution of how to effectively use these diagnostic tools is crucial for healthcare professionals who encounter these BD/DNC cases in their practice.
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Affiliation(s)
- Pokhraj Prakashchandra Suthar
- Department of Diagnostic Radiology & Nuclear Medicine, Rush University Medical Center, Chicago, IL 60612, USA; (M.D.J.); (A.K.); (L.D.P.); (J.S.S.)
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McKinnon NK, Maratta C, Zuckier LS, Boyd JG, Chassé M, Hornby L, Kramer A, Kromm J, Mooney OT, Muthusami P, Nitulescu R, Park J, Slessarev M, Basmaji J. Ancillary investigations for death determination in infants and children: a systematic review and meta-analysis. Can J Anaesth 2023; 70:749-770. [PMID: 37131035 PMCID: PMC10203011 DOI: 10.1007/s12630-023-02418-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 05/04/2023] Open
Abstract
PURPOSE We performed a systematic review and meta-analysis to determine the diagnostic test accuracy of ancillary investigations for declaration of death by neurologic criteria (DNC) in infants and children. SOURCE We searched MEDLINE, EMBASE, Web of Science, and Cochrane databases from their inception to June 2021 for relevant randomized controlled trials, observational studies, and abstracts published in the last three years. We identified relevant studies using Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology and a two-stage review. We assessed the risk of bias using the QUADAS-2 tool, and applied Grading of Recommendations Assessment, Development, and Evaluation methodology to determine the certainty of evidence. A fixed-effects model was used to meta-analyze pooled sensitivity and specificity data for each ancillary investigation with at least two studies. PRINCIPAL FINDINGS Thirty-nine eligible manuscripts assessing 18 unique ancillary investigations (n = 866) were identified. The sensitivity and specificity ranged from 0.00 to 1.00 and 0.50 to 1.00, respectively. The quality of evidence was low to very low for all ancillary investigations, with the exception of radionuclide dynamic flow studies for which it was graded as moderate. Radionuclide scintigraphy using the lipophilic radiopharmaceutical 99mTc-hexamethylpropyleneamine oxime (HMPAO) with or without tomographic imaging were the most accurate ancillary investigations with a combined sensitivity of 0.99 (95% highest density interval [HDI], 0.89 to 1.00) and specificity of 0.97 (95% HDI, 0.65 to 1.00). CONCLUSION The ancillary investigation for DNC in infants and children with the greatest accuracy appears to be radionuclide scintigraphy using HMPAO with or without tomographic imaging; however, the certainty of the evidence is low. Nonimaging modalities performed at the bedside require further investigation. STUDY REGISTRATION PROSPERO (CRD42021278788); registered 16 October 2021.
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Affiliation(s)
- Nicole K McKinnon
- Department of Critical Care, The Hospital for Sick Children (SickKids), 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Neuroscience and Mental Health, Peter Gilgan Centre for Research and Learning, Toronto, ON, Canada.
| | - Christina Maratta
- Department of Critical Care, The Hospital for Sick Children (SickKids), 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lionel S Zuckier
- Division of Nuclear Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Departments of Medicine and Radiology, University of Ottawa, Ottawa, ON, Canada
| | - J Gordon Boyd
- Departments of Medicine (Neurology) and Critical Care Medicine, Kingston General Hospital, Kingston, ON, Canada
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Michaël Chassé
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Centre de Recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montreal, QC, Canada
| | | | - Andreas Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Julie Kromm
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Alberta Health Services, Calgary, AB, Canada
| | - Owen T Mooney
- Section of Critical Care, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Prakash Muthusami
- Department of Diagnostic Imaging, Hospital for Sick Children (SickKids), Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Roy Nitulescu
- Centre de Recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montreal, QC, Canada
| | - Jaewoo Park
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marat Slessarev
- Department of Medicine, Western University, London, ON, Canada
| | - John Basmaji
- Department of Medicine, Western University, London, ON, Canada
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Muacevic A, Adler JR, Amaniti E, Matamis D, Pourzitaki C. Relationships Between Resting Energy Expenditure and Transcranial Doppler Measurements in Patients With and Without Brain Death. Cureus 2022; 14:e32093. [PMID: 36601217 PMCID: PMC9804031 DOI: 10.7759/cureus.32093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction Brain metabolism deteriorates during brain death, suggesting that cerebral metabolic measurements could serve as a prognostic factor. The application of transcranial Doppler can be useful in evaluating patients evolving to brain death. Resting energy expenditure is lower than expected in patients with brain death, and this is caused by the decrease in cerebral blood flow and consequently lower oxygen supply. The primary aim of this retrospective study is to investigate the early metabolic changes in patients with clinical criteria of brain death and examine if these changes are related to a gradual decrease in blood flow velocities in the middle cerebral artery. Methods All consecutive patients from 1st June 2018 to 30th April 2022, admitted to the ICU with brain injury and a GCS ≤ 8, were included retrospectively in the study. Patients were allocated into two groups: Group A, patients without clinical signs of brain death (n = 32), and Group B, patients with brain death (n = 34). In each group, three sets of metabolic measurements were performed concomitantly with cerebral blood flow velocities using transcranial Doppler (a) upon admission to the ICU, (b) once hemodynamic stabilization was obtained, and (c) 48 hours after their hemodynamic stabilization or when brain death was confirmed by clinical criteria. Resting energy expenditure (REE) measurements were performed using a metabolic computer. Cerebral blood flow velocities were measured after a period of 30 min using a 2-MHZ 2D ultrasound probe. Results Brain-dead patients had a significant decrease in their metabolic parameters as the cerebral blood flow velocities recorded with the transcranial Doppler deteriorated, (REE Group A = 1667.65 ± 597 vs Group B = 1376.12 ± 615, p = 0.05 and REE predicted Group A = 113.19 ± 44.9 vs Group B = 93.29 ± 41.5, p = 0.066 for measurement 1; REE Group A = 1844 ± 530.9 vs Group B = 1219.97 ± 489, p < 0.001 and REE predicted Group A = 124.38 ± 39 vs Group B = 81.35 ± 30.4, p < 0.001 for measurement 2; REE Group A = 1750.97 ± 414, p < 0.001 and REE predicted Group A = 116.38 ± 19.2 vs Group B = 56.09 ± 19.6, p < 0.001 for measurement 3). Multiple stepwise regression analysis revealed a strong relationship between age, the worsening of the blood flow velocities pattern, and the decrease in REE (multiple R = 0.264, F = 5.55, p = 0.009). Furthermore, a statistically significant correlation was found between temperature and REE (correlation coefficient = 0.500, 0.674, 0.784 for measurements 1, 2, and 3, respectively, and p < 0.001 for all measures). Conclusions In brain-dead patients, the gradual decrease in cerebral blood flow leads to a decrease in REE as well as thermogenetic control. These changes can be detected early after the patient's admission to the ICU.
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Fainberg N, Mataya L, Kirschen M, Morrison W. Pediatric brain death certification: a narrative review. Transl Pediatr 2021; 10:2738-2748. [PMID: 34765497 PMCID: PMC8578760 DOI: 10.21037/tp-20-350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/05/2021] [Indexed: 11/30/2022] Open
Abstract
In the five decades since its inception, brain death has become an accepted medical and legal concept throughout most of the world. There was initial reluctance to apply brain death criteria to children as they are believed more likely to regain neurologic function following injury. In spite of early trepidation, criteria for pediatric brain death certification were first proposed in 1987 by a multidisciplinary committee comprised of experts in the medical and legal communities. Protocols have since been developed to standardize brain death determination, but there remains substantial variability in practice throughout the world. In addition, brain death remains a topic of considerable ethical, philosophical, and legal controversy, and is often misrepresented in the media. In the present article, we discuss the history of brain death and the guidelines for its determination. We provide an overview of past and present challenges to its concept and diagnosis from biophilosophical, ethical and legal perspectives, and highlight differences between adult and pediatric brain death determination. We conclude by anticipating future directions for brain death as related to the emergence of new technologies. It is our position that providers should endorse the criteria for brain death diagnosis in children as proposed by the Society of Critical Care Medicine (SCCM), American Academy of Pediatrics (AAP), and Child Neurology Society (CNS), in order to prevent controversy and subjectivity surrounding what constitutes life versus death.
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Affiliation(s)
- Nina Fainberg
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leslie Mataya
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew Kirschen
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, USA
| | - Wynne Morrison
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, USA
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Millet A, Evain JN, Desrumaux A, Francony G, Bouzat P, Mortamet G. Clinical applications of transcranial Doppler in non-trauma critically ill children: a scoping review. Childs Nerv Syst 2021; 37:2759-2768. [PMID: 34244843 DOI: 10.1007/s00381-021-05282-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/29/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Many applications of transcranial Doppler (TCD) as a diagnosis or monitoring tool have raised interest in the last decades. It is important that clinicians know when and how to perform TCD in this population, what parameter to assess and monitor and how to interpret it. OBJECTIVE This review aims to describe the emerging clinical applications of TCD in critically ill children excluding those suffering from trauma. METHODS Databases Web of Science, Cochrane and PubMed were searched in May 2020. We considered all publications since the year 2000 addressing the use of TCD as a prognostic, diagnostic or follow-up tool in children aged 0 to 15 years admitted to intensive care or emergency units, excluding neonatology and traumatic brain injury. Two independent reviewers selected 82 abstracts and full-text articles from the 2011 unique citations identified at the outset. RESULTS TCD provides crucial additional information at bedside about cerebrovascular hemodynamics. Many clinical applications include the diagnosis and management of various medical and surgical neurologic conditions (central nervous system infections, arterial ischemic stroke, subarachnoid hemorrhage and vasospasm, brain death, seizures, metabolic disease, hydrocephalus) as well as monitoring the impact systemic conditions on brain perfusion (hemodynamic instability, circulatory assistance). CONCLUSION To conclude, TCD has become an invaluable asset for non-invasive neuromonitoring in critically ill children excluding those suffering from trauma. However, the scope of TCD remains unclearly defined yet and reference values in critically ill children are still lacking.
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Affiliation(s)
- Anne Millet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Jean-Noël Evain
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - Amélie Desrumaux
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Gilles Francony
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - Pierre Bouzat
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France.
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Transcranial Doppler: A Useful Tool to Predict Brain Death Still Not Confirmed by Clinical Assessment. Transplant Proc 2021; 53:1803-1807. [PMID: 33962775 DOI: 10.1016/j.transproceed.2021.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/10/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Diagnosing brain death (BD) with accuracy and urgency is of great importance because an early diagnosis may guide the clinical management, optimize hospital beds, and facilitate organ transplantation. The clinical diagnosis of nonreactive and irreversible coma can be confirmed with additional tests. Among the complimentary exams that may testify brain circulatory arrest, transcranial Doppler (TCD) can be an option. It is a real-time, bedside, inexpensive, noninvasive method that assesses cerebral blood flow. In patients with suspected BD, especially those who are under sedative drugs, early diagnosis is imperative. The aim of the present study was to evaluate the role of TCD in predicting BD. METHODS One hundred consecutive comatose patients with a Glasgow Coma Scale score of less than 5, owing to different etiologies, were included. TCD was performed in all patients. The TCD operator was blinded for clinical and neurologic data. This study is in compliance with the Declaration of Helsinki. RESULTS Sixty-nine patients with TCD-brain circulatory collapse were diagnosed later with BD. Of the 31 patients with brain circulatory activity, 8 (25.8%) were clinically brain dead and 23 (74.2%) were alive. TCD showing brain circulatory collapse had a sensitivity of 89.6%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 74.2%. CONCLUSION TCD is highly specific (100%) and sensitive (89.6%) as a method to confirm the clinical diagnosis of BD, even in patients under sedation. The possibility of patients presenting with cerebral circulatory activity and clinical diagnosis of BD was demonstrated to occur.
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Yildizdas D, Aslan N. Is Ocular Sonography a Reliable Method for the Assessment of Elevated Intracranial Pressure in Children? J Pediatr Intensive Care 2021; 10:14-22. [PMID: 33585057 DOI: 10.1055/s-0040-1716385] [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: 05/07/2020] [Accepted: 05/21/2020] [Indexed: 10/23/2022] Open
Abstract
Point-of-care ultrasound has been widely used by clinicians at the bedside in recent years. Various types of point-of-care ultrasound practices are employed, especially in pediatric emergency rooms and intensive care units. Pediatric intensive care specialists perform point-of-care ultrasound virtually as a part of physical examination since it provides just-in-time vital clinical information, which could assist in acute management strategies in critically ill patients. Measurement of optic nerve sheath diameter using point-of-care ultrasound is a noninvasive and radiation-free technique to determine raised intracranial pressure. Ophthalmic artery and central retinal artery Doppler indices can be used as transcranial Doppler to assess raised intracranial pressure. The aim of this review was to provide detailed information on ultrasonographic measurements of optic nerve sheath diameter and central retinal artery Doppler indices as techniques of interest for predicting increased intracranial pressure in pediatric patients in view of the literature.
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Affiliation(s)
- Dincer Yildizdas
- Department of Pediatric Intensive Care, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Nagehan Aslan
- Department of Pediatric Intensive Care, Faculty of Medicine, Cukurova University, Adana, Turkey
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Blanco P, Menéndez MF, Figueroa L. Reverberating flow pattern in the central retinal artery in cerebral circulatory arrest. Neurology 2020; 94:276-277. [DOI: 10.1212/wnl.0000000000008918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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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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Hwang M, Riggs BJ, Katz J, Seyfert D, Northington F, Shenandoah R, Burd I, McArthur J, Darge K, Thimm MA, Huisman TAGM. Advanced Pediatric Neurosonography Techniques: Contrast-Enhanced Ultrasonography, Elastography, and Beyond. J Neuroimaging 2017; 28:150-157. [PMID: 29280236 DOI: 10.1111/jon.12492] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 11/12/2017] [Accepted: 11/15/2017] [Indexed: 12/29/2022] Open
Abstract
Recent technical advances in neurosonography continue broadening the diagnostic utility, sensitivity, and specificity of ultrasound for detecting intracranial abnormalities bed side. The clinical and functional applications of neurosonography have significantly expanded since the 1980s when transcranial Doppler sonography first allowed anatomic and hemodynamic delineation of the intracranial vessels through the thin temporal skull. In the past few years, contrast-enhanced ultrasonography, elastography, 3D/4D reconstruction tools, and high-resolution microvessel imaging techniques have further enhanced the diagnostic significance of neurosonography. Given these advances, a thorough familiarity with these new techniques and devices is crucial for a successful clinical application allowing improved patient care. It is essential that future neurosonography studies compare these advanced techniques against the current "gold standard" computed tomography and magnetic resonance imaging to assure the accuracy of their diagnostic potential. This review will provide a comprehensive update on currently available advanced neurosonography techniques.
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Affiliation(s)
- Misun Hwang
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD
| | - Becky J Riggs
- Division of Pediatric Anesthesiology and Critical Care Medicine, Charlotte Bloomberg Children's Center, Johns Hopkins Hospital, Baltimore, MD
| | - Joseph Katz
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD
| | - Donna Seyfert
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD
| | | | - Robinson Shenandoah
- Division of Pediatric Neurology and Neurological Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Irina Burd
- Division of Maternal Fetal Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Justin McArthur
- Division of Neurology and Neurological Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Kassa Darge
- Division of Pediatric Radiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Thierry A G M Huisman
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD
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Gui T, Peng P, Liu X, Jin L, Chen W. Clinical and ultrasound parameters in prediction of excessive hemorrhage during management of cesarean scar pregnancy. Ther Clin Risk Manag 2017; 13:807-812. [PMID: 28721061 PMCID: PMC5501626 DOI: 10.2147/tcrm.s139682] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PRECIS During the management of cesarean scar pregnancy, gestational mass size >6 cm, uterine scar thickness <0.2 cm, peak systolic velocity >70 cm/s, and resistance index <0.35 are independent risk factors for excessive hemorrhage. OBJECTIVE The objective of this study was to investigate risk factors associated with excessive hemorrhage during the management of cesarean scar pregnancy (CSP). PATIENTS AND METHODS A retrospective case-control study was conducted, including 40 patients who experienced excessive bleeding and 80 controls without severe hemorrhage. RESULTS Six parameters (two clinical and four ultrasound parameters) potentially related to excessive hemorrhage were analyzed. Single-variable statistical analyses showed that the case group had higher gestational age (74.1±23.6 days), higher pretreatment serum β-human chorionic gonadotropin (HCG) level (46,201±32,294 mIU/mL), larger gestational mass size (6.5±2.2 cm), thinner uterine scar thickness (0.17±0.12 cm), and richer peritrophoblastic perfusion (peak systolic velocity [PSV] 72.8±33.7 cm/s, resistance index [RI] 0.35±0.12), showing statistical significance compared with the control group. Further multivariable logistic regression analysis of the association between each of the risk factors and hemorrhage confirmed that increased gestational mass size and PSV were risk factors for hemorrhage (odds ratio [OR] 3.624, 95% confidence interval [CI] [1.179-11.138] and OR 1.062, 95% CI [1.007-1.121]) and increased uterine scar thickness and RI were protective factors against hemorrhage (OR 0.181, 95% CI [0.034-0.957] and OR 0.851, 95% CI [0.729-0.994]); however, there was no statistical significance between the two clinical parameters. CONCLUSION Gestational mass size >6 cm, uterine scar thickness <0.2 cm, PSV >70 cm/s, and RI <0.35 are independent risk factors for excessive hemorrhage during the management of CSP.
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Affiliation(s)
- Ting Gui
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Ping Peng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xinyan Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Li Jin
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Weilin Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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To See or Not to See: Ultrasound as an Ancillary Study to Determine Brain Death. Pediatr Crit Care Med 2017; 18:284-285. [PMID: 28257369 DOI: 10.1097/pcc.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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