1
|
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.
Collapse
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
| |
Collapse
|
2
|
Farg H, Elnakib A, Gebreil A, Alksas A, van Bogaert E, Mahmoud A, Khalil A, Ghazal M, Abou El-Ghar M, El-Baz A, Contractor S. Diagnostic value of PET imaging in clinically unresponsive patients. Br J Radiol 2024; 97:283-291. [PMID: 38308033 DOI: 10.1093/bjr/tqad040] [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: 01/18/2023] [Revised: 07/27/2023] [Accepted: 11/21/2023] [Indexed: 02/04/2024] Open
Abstract
Rapid advancements in the critical care management of acute brain injuries have facilitated the survival of numerous patients who may have otherwise succumbed to their injuries. The probability of conscious recovery hinges on the extent of structural brain damage and the level of metabolic and functional cerebral impairment, which remain challenging to assess via laboratory, clinical, or functional tests. Current research settings and guidelines highlight the potential value of fluorodeoxyglucose-PET (FDG-PET) for diagnostic and prognostic purposes, emphasizing its capacity to consistently illustrate a metabolic reduction in cerebral glucose uptake across various disorders of consciousness. Crucially, FDG-PET might be a pivotal tool for differentiating between patients in the minimally conscious state and those in the unresponsive wakefulness syndrome, a persistent clinical challenge. In patients with disorders of consciousness, PET offers utility in evaluating the degree and spread of functional disruption, as well as identifying irreversible neural damage. Further, studies that capture responses to external stimuli can shed light on residual or revived brain functioning. Nevertheless, the validity of these findings in predicting clinical outcomes calls for additional long-term studies with larger patient cohorts suffering from consciousness impairment. Misdiagnosis of conscious illnesses during bedside clinical assessments remains a significant concern. Based on the clinical research settings, current clinical guidelines recommend PET for diagnostic and/or prognostic purposes. This review article discusses the clinical categories of conscious disorders and the diagnostic and prognostic value of PET imaging in clinically unresponsive patients, considering the known limitations of PET imaging in such contexts.
Collapse
Affiliation(s)
- Hashim Farg
- Radiology Department, Urology and Nephrology Center, Mansoura University, 35516 Mansoura, Egypt
| | - Ahmed Elnakib
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Ahmad Gebreil
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Ahmed Alksas
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Eric van Bogaert
- Department of Radiology, University of Louisville, Louisville, KY 40202, United States
| | - Ali Mahmoud
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Ashraf Khalil
- College of Technological Innovation, Zayed University, Abu Dhabi 4783, United Arab Emirates
| | - Mohammed Ghazal
- Electrical, Computer, and Biomedical Engineering Department, Abu Dhabi University, Abu Dhabi 59911, United Arab Emirates
| | - Mohamed Abou El-Ghar
- Radiology Department, Urology and Nephrology Center, Mansoura University, 35516 Mansoura, Egypt
| | - Ayman El-Baz
- BioImaging Lab, Bioengineering Department, University of Louisville, Louisville, KY 40292, United States
| | - Sohail Contractor
- Department of Radiology, University of Louisville, Louisville, KY 40202, United States
| |
Collapse
|
3
|
Alcock S, Singh S, Wiens EJ, Singh N, Ande SR, Lampron K, Huang B, Kirkpatrick I, Trivedi A, Schaffer SA, Shankar JS. CT perfusion for Assessment of poor Neurological outcome in Comatose Cardiac Arrest Patients (CANCCAP): protocol for a prospective study. BMJ Open 2023; 13:e071166. [PMID: 37270194 DOI: 10.1136/bmjopen-2022-071166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
INTRODUCTION Cardiac arrest remains one of the most common causes of death with the majority occurring outside of hospitals (out of hospital cardiac arrest). Despite advancements in resuscitation management, approximately 50% of comatose cardiac arrest patients (CCAP) will suffer a severe unsurvivable brain injury. To assess brain injury, a neurological examination is conducted, however, its reliability in predicting outcomes in the first days following cardiac arrest is limited. Non-contrast CT is the most employed scan to assess hypoxic changes, even though it is not sensitive to early hypoxic-ischaemic changes in the brain. CT perfusion (CTP) has shown high sensitivity and specificity in brain death patients, although its use in predicting poor neurological outcome in CCAP has not yet been explored. The purpose of this study is to validate CTP for predicting poor neurological outcome (modified Rankin scale, mRS≥4) at hospital discharge in CCAP. METHODS AND ANALYSIS The CT Perfusion for Assessment of poor Neurological outcome in Comatose Cardiac Arrest Patients study is a prospective cohort study funded by the Manitoba Medical Research Foundation. Newly admitted CCAP receiving standard Targeted Temperature Management are eligible. Patients undergo a CTP at the same time as the admission standard of care head CT. Admission CTP findings will be compared with the reference standard of an accepted bedside clinical assessment at the time of admission. Deferred consent will be used. The primary outcome is a binary outcome of good neurological status, defined as mRs<4 or poor neurological status (mRs≥4) at hospital discharge. A total of 90 patients will be enrolled. 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 at the end of the study. TRIAL REGISTRATION NUMBER NCT04323020.
Collapse
Affiliation(s)
- Susan Alcock
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sarbjeet Singh
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Evan J Wiens
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Navjit Singh
- University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Sudharsana Rao Ande
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kristen Lampron
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Beili Huang
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Iain Kirkpatrick
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anurag Trivedi
- Section of Neurology, Department of Internal Medicine, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Stephen Allan Schaffer
- Sections of Cardiology and Critical Care Medicine, Department of Internal Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Jai Shiva Shankar
- Department of Radiology, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| |
Collapse
|
4
|
Goubran D, Batoo D, Linton J, Shankar J. Initial CT Imaging Predicts Mortality in Severe Traumatic Brain Injuries in Pediatric Population-A Systematic Review and Meta-Analysis. Tomography 2023; 9:541-551. [PMID: 36961003 PMCID: PMC10037655 DOI: 10.3390/tomography9020044] [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: 01/12/2023] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 03/04/2023] Open
Abstract
The purpose of this systematic review was to analyze evidence based on existing studies on the ability of initial CT imaging to predict mortality in severe traumatic brain injuries (TBIs) in pediatric patients. An experienced librarian searched for all existing studies based on the inclusion and exclusion criteria. The studies were screened by two blinded reviewers. Of the 3277 studies included in the search, data on prevalence of imaging findings and mortality rate could only be extracted from 22 studies. A few of those studies had patient-specific data relating specific imaging findings to outcome, allowing the data analysis, calculation of the area under the curve (AUC) and receiver operating characteristic (ROC), and generation of a forest plot for each finding. The data were extracted to calculate the sensitivity (SN), specificity (SP), positive predictive value (PPV), negative predicted value (NPV), AUC, and ROC for extradural hematoma (EDH), subdural hematoma (SDH), traumatic subarachnoid hemorrhage (tSAH), skull fractures, and edema. There were a total of 2219 patients, 747 females and 1461 males. Of the total, 564 patients died and 1651 survived; 293 patients had SDH, 76 had EDH, 347 had tSAH, 244 had skull fractures, and 416 had edema. The studies included had high bias and lower grade of evidence. Out of the different CT scan findings, brain edema had the highest SN, PPV, NPV, and AUC. EDH had the highest SP to predict in-hospital mortality.
Collapse
Affiliation(s)
- Doris Goubran
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Divjeet Batoo
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Janice Linton
- Indigenous Health Liaison Librarian, Neil John Maclean Health Sciences Library, Winnipeg, MB R3E 3P5, Canada
| | - Jai Shankar
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University Of Manitoba, Winnipeg, MB R3E 0W2, Canada
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada
| |
Collapse
|
5
|
Plourde G, Briard JN, Shemie SD, Shankar JJS, Chassé M. In reply: Mistaken concepts on the use of ancillary testing in brain death diagnosis. Can J Anaesth 2022; 69:407-408. [PMID: 34970726 DOI: 10.1007/s12630-021-02186-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Guillaume Plourde
- Division of Critical Care, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Joel Neves Briard
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
| | - Sam D Shemie
- Division of Critical Care, Montreal Children's Hospital, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Deceased Organ Donation, Canadian Blood Services, Ottawa, ON, Canada
| | | | - Michaël Chassé
- Division of Critical Care, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.
- Centre de recherche du CHUM, Université de Montréal, Montreal, QC, Canada.
| |
Collapse
|
6
|
Sarkulova Z, Tokshilykova A, Khamidulla A, Utepkaliyeva A, Ayaganov D, Sarkulov M, Tamosuitis T. Establishing prognostic significance of hypoxia predictors in patients with acute cerebral pathology. Neurol Res 2021; 44:362-370. [PMID: 34758699 DOI: 10.1080/01616412.2021.1996981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES This research aims to study the prognostic role of serum S100 as a predictor of mortality in vascular and traumatic brain injuries. METHODS This prospective cohort study involved 219 patients. In the blood serum, neuron-specific markers (S100, NSE) and glucose, acid-base state and gas composition of arterial blood were obtained at admission, on the 3rd, 5th and 7th days of patients' stay in the intensive care unit. RESULTS The most significant risk factor for an unfavorable outcome is the marker S100 with a cut-off point of 0.2 mcg/l. The analysis results indicate a statistically significant direct relationship between S100 > 0.2 mcg/l and NSE ≥ 18.9 ng/ml compared to other variables, while the chance ratio (OR) is 11.9 (95%CI:3.2927-1.6693;). With blood sugar increase above 7.4 mmol/l, the OR is 3.82 (95% CI: 2.1289-0.5539;); with a Glasgow scale below 13 points, the OR is 3.69 (95% CI: 2.1316-0.4819;); with an increase in pCO2 < 43.5 mm Hg, the OR was 3.15 (95% CI: 1.8916- 0.4062;). The obtained model certainty measure according to pseudo R2 Nagelkerke criterion is 263.5, showing the excellent quality of the mathematical model's predictive ability. The developed prognostic model, including the dependent variable S100 and independent variables as predictors of a poor outcome of NSE, pCO2, GCS and Hb, reached a cut-off point of 84.51%, AUC - 0.88 with high levels of sensitivity and specificity: 91.89% and 64.14%, respectively. NOVELTY This model can be used to predict the outcome in patients with acute cerebral pathology.
Collapse
Affiliation(s)
- Zhanslu Sarkulova
- Department of Anesthesiology and Resuscitation, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Ainur Tokshilykova
- Department of Anesthesiology and Resuscitation, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Alima Khamidulla
- Neurology Department, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Aigul Utepkaliyeva
- Neurology Department, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Dinmukhamed Ayaganov
- Department of Neurology, a Course in Psychiatry and Narcology Department, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Marat Sarkulov
- Urology Department, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Tomas Tamosuitis
- Neurosurgery Intensive Care Unit Neurosurgery Department, Organ Procurement Program of the Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
| |
Collapse
|
7
|
Shankar JJS. Variation in CT perfusion protocol has implications on defining irreversibly damaged ischemic brain parenchyma. Eur Radiol 2021; 31:8315-8316. [PMID: 34338843 DOI: 10.1007/s00330-021-08209-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 06/29/2021] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
KEY POINTS • Computed tomographic perfusion (CTP) is increasingly being used in the characterization of brain ischemia.• Variations in post-processing protocols continue to be a challenge, resulting in a slight variation of CTP results.• We need to adopt a universal acquisition protocol to help optimize output of CTP.
Collapse
Affiliation(s)
- Jai Jai Shiva Shankar
- Rady Faculty of Health Sciences, Radiology Department, University of Manitoba, GA216-820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
| |
Collapse
|
8
|
Treating Traumatic Brain Injuries with Electroceuticals: Implications for the Neuroanatomy of Consciousness. NEUROSCI 2021. [DOI: 10.3390/neurosci2030018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
According to the Centers for Disease Control and Prevention (CDC), traumatic brain injury (TBI) is the leading cause of loss of consciousness, long-term disability, and death in children and young adults (age 1 to 44). Currently, there are no United States Food and Drug Administration (FDA) approved pharmacological treatments for post-TBI regeneration and recovery, particularly related to permanent disability and level of consciousness. In some cases, long-term disorders of consciousness (DoC) exist, including the vegetative state/unresponsive wakefulness syndrome (VS/UWS) characterized by the exhibition of reflexive behaviors only or a minimally conscious state (MCS) with few purposeful movements and reflexive behaviors. Electroceuticals, including non-invasive brain stimulation (NIBS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS) have proved efficacious in some patients with TBI and DoC. In this review, we examine how electroceuticals have improved our understanding of the neuroanatomy of consciousness. However, the level of improvements in general arousal or basic bodily and visual pursuit that constitute clinically meaningful recovery on the Coma Recovery Scale-Revised (CRS-R) remain undefined. Nevertheless, these advancements demonstrate the importance of the vagal nerve, thalamus, reticular activating system, and cortico-striatal-thalamic-cortical loop in the process of consciousness recovery.
Collapse
|