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Betancur MI, Case A, Ilich E, Mehta N, Meehan S, Pogrebivsky S, Keir ST, Stevenson K, Brahma B, Gregory S, Chen W, Ashley DM, Bellamkonda R, Mokarram N. A neural tract-inspired conduit for facile, on-demand biopsy of glioblastoma. Neurooncol Adv 2024; 6:vdae064. [PMID: 38813113 PMCID: PMC11135361 DOI: 10.1093/noajnl/vdae064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
Background A major hurdle to effectively treating glioblastoma (GBM) patients is the lack of longitudinal information about tumor progression, evolution, and treatment response. Methods In this study, we report the use of a neural tract-inspired conduit containing aligned polymeric nanofibers (i.e., an aligned nanofiber device) to enable on-demand access to GBM tumors in 2 rodent models. Depending on the experiment, a humanized U87MG xenograft and/or F98-GFP+ syngeneic rat tumor model was chosen to test the safety and functionality of the device in providing continuous sampling access to the tumor and its microenvironment. Results The aligned nanofiber device was safe and provided a high quantity of quality genomic materials suitable for omics analyses and yielded a sufficient number of live cells for in vitro expansion and screening. Transcriptomic and genomic analyses demonstrated continuity between material extracted from the device and that of the primary, intracortical tumor (in the in vivo model). Conclusions The results establish the potential of this neural tract-inspired, aligned nanofiber device as an on-demand, safe, and minimally invasive access point, thus enabling rapid, high-throughput, longitudinal assessment of tumor and its microenvironment, ultimately leading to more informed clinical treatment strategies.
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Affiliation(s)
| | - Ayden Case
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Ekaterina Ilich
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Nalini Mehta
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Sean Meehan
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Sabrina Pogrebivsky
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Stephen T Keir
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Kevin Stevenson
- Molecular Physiology Institute, Duke University, Durham, North Carolina, USA
| | - Barun Brahma
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Simon Gregory
- Molecular Physiology Institute, Duke University, Durham, North Carolina, USA
| | - Wei Chen
- Center for Genomic and Computational Biology, Duke University, Durham, Georgia, USA
| | - David M Ashley
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Ravi Bellamkonda
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
- Department of Biology, Emory University, Atlanta, Georgia, USA
| | - Nassir Mokarram
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
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Peckham ME, Anderson JS, Rassner UA, Shah LM, Hinckley PJ, de Havenon A, Kim SE, McNally JS. Low b-value diffusion weighted imaging is promising in the diagnosis of brain death and hypoxic-ischemic injury secondary to cardiopulmonary arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:165. [PMID: 29925413 PMCID: PMC6011248 DOI: 10.1186/s13054-018-2087-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/30/2018] [Indexed: 12/20/2022]
Abstract
Background Cardiorespiratory arrest can result in a spectrum of hypoxic ischemic brain injury leading to global hypoperfusion and brain death (BD). Because up to 40% of patients with BD are viable organ donors, avoiding delayed diagnosis of this condition is critical. High b-value diffusion weighted imaging (DWI) measures primarily molecular self-diffusion; however, low b-values are sensitive to perfusion. We investigated the feasibility of low b-value DWI in discriminating the global hypoperfusion of BD and hypoxic ischemic encephalopathy (HIE). Methods We retrospectively reviewed cardiorespiratory arrest subjects with a diagnosis of HIE or BD. Inclusion criteria included brain DWI acquired at both low (50 s/mm2) and high (1000–2000 s/mm2) b-values. Automated segmentation was used to determine mean b50 apparent diffusion coefficient (ADC) values in gray and white matter regions. Normal subjects with DWI at both values were used as age- and sex-matched controls. Results We evaluated 64 patients (45 with cardiorespiratory arrest and 19 normal). Cardiorespiratory arrest patients with BD had markedly lower mean b50 ADC in gray matter regions compared with HIE (0.70 ± 0.18 vs. 1.95 ± 0.25 × 10−3 mm2/s, p < 0.001) and normal subjects (vs. 1.79 ± 0.12 × 10−3 mm2/s, p < 0.001). HIE had higher mean b50 ADC compared with normal (1.95 ± 0.25 vs. 1.79 ± 0.12 × 10−3 mm2/s, p = 0.016). There was wide separation of gray matter ADC values in BD subjects compared with age matched normal and HIE subjects. White matter values were also markedly decreased in the BD population, although they were less predictive than gray matter. Conclusion Low b-value DWI is promising for the discrimination of HIE with maintained perfusion and brain death in cardiorespiratory arrest.
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Affiliation(s)
- Miriam E Peckham
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA. .,Department of Radiology and Imaging Sciences, University of Utah Health Sciences Center, 30 North, 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA.
| | - Jeffrey S Anderson
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Ulrich A Rassner
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Lubdha M Shah
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Peter J Hinckley
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Seong-Eun Kim
- Utah Center for Advanced Imaging Research, Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - J Scott McNally
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
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Abstract
The neurological determination of death (NDD) is primarily considered to be clinical. However, situations may arise where confounding factors make this clinical assessment difficult or impossible. As a result, ancillary tests have been developed in order to aid in the confirmation of brain death. As assessment of neuronal electrical activity; electroencephalography (EEG) is no longer recommended in this determination, tools assessing cerebral perfusion, as reflected by the presence or absence of cerebral blood flow (CBF), are the mainstay of NDD. The preferred ancillary test currently is Hexamethylpropylene amine oxime-single photon emission computed tomography (HMPAO SPECT) radionuclide angiography. When this is not available, or is equivocal, 4-vessel cerebral angiography can be used to determine the presence or absence of intracranial blood flow. However, as cerebral angiography has its own limitations, other techniques are sought by physicians in the Intensive Care and Neuro-intensive Care settings to replace cerebral angiography. In this article, we briefly review the history of diagnosis of brain death, pathophysiologic issues in making this determination, and currently available CBF imaging techniques, discussing each in turn with respect to their utility in the diagnosis of brain death.
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4
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Gadolinium-enhanced magnetic resonance angiography in brain death. Sci Rep 2014; 4:3659. [PMID: 24413880 PMCID: PMC3888970 DOI: 10.1038/srep03659] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 12/16/2013] [Indexed: 11/24/2022] Open
Abstract
Confirmatory tests for the diagnosis of brain death in addition to clinical findings may shorten observation time required in some countries and may add certainty to the diagnosis under specific circumstances. The practicability of Gadolinium-enhanced magnetic resonance angiography to confirm cerebral circulatory arrest was assessed after the diagnosis of brain death in 15 patients using a 1.5 Tesla MRI scanner. In all 15 patients extracranial blood flow distal to the external carotid arteries was undisturbed. In 14 patients no contrast medium was noted within intracerebral vessels above the proximal level of the intracerebral arteries. In one patient more distal segments of the anterior and middle cerebral arteries (A3 and M3) were filled with contrast medium. Gadolinium-enhanced MRA may be considered conclusive evidence of cerebral circulatory arrest, when major intracranial vessels fail to fill with contrast medium while extracranial vessels show normal blood flow.
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Luchtmann M, Bernarding J, Beuing O, Kohl J, Bondar I, Skalej M, Firsching R. Controversies of Diffusion Weighted Imaging in the Diagnosis of Brain Death. J Neuroimaging 2013; 23:463-8. [DOI: 10.1111/jon.12033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 02/06/2013] [Accepted: 02/23/2013] [Indexed: 01/06/2023] Open
Affiliation(s)
- Michael Luchtmann
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg; Leipziger Str. 44 39120 Magdeburg
| | - Johannes Bernarding
- Institute of Biometry and Medical Informatics, Otto-von-Guericke-University Magdeburg; Leipziger Str. 44 39120 Magdeburg
| | - Oliver Beuing
- Institute of Neuroradiology, Otto-von-Guericke-University Magdeburg; Leipziger Str. 44 39120 Magdeburg
| | - Jana Kohl
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg; Leipziger Str. 44 39120 Magdeburg
| | - Imre Bondar
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg; Leipziger Str. 44 39120 Magdeburg
| | - Martin Skalej
- Institute of Neuroradiology, Otto-von-Guericke-University Magdeburg; Leipziger Str. 44 39120 Magdeburg
| | - Raimund Firsching
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg; Leipziger Str. 44 39120 Magdeburg
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Severe brain damage after punitive training technique with a choke chain collar in a German shepherd dog. J Vet Behav 2013. [DOI: 10.1016/j.jveb.2013.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Tsai F, Lee KW, Kao HW, Chen CY. Susceptibility-Weighted Imaging, an Additional Tool to Diagnose Brain Death: Initial Experience. Neuroradiol J 2012; 25:505-8. [DOI: 10.1177/197140091202500501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 10/07/2012] [Indexed: 11/16/2022] Open
Abstract
We describe findings suggestive of brain death on susceptibility-weighted imaging. We retrospectively reviewed brain magnetic resonance (MR) images of 15 patients who had cardiac arrest and found four cases with evidence of brain death. We then reviewed susceptibility-weighted imaging (SWI) findings on these cases. SWI images in the four cases with brain death showed deoxygenated blood in intracranial arteries. This preliminary result suggests that SWI may be used to diagnose brain death.
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Affiliation(s)
- F.Y. Tsai
- Imaging Research Center, Taipei Medical University; Taipei, Taiwan
- UC Irvine Medical Center; Orange, CA, USA
| | - K-W. Lee
- Imaging Research Center, Taipei Medical University; Taipei, Taiwan
- Chang-Hua Christian Hospital; Chang-Hua, Taiwan
| | - H-W. Kao
- Tri-Service General Hospital, National Defense Medical Center; Taipei, Taiwan
| | - C-Y. Chen
- Imaging Research Center, Taipei Medical University; Taipei, Taiwan
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Sohn CH, Lee HP, Park JB, Chang HW, Kim E, Kim E, Park UJ, Kim HT, Ku J. Imaging findings of brain death on 3-tesla MRI. Korean J Radiol 2012; 13:541-9. [PMID: 22977320 PMCID: PMC3435850 DOI: 10.3348/kjr.2012.13.5.541] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 01/20/2012] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To demonstrate the usefulness of 3-tesla (3T) magnetic resonance imaging (MRI) including T2-weighted imaging (T2WI), diffusion weighted imaging (DWI), time-of-flight (TOF) magnetic resonance angiography (MRA), T2*-weighted gradient recalled echo (GRE), and susceptibility weighted imaging (SWI) in diagnosing brain death. MATERIALS AND METHODS Magnetic resonance imaging findings for 10 patients with clinically verified brain death (group I) and seven patients with comatose or stuporous mentality who did not meet the clinical criteria of brain death (group II) were retrospectively reviewed. RESULTS Tonsilar herniation and loss of intraarterial flow signal voids (LIFSV) on T2WI were highly sensitive and specific findings for the diagnosis of brain death (p < 0.001 and < 0.001, respectively). DWI, TOF-MRA, and GRE findings were statistically different between the two groups (p = 0.015, 0.029, and 0.003, respectively). However, cortical high signal intensities in T2WI and SWI findings were not statistically different between the two group (p = 0.412 and 1.0, respectively). CONCLUSION T2-weighted imaging, DWI, and MRA using 3T MRI may be useful for diagnosing brain death. However, SWI findings are not specific due to high false positive findings.
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Affiliation(s)
- Chul-Ho Sohn
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 110-744, Korea
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Selcuk H, Albayram S, Tureci E, Hasiloglu ZI, Kizilkilic O, Cagil E, Kocer N, Islak C. Diffusion-weighted imaging findings in brain death. Neuroradiology 2011; 54:547-54. [PMID: 21792617 DOI: 10.1007/s00234-011-0912-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 07/06/2011] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The purpose of the present study was to determine the role of diffusion-weighted imaging (DWI) and to investigate the use of DWI in the diagnosis of brain death (BD). METHODS We prospectively evaluated 22 patients diagnosed with clinical BD (9 women, 13 men; mean age, 39.63 ± 15.1 years; age range, 9-66 years). All clinical criteria for BD were present in all 22 patients before magnetic resonance imaging, including a positive apnea test. For all cases, DW images, T2-weighted images, and fluid-attenuated inversion recovery were obtained. Thirteen distinct neuroanatomical structures were selected for analysis in all the cases. For each region of interest, the mean, standard deviation, and range of the average apparent diffusion coefficient (ADCav) values were obtained. RESULTS For BD patients, ADC values in all neuroanatomical structures were significantly lower than those for control subjects. We determined how ADC values in all structures were related to the diagnostic condition as well as the appropriate threshold ADC values to classify a subject as BD or control. The sensitivity, specificity, positive and negative predictive values, and correct classification rate of ADC cutoff values to distinguish BD from control groups were 100%. CONCLUSIONS DWI might be used as a noninvasive confirmatory test for the diagnosis of BD in the future.
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Affiliation(s)
- Hakan Selcuk
- Department of Radiology, Division of Neuroradiology, Bakirkoy State Hospital, KMP Istanbul 34300, Turkey
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10
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Scheurer E, Lovblad KO, Kreis R, Maier SE, Boesch C, Dirnhofer R, Yen K. Forensic application of postmortem diffusion-weighted and diffusion tensor MR imaging of the human brain in situ. AJNR Am J Neuroradiol 2011; 32:1518-24. [PMID: 21659482 DOI: 10.3174/ajnr.a2508] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE DWI and DTI of the brain have proved to be useful in many neurologic disorders and in traumatic brain injury. This prospective study aimed at the evaluation of the influence of the PMI and the cause of death on the ADC and FA for the application of DWI and DTI in forensic radiology. MATERIALS AND METHODS DWI and DTI of the brain were performed in situ in 20 deceased subjects with mapping of the ADC and FA. Evaluation was performed in different ROIs, and the influence of PMI and cause of death was assessed. RESULTS Postmortem ADC values of the brain were decreased by 49%-72% compared with healthy living controls. With increasing PMI, ADCs were significantly reduced when considering all ROIs together and, particularly, GM regions (all regions, P < .05; GM, P < .01), whereas there was no significant effect in WM. Concerning the cause of death, ADCs were significantly lower in mechanical and hypoxic brain injury than in brains from subjects having died from heart failure (traumatic brain injury, P < .005; hypoxia, P < .001). Postmortem FA was not significantly different from FA in living persons and showed no significant influence of PMI or cause of death. CONCLUSIONS Performing postmortem DWI and DTI of the brain in situ can provide valuable information for application in forensic medicine. ADC could be used as an indicator of PMI and could help in the assessment of the cause of death.
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Affiliation(s)
- E Scheurer
- Ludwig Boltzmann Institute for Clinical-Forensic Imaging, Graz, Austria.
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11
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Gutierrez LG, Rovira A, Portela LAP, Leite CDC, Lucato LT. CT and MR in non-neonatal hypoxic-ischemic encephalopathy: radiological findings with pathophysiological correlations. Neuroradiology 2010; 52:949-76. [PMID: 20585768 DOI: 10.1007/s00234-010-0728-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 06/04/2010] [Indexed: 11/29/2022]
Abstract
Non-neonatal hypoxic-ischemic encephalopathy is a clinical condition often related to cardiopulmonary arrest that demands critical management and treatment decisions. Management depends mainly on the degree of neurological impairment and prognostic considerations. Computed tomography (CT) is often used to exclude associated or mimicking pathology. If any, only nonspecific signs such as cerebral edema, sulci effacement, and decreased gray matter (GM)/white matter (WM) differentiation are evident. Pseudosubarachnoid hemorrhage, a GM/WM attenuation ratio <1.18, and inverted GM attenuation are associated with a poor prognosis. Magnetic resonance (MR) imaging is more sensitive than CT in assessing brain damage in hypoxic-ischemic encephalopathy. Some MR findings have similarities to those seen pathologically, based on spatial distribution and time scale, such as lesions distributed in watershed regions and selective injury to GM structures. In the acute phase, lesions are better depicted using diffusion-weighted imaging (DWI) because of the presence of cytotoxic edema, which, on T2-weighted images, only become apparent later in the early subacute phase. In the late subacute phase, postanoxic leukoencephalopathy and contrast enhancement could be observed. In the chronic phase, atrophic changes predominate over tissue signal changes. MR can be useful for estimating prognosis when other tests are inconclusive. Some findings, such as the extent of lesions on DWI and presence of a lactate peak and depleted N-acetyl aspartate peak on MR spectroscopy, seem to have prognostic value.
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Affiliation(s)
- Leonardo Guilhermino Gutierrez
- Diagnostic Imaging Division, Hospital Alemão Oswaldo Cruz and Hospital do Coração, Praça Amadeu Amaral, 47-Conj. 112, São Paulo, 01327-904, Brazil,
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12
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Choi SP, Park KN, Park HK, Kim JY, Youn CS, Ahn KJ, Yim HW. Diffusion-weighted magnetic resonance imaging for predicting the clinical outcome of comatose survivors after cardiac arrest: a cohort study. Crit Care 2010; 14:R17. [PMID: 20152021 PMCID: PMC2875532 DOI: 10.1186/cc8874] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Revised: 10/29/2009] [Accepted: 02/12/2010] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION The aim of this study was to examine whether the patterns of diffusion-weighted imaging (DWI) abnormalities and quantitative regional apparent diffusion coefficient (ADC) values can predict the clinical outcome of comatose patients following cardiac arrest. METHODS Thirty-nine patients resuscitated from out-of-hospital cardiac arrest were prospectively investigated. Within five days of resuscitation, axial DWIs were obtained and ADC maps were generated using two 1.5-T magnetic resonance scanners. The neurological outcomes of the patients were assessed using the Glasgow Outcome Scale (GOS) score at three months after the cardiac arrest. The brain injuries were categorised into four patterns: normal, isolated cortical injury, isolated deep grey nuclei injury, and mixed injuries (cortex and deep grey nuclei). Twenty-three subjects with normal DWIs served as controls. The ADC and percent ADC values (the ADC percentage as compared to the control data from the corresponding region) were obtained in various regions of the brains. We analysed the differences between the favourable (GOS score 4 to 5) and unfavourable (GOS score 1 to 3) groups with regard to clinical data, the DWI abnormalities, and the ADC and percent ADC values. RESULTS The restricted diffusion abnormalities in the cerebral cortex, caudate nucleus, putamen and thalamus were significantly different between the favourable (n = 13) and unfavourable (n = 26) outcome groups. The cortical pattern of injury was seen in one patient (3%), the deep grey nuclei pattern in three patients (8%), the cortex and deep grey nuclei pattern in 21 patients (54%), and normal DWI findings in 14 patients (36%). The cortex and deep grey nuclei pattern was significantly associated with the unfavourable outcome (20 patients with unfavourable vs. 1 patient with favourable outcomes, P < 0.001). In the 22 patients with quantitative ADC analyses, severely reduced ADCs were noted in the unfavourable outcome group. The optimal cutoffs for the mean ADC and the percent ADC values determined by receiver operating characteristic (ROC) curve analysis in the cortex, caudate nucleus, putamen, and thalamus predicted the unfavourable outcome with sensitivities of 67 to 93% and a specificity of 100%. CONCLUSIONS The patterns of brain injury in early diffusion-weighted imaging (DWI) (less than or equal to five days after resuscitation) and the quantitative measurement of regional ADC may be useful for predicting the clinical outcome of comatose patients after cardiac arrest.
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Affiliation(s)
- Seung Pill Choi
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul, 137-701, Korea
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Yen K, Lövblad KO, Scheurer E, Ozdoba C, Thali MJ, Aghayev E, Jackowski C, Anon J, Frickey N, Zwygart K, Weis J, Dirnhofer R. Post-mortem forensic neuroimaging: correlation of MSCT and MRI findings with autopsy results. Forensic Sci Int 2007; 173:21-35. [PMID: 17336008 DOI: 10.1016/j.forsciint.2007.01.027] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Revised: 12/15/2006] [Accepted: 01/21/2007] [Indexed: 10/23/2022]
Abstract
Multislice-computed tomography (MSCT) and magnetic resonance imaging (MRI) are increasingly used for forensic purposes. Based on broad experience in clinical neuroimaging, post-mortem MSCT and MRI were performed in 57 forensic cases with the goal to evaluate the radiological methods concerning their usability for forensic head and brain examination. An experienced clinical radiologist evaluated the imaging data. The results were compared to the autopsy findings that served as the gold standard with regard to common forensic neurotrauma findings such as skull fractures, soft tissue lesions of the scalp, various forms of intracranial hemorrhage or signs of increased brain pressure. The sensitivity of the imaging methods ranged from 100% (e.g., heat-induced alterations, intracranial gas) to zero (e.g., mediobasal impression marks as a sign of increased brain pressure, plaques jaunes). The agreement between MRI and CT was 69%. The radiological methods prevalently failed in the detection of lesions smaller than 3mm of size, whereas they were generally satisfactory concerning the evaluation of intracranial hemorrhage. Due to its advanced 2D and 3D post-processing possibilities, CT in particular possessed certain advantages in comparison with autopsy with regard to forensic reconstruction. MRI showed forensically relevant findings not seen during autopsy in several cases. The partly limited sensitivity of imaging that was observed in this retrospective study was based on several factors: besides general technical limitations it became apparent that clinical radiologists require a sound basic forensic background in order to detect specific signs. Focused teaching sessions will be essential to improve the outcome in future examinations. On the other hand, the autopsy protocols should be further standardized to allow an exact comparison of imaging and autopsy data. In consideration of these facts, MRI and CT have the power to play an important role in future forensic neuropathological examination.
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Affiliation(s)
- Kathrin Yen
- Institute of Forensic Medicine, University of Bern, 3012 Bern, Switzerland.
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14
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Marrache F, Mégarbane B, Pirnay S, Rhaoui A, Thuong M. Difficulties in assessing brain death in a case of benzodiazepine poisoning with persistent cerebral blood flow. Hum Exp Toxicol 2005; 23:503-5. [PMID: 15553176 DOI: 10.1191/0960327104ht478cr] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Assessing brain death may sometimes be difficult, with isoelectric EEG following psychotrope overdoses or normal cerebral blood flow (CBF) persisting despite brain death in the case of ventricular drainage or craniotomy. A 42-year-old man, resuscitated after cardiac arrest following a suicidal ingestion of ethanol, bromazepam and zopiclone, was admitted in deep coma. On day 4, his brainstem reflexes and EEG activity disappeared. On day 5, his serum bromazepam concentration was 817 ng/ml (therapeutic: 80-150). The patient was unresponsive to 1 mg of flumazenil. MRI showed diffuse cerebral swelling. CBF assessed by angiography and Doppler remained normal and EEG isoelectric until he died on day 8 with multiorgan failure. There was a discrepancy between the clinically and EEG-assessed brain death, and CBF persistence. We hypothesized that brain death, resulting from diffuse anoxic injury, may lead, in the absence of major intracranial hypertension, to angiographic misdiagnoses. Therefore, EEG remains useful to assess diagnosis in such unusual cases.
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Abstract
Brain death, the colloquial term for the determination of human death by showing the irreversible cessation of the clinical functions of the brain, has been practiced since the 1960s and is growing in acceptance throughout the world. Of the three concepts of brain death--the whole-brain formulation, the brain stem formulation, and the higher brain formulation--the whole-brain formulation is accepted and practiced most widely. There is a rigorous conceptual basis for regarding whole-brain death as human death based on the biophilosophical concept of the loss of the organism as a whole. The diagnosis of brain death is primarily a clinical determination but laboratory tests showing the cessation of intracranial blood flow can be used to confirm the clinical diagnosis in cases in which the clinical tests cannot be fully performed or correctly interpreted. Because of evidence that some physicians fail to perform or record brain death tests properly, it is desirable to require a confirmatory test when inadequately experienced physicians conduct brain death determinations. The world's principal religions accept brain death with a few exceptions. Several scholars continue to reject brain death on conceptual grounds and urge that human death determination be based on the irreversible cessation of circulation. But despite the force of their arguments they have neither persuaded any jurisdictions to abandon brain death statutes nor convinced medical groups to change clinical practice guidelines. Other scholars who, on more pragmatic grounds, have called for the abandonment of brain death as an anachronism or an unnecessary prerequisite for multi-organ procurement, similarly have not convinced public policy makers to withdraw the dead-donor rule. Despite a few residual areas of controversy, brain death is a durable concept that has been accepted well and has formed the basis of successful public policy in diverse societies throughout the world.
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Affiliation(s)
- James L Bernat
- Neurology Section, Dartmouth Medical School, Hanover, NH 03755, USA.
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Abstract
Postmortem brain of a ten-month-old child was examined by MR imaging, and diffusion MR imaging at the 12th hour after death in order to disclose the cause of death. There were basal ganglion lesions indicating a mitochondrial disorder. There was a prominent difference between the ADC values of the white matter (0.28+/-0.04 x 10(-3) mm2/s) and cortex (0.42+/-0.04 x 10(-3) mm2/s), and this was statistically significant (p< 0.0001). This difference suggested that in the postmortem brain the conditions in the white matter leading to restriction of movement of water molecules are more severe than that in the cortex.
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Affiliation(s)
- R N Sener
- Department of Radiology, Ege University Hospital, Bornova, Izmir, 35100 Turkey.
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Bernat JL. On Irreversibility as a Prerequisite for Brain Death Determination. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2004; 550:161-7. [PMID: 15053434 DOI: 10.1007/978-0-306-48526-8_14] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- James L Bernat
- Neurology Section, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA
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Watanabe T, Honda Y, Fujii Y, Koyama M, Tanaka R. Serial evaluation of axonal function in patients with brain death by using anisotropic diffusion-weighted magnetic resonance imaging. J Neurosurg 2004; 100:56-60. [PMID: 14743912 DOI: 10.3171/jns.2004.100.1.0056] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The purposes of this study were to evaluate the serial changes in diffusion anisotropy of the brain, probably reflecting axonal function in brain-dead patients, and thus to explore the possibility of quantitatively estimating the risk of brain death.
Methods. Ten patients suffering from stroke with or without impending brain death and 10 healthy volunteers were studied using three-dimensional anisotropy contrast (3DAC) magnetic resonance (MR) axonography with the aid of a 1.5-tesla MR imaging system. To detect changes in the diffusion anisotropy of neural bundles, the corticospinal tract was evaluated.
Diffusion anisotropy of short axonal fibers decreased immediately after apparent brain death. Whereas the trichromatic coefficients of the corticospinal tract greatly diminished between 6 and 12 hours after apparent brain death, the coefficients of the corpus callosum and the optic radiation decreased in less time, that is, between 1 and 6 hours. The coefficients of these three bundles turned isotropic between 24 and 44 hours after apparent brain death.
Conclusions. Results of 3DAC MR axonography revealed that diffusion anisotropy of neural bundles diminished between 1 and 12 hours after the onset of apparent brain death, probably depending on the length of the bundles, and disappeared between 24 and 44 hours after the onset of brain death, which might reflect dynamic changes of axonal structure and indirectly herald axonal dysfunction. These findings seem to be greatly helpful in establishing an appropriate method to estimate the risk of brain death quantitatively and in forming the basis of future definitions of brain death.
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Affiliation(s)
- Toru Watanabe
- Department of Neurosurgery, Suibarago General Hospital, Kita-kanbara-gun, Niigata, Japan.
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Moritz CH, Rowley HA, Haughton VM, Swartz KR, Jones J, Badie B. Functional MR imaging assessment of a non-responsive brain injured patient. Magn Reson Imaging 2001; 19:1129-32. [PMID: 11711238 DOI: 10.1016/s0730-725x(01)00432-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Functional magnetic resonance imaging (fMRI) was requested to assist in the evaluation of a comatose 38-year-old woman who had sustained multiple cerebral contusions from a motor vehicle accident. Previous electrophysiologic studies suggested absence of thalamocortical processing in response to median nerve stimulation. Whole-brain fMRI was performed utilizing visual, somatosensory, and auditory stimulation paradigms. Results demonstrated intact task-correlated sensory and cognitive blood oxygen level dependent (BOLD) hemodynamic response to stimuli. Electrodiagnostic studies were repeated and evoked potentials indicated supratentorial recovery in the cerebrum. At 3-months post trauma the patient had recovered many cognitive & sensorimotor functions, accurately reflecting the prognostic fMRI evaluation. These results indicate that fMRI examinations may provide a useful evaluation for brain function in non-responsive brain trauma patients.
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Affiliation(s)
- C H Moritz
- Department of Radiology, University of Wisconsin, Madison, WI, USA.
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Abstract
Although all of this information may create the impression that caring for a potential organ donor is an exceedingly complex task, in the authors' experience, this often is not true, and much energy can--and should--be devoted to the care of the bereaved family. Of crucial importance are the early recognition of brain death and the consequent radical switch of the treatment goal from preservation of the patient's brain and life to preservation of organs for the lives of others. Care for the donor is the natural extension of care for a critically ill or injured patient. During the foregoing discussion, the authors had to stress the absence of sound evidence on many points. Because many reports originate from transplant centers dedicated to a specific organ, gaining a comprehensive view on management options in the ICU further is hampered. Thus, this situation leaves another field in which investigations originating from pediatric intensivists could provide evidence urgently needed to make optimal choices. The next decade should see the thyroid hormone controversy solved by at least one controlled prospective study and the differential applicability of inotropic, vasoactive, or fluid-centered strategies. It seems self-evident that only graft survival and related parameters can form adequate endpoints for future studies.
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Affiliation(s)
- N Lutz-Dettinger
- Division of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium.
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