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Barami K. Confounding factors impacting the Glasgow coma score: a literature review. Neurol Res 2024; 46:479-486. [PMID: 38497232 DOI: 10.1080/01616412.2024.2329860] [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: 07/06/2023] [Accepted: 02/22/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND The Glasgow coma score (GCS) is a clinical tool used to measure level of consciousness in traumatic brain injury and other settings. Despite its widespread use, there are many inaccuracies in its reporting. One source of inaccuracy is confounding factors which affect consciousness as well as each sub-score of the GCS. The purpose of this article was to create a comprehensive list of confounding factors in order to improve the accuracy of the GCS and ultimately improve decision-making. METHODS An English language literature search was conducted discussing GCS and multiple other keywords. Ultimately, 64 out of 3972 articles were included for further analysis. RESULTS A multitude of confounding factors were identified which may affect consciousness or GCS sub-scores including the eye exam, motor exam and the verbal response. CONCLUSIONS An up-to-date comprehensive list of confounding factors has been created that may be used to aide in GCS recording in hopes of improving its accuracy and utility.
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Affiliation(s)
- Kaveh Barami
- St. Francis Hospital, Trinity Health of New England, Hartford, CT, USA
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Hansen KIT, Kelsen J, Othman MH, Stavngaard T, Kondziella D. Confirmatory digital subtraction angiography after clinical brain death/death by neurological criteria: impact on number of donors and organ transplants. PeerJ 2023; 11:e15759. [PMID: 37492400 PMCID: PMC10364806 DOI: 10.7717/peerj.15759] [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] [Received: 05/04/2023] [Accepted: 06/26/2023] [Indexed: 07/27/2023] Open
Abstract
Background Demand for organs exceeds the number of transplants available, underscoring the need to optimize organ donation procedures. However, protocols for determining brain death (BD)/death by neurological criteria (DNC) vary considerably worldwide. In Denmark, digital subtraction angiography (DSA) is the only legally approved confirmatory test for diagnosing BD/DNC. We investigated the effect of the time delay caused by (repeat) confirmatory DSA on the number of organs donated by patients meeting clinical criteria for BD/DNC. We hypothesized that, first, patients investigated with ≥2 DSAs donate fewer organs than those investigated with a single DSA; second, radiological interpretation of DSA is subject to interrater variability; and third, residual intracranial circulation is inversely correlated with inotropic blood pressure support. Methods All DSAs performed over a 7-year period as part of BD/DNC protocols at Rigshospitalet, Copenhagen University Hospital, Denmark, were included. Clinical data were extracted from electronic health records. DSAs were reinterpreted by an independent neurinterventionist blinded to the original radiological reports. Results We identified 130 DSAs in 100 eligible patients. Patients with ≥2 DSAs (n = 20) donated fewer organs (1.7 +/- 1.6 SD) than patients undergoing a single DSA (n = 80, 2.6 +/- 1.7 organs, p = 0.03), and they became less often donors (n = 12, 60%) than patients with just 1 DSA (n = 65, 81.3%; p = 0.04). Interrater agreement of radiological DSA interpretation was 88.5% (Cohen's kappa = 0.76). Patients with self-maintained blood pressure had more often residual intracranial circulation (n = 13/26, 50%) than patients requiring inotropic support (n = 14/74, 18.9%; OR = 0.23, 95% CI [0.09-0.61]; p = 0.002). Discussion In potential donors who fulfill clinical BD/DNC criteria, delays caused by repetition of confirmatory DSA result in lost donors and organ transplants. Self-maintained blood pressure at the time of clinical BD/DNC increases the odds for residual intracranial circulation, creating diagnostic uncertainty because radiological DSA interpretation is not uniform. We suggest that avoiding unnecessary repetition of confirmatory investigations like DSA may result in more organs donated.
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Affiliation(s)
- Karen Irgens Tanderup Hansen
- University of Southern Denmark, Faculty of Health Science, Odense, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Kelsen
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marwan H. Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Trine Stavngaard
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Shlobin NA, Aru J, Vicente R, Zemmar A. What happens in the brain when we die? Deciphering the neurophysiology of the final moments in life. Front Aging Neurosci 2023; 15:1143848. [PMID: 37228251 PMCID: PMC10203241 DOI: 10.3389/fnagi.2023.1143848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/12/2023] [Indexed: 05/27/2023] Open
Abstract
When do we die and what happens in the brain when we die? The mystery around these questions has engaged mankind for centuries. Despite the challenges to obtain recordings of the dying brain, recent studies have contributed to better understand the processes occurring during the last moments of life. In this review, we summarize the literature on neurophysiological changes around the time of death. Perhaps the only subjective description of death stems from survivors of near-death experiences (NDEs). Hallmarks of NDEs include memory recall, out-of-body experiences, dreaming, and meditative states. We survey the evidence investigating neurophysiological changes of these experiences in healthy subjects and attempt to incorporate this knowledge into the existing literature investigating the dying brain to provide valuations for the neurophysiological footprint and timeline of death. We aim to identify reasons explaining the variations of data between studies investigating this field and provide suggestions to standardize research and reduce data variability.
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Affiliation(s)
- Nathan A. Shlobin
- Department of Neurosurgery, Henan Provincial People’s Hospital, Henan University School of Medicine, Zhengzhou, China
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jaan Aru
- Institute of Computer Science, University of Tartu, Tartu, Estonia
| | - Raul Vicente
- Institute of Computer Science, University of Tartu, Tartu, Estonia
| | - Ajmal Zemmar
- Department of Neurosurgery, Henan Provincial People’s Hospital, Henan University School of Medicine, Zhengzhou, China
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, United States
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Machado C. Jahi McMath, a New Disorder of Consciousness. REVISTA LATINOAMERICANA DE BIOÉTICA 2021. [DOI: 10.18359/rlbi.5635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
In this paper, I review the case of Jahi McMath, who was diagnosed with brain death (BD). Nonetheless, ancillary tests performed nine months after the initial brain insult showed conservation of intracranial structures, EEG activity, and autonomic reactivity to the “Mother Talks” stimulus. She was clinically in an unarousable and unresponsive state, without evidence of self-awareness or awareness of the environment. However, the total absence of brainstem reflexes and partial responsiveness rejected the possibility of a coma. Jahi did not have uws because she was not in a wakefulness state and showed partial responsiveness. She could not be classified as a LIS patient either because LIS patients are wakeful and aware, and although quadriplegic, they fully or partially preserve brainstem reflexes, vertical eye movements or blinking, and respire on their own. She was not in an MCS because she did not preserve arousal and preserved awareness only partially. The CRS-R resulted in a very low score, incompatible with MCS patients. mcs patients fully or partially preserve brainstem reflexes and usually breathe on their own. MCS has always been described as a transitional state between a coma and UWS but never reported in a patient with all clinical BD findings. This case does not contradict the concept of BD but brings again the need to use ancillary tests in BD up for discussion. I concluded that Jahi represented a new disorder of consciousness, non-previously described, which I have termed “reponsive unawakefulness syndrome” (RUS).
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Kondziella D. The Neurology of Death and the Dying Brain: A Pictorial Essay. Front Neurol 2020; 11:736. [PMID: 32793105 PMCID: PMC7385288 DOI: 10.3389/fneur.2020.00736] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/15/2020] [Indexed: 01/18/2023] Open
Abstract
As neurologists earn their living with the preservation and restoration of brain function, they are also well-positioned to address the science behind the transition from life to death. This essay in pictures highlights areas of neurological expertise needed for brain death determination; shows pitfalls to avoid during the clinical examination and interpretation of confirmatory laboratory tests in brain death protocols; illustrates the great variability of brain death legislations around the world; discusses arguments for the implementation of donation after circulatory death (DCD); points to unresolved questions related to DCD and the time between cardiac standstill and organ procurement (“hands-off period”); provides an overview of the epidemiology and semiology of near-death experiences, including their importance for religion, literature, and the visual arts; suggests biological mechanisms for near-death experiences such as dysfunction of temporoparietal cortex, N-methyl-D-aspartate receptor antagonism, migraine aura, and rapid eye movement sleep; hypothesizes that thanatosis (aka. death-feigning, a common behavioral trait in the animal kingdom) represents the evolutionary origin of near-death experiences; and speculates about the future implications of recent attempts of brain resuscitation in an animal model. The aim is to provide the reader with a thorough understanding that the boundaries within the neurology of death and the dying brain are being pushed just like everywhere else in the clinical neurosciences.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Carneiro BV, Garcia GH, Isensee LP, Besen BAMP. Optimization of conditions for apnea testing in a hypoxemic brain dead patient. Rev Bras Ter Intensiva 2019; 31:106-110. [PMID: 30970095 PMCID: PMC6443318 DOI: 10.5935/0103-507x.20190015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/27/2018] [Indexed: 11/20/2022] Open
Abstract
We report the case of a patient in whom brain death was suspected and associated with atelectasis and moderate to severe hypoxemia even though the patient was subjected to protective ventilation, a closed tracheal suction system, positive end-expiratory pressure, and recruitment maneuvers. Faced with the failure to obtain an adequate partial pressure of oxygen for the apnea test, we elected to place the patient in a prone position, use higher positive end-expiratory pressure, perform a new recruitment maneuver, and ventilate with a higher tidal volume (8mL/kg) without exceeding the plateau pressure of 30cmH2O. The apnea test was performed with the patient in a prone position, with continuous positive airway pressure coupled with a T-piece. The delay in diagnosis was 10 hours, and organ donation was not possible due to circulatory arrest. This report demonstrates the difficulties in obtaining higher levels of the partial pressure of oxygen for the apnea test. The delays in the diagnosis of brain death and in the organ donation process are discussed, as well as potential strategies to optimize the partial pressure of oxygen to perform the apnea test according to the current recommendations.
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Affiliation(s)
- Bárbara Vieira Carneiro
- Unidade de Terapia Intensiva Clínica, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Guilherme Henrique Garcia
- Unidade de Terapia Intensiva Clínica, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Larissa Padrão Isensee
- Unidade de Terapia Intensiva Clínica Médica, Divisão de Fisioterapia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Bruno Adler Maccagnan Pinheiro Besen
- Unidade de Terapia Intensiva Clínica, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
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Robbins NM, Bernat JL. Practice Current: When do you order ancillary tests to determine brain death? Neurol Clin Pract 2018; 8:266-274. [PMID: 30105167 DOI: 10.1212/cpj.0000000000000473] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/11/2018] [Indexed: 11/15/2022]
Abstract
Brain death has been accepted as a legal definition of death in most countries, but practices for determining brain death vary widely. One source of variation is in the use of ancillary tests to assist in the diagnosis of brain death. Through case-based discussions with 3 experts from 3 continents, this article discusses selected aspects of brain death, with a focus on the use of ancillary tests. In particular, we explore the following questions: Are ancillary tests necessary, or is the clinical examination sufficient? What ancillary tests are preferred, and under which circumstances? Are ancillary tests required when the primary mechanism of injury is brainstem injury? Should the family's wishes play a role in the need for ancillary tests? The same case-based questions were posed to the rest of our readership in an online survey, the preliminary results of which are also presented.
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Affiliation(s)
- Nathaniel M Robbins
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - James L Bernat
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH
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Confirmation of brain death using optical methods based on tracking of an optical contrast agent: assessment of diagnostic feasibility. Sci Rep 2018; 8:7332. [PMID: 29743483 PMCID: PMC5943525 DOI: 10.1038/s41598-018-25351-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/09/2018] [Indexed: 11/20/2022] Open
Abstract
We aimed to determine whether optical methods based on bolus tracking of an optical contrast agent are useful for the confirmation of cerebral circulation cessation in patients being evaluated for brain death. Different stages of cerebral perfusion disturbance were compared in three groups of subjects: controls, patients with posttraumatic cerebral edema, and patients with brain death. We used a time-resolved near-infrared spectroscopy setup and indocyanine green (ICG) as an intravascular flow tracer. Orthogonal partial least squares-discriminant analysis (OPLS-DA) was carried out to build statistical models allowing for group separation. Thirty of 37 subjects (81.1%) were classified correctly (8 of 9 control subjects, 88.9%; 13 of 15 patients with edema, 86.7%; and 9 of 13 patients with brain death, 69.2%; p < 0.0001). Depending on the combination of variables used in the OPLS-DA model, sensitivity, specificity, and accuracy were 66.7–92.9%, 81.8–92.9%, and 77.3–89.3%, respectively. The method was feasible and promising in the demanding intensive care unit environment. However, its accuracy did not reach the level required for brain death confirmation. The potential usefulness of the method may be improved by increasing the depth of light penetration, confirming its accuracy against other methods evaluating cerebral flow cessation, and developing absolute parameters for cerebral perfusion.
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Abstract
End-organ failure is associated with high mortality and morbidity, in addition to increased health care costs. Organ transplantation is the only definitive treatment that can improve survival and quality of life in such patients; however, due to the persistent mismatch between organ supply and demand, waiting lists continue to grow across the world. Careful intensive care management of the potential organ donor with goal-directed therapy has the potential to optimize organ function and improve donation yield.
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Li Y, Liu S, Xun F, Liu Z, Huang X. Use of Transcranial Doppler Ultrasound for Diagnosis of Brain Death in Patients with Severe Cerebral Injury. Med Sci Monit 2016; 22:1910-5. [PMID: 27264088 PMCID: PMC4920100 DOI: 10.12659/msm.899036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background The aim of this study was to investigate the use of transcranial Doppler (TCD) for diagnosis of brain death in patients with severe cerebral injury. Material/Methods This retrospective study enrolled 42 patients based on inclusion and exclusion criteria. All patients were divided into either the brain death group or the survival group according to prognosis. Blood flow of the brain was examined by TCD and analyzed for spectrum changes. The average blood flow velocity (Vm), pulse index (PI), and diastolic blood flow in reverse (RDF) were recorded and compared. Results The data demonstrated that the average speed of bilateral middle cerebral artery blood flow in the brain death group was significantly reduced (P<0.05). However, the PI of the brain death group increased significantly. Moreover, RDF spectrum and nail-like sharp peak spectrum of the brain death group was higher than in the survival group. Conclusions Due to its simplicity, high repeatability, and specificity, TCD combined with other methods is highly valuable for diagnosis of brain death in patients with severe brain injury.
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Affiliation(s)
- Yuequn Li
- Department of Transcranial Doppler Ultrasound, The Affiliated Hospital of Jining Medical College, Jining, Shandong, China (mainland)
| | - Shangwei Liu
- Department of Transcranial Doppler Ultrasound, The Affiliated Hospital of Jining Medical College, Jining, Shandong, China (mainland)
| | - Fangfang Xun
- Department of Transcranial Doppler Ultrasound, The Affiliated Hospital of Jining Medical College, Jining, Shandong, China (mainland)
| | - Zhan Liu
- Department of Transcranial Doppler Ultrasound, The Affiliated Hospital of Jining Medical College, Jining, Shandong, China (mainland)
| | - Xiuying Huang
- Department of Transcranial Doppler Ultrasound, The Affiliated Hospital of Jining Medical College, Jining, Shandong, China (mainland)
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