1
|
Hoffmann O, Salih F, Masuhr F. Computed tomography angiography in the diagnosis of brain death: Implementation and results in Germany. Eur J Neurol 2024; 31:e16209. [PMID: 38217344 DOI: 10.1111/ene.16209] [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: 10/11/2023] [Revised: 12/06/2023] [Accepted: 12/28/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Computed tomography angiography (CTA) has been investigated as a confirmatory study (CS) for the diagnosis of brain death (BD). International consensus regarding its use, study parameters, and evaluation criteria is lacking. In the German BD guideline, a CTA protocol was first introduced in 2015. METHODS The authors obtained a comprehensive dataset of all BD examinations in adults from the German organ procurement organization to investigate implementation, results, and impact of CTA on BD determination during the first 4 years. RESULTS In 5152 patients with clinically absent brain function, 1272 CTA were reported by 676 hospitals. Use of CTA increased from 17.2% of patients in the first year to 29.7% in the final year. CTA replaced other CS such as electroencephalography without increasing overall CS frequency. Technical failure was rare (0.9%); 89.3% of studies were positive. Negative results (9.8%) were more frequent with secondary brain injury, longer duration of the clinical BD syndrome, or unreliable clinical assessment. Median time to diagnosis was longer with CTA (2.6 h) versus other CS (1.6 h). CTA had no differential impact on the rate of confirmed BD and did not improve access of small hospitals to CS for BD determination. CONCLUSIONS CTA expands the range of available CS for the diagnosis of BD in adults. Real-world evidence from a large cohort confirms usability of the German CTA protocol within the guideline-specified context.
Collapse
Affiliation(s)
- Olaf Hoffmann
- Department of Neurology, Alexianer St. Josefs Hospital, Potsdam, Germany
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Germany
| | - Farid Salih
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Masuhr
- Klinik für Neurologie, Bundeswehrkrankenhaus Berlin, Berlin, Germany
| |
Collapse
|
2
|
Hoffmann O, Salih F, Masuhr F. [Diagnosis of brain death in Germany-Implementation of the guidelines of the German Medical Association]. DER NERVENARZT 2023; 94:1129-1138. [PMID: 37462719 PMCID: PMC10684634 DOI: 10.1007/s00115-023-01520-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The 4th update of the guidelines of the German Medical Association on the diagnosis of irreversible loss of brain function (brain death, BD) has introduced important new regulations regarding the required qualification of the examiners, approved procedures for ancillary testing, and a clarification regarding the sequencing of diagnostic steps. OBJECTIVE Investigation of the implementation and practical effects on the diagnosis of brain death. METHOD Descriptive evaluation of the routine documentation of the German Organ Procurement Organization, comparing the periods July 2011-June 2015 (3rd update) and July 2015-June 2019 (4th update). RESULTS Patient numbers decreased from 6100 to 5403. The largest decrease affected hospitals without neurosurgery. Children were not affected. With the 4th update, clinical diagnostics were increasingly performed during on-call hours by external neurologists. Of the patients 83.8% now received ancillary tests compared to 80.1% previously. Computed tomography angiography (CTA), first introduced in the 4th update, was applied in 23.2% and established complete loss of cerebral circulation in 89.4%. The time between first documentation of the clinical signs of BD and certification of BD increased from 7.0 ± 12.7 h to 8.2 ± 14.2 h. The diagnosis was slightly less frequent with 95.3% compared to 96.6%. CONCLUSION The updated standards were implemented in accordance with the guidelines. The demand for external consulting neurologists and neurosurgeons as well as the time required for BD assessment have increased. Negative effects on pediatric BD diagnostics were not apparent. CTA is widely and successfully used in adults as a new ancillary diagnostic procedure.
Collapse
Affiliation(s)
- Olaf Hoffmann
- Klinik für Neurologie, Alexianer St. Josefs-Krankenhaus Potsdam, Potsdam, Deutschland.
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Deutschland.
- Neurocure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Deutschland.
- Klinik für Neurologie, Alexianer St. Josefs-Krankenhaus Potsdam, Allee nach Sanssouci 7, 14471, Potsdam, Deutschland.
| | - Farid Salih
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Deutschland
| | - Florian Masuhr
- Klinik für Neurologie, Bundeswehrkrankenhaus Berlin, Berlin, Deutschland
| |
Collapse
|
3
|
Robba C, Taccone FS. How I use Transcranial Doppler. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:420. [PMID: 31870405 PMCID: PMC6929281 DOI: 10.1186/s13054-019-2700-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 12/11/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Chiara Robba
- Policlinico San Martino, IRCCS per l'Oncologia e Neuroscienze, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
| |
Collapse
|
4
|
[Diagnosis of irreversible loss of brain function ("brain death")-what is new?]. DER NERVENARZT 2019; 90:1021-1030. [PMID: 31312849 DOI: 10.1007/s00115-019-0765-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The determination of the irreversible cessation of brain function (ICBF) is conducted in Germany according to the guideline of the German Medical Association, which is currently its fourth update issued in July 2015. This article provides an assessment of the current situation including an international comparison. International case reports with allegedly incorrect ICBF diagnosis are reviewed from the point of view of the German guideline. These case reports underpin the validity of the German guideline, especially its following provisions: (1) in patients with known or suspected adaptation to chronic hypercapnia, apnea cannot be diagnosed as usual; therefore in such a case the proof of cerebral circulatory arrest is mandatory; (2) if perfusion scintigraphy is used for proof of cerebral circulatory arrest, only validated lipophilic radiopharmaceuticals are allowed. This is compatible with new research data which indicate that cellular function can be reactivated for several hours after circulatory arrest but not the brain function. The recently updated recommendations of the German Society for Clinical Neurophysiology and Functional Imaging (DGKN) for ancillary testing include editorial adaptations (e.g., the more precise specification of the electrode positions for electroencephalography), standards of display screen with digital electroencephalography and age-related minimum values of mean arterial pressure for Doppler and duplex sonography in children. The novel requirements regarding the institutional organization of ICBF diagnostics in Germany issued in the "Second law on the amendment of transplantation law-improvement of the cooperation and the framework for organ donation" that became effective recently are presented and discussed critically in this review.
Collapse
|
5
|
The Role of Transcranial Doppler as a Monitoring Tool in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
6
|
Absent Cerebellar Circulation With Intact Cerebral Blood Flow on a 99mTc Bicisate "Brain Death" Study. Clin Nucl Med 2017; 42:983-984. [PMID: 29076900 DOI: 10.1097/rlu.0000000000001866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 55-year old woman presented in an obtunded state and was found to have a subarachnoid hemorrhage. After endovascular repair, her condition deteriorated, and brain death was suspected. A Tc bicisate brain blood flow study was performed, which showed a complete absence of blood flow to the cerebellum despite intact circulation to the cerebral hemispheres. These atypical findings are likely a result of a transient intracranial pressure differential and the timing of the study. A timely and accurate declaration of brain death has important psychosocial and ethical implications, particularly when organ donation is being considered.
Collapse
|
7
|
Lau VI, Arntfield RT. Point-of-care transcranial Doppler by intensivists. Crit Ultrasound J 2017; 9:21. [PMID: 29030715 PMCID: PMC5640565 DOI: 10.1186/s13089-017-0077-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/06/2017] [Indexed: 11/10/2022] Open
Abstract
In the unconscious patient, there is a diagnostic void between the neurologic physical exam, and more invasive, costly and potentially harmful investigations. Transcranial color-coded sonography and two-dimensional transcranial Doppler imaging of the brain have the potential to be a middle ground to bridge this gap for certain diagnoses. With the increasing availability of point-of-care ultrasound devices, coupled with the need for rapid diagnosis of deteriorating neurologic patients, intensivists may be trained to perform point-of-care transcranial Doppler at the bedside. The feasibility and value of this technique in the intensive care unit to help rule-in specific intra-cranial pathologies will form the focus of this article. The proposed scope for point-of-care transcranial Doppler for the intensivist will be put forth and illustrated using four representative cases: presence of midline shift, vasospasm, raised intra-cranial pressure, and progression of cerebral circulatory arrest. We will review the technical details, including methods of image acquisition and interpretation. Common pitfalls and limitations of point-of-care transcranial Doppler will also be reviewed, as they must be understood for accurate diagnoses during interpretation, as well as the drawbacks and inadequacies of the modality in general.
Collapse
Affiliation(s)
- Vincent Issac Lau
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
- London Health Sciences Centre, Victoria Hospital Rm, D2-528, 800 Commissioners Road East, London, ON N6A 5W9 Canada
| | - Robert Thomas Arntfield
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
- London Health Sciences Centre, Victoria Hospital Rm, D2-528, 800 Commissioners Road East, London, ON N6A 5W9 Canada
| |
Collapse
|
8
|
Obeidat N, Sallout B, Albaqawi B, Al AlAali W. The impact of fetal middle cerebral artery Doppler on the outcome of congenital hydrocephalus. J Matern Fetal Neonatal Med 2017; 31:413-417. [DOI: 10.1080/14767058.2017.1286318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Nail Obeidat
- Department of Obstetrics and Gynecology, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
- Department of Fetal Medicine and Ultrasound, Women’s’ Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Bahauddin Sallout
- Department of Fetal Medicine and Ultrasound, Women’s’ Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Badi Albaqawi
- Department of Fetal Medicine and Ultrasound, Women’s’ Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Wajeih Al AlAali
- Department of Fetal Medicine and Ultrasound, Women’s’ Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
9
|
Chang JJ, Tsivgoulis G, Katsanos AH, Malkoff MD, Alexandrov AV. Diagnostic Accuracy of Transcranial Doppler for Brain Death Confirmation: Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2016; 37:408-14. [PMID: 26514611 DOI: 10.3174/ajnr.a4548] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/11/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Transcranial Doppler is a useful ancillary test for brain death confirmation because it is safe, noninvasive, and done at the bedside. Transcranial Doppler confirms brain death by evaluating cerebral circulatory arrest. Case series studies have generally reported good correlations between transcranial Doppler confirmation of cerebral circulatory arrest and clinical confirmation of brain death. The purpose of this study is to evaluate the utility of transcranial Doppler as an ancillary test in brain death confirmation. MATERIALS AND METHODS We conducted a systematic review of the literature and a diagnostic test accuracy meta-analysis to compare the sensitivity and specificity of transcranial Doppler confirmation of cerebral circulatory arrest, by using clinical confirmation of brain death as the criterion standard. RESULTS We identified 22 eligible studies (1671 patients total), dating from 1987 to 2014. Pooled sensitivity and specificity estimates from 12 study protocols that reported data for the calculation of both values were 0.90 (95% CI, 0.87-0.92) and 0.98 (95% CI, 0.96-0.99), respectively. Between-study differences in the diagnostic performance of transcranial Doppler were found for both sensitivity (I(2) = 76%; P < .001) and specificity (I(2) = 74.3%; P < .001). The threshold effect was not significant (Spearman r = -0.173; P = .612). The area under the curve with the corresponding standard error (SE) was 0.964 ± 0.018, while index Q test ± SE was estimated at 0.910 ± 0.028. CONCLUSIONS The results of this meta-analysis suggest that transcranial Doppler is a highly accurate ancillary test for brain death confirmation. However, transcranial Doppler evaluates cerebral circulatory arrest rather than brain stem function, and this limitation needs to be taken into account when interpreting the results of this meta-analysis.
Collapse
Affiliation(s)
- J J Chang
- From the Department of Neurology (J.J.C., G.T., M.D.M., A.V.A.), University of Tennessee Health Science Center, Memphis, Tennessee
| | - G Tsivgoulis
- From the Department of Neurology (J.J.C., G.T., M.D.M., A.V.A.), University of Tennessee Health Science Center, Memphis, Tennessee Second Department of Neurology (G.T., A.H.K.), Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece International Clinical Research Center (G.T.), St. Anne's University Hospital in Brno, Czech Republic
| | - A H Katsanos
- Second Department of Neurology (G.T., A.H.K.), Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece Department of Neurology (A.H.K.), University of Ioannina, School of Medicine, Ioannina, Epirus, Greece
| | - M D Malkoff
- From the Department of Neurology (J.J.C., G.T., M.D.M., A.V.A.), University of Tennessee Health Science Center, Memphis, Tennessee
| | - A V Alexandrov
- From the Department of Neurology (J.J.C., G.T., M.D.M., A.V.A.), University of Tennessee Health Science Center, Memphis, Tennessee
| |
Collapse
|
10
|
Cameron EJ, Bellini A, Damian MS, Breen DP. Confirmation of brainstem death. Pract Neurol 2016; 16:129-35. [DOI: 10.1136/practneurol-2015-001297] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 11/03/2022]
|
11
|
Hashemian SM, Delavarkasmaei H, Najafizadeh K, Mojtabae M, Ardehali SH, Kamranmanesh MR, Basharzad N, Ghorbani F. Role of Transcranial Doppler Sonography in Diagnosis of Brain Death: A Single Center Study. TANAFFOS 2016; 15:213-217. [PMID: 28469677 PMCID: PMC5410117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Diagnosis of brain death relies on clinical and electroencephalographic (EEG) criteria. Waiting for 24 hours is mandatory to make definitive diagnosis of the condition in the Iranian protocol. Although it has been previously shown that oscillatory or spiked systolic or reversed diastolic flow patterns in transcranial Doppler sonography (TCD) are associated with faster brain death confirmation, it has not yet been approved in our protocol. Thus, the aim of this study was to assess the applicability of this method to our organ donation system. MATERIALS AND METHODS This study was performed in Masih Daneshvari Organ Procurement Unit from July to December 2009. TCD from the middle cerebral and basilar arteries was attempted in 35 patients who fulfilled the clinical and EEG criteria for brain death. Extensive skull defects and hypotension (blood pressure < 80 mmHg) were the exclusion criteria. Examinations were made for about 30 minutes via temporal and occipital windows as soon as possible after diagnosis of brain death. RESULTS The mean age of cases was 31.9±14.78 years and 18 (51.4%) were males. The most prevalent cause of brain death was trauma (in 19 or 54.2% of cases). We were unable to detect any intracranial artery in 2 (5.7%) cases. There were no false negative or false positive results in the remaining ones. Detected ultrasonic patterns of cerebral vascular flow were systolic spike and oscillating signal in 29 (87.9%) and 4 (12.1%) donors, respectively. CONCLUSION Our study showed that TCD results in brain dead cases were concordant with clinical and EEG criteria. Therefore, TCD, as a confirmatory test, can be applied for rapid diagnosis of brain death.
Collapse
Affiliation(s)
- Seyed Mohammadreza Hashemian
- Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hosein Delavarkasmaei
- Department of Neurology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Katayoun Najafizadeh
- Lung Transplantation Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Meysam Mojtabae
- Lung Transplantation Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Hossein Ardehali
- Department of Critical Care, Shohadaye-Tajrish Hospital, Shahid Beheshti University of Medical Sciences
| | - Mohammad Reza Kamranmanesh
- Department of Anesthesiology & Critical Care and Pain Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Niloofar Basharzad
- Department of Pulmonology and Intensive Care Medicine, Shahid Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fariba Ghorbani
- Tracheal Diseases Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Correspondence to: Ghorbani F Address: Tracheal Diseases Research Center (TDRC), NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Email address:
| |
Collapse
|
12
|
Keshtkaran Z, Sharif F, Navab E, Gholamzadeh S. Lived Experiences of Iranian Nurses Caring for Brain Death Organ Donor Patients: Caring as "Halo of Ambiguity and Doubt". Glob J Health Sci 2015; 8:281-92. [PMID: 26925919 PMCID: PMC4965685 DOI: 10.5539/gjhs.v8n7p281] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 12/18/2015] [Indexed: 11/24/2022] Open
Abstract
Background: Brain death is a concept in which its criteria have been expressed as documentations in Harvard Committee of Brain Death. The various perceptions of caregiver nurses for brain death patients may have effect on the chance of converting potential donors into actual organ donors. Objective: The present study has been conducted in order to perceive the experiences of nurses in care-giving to the brain death of organ donor patients. Methods: This qualitative study was carried out by means of Heidegger’s hermeneutic phenomenology. Eight nurses who have been working in ICU were interviewed. The semi-structured interviews were recorded by a tape-recorder and the given texts were transcribed and the analyses were done by Van-Mannen methodology and (thematic) analysis. Results: One of the foremost themes extracted from this study included ‘Halo of ambiguity and doubt’ that comprised of two sub-themes of ‘having unreasonable hope’ and ‘Conservative acceptance of brain death’. The unreasonable hope included lack of trust (uncertainty) in diagnosis and verification of brain death, passing through denial wall, and avoidance from explicit and direct disclosure of brain death in patients’ family. In this investigation, the nurses were involved in a type of ambiguity and doubt in care-giving to the potentially brain death of organ donor patients, which were also evident in their interaction with patients’ family and for this reason, they did not definitely announce the brain death and so far they hoped for treatment of the given patient. Such confusion and hesitance both caused annoyance of nurses and strengthening the denial of patients’ family to be exposed to death. Conclusion: The results of this study reveal the fundamental perceived care-giving of brain death in organ donor patients and led to developing some strategies to improve care-giving and achievement in donation of the given organ and necessity for presentation of educational and supportive services for nurses might become more evident than ever.
Collapse
|
13
|
Escudero D, Otero J, Quindós B, Viña L. Limitaciones del Doppler transcraneal en el diagnóstico de la muerte encefálica. Med Intensiva 2015; 39:324. [DOI: 10.1016/j.medin.2015.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/22/2015] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
|
14
|
Doppler transcraneal en el diagnóstico de la muerte encefálica. ¿Es útil o retrasa el diagnóstico? Med Intensiva 2015; 39:244-50. [DOI: 10.1016/j.medin.2014.11.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 11/07/2014] [Accepted: 11/11/2014] [Indexed: 11/21/2022]
|
15
|
Brunser AM, Lavados PM, Cárcamo DA, Hoppe A, Olavarría VV, López J, Muñoz P, Rivas R. Accuracy of Power Mode Transcranial Doppler in the Diagnosis of Brain Death. J Med Ultrasound 2015. [DOI: 10.1016/j.jmu.2014.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
16
|
Kasule OH. Brain death: Criteria, signs, and tests 1Presented at a joint physician-jurist seminar on brain death held in Riyadh on April 16, 2012.1. J Taibah Univ Med Sci 2013. [DOI: 10.1016/j.jtumed.2013.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
|
17
|
Transcranial Doppler shortens the time between clinical brain death and angiographic confirmation: a randomized trial. Transplantation 2012; 94:585-8. [PMID: 22918218 DOI: 10.1097/tp.0b013e3182612947] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Brain death diagnosis relies on clinical signs, but confirmatory tests are legally mandatory in some countries. In France, transcranial Doppler (TCD) is not recognized as a legal test to confirm brain death. Nevertheless, experts recommend its use to determine the need for a legal confirmatory test. The aim of this study was to test the hypothesis that TCD shortens the time between clinical brain death and computed tomography angiography (CTA) confirmation. METHODS We conducted a prospective randomized controlled study to evaluate the benefit of a TCD-directed strategy before performing the CTA to confirm brain death. Once the clinical diagnosis of brain death was established, subjects were randomized in a conventional group (CTA 6 hr later as recommended in France) or a TCD group (TCD examination every 2 hr until intracranial brain death flow patterns were found). Forty-four subjects were needed to show a difference of 2 hr between the two strategies. RESULTS TCD strategy resulted in a shorter time between clinical diagnosis of brain death and CTA confirmation compared with conventional strategy (2.0 [1.3-2.6] vs. 7.2 [6.3-9.5] hr, P<0.0001). The number of brain CTA performed to confirm the diagnosis of brain death was not different between groups. CONCLUSIONS Our results suggest that TCD-directed strategy allows reducing the time between clinical diagnosis of brain death and CTA confirmation.
Collapse
|
18
|
Sharma D, Souter MJ, Moore AE, Lam AM. Clinical experience with transcranial Doppler ultrasonography as a confirmatory test for brain death: a retrospective analysis. Neurocrit Care 2011; 14:370-6. [PMID: 20694525 DOI: 10.1007/s12028-010-9415-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transcranial Doppler (TCD) ultrasonography to demonstrate cerebral circulatory arrest (CCA) is a confirmatory test for brain death (BD). The primary aim of this retrospective study was to evaluate the practical utility of TCD to confirm BD when clinical diagnosis was not feasible due to confounding factors. Secondary aims were to evaluate the reasons for inability of TCD to confirm BD and to assess the outcome of patients not brain dead according to the TCD criteria. METHODS TCD waveforms and medical records of all the patients examined to confirm suspected BD between 2001 and 2007, where clinical diagnosis was not possible, were analyzed. BD was diagnosed based on CCA criteria recommended by the Task Force Group on cerebral death of the Neurosonology Research Group of the World Federation of Neurology. Final outcome of patients and the use of other ancillary tests were noted. RESULTS Ninety patients (61 males), aged 40 ± 21 (range 3-84) years underwent TCD examination for confirmation of suspected BD. TCD confirmed BD in 51 (57%) patients and was inconclusive in 38 (43%), with no flow signals on the first examination in 7 (8%) patients and the waveform patterns in 31 (35%) being inconsistent with BD. Fourteen of the 19 patients who had CCA pattern in at least one artery but did not meet all the criteria for BD were subsequently found brain dead according to SPECT/clinical criteria or suffered cardiovascular death. CONCLUSION Using the conventional criteria, TCD confirmed BD in a large proportion, of patients where clinical diagnosis could not be made. The presence of CCA pattern in one or more major cerebral artery may be prognostic of unfavorable outcome, even when BD criteria are not satisfied.
Collapse
Affiliation(s)
- Deepak Sharma
- Department of Anesthesiology & Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | | | | | | |
Collapse
|
19
|
Llompart-Pou J, Abadal J, Velasco J, Homar J, Blanco C, Ayestarán J, Pérez-Bárcena J. Contrast-Enhanced Transcranial Color Sonography in the Diagnosis of Cerebral Circulatory Arrest. Transplant Proc 2009; 41:1466-8. [DOI: 10.1016/j.transproceed.2008.12.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Accepted: 12/02/2008] [Indexed: 10/20/2022]
|
20
|
Pitfalls in the Diagnosis of Brain Death. Neurocrit Care 2009; 11:276-87. [DOI: 10.1007/s12028-009-9231-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Accepted: 04/28/2009] [Indexed: 11/25/2022]
|
21
|
|
22
|
Wang K, Yuan Y, Xu ZQ, Wu XL, Luo BY. Benefits of combination of electroencephalography, short latency somatosensory evoked potentials, and transcranial Doppler techniques for confirming brain death. J Zhejiang Univ Sci B 2009; 9:916-20. [PMID: 18988311 DOI: 10.1631/jzus.b0820123] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Optimization of combining electroencephalography (EEG), short latency somatosensory evoked potentials (SLSEP) and transcranial Doppler (TCD) techniques to diagnose brain death. METHODS One hundred and eleven patients (69 males, 42 females) from the major hospitals of Zhejiang Province were examined with portable EEG, SLSEP and TCD devices. Re-examinations occurred < or =12 h later. RESULTS The first examination revealed that the combination of SLSEP and EEG led to more sensitive diagnoses than the combination of SLSEP and TCD. Re-examination confirmed this and also revealed that the combination of TCD and EEG was the most sensitive. CONCLUSION The results show that using multiple techniques to diagnose brain death is superior to using single method, and that the combination of SLSEP and EEG is better than other combinations.
Collapse
Affiliation(s)
- Kang Wang
- Department of Neurology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | | | | | | | | |
Collapse
|
23
|
Conti A, Iacopino DG, Spada A, Cardali SM, Giusa M, La Torre D, Campennì A, Penna O, Baldari S, Tomasello F. Transcranial Doppler ultrasonography in the assessment of cerebral circulation arrest: improving sensitivity by transcervical and transorbital carotid insonation and serial examinations. Neurocrit Care 2009; 10:326-35. [PMID: 19238589 DOI: 10.1007/s12028-009-9199-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2008] [Accepted: 01/29/2009] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Transcranial Doppler (TCD) can detect the cerebral circulation arrest (CCA) in brain death. TCD is highly specific, but less sensitive because of false-negatives accounting for up to 10%. The aim of the study was to explore the diagnostic accuracy of TCD and to determine whether it can be augmented by strategies such as the insonation of the extracranial internal carotid artery (ICA) and sequential examinations. METHODS Data of 184 patients, who met clinical criteria of brain death, observed from 1998 through 2006, were retrospectively reviewed. The study of cerebral arteries was performed through the transtemporal approach, suboccipital insonation of the vertebro-basilar system, transorbital insonation of the ICA and ophthalmic artery, and transcervical insonation of the extracranial ICA. Repeated exams were performed in cases of persistent diastolic flow. RESULTS The specificity of the testing was 100%, no false-positive cases were recorded. The sensitivity of conventional TCD examination was 82.1%. The insonation of the extracranial ICA increased sensitivity to 88% allowing the detection of CCA in those patients lacking temporal windows; serial examinations further increased sensitivity to 95.6%. CONCLUSIONS The addition of insonation of the cervical ICA and of the siphon increased sensitivity of TCD. Nevertheless, a CCA flow patterns may appear later on those segments. Serial examinations, may be needed in those cases.
Collapse
Affiliation(s)
- Alfredo Conti
- Department of Neurosurgery, University of Messina, Policlinico Universitario, Via Consolare Valeria 1, 98125, Messina, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Abstract
Transcranial Doppler has several practical applications in neurocritical care. It has its main application in the diagnosis and monitoring of vasospasm in patients with subarachnoid hemorrhage. In addition, it holds promise for the detection of critical elevations of intracranial pressure. Its ability to measure CO2 reactivity and autoregulation may ultimately allow intensivists to optimize cerebral perfusion pressure and ventilatory therapy for the individual patient. Transcranial Doppler findings of brain death are well described and can be useful as a screening tool.
Collapse
Affiliation(s)
- Maher Saqqur
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | |
Collapse
|