Brazilian guidelines for the application of transcranial ultrasound as a diagnostic test for the confirmation of brain death

Is a Second Transcranial Doppler Study Needed to Confirm Neurocirculatory Arrest?

BACKGROUND

In determining brain death, transcranial Doppler (TCD) is one of the recommended ancillary tests when clinical examinations and apnea tests are contraindicated. The American Academy of Neurology 2023 guideline updates and 2020 World Brain Death Project advise conducting two TCDs 30 min apart to diagnose neurocirculatory arrest. Our study aimed to evaluate whether a second TCD is necessary when the first TCD shows neurocirculatory arrest (no flow, oscillating flow, or systolic spikes).

METHODS

We conducted a single-center retrospective analysis of patients admitted to intensive care units from January 1, 2021, to February 1, 2025, at a community-based academic hospital. We included patients whose first study showed neurocirculatory arrest and who subsequently underwent a confirmatory TCD at least 30 min apart. A total of 48 patients were included in our final analysis. We compared the findings of the first TCD study with those of the second study and noted any differences.

RESULTS

In all 48 patients (100%), the second TCD confirmed the findings of the first TCD. Of these 48 patients, 44 patients (91.7%) had the same flow pattern on repeat TCD examination and 4 patients' (8.30%) TCDs showed different flow patterns, although still consistent with neurocirculatory arrest. Of the 44 patients with the same flow patterns found on first and repeat TCD examinations, 18 patients (40.9%) had both TCDs demonstrate brief systolic spikes; three patients (6.80%) had both TCDs demonstrate brief systolic spikes and oscillating flow; eight patients (18.2%) had both TCDs demonstrate no flow; seven patients (15.9%) had both TCDs demonstrate no flow and brief systolic spikes; one patient (2.30%) had both TCDs demonstrate no flow, brief systolic spikes, and oscillating flow; and, lastly, seven patients (15.9%) had both TCDs demonstrate oscillating flow.

CONCLUSIONS

We found that requiring two sequential TCD examinations to confirm neurocirculatory arrest may be unnecessary when the first TCD shows neurocirculatory arrest. Further investigation and studies such as ours in larger populations are warranted.

Transcranial Doppler and Color-Coded Doppler Use for Brain Death Determination in Adult Patients: A Pictorial Essay

Transcranial Doppler (TCD) is a repeatable, at-the-bedside, helpful tool for confirming cerebral circulatory arrest (CCA). Despite its variable accuracy, TCD is increasingly used during brain death determination, and it is considered among the optional ancillary tests in several countries. Among its limitations, the need for skilled operators with appropriate knowledge of typical CCA patterns and the lack of adequate acoustic bone windows for intracranial arteries assessment are critical. The purpose of this review is to describe how to evaluate cerebral circulatory arrest in the intensive care unit with TCD and transcranial duplex color-coded doppler (TCCD).

POCUS, how can we include the brain? An overview

Point-of-care ultrasound (POCUS) is an essential tool to assess and manage different pathologies in the intensive care unit, and many protocols have been proposed for its application in critical care literature. However, the brain has been overlooked in these protocols.

Brain ultrasonography (BU) is easily available, and it allows a goal-directed approach thanks to its repeatability and immediate interpretation and provides a quick management and real time assessment of patients’ conditions. Based on recent studies, the increasing interest from intensivists, and the undeniable benefits of ultrasound, the main goal of this overview is to describe the main evidence and progresses in the incorporation of BU into the POCUS approach in the daily practice, and thus becoming POCUS-BU. This integration would allow a noninvasive global assessment to entail an integrated analysis of the critical care patients.

Transcranial Doppler: A Useful Tool to Predict Brain Death Still Not Confirmed by Clinical Assessment

BACKGROUND

Diagnosing brain death (BD) with accuracy and urgency is of great importance because an early diagnosis may guide the clinical management, optimize hospital beds, and facilitate organ transplantation. The clinical diagnosis of nonreactive and irreversible coma can be confirmed with additional tests. Among the complimentary exams that may testify brain circulatory arrest, transcranial Doppler (TCD) can be an option. It is a real-time, bedside, inexpensive, noninvasive method that assesses cerebral blood flow. In patients with suspected BD, especially those who are under sedative drugs, early diagnosis is imperative. The aim of the present study was to evaluate the role of TCD in predicting BD.

METHODS

One hundred consecutive comatose patients with a Glasgow Coma Scale score of less than 5, owing to different etiologies, were included. TCD was performed in all patients. The TCD operator was blinded for clinical and neurologic data. This study is in compliance with the Declaration of Helsinki.

RESULTS

Sixty-nine patients with TCD-brain circulatory collapse were diagnosed later with BD. Of the 31 patients with brain circulatory activity, 8 (25.8%) were clinically brain dead and 23 (74.2%) were alive. TCD showing brain circulatory collapse had a sensitivity of 89.6%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 74.2%.

CONCLUSION

TCD is highly specific (100%) and sensitive (89.6%) as a method to confirm the clinical diagnosis of BD, even in patients under sedation. The possibility of patients presenting with cerebral circulatory activity and clinical diagnosis of BD was demonstrated to occur.

Reliability of Assessing Non-severe Elevation of Intracranial Pressure Using Optic Nerve Sheath Diameter and Transcranial Doppler Parameters

Background/Aims: Non-invasive measurement of intracranial pressure (ICP) using ultrasound has garnered increasing attention. This study aimed to compare the reliability of ultrasonographic measurement of optic nerve sheath diameter (ONSD) and transcranial Doppler (TCD) in detecting potential ICP elevations. Methods: Patients who needed lumbar puncture (LP) in the Department of Neurology were recruited from December 2016 to July 2017. The ONSD and TCD measurements were completed before LP. Results: One hundred sixty-five participants (mean age, 41.96 ± 14.64 years; 80 men; 29 patients with elevated ICP) were included in this study. The mean ICP was 170 ± 52 mmH₂O (range, 75-400 mmH₂O). Univariate analyses revealed that ICP was non-significantly associated with TCD parameters and significantly associated with ONSD (r = 0.60, P < 0.001). The mean ONSD of the elevated ICP group was significantly higher than that of the normal ICP group (4.53 ± 0.40 mm vs. 3.97 ± 0.23 mm; P < 0.001). Multivariate linear regression determined that the difference between ICP and ONSD is significant. Conclusions: In the early stage of intracranial hypertension, ONSD is more reliable for evaluating ICP than TCD.

Latin American consensus on the use of transcranial Doppler in the diagnosis of brain death

Transcranial Doppler evaluates cerebral hemodynamics in patients with brain injury and is a useful technical tool in diagnosing cerebral circulatory arrest, usually present in the brain-dead patient. This Latin American Consensus was formed by a group of 26 physicians experienced in the use of transcranial Doppler in the context of brain death. The purpose of this agreement was to make recommendations regarding the indications, technique, and interpretation of the study of transcranial ultrasonography in patients with a clinical diagnosis of brain death or in the patient whose clinical diagnosis presents difficulties; a working group was formed to enable further knowledge and to strengthen ties between Latin American physicians working on the same topic. A review of the literature, concepts,and experiences were exchanged in two meetings and via the Internet. Questions about pathophysiology, equipment, techniques, findings, common problems, and the interpretation of transcranial Doppler in the context of brain death were answered. The basic consensus statements are the following: cerebral circulatory arrest is the final stage in the evolution of progressive intracranial hypertension, which is visualized with transcranial Doppler as a "pattern of cerebral circulatory arrest". The following are accepted as the standard of cerebral circulatory arrest: reverberant pattern, systolic spikes, and absence of previously demonstrated flow. Ultrasonography should be used - in acceptable hemodynamic conditions - in the anterior circulation bilaterally (middle cerebral artery) and in the posterior (basilar artery) territory. If no ultrasonographic images are found in any or all of these vessels, their proximal arteries are acceptable to be studied to look for a a pattern of cerebral circulatory arrest.