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Deana C, Biasucci DG, Aspide R, Brasil S, Vergano M, Leonardis F, Rica E, Cammarota G, Dauri M, Vetrugno G, Longhini F, Maggiore SM, Rasulo F, Vetrugno L. Transcranial Doppler and Color-Coded Doppler Use for Brain Death Determination in Adult Patients: A Pictorial Essay. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:979-992. [PMID: 38279568 DOI: 10.1002/jum.16421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 01/28/2024]
Abstract
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).
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Affiliation(s)
- Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Daniele G Biasucci
- Department of Clinical Science and Translational Medicine, "Tor Vergata" University, Rome, Italy
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
- Catholic University of the Sacred Heart (UCSC), Rome, Italy
| | - Raffaele Aspide
- Anesthesia and Neurointensive Care Unit, Istituto delle Scienze Neurologiche IRCCS, Bologna, Italy
| | - Sergio Brasil
- Neurosurgical Division, Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Francesca Leonardis
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
- Department of Surgical Science, "Tor Vergata" University, Rome, Italy
| | - Ermal Rica
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Gianmaria Cammarota
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, "Tor Vergata" University, Rome, Italy
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
| | - Giuseppe Vetrugno
- Catholic University of the Sacred Heart (UCSC), Rome, Italy
- Risk Management, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Salvatore Maurizio Maggiore
- Department of Innovative Technologies in Medicine & Dentistry, Section of Anesthesia and Intensive Care, "G. D'Annunzio" University, "SS. Annunziata" Hospital, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, "SS. Annunziata" Hospital, Chieti, Italy
| | - Frank Rasulo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency, "SS. Annunziata" Hospital, Chieti, Italy
- Department of Medical, Oral and Biotechnological Science, "G. d'Annunzio" Chieti-Pescara University, Chieti, Italy
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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.
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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
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Arsava EM, Ayvacioglu Cagan C, Gumeler E, Parlak S, Oguz KK, Topcuoglu MA. Comparison of early- and late-phase CT angiography findings in brain death. J Neurol 2022; 269:5973-5980. [PMID: 35842546 DOI: 10.1007/s00415-022-11281-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/05/2022] [Accepted: 07/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Late-phase images on computed tomography angiography (CTA), traditionally used for assessing cerebral circulatory arrest in brain death, suffer from suboptimal diagnostic yield due to stasis filling. Herein, we assessed contrast filling in individual intracranial arteries and veins in the early and late phases of CTA in patients with clinically confirmed brain death. METHODS Contrast opacification within 28 arterial/venous segments was evaluated in both phases of CTA in 79 patients. This information was combined with reports in the literature to calculate prevalence of contrast filling in different intracranial vessels. Additionally, diagnostic sensitivity of 4-point, 7-point, and 10-point scores defined for brain death were compared among ratings based on early, late, and both phases (arteries rated on early, veins rated on late phase) of imaging. RESULTS The median (IQR) number of vessel segments with contrast opacification was 0 (0-2) in early phase and 6 (0-10) in late phase. All segments showed increased prevalence of opacification when evaluated in late phase (p < 0.05). The M4 segments of MCA, internal cerebral veins, and vein of Galen had the lowest percentage of opacification in both phases. The sensitivity of 4-, 7-, and 10-point scoring algorithms increased from 59-91% to 94-99% when ratings were performed using early-phase images rather than based solely on late-phase images. CONCLUSIONS The incorporation of early-phase images might be considered as a strategy to improve the sensitivity of CTA as an ancillary test in confirming brain death, especially in patients without missing or questionable elements in clinical examination.
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Affiliation(s)
- Ethem Murat Arsava
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
| | | | - Ekim Gumeler
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Safak Parlak
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kader Karli Oguz
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Brasil S. Mistaken concepts on the use of ancillary testing in brain death diagnosis. Can J Anaesth 2022; 69:405-406. [PMID: 34939138 DOI: 10.1007/s12630-021-02185-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022] Open
Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, University of São Paulo, São Paulo, Brazil.
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Brasil S, Solla DJF, Nogueira RDC, Teixeira MJ, Malbouisson LMS, Paiva WDS. A Novel Noninvasive Technique for Intracranial Pressure Waveform Monitoring in Critical Care. J Pers Med 2021; 11:1302. [PMID: 34945774 PMCID: PMC8707681 DOI: 10.3390/jpm11121302] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We validated a new noninvasive tool (B4C) to assess intracranial pressure waveform (ICPW) morphology in a set of neurocritical patients, correlating the data with ICPW obtained from invasive catheter monitoring. MATERIALS AND METHODS Patients undergoing invasive intracranial pressure (ICP) monitoring were consecutively evaluated using the B4C sensor. Ultrasound-guided manual internal jugular vein (IJV) compression was performed to elevate ICP from the baseline. ICP values, amplitudes, and time intervals (P2/P1 ratio and time-to-peak [TTP]) between the ICP and B4C waveform peaks were analyzed. RESULTS Among 41 patients, the main causes for ICP monitoring included traumatic brain injury, subarachnoid hemorrhage, and stroke. Bland-Altman's plot indicated agreement between the ICPW parameters obtained using both techniques. The strongest Pearson's correlation for P2/P1 and TTP was observed among patients with no cranial damage (r = 0.72 and 0.85, respectively) to the detriment of those who have undergone craniotomies or craniectomies. P2/P1 values of 1 were equivalent between the two techniques (area under the receiver operator curve [AUROC], 0.9) whereas B4C cut-off 1.2 was predictive of intracranial hypertension (AUROC 0.9, p < 000.1 for ICP > 20 mmHg). CONCLUSION B4C provided biometric amplitude ratios correlated with ICPW variation morphology and is useful for noninvasive critical care monitoring.
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Affiliation(s)
- Sérgio Brasil
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Davi Jorge Fontoura Solla
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Ricardo de Carvalho Nogueira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Manoel Jacobsen Teixeira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | | | - Wellingson da Silva Paiva
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
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Zampakis P, Panagiotopoulos V, Kalogeropoulou C, Karachaliou M, Aretha D, Sioulas N, Dimoulia S, Karnabatidis D, Fligou F. Computed tomography angiography scoring systems and the role of skull defects in the confirmation of brain death. Sci Rep 2021; 11:15081. [PMID: 34302043 PMCID: PMC8302591 DOI: 10.1038/s41598-021-94763-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 07/15/2021] [Indexed: 01/07/2023] Open
Abstract
To assess and compare all current computed tomography angiography (CTA) scoring systems for the diagnostic workup of brain death (BD) to digital subtraction angiography (DSA) and clinical tests. Fifty-two patients with a clinical suspicion of BD underwent CTA and subsequently DSA. The diagnostic performance of all current CTA scoring systems was compared to that of DSA, in all patients with a suspicion of BD. A comparison to clinical tests was made only in DSA-positive for BD patients (n = 49), since in DSA-negative BD patients (n = 3) clinical tests were not performed. Further subgroup analysis was performed in relation to skull defects (SDs) stratification. Statistical analysis was conducted by applying statistics-contingency tables, Cochran's-Q test and McNemar's test. The CTA -10, and -7- and all 4-point scoring systems, showed overall sensitivities of 81,6%, 87.8% and 95.9% respectively and 100% specificity, when compared to DSA. In patients with a clinical verification of BD, the CTA -10 and -7-point scoring systems were significantly inferior to clinical tests (p = 0.004 and p = 0.031), while the 4-point scoring systems showed no such difference (p = 0.5). All 4-point scoring systems showed 100% sensitivity in patients with a minor SD or no SD. In patients with a major SD, all CTA scoring systems (- 10, - 7- and all 4-point) were less sensitive (62.5%, 62.5% and 75% respectively). The presence of a major SD was associated with an 8 × relative risk for false negative results in all 4-point scoring systems. CTA showed excellent diagnostic performance in patients with a suspicion of BD. The 4-point CTA scoring systems are the most sensitive for the diagnosis of BD, although in patients with a major SD patient, the role of CTA is ambiguous.
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Affiliation(s)
- Petros Zampakis
- Department of Radiology, University Hospital of Patras GR, 265 04, Patras, Greece.
| | | | | | - Maria Karachaliou
- Department of Radiology, University Hospital of Patras GR, 265 04, Patras, Greece
| | - Diamanto Aretha
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras. GR, 265 04, Patras, Greece
| | - Nektarios Sioulas
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras. GR, 265 04, Patras, Greece
| | - Sofia Dimoulia
- Department of Radiology, University Hospital of Patras GR, 265 04, Patras, Greece
| | | | - Fotini Fligou
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras. GR, 265 04, Patras, Greece
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Cerebral Hemodynamics and Intracranial Compliance Impairment in Critically Ill COVID-19 Patients: A Pilot Study. Brain Sci 2021; 11:brainsci11070874. [PMID: 34208937 PMCID: PMC8301789 DOI: 10.3390/brainsci11070874] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 12/18/2022] Open
Abstract
Introduction: One of the possible mechanisms by which the new coronavirus (SARS-Cov2) could induce brain damage is the impairment of cerebrovascular hemodynamics (CVH) and intracranial compliance (ICC) due to the elevation of intracranial pressure (ICP). The main objective of this study was to assess the presence of CVH and ICC alterations in patients with COVID-19 and evaluate their association with short-term clinical outcomes. Methods: Fifty consecutive critically ill COVID-19 patients were studied with transcranial Doppler (TCD) and non-invasive monitoring of ICC. Subjects were included upon ICU admission; CVH was evaluated using mean flow velocities in the middle cerebral arteries (mCBFV), pulsatility index (PI), and estimated cerebral perfusion pressure (eCPP), while ICC was assessed by using the P2/P1 ratio of the non-invasive ICP curve. A CVH/ICC score was computed using all these variables. The primary composite outcome was unsuccessful in weaning from respiratory support or death on day 7 (defined as UO). Results: At the first assessment (n = 50), only the P2/P1 ratio (median 1.20 [IQRs 1.00–1.28] vs. 1.00 [0.88–1.16]; p = 0.03) and eICP (14 [11–25] vs. 11 [7–15] mmHg; p = 0.01) were significantly higher among patients with an unfavorable outcome (UO) than others. Patients with UO had a significantly higher CVH/ICC score (9 [8–12] vs. 6 [5–7]; p < 0.001) than those with a favorable outcome; the area under the receiver operating curve (AUROC) for CVH/ICC score to predict UO was 0.86 (95% CIs 0.75–0.97); a score > 8.5 had 63 (46–77)% sensitivity and 87 (62–97)% specificity to predict UO. For those patients undergoing a second assessment (n = 29), after a median of 11 (5–31) days, all measured variables were similar between the two time-points. No differences in the measured variables between ICU non-survivors (n = 30) and survivors were observed. Conclusions: ICC impairment and CVH disturbances are often present in COVID-19 severe illness and could accurately predict an early poor outcome.
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