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Lambe G, Dempsey P, Bolger M, Bolster F. Self-harm, suicide and brain death: the role of the radiologist. Clin Radiol 2024; 79:239-249. [PMID: 38341342 DOI: 10.1016/j.crad.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 02/12/2024]
Abstract
Suicide is a leading cause of death worldwide and takes many forms, which include hanging, jumping from a height, sharp force trauma, ingestion/poisoning, drowning, and firearm injuries. Self-harm and suicide are associated with particular injuries and patterns of injury. Many of these patterns are apparent on imaging. Self-harm or suicidal intent may be overlooked initially in such cases, particularly when the patient is unconscious or uncooperative. Correct identification of these findings by the radiologist will allow a patient's management to be tailored accordingly and may prevent future suicide attempts. The initial role of the radiologists in these cases is to identify life-threatening injuries that require urgent medical attention. The radiologist can add value by drawing attention to associated injuries, which may have been missed on initial clinical assessment. In many cases of self-harm and suicide, imaging is more reliable than clinical assessment. The radiologist may be able to provide important prognostic information that allows clinicians to manage expectations and plan appropriately. Furthermore, some imaging studies will provide essential forensic information. Unfortunately, many cases of attempted suicide will end in brain death. The radiologist may have a role in these cases in identifying evidence of hypoxic-ischaemic brain injury, confirming a diagnosis of brain death through judicious use of ancillary tests and, finally, in donor screening for organ transplantation. A review is presented to illustrate the imaging features of self-harm, suicide, and brain death, and to highlight the important role of the radiologist in these cases.
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Affiliation(s)
- G Lambe
- Department of Radiology, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland.
| | - P Dempsey
- Department of Radiology, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland
| | - M Bolger
- Department of Radiology, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland
| | - F Bolster
- Department of Radiology, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland
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Computed Tomography Angiography (CTA) in Selected Scenarios with Risk of Possible False-Positive or False-Negative Conclusions in Diagnosing Brain Death. LIFE (BASEL, SWITZERLAND) 2022; 12:life12101551. [PMID: 36294986 PMCID: PMC9604663 DOI: 10.3390/life12101551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
It is widely accepted that brain death (BD) is a diagnosis based on clinical examination. However, false-positive and false-negative evaluation results may be serious limitations. Ancillary tests are used when there is uncertainty about the reliability of the neurologic examination. Computed tomography angiography (CTA) is an ancillary test that tends to have the lowest false-positive rates. However, there are various influencing factors that can have an unfavorable effect on the validity of the examination method. There are inconsistent protocols regarding the evaluation criteria such as scoring systems. Among the most widely used different scoring systems the 4-point CTA-scoring system has been accepted as the most reliable method. Appropriate timing and/or Doppler pre-testing could reduce the number of possible premature examinations and increase the sensitivity of CTA in diagnosing cerebral circulatory arrest (CCA). In some cases of inconclusive CTA, the whole brain computed tomography perfusion (CTP) could be a crucial adjunct. Due to the increasing significance of CTA/CTP in determining BD, the methodology (including benefits and limitations) should also be conveyed via innovative electronic training tools, such as the BRAINDEXweb teaching tool based on an expert system.
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Spears W, Mian A, Greer D. Brain death: a clinical overview. J Intensive Care 2022; 10:16. [PMID: 35292111 PMCID: PMC8925092 DOI: 10.1186/s40560-022-00609-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/06/2022] [Indexed: 01/01/2023] Open
Abstract
Brain death, also commonly referred to as death by neurologic criteria, has been considered a legal definition of death for decades. Its determination involves many considerations and subtleties. In this review, we discuss the philosophy and history of brain death, its clinical determination, and special considerations. We discuss performance of the main clinical components of the brain death exam: assessment of coma, cranial nerves, motor testing, and apnea testing. We also discuss common ancillary tests, including advantages and pitfalls. Special discussion is given to extracorporeal membrane oxygenation, target temperature management, and determination of brain death in pediatric populations. Lastly, we discuss existing controversies and future directions in the field.
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Affiliation(s)
- William Spears
- Department of Neurology, Boston University, Boston Medical Center, 85 East Concord Street, Room 1145, Boston, MA, 02118, USA
| | - Asim Mian
- Department of Radiology, Boston University, Boston Medical Center, 820 Harrison Avenue FGH, 3rd floor, Boston, USA
| | - David Greer
- Department of Neurology, Boston University, Boston Medical Center, 85 East Concord Street, Room 1145, Boston, MA, 02118, USA.
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4
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Corrêa DG, de Souza SR, Nunes PGC, Coutinho Jr. AC, da Cruz Jr. LCH. The role of neuroimaging in the determination of brain death. Radiol Bras 2022; 55:365-372. [PMID: 36514681 PMCID: PMC9743262 DOI: 10.1590/0100-3984.2022.0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/24/2022] [Indexed: 11/16/2022] Open
Abstract
Brain death is the irreversible cessation of all brain function. Although protocols for its determination vary among countries, the concept of brain death is widely accepted, despite ethical and religious issues. The pathophysiology of brain death is related to hypoxia and ischemia in the setting of extensive brain injury. It is also related to the effects of brain edema, which increases intracranial pressure, leading to cerebral circulatory arrest. Although the diagnosis of brain death is based on clinical parameters, the use of neuroimaging to demonstrate diffuse brain injury as the cause of coma prior to definitive clinical examination is a prerequisite. Brain computed tomography (CT) and magnetic resonance imaging (MRI) demonstrate diffuse edema, as well as ventricular and sulcal effacement, together with brain herniation. Angiography (by CT or MRI) demonstrates the absence of intracranial arterial and venous flow. In some countries, electroencephalography, cerebral digital subtraction angiography, transcranial Doppler ultrasound, or scintigraphy/single-photon emission CT are currently used for the definitive diagnosis of brain death. Although the definition of brain death relies on clinical features, radiologists could play an important role in the early recognition of global hypoxic-ischemic injury and the absence of cerebral vascular perfusion.
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Affiliation(s)
- Diogo Goulart Corrêa
- Department of Radiology, Clínica de Diagnóstico por Imagem
(CDPI)/Dasa, Rio de Janeiro, RJ, Brazil. , Department of Radiology, Universidade Federal Fluminense (UFF),
Niterói, RJ, Brazil. ,Correspondence: Dr. Diogo Goulart Corrêa. Clínica de
Diagnóstico por Imagem (CDPI)/Dasa – Departamento de Radiologia. Avenida das
Américas, 4666, Barra da Tijuca. Rio de Janeiro, RJ, Brazil, 22640-102.
| | - Simone Rachid de Souza
- Department of Pathology, Universidade Federal do Rio de Janeiro (UFRJ), Rio
de Janeiro, RJ, Brazil.
| | | | - Antonio Carlos Coutinho Jr.
- Department of Radiology, Clínica de Diagnóstico por Imagem
(CDPI)/Dasa, Rio de Janeiro, RJ, Brazil. , Department of Radiology, Fátima Digittal, Casa de Saúde Nossa
Senhora de Fátima, Nova Iguaçu, RJ, Brazil.
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5
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Thomson D, Joubert I, De Vasconcellos K, Paruk F, Mokogong S, Mathivha R, McCulloch M, Morrow B, Baker D, Rossouw B, Mdladla N, Richards GA, Welkovics N, Levy B, Coetzee I, Spruyt M, Ahmed N, Gopalan D. South African guidelines on the determination of death. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2021; 37:10.7196/SAJCC.2021v37i1b.466. [PMCID: PMC10193841 DOI: 10.7196/sajcc.2021v37i1b.466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 05/20/2023] Open
Abstract
Summary
Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis
and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination
of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South
African context and legal system. The aim is to provide clear medical standards for healthcare providers to follow in the determination
of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will
provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken
with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence.
The consensus guidelines were compiled using the AGREE II checklist with an 18-member expert panel participating in a three-round
modified Delphi process. Checklists and advice sheets were created to assist with application of these guidelines in the clinical environment
(https://criticalcare.org.za/resource/death-determination-checklists/). Key points Brain death and circulatory death are the accepted terms for defining death in the hospital context. Death determination is a clinical diagnosis which can be made with complete certainty provided that all preconditions are met. The determination of death in children is held to the same standard as in adults but cannot be diagnosed in children <36 weeks’ corrected
gestation. Brain-death testing while on extra-corporeal membrane oxygenation is outlined. Recommendations are given on handling family requests for accommodation and on consideration of the potential for organ donation. The use of a checklist combined with a rigorous testing process, comprehensive documentation and adequate counselling of the family
are core tenets of death determination. This is a standard of practice to which all clinicians should adhere in end-of-life care.
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Affiliation(s)
- D Thomson
- Division of Critical Care, Department of Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - I Joubert
- Division of Critical Care, Department of Anaesthesia and Peri-operative Medicine, University of Cape Town and Groote Schuur Hospital,
Cape Town, South Africa
| | - K De Vasconcellos
- Department of Critical Care, King Edward VIII Hospital, Durban, South Africa; Discipline of Anaesthesiology and Critical Care, School of Clinical
Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - F Paruk
- Department of Critical Care, University of Pretoria, South Africa
| | - S Mokogong
- Department of Neurosurgery, University of Pretoria, South Africa
| | - R Mathivha
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M McCulloch
- Paediatric Intensive Care Unit and Transplant Unit, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of
Cape Town, South Africa
| | - B Morrow
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - D Baker
- Department of Adult Critical Care, Livingstone Hospital and Faculty of Health Sciences, Walter Sisulu University, Port Elizabeth, South Africa
| | - B Rossouw
- Paediatric Intensive Care Unit, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
| | - N Mdladla
- Dr George Mukhari Academic Hospital, Sefako Makgatho University, Johannesburg, South Africa
| | - G A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - N Welkovics
- Netcare Unitas Hospital, Centurion, South Africa
| | - B Levy
- Netcare Rosebank Hospital, Johannesburg, South Africa
| | - I Coetzee
- Department of Nursing Science, University of Pretoria, South Africa
| | - M Spruyt
- Busamed Bram Fischer International Airport Hospital, Bloemfontein, South Africa
| | - N Ahmed
- Consolidated Critical Care Unit, Tygerberg Hospital, Department of Surgical Sciences, Department of Anaesthesiology and Critical Care, Faculty
of Medicine and Health Sciences, Stellenbosch University, Cape Town
| | - D Gopalan
- Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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Jeon BU, Yu IK, Kim TK, Kim HY, Hwang S. Susceptibility-Weighted Imaging as a Distinctive Imaging Technique for Providing Complementary Information for Precise Diagnosis of Neurologic Disorder. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2021; 82:99-115. [PMID: 36237474 PMCID: PMC9432415 DOI: 10.3348/jksr.2020.0054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/17/2020] [Accepted: 07/11/2020] [Indexed: 01/25/2023]
Abstract
Various sequences have been developed for MRI to aid in the radiologic diagnosis. Among the various MR sequences, susceptibility-weighted imaging (SWI) is a high-spatial-resolution, three-dimensional gradient-echo MR sequence, which is very sensitive in detecting deoxyhemoglobin, ferritin, hemosiderin, and bone minerals through local magnetic field distortion. In this regard, SWI has been used for the diagnosis and treatment of various neurologic disorders, and the improved image quality has enabled to acquire more useful information for radiologists. Here, we explain the principle of various signals on SWI arising in neurological disorders and provide a retrospective review of many cases of clinically or pathologically proven disease or components with distinctive imaging features of various neurological diseases. Additionally, we outline a short and condensed overview of principles of SWI in relation to neurological disorders and describe various cases with characteristic imaging features on SWI. There are many different types diseases involving the brain parenchyma, and they have distinct SWI features. SWI is an effective imaging tool that provides complementary information for the diagnosis of various diseases.
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Affiliation(s)
- Byeong-Uk Jeon
- Department of Radiology, Eulji University Hospital, Daejeon, Korea
| | - In Kyu Yu
- Department of Radiology, Eulji University Hospital, Daejeon, Korea
| | - Tae Kun Kim
- Department of Radiology, Eulji University Hospital, Daejeon, Korea
| | - Ha Youn Kim
- Department of Radiology, Eulji University Hospital, Daejeon, Korea
| | - Seungbae Hwang
- Department of Radiology, Chonbuk National University Hospital, Jeonju, Korea
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7
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Greer DM, Shemie SD, Lewis A, Torrance S, Varelas P, Goldenberg FD, Bernat JL, Souter M, Topcuoglu MA, Alexandrov AW, Baldisseri M, Bleck T, Citerio G, Dawson R, Hoppe A, Jacobe S, Manara A, Nakagawa TA, Pope TM, Silvester W, Thomson D, Al Rahma H, Badenes R, Baker AJ, Cerny V, Chang C, Chang TR, Gnedovskaya E, Han MK, Honeybul S, Jimenez E, Kuroda Y, Liu G, Mallick UK, Marquevich V, Mejia-Mantilla J, Piradov M, Quayyum S, Shrestha GS, Su YY, Timmons SD, Teitelbaum J, Videtta W, Zirpe K, Sung G. Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project. JAMA 2020; 324:1078-1097. [PMID: 32761206 DOI: 10.1001/jama.2020.11586] [Citation(s) in RCA: 262] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
IMPORTANCE There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries. OBJECTIVE To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel. PROCESS Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery. EVIDENCE SYNTHESIS Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed. RECOMMENDATIONS Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability. CONCLUSIONS AND RELEVANCE This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.
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Affiliation(s)
- David M Greer
- Boston University School of Medicine, Boston, Massachusetts
| | - Sam D Shemie
- McGill University, Montreal Children's Hospital, Montreal, Canada
- Canadian Blood Services, Ottawa, Canada
| | | | | | | | | | - James L Bernat
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | | | - Anne W Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis
| | - Marie Baldisseri
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas Bleck
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Arnold Hoppe
- Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Stephen Jacobe
- University of Sydney and Children's Hospital of Westmead, Westmead, Australia
| | | | | | | | | | | | | | - Rafael Badenes
- Hospital Clinic Universitari, University of Valencia, Valencia, Spain
| | - Andrew J Baker
- St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Canada
| | - Vladimir Cerny
- J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic
| | | | - Tiffany R Chang
- The University of Texas Health Science Center at Houston, Houston
| | | | - Moon-Ku Han
- Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | | | | | | | - Gang Liu
- Capital Medical University, Beijing, China
| | | | | | | | | | | | | | | | | | | | - Walter Videtta
- National Hospital, Alejandro Posadas, Buenos Aires, Argentina
| | | | - Gene Sung
- University of Southern California, Los Angeles
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8
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Huang H, Eichelberger H, Chan M, Valdes E, Kister I, Krupp L, Weinberg H, Galetta S, Frontera J, Zhou T, Kahn DE, Lord A, Lewis A. Pearls & Oy-sters: Leukoencephalopathy in critically ill patients with COVID-19. Neurology 2020; 95:753-757. [PMID: 32788252 DOI: 10.1212/wnl.0000000000010636] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Hao Huang
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY.
| | - Hillary Eichelberger
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
| | - Monica Chan
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
| | - Eduard Valdes
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
| | - Ilya Kister
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
| | - Lauren Krupp
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
| | - Harold Weinberg
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
| | - Steven Galetta
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
| | - Jennifer Frontera
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
| | - Ting Zhou
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
| | - D Ethan Kahn
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
| | - Aaron Lord
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
| | - Ariane Lewis
- From the Departments of Neurology (H.H., H.E., M.C., E.V., I.K., L.K., H.W., S.G., J.F., T.Z., D.E.K., A. Lord, A. Lewis) and Neurosurgery (J.F., T.Z., D.E.K., A. Lord, A. Lewis), NYU Langone Medical Center, New York, NY
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9
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Jang J, Oh SH, Nam Y, Lee K, Choi HS, Jung SL, Ahn KJ, Park KN, Kim BS. Prognostic value of phase information of 2D T2*-weighted gradient echo brain imaging in cardiac arrest survivors: A preliminary study. Resuscitation 2019; 140:142-149. [PMID: 31153942 DOI: 10.1016/j.resuscitation.2019.05.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/20/2019] [Accepted: 05/23/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Predicting neurological outcomes after cardiac arrest is important to guide therapeutic decisions. We assessed the prognostic value of phase information of 2D T2*-weighted gradient echo imaging (T2*WI) of the brain in CA survivors. METHODS This study included cardiac arrest survivors who had undergone MRI for prognostication. After application of homodyne filtering to T2*WI phase images, the contrast of three venous structures was assessed as normal (score 0) or abnormal (score 1): the superior sagittal sinus, the cortical veins, and the thalamostriate veins. The scores were summarized into a gradient-recalled echo (GRE) summary score. The prognostic performances of T2*WI, diffusion-weighted imaging (DWI), electroencephalography and serum biomarkers were evaluated using receiver operating characteristic (ROC) curves. RESULTS Of the 39 enrolled patients, 12 (31%) had good outcomes and 27 (69%) had poor outcomes. ROC curve analysis showed that T2*WI had good prognostic performance; the area under the curve (AUC) of the GRE summary score (0.980, 95% confidence interval CI 0.950-1.000) was comparable to those of conventional outcome predictors, including DWI patterns (0.949, 95% CI 0.889-1.000). The AUC increased when the summary GRE score was added to DWI patterns (0.991, 95% CI 0.973-1.000), although the difference was not statistically significant (P=0.117). Most subjects with isoelectric electroencephalography (5/6) showed abnormally high phase contrast in the cerebral veins. CONCLUSIONS Filtered phase images of T2*WI showed good prognostic value and can reveal various features of the cerebral metabolic consequences of cardiac arrest, such as decreased neuronal activity and brain death-like patterns.
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Affiliation(s)
- Jinhee Jang
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Yoonho Nam
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kijeong Lee
- Department of Neurology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Seok Choi
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - So-Lyung Jung
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kook-Jin Ahn
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bum-Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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10
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Rizvi T, Batchala P, Mukherjee S. Brain Death: Diagnosis and Imaging Techniques. Semin Ultrasound CT MR 2018; 39:515-529. [DOI: 10.1053/j.sult.2018.01.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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11
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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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12
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Park JE, Han K, Sung YS, Chung MS, Koo HJ, Yoon HM, Choi YJ, Lee SS, Kim KW, Shin Y, An S, Cho HM, Park SH. Selection and Reporting of Statistical Methods to Assess Reliability of a Diagnostic Test: Conformity to Recommended Methods in a Peer-Reviewed Journal. Korean J Radiol 2017; 18:888-897. [PMID: 29089821 PMCID: PMC5639154 DOI: 10.3348/kjr.2017.18.6.888] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 07/28/2017] [Indexed: 12/13/2022] Open
Abstract
Objective To evaluate the frequency and adequacy of statistical analyses in a general radiology journal when reporting a reliability analysis for a diagnostic test. Materials and Methods Sixty-three studies of diagnostic test accuracy (DTA) and 36 studies reporting reliability analyses published in the Korean Journal of Radiology between 2012 and 2016 were analyzed. Studies were judged using the methodological guidelines of the Radiological Society of North America-Quantitative Imaging Biomarkers Alliance (RSNA-QIBA), and COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) initiative. DTA studies were evaluated by nine editorial board members of the journal. Reliability studies were evaluated by study reviewers experienced with reliability analysis. Results Thirty-one (49.2%) of the 63 DTA studies did not include a reliability analysis when deemed necessary. Among the 36 reliability studies, proper statistical methods were used in all (5/5) studies dealing with dichotomous/nominal data, 46.7% (7/15) of studies dealing with ordinal data, and 95.2% (20/21) of studies dealing with continuous data. Statistical methods were described in sufficient detail regarding weighted kappa in 28.6% (2/7) of studies and regarding the model and assumptions of intraclass correlation coefficient in 35.3% (6/17) and 29.4% (5/17) of studies, respectively. Reliability parameters were used as if they were agreement parameters in 23.1% (3/13) of studies. Reproducibility and repeatability were used incorrectly in 20% (3/15) of studies. Conclusion Greater attention to the importance of reporting reliability, thorough description of the related statistical methods, efforts not to neglect agreement parameters, and better use of relevant terminology is necessary.
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Affiliation(s)
- Ji Eun Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Kyunghwa Han
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Yu Sub Sung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Mi Sun Chung
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul 06973, Korea
| | - Hyun Jung Koo
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Young Jun Choi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Youngbin Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Suah An
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Hyo-Min Cho
- Korea Research Institute of Standards and Science, Daejeon 34113, Korea
| | - Seong Ho Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
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Lanfermann H. [Angiographic procedures for determination of cessation of cerebral circulation]. DER NERVENARZT 2016; 87:144-8. [PMID: 26810326 DOI: 10.1007/s00115-015-0047-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In several European countries catheter angiography is permitted as a confirmatory procedure for the determination of irreversible loss of brain function (brain death). In Germany catheter angiography requires the possibility of a therapeutic implication as a prerequisite. In the updated German guidelines computed tomography angiography (CTA) has been accredited as a new confirmatory procedure if a standardized protocol and predefined assessment parameters are adhered to. The CTA can be performed within a few minutes, even in situations with unstable intensive care patients. Magnetic resonance (MR) angiography has not yet been adequately validated and is not permitted in Germany as a confirmatory procedure for the determination of irreversible loss of brain function.
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Affiliation(s)
- H Lanfermann
- Institut für Diagnostische und Interventionelle Neuroradiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
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Choi YJ, Chung MS, Koo HJ, Park JE, Yoon HM, Park SH. Does the Reporting Quality of Diagnostic Test Accuracy Studies, as Defined by STARD 2015, Affect Citation? Korean J Radiol 2016; 17:706-14. [PMID: 27587959 PMCID: PMC5007397 DOI: 10.3348/kjr.2016.17.5.706] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 05/29/2016] [Indexed: 01/30/2023] Open
Abstract
Objective To determine the rate with which diagnostic test accuracy studies that are published in a general radiology journal adhere to the Standards for Reporting of Diagnostic Accuracy Studies (STARD) 2015, and to explore the relationship between adherence rate and citation rate while avoiding confounding by journal factors. Materials and Methods All eligible diagnostic test accuracy studies that were published in the Korean Journal of Radiology in 2011–2015 were identified. Five reviewers assessed each article for yes/no compliance with 27 of the 30 STARD 2015 checklist items (items 28, 29, and 30 were excluded). The total STARD score (number of fulfilled STARD items) was calculated. The score of the 15 STARD items that related directly to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 was also calculated. The number of times each article was cited (as indicated by the Web of Science) after publication until March 2016 and the article exposure time (time in months between publication and March 2016) were extracted. Results Sixty-three articles were analyzed. The mean (range) total and QUADAS-2-related STARD scores were 20.0 (14.5–25) and 11.4 (7–15), respectively. The mean citation number was 4 (0–21). Citation number did not associate significantly with either STARD score after accounting for exposure time (total score: correlation coefficient = 0.154, p = 0.232; QUADAS-2-related score: correlation coefficient = 0.143, p = 0.266). Conclusion The degree of adherence to STARD 2015 was moderate for this journal, indicating that there is room for improvement. When adjusted for exposure time, the degree of adherence did not affect the citation rate.
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Affiliation(s)
- Young Jun Choi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Mi Sun Chung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Hyun Jung Koo
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Ji Eun Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seong Ho Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
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15
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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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