Transcranial Doppler in Brain Death Confirmation in Clinical Practice

A. Lovrencic-Huzjan; V. Vukovic; A. Gopcevic; M. Vucic; V. Kriksic; V. Demarin

doi:10.1055/s-0029-1245237

Ultraschall in der Medizin - European Journal of Ultrasound, Table of Contents

Ultraschall Med 2011; 32(1): 62-66
DOI: 10.1055/s-0029-1245237

Originalarbeiten/Original Article

Transcranial Doppler in Brain Death Confirmation in Clinical Practice

Klinische Wertigkeit der transkraniellen Dopplersonografie in der HirntoddiagnostikA. Lovrencic-Huzjan¹ , V. Vukovic¹ , A. Gopcevic² , M. Vucic² , V. Kriksic² , V. Demarin¹

¹University Department of Neurology, University hospital ”Sestre milosrdnice”, Zagreb
²Department of Anesthesiology, University hospital ”Sestre milosrdnice”, Zagreb

Abstract

Zusammenfassung

Ziel: Die transkranielle Dopplersonografie (TCD) kann in der Hirntoddiagnostik als apparative Zusatzuntersuchung angewendet werden. Ziel der Studie war die Darstellung des Nutzens der TCD zur Bestätigung des Hirntodes. Material und Methoden: Vierundvierzig Patienten mit zum Hirntod führender schwerer Hirnschädigung wurden im Verlauf von 4 Jahren untersucht. Nach klinischer Hirntoddiagnostik erfolgte der adäquate apparative Bestätigungstest entsprechend der Verfassung des Patienten und unter Berücksichtigung der Ausschlusskriterien des Studienprotokolls. Aufgrund nicht eindeutiger Ergebnisse mussten einige Patienten wiederholt untersucht werden. Ergebnisse: Von 44 eingeschlossenen Patienten hatten 19 ein Schädel-Hirn-Trauma, 11 massive aneurysmatische Subarachnoidalblutungen, 1 Patient eine arteriovenöse subarachnoidale und intrazerebrale Blutung, 12 hypertensive intrazerebrale Blutungen und 1 Patient einen ischämischen Schlaganfall. Als Primärtest wurde eine TCD bei 30 Patienten, eine Hirnszintigrafie bei 2, eine CT-Angiografie (CTA) bei 10, und eine konventionelle zerebrale Angiografie bei 2 Patienten durchgeführt. Die Diagnose konnte hiermit bei jeweils 26, 3, 9, bzw. 2 Patienten bestätigt werden. Aufgrund nicht konklusiver Ergebnisse musste die CTA bei 5 Patienten wiederholt werden. Bei den mit TCD untersuchten Patienten war die Zeitdauer bis zur Diagnosestellung am kürzesten; bei der Mehrzahl der Patienten (61 %) konnte die Diagnose des zerebralen Zirkulationsstillstandes binnen 2 Stunden nach der klinischen Hirntoddiagnose bestätigt werden. Schlussfolgerung: Die TCD ist eine Erfolg versprechende Zusatzuntersuchung zur Bestätigung des zerebralen Zirkulationsstillstandes in der Hirntoddiagnostik.

Abstract

Purpose: Transcranial Doppler (TCD) can be used as a confirmatory test in brain death. The aim was to present the usefulness of TCD in brain death confirmation. Materials and Methods: Forty-four patients with severe brain lesions leading to brain death were treated over a 4-year period. After the clinical diagnosis of brain death was made, the appropriate confirmatory test was chosen according to patient condition, taking into consideration the restrictions of the test protocol. Due to the inconclusive test results, some patients underwent repeat testing. Results: Among 44 patients, 19 had neurotrauma, 11 massive aneurysmal subarachnoidal hemorrhages, 1 arteriovenous subarachnoidal and parenchymal hemorrhage, 12 hypertensive parenchymal hemorrhages, and 1 ischemic stroke. As a primary test, TCD was used in 30, brain scintigraphy in 2, multislice CT angiography (CTA) in 10, and cerebral angiography in 2 patients, and the diagnosis was confirmed in 26, 3, 9 and 2 patients, respectively. Due to inconclusive results CTA was repeated in five patients. In patients in whom TCD was applied, the time to confirm the diagnosis was the shortest, and in most (61 %) cerebral circulatory arrest was confirmed within 2 hours of clinical diagnosis. Conclusion: TCD is a favorable confirmatory test for cerebral circulatory arrest in brain death diagnosis.

Key words

brain - testes - ultrasound Doppler

Full Text

References

1 Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA. 1968; 205 337-340
2 Wijdicks E FM. Determining brain death in adults. Neurology. 1995; 45 1003-1011
3 Report of the Quality Standards Subcommittee of the American Academy of Neurology. Practice parameters for determining brain death in adults (Summary statement). Neurology. 1995; 45 1012-1014
4 Wijdicks E FM. Brain death worldwide. Accepted fact but no global consensus in diagnostic criteria. Neurology. 2002; 58 20-25
5 Greer D M, Varelas P, Haque S. et al . Variability of brain death determination guidelines in leading US neurologic institutions. Neurology. 2008; 70 284-289
6 Zakon o uzimanju i presadivanju dijelova ljudskog tijela u svrhu lijecenja. Narodne novine. 2004; 177 3080
7 Pravilnik o nacinu, postupku i medicinskim kriterijima za utvrdivanje smrti osobe ciji se dijelovi tijela mogu uzimati radi presadivanja. Narodne novine. 2006; 3 92
8 Demarin V, Lovrencic-Huzjan A, Vargek-Solter V. et al . Consensus opinion on diagnosing brain death -guidelines for use of confirmatory tests. Report of Croatian Neurovascular Society and University Department of Neurology, Sestre milosrdnice University Hospital, Reference Center for Neurovascular Disorders and the Ministry of Health of Republic of Croatia. Acta clin Croat. 2005; 44 65-79
9 Ducrocq X, Hassler W, Moritake K. et al . Consensus opinion on diagnosis of cerebral circulatory arrest using Doppler sonography. Task Force Group on cerebral death of the Neurosonology Research Group of the World Federation of Neurology. J Neurol Sci. 1998; 159 145-150
10 Lovrencic-Huzjan A, Vukovic V, Jergovic K. et al . Transcranial Doppler as a confirmatory test in brain death. Acta Clin Croat. 2006; 45 365-373
11 Lovrencic-Huzjan A, Vukovic V, Demarin V. Neurosonology in stroke. Acta Clin Croat. 2006; 45 385-401
12 Sloan M A, Alexandrov A V, Tegeler C H. et al . Assessment: Transcranial Doppler ultrasonography. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2004; 62 1468-1481
13 Quereshi A I, Kirmani J F, Xavier A R. et al . Computed tomographic angiography for diagnosis of brain death. Neurology. 2004; 62 5652-653
14 Leclerc X, Taschner C A, Vidal A. et al . The role of spiral CT for the assessment of the intracranial circulation in suspected brain-death. J Neuroradiol. 2006; 33 90-95
15 Ducrocq X, Braun M, Debouverie M. et al . Brain death and transcranial Doppler: experience in 130 cases of brain dead patients. J Neurol Sci. 1998; 160 41-46
16 Kuo J R, Chen C F, Chio C C. et al . Time dependent validity in the diagnosis of brain death using transcranial Doppler sonography. J Neurol Neurosurg Psychiatry. 2006; 77 646-649
17 Dosemeci L, Dora B, Yilmaz M. et al . Utility of transcranial Doppler ultrasonography for confirmatory diagnosis of brain death: two sides of the coin. Transplantation. 2004; 77 71-75
18 Freitas A G, Andre de C. Sensitivity of transcranial Doppler for confirming brain death: a prospective study of 270 cases. Acta Neurol Scand. 2006; 113 426-432
19 Poularas J, Karakitsos D, Kouraklis G. et al . Comparison between transcranial color Doppler ultrasonography and angiography in the confirmation of brain death. Transplant Proc. 2006; 38 1213-1217
20 Monteiro L M, Bollen C W, Huffelen A C. et al . Transcranial Doppler ultrasonography to confirm brain death: a meta-analysis. Intensive Care Med. 2006; 32 1937-1944
21 Quesnel van C, Fulgencio J P, Adrie C. et al . Limitations of computed tomographic angiography in the diagnosis of brain death. Intensive Care Med. 2007; 33 2129-2135
22 Frampas E, Videcoq M, Kerviler de E. et al . CT Angiography for brain death diagnosis. AJNR, Online-Publication. 2009; DOI: 10.3174 /ajnr.A 1614

Prof. Arijana Lovrencic-Huzjan

Department of Neurology, University hospital ”Sestre milosrdnice”, Zagreb

Vinogradska 29

10 000 Zagreb, Kroatia

Phone: ++ 3 85/1/3 76 82 82

Fax: ++ 3 85/1/3 76 82 82

Email: arijana.lovrencic-huzjan@zg.htnet.hr