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The role of cervical color Doppler ultrasound in the diagnosis of brain death

  • Alessandro Pedicelli
  • Margherita Bartocci
  • Emilio Lozupone
  • Francesco D’Argento
  • Andrea Alexandre
  • Giuseppe Garignano
  • Ciro D’Alò
  • Viola Giacobbe
  • Iacopo Valente
  • Cesare Colosimo
Diagnostic Neuroradiology
  • 65 Downloads

Abstract

Purpose

Brain death (BD) is defined as the irreversible destruction of all brain functions. It is usually diagnosed through a clinical examination, but in certain circumstances, ancillary examinations (such as digital subtraction angiography (DSA), transcranial color Doppler (TCD), computed tomography angiography (CTA), magnetic resonance angiography (MRA), or radionuclide scanning) are required as confirmatory tests. In many countries, cervical color Doppler sonography (CCD) is not recognized as a valid test.

The aim of our study is to assess its accuracy as a non-invasive, inexpensive, and easily available examination to determine cerebral circulatory arrest (CCA).

Methods

We performed a retrospective study in which 123 patients with clinical diagnosis of BD underwent bedside cervical color Doppler as an additional examination for CCA assessment. We compared these cervical color Doppler findings with the results of validated ancillary tests such as CTA, TCD, and DSA.

Results

Cervical color Doppler exams showed a sensitivity of 78% (96/123 patients) in detecting CCA compared to standard ancillary tests. Twenty-seven patients showed a persistent diastolic flow in one or two of the four arterial vessels examined and thus considered as false negatives.

Conclusion

Our results show that cervical color Doppler may become a reliable and safe technique in detecting CCA, which can shorten the time for declaring brain death. In particular, in patients lacking good bone windows at transcranial color Doppler, cervical color Doppler of the cervical internal carotids and vertebral arteries could be recommended to increase the sensitivity of transcranial color Doppler, or as an alternative bedside examination.

Keywords

Brain death Cerebral circulatory arrest Transcranial color Doppler Cervical color Doppler Ancillary test 

Notes

Compliance with ethical standards

Funding

No funding was received for this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

Informed consent

For this type of retrospective study formal consent is not required.

References

  1. 1.
    Monteiro LM, Bollen CW, Van Huffelen AC et al (2006) Transcranial Doppler ultrasonography to confirm brain death: a meta-analysis. Intensive Care Med 32:1937–1944.  https://doi.org/10.1007/s00134-006-0353-9 CrossRefPubMedGoogle Scholar
  2. 2.
    Wijdicks E (2002) Brain death worldwide: accepted fact but no global consensus in diagnostic criteria. Neurology 58:20–25CrossRefGoogle Scholar
  3. 3.
    Wijdicks EF, Varelas PN, Gronseth GS, et al (2010) Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 74:1911–1918 . doi:  https://doi.org/10.1212/WNL.0b013e3181e242a8 CrossRefGoogle Scholar
  4. 4.
    Machado C (2010) Diagnosis of brain death. Neurol Int 2:7–13.  https://doi.org/10.4081/ni.2010.e2 CrossRefGoogle Scholar
  5. 5.
    Centro Nazionale Trapianti (2009) Linee guida: applicazione delle indagini strumentali di flusso ematico cerebraleGoogle Scholar
  6. 6.
    Ministero della Sanità (1994) DM n. 582 del 22 agosto 1994 “Regolamento recante le modalità per l’accertamento e la certificazione di morte. Vol. IGoogle Scholar
  7. 7.
    Kramer AH (2015) Ancillary testing in brain death. Semin Neurol 2:125–138.  https://doi.org/10.1055/s-0035-1547541 CrossRefGoogle Scholar
  8. 8.
    Heran MKS, Heran NS, Shemie SD (2008) Review article a review of ancillary tests in evaluating brain deathGoogle Scholar
  9. 9.
    Mata-Zubillaga D, Oulego-Erroz I (2012) Persistent cerebral blood flow by transcranial Doppler ultrasonography in an asphyxiated newborn meeting brain death diagnosis: case report and review of the literature. J Perinatol 32:473–475.  https://doi.org/10.1038/jp.2011.147 CrossRefPubMedGoogle Scholar
  10. 10.
    Cabrer C, Domínguez-Roldan JM, Manyalich M et al (2003) Persistence of intracranial diastolic flow in transcranial Doppler sonography exploration of patients in brain death. Transplant Proc 35:1642–1643.  https://doi.org/10.1016/S0041-1345(03)00692-4 CrossRefPubMedGoogle Scholar
  11. 11.
    Marinoni M, Alari F, Mastronardi V, Peris A, Innocenti P (2011) The relevance of early TCD monitoring in the intensive care units for the confirming of brain death diagnosis. Neurol Sci 32:73–77.  https://doi.org/10.1007/s10072-010-0407-1 CrossRefPubMedGoogle Scholar
  12. 12.
    Welschehold S, Boor S, Reuland K, Thömke F, Kerz T, Reuland A, Beyer C, Gartenschläger M, Wagner W, Giese A, Müller-Forell W (2012) Apparative Zusatzverfahren bei der Hirntoddiagnostik: Ein Vergleich von SEP, AEP, EEG, TCD und CT-Angiographie. Dtsch Arztebl Int 109:624–630.  https://doi.org/10.3238/arztebl.2012.0624 CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Ducrocq X, Hassler W, Moritake K, Newell DW, von Reutern GM, Shiogai TSR (1998) 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 159:145–150CrossRefGoogle Scholar
  14. 14.
    The Quality Standards Subcommittee of the American Academy of Neurology (1995) Practice parameters for determining brain death in adults (summary statement). Neurology 45:1012–1014CrossRefGoogle Scholar
  15. 15.
    Aaslid R, Markwalder T-M, Nornes H (1982) Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 57:769–774.  https://doi.org/10.3171/jns.1982.57.6.0769 CrossRefPubMedGoogle Scholar
  16. 16.
    Kirsch JD, Mathur M, Johnson MH, Gowthaman G, Scoutt LM (2013) *Doppler technique: advances in transcranial Doppler US: imaging ahead. Radiographics 33:E1–E14.  https://doi.org/10.1148/rg.331125071 CrossRefPubMedGoogle Scholar
  17. 17.
    Ducrocq X, Braun M, Debouverie M, Junges C, Hummer M, Vespignani H (1998) Brain death and transcranial Doppler: experience in 130 cases of brain dead patients. J Neurol Sci 18:41–46CrossRefGoogle Scholar
  18. 18.
    Centro Nazionale Trapianti (2014) Emendamento alle Lineeguida nazionali della Consulta “Applicazione delle indagini strumentali di flusso ematico cerebrale” emanate il 20 febbraio 2009Google Scholar
  19. 19.
    Escudero D, Otero J, Marqués L, Parra D, Gonzalo JA, Albaiceta GM, Cofiño L, Blanco A, Vega P, Murias E, Meilan Á, Roger RL, Taboada F (2009) Diagnosing brain death by CT perfusion and multislice CT angiography. Neurocrit Care 11:261–271.  https://doi.org/10.1007/s12028-009-9243-7 CrossRefPubMedGoogle Scholar
  20. 20.
    Gardiner D, Shemie S, Manara A, Opdam H (2012) International perspective on the diagnosis of death. Br J Anaesth 108:i14–i28.  https://doi.org/10.1093/bja/aer397 CrossRefPubMedGoogle Scholar
  21. 21.
    (1996) Décret no 96–1041 du 2 décembre 1996 relatif au constat de la mort préalable au prélèvement d’organes, de tissus et de cellules à des fins thérapeutiques ou scientifiques et modifiant le code de la santé publique. 17615Google Scholar
  22. 22.
    Chassé M, Glen P, Doyle M-A, McIntyre L, English SW, Knoll G, Lizé JF, Shemie SD, Martin C, Turgeon AF, Lauzier F, Fergusson DA (2013) Ancillary testing for diagnosis of brain death: a protocol for a systematic review and meta-analysis. Syst Rev 2:100.  https://doi.org/10.1186/2046-4053-2-100 CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Citerio G, Crippa IA, Bronco A, Vargiolu A, Smith M (2014) Variability in brain death determination in Europe: looking for a solution. Neurocrit Care 21:376–382.  https://doi.org/10.1007/s12028-014-9983-x CrossRefPubMedGoogle Scholar
  24. 24.
    Young GB, Shemie SD, Doig CJ, Teitelbaum J (2006) Brief review: the role of ancillary tests in the neu- rological determination of death. Radiology:620–627Google Scholar
  25. 25.
    Berenguer CM, Davis FE, Howington JU (2010) Brain death confirmation: comparison of computed tomographic angiography with nuclear medicine perfusion scan. J Trauma - Inj Infect Crit Care 68:553–558.  https://doi.org/10.1097/TA.0b013e3181cef18a CrossRefGoogle Scholar
  26. 26.
    Orban JC, El-Mahjoub A, Rami L et al (2012) Transcranial Doppler shortens the time between clinical brain death and angiographic confirmation: a randomized trial. Transplantation 94:585–588.  https://doi.org/10.1097/TP.0b013e3182612947 CrossRefPubMedGoogle Scholar
  27. 27.
    Karantanas AH, Hadjigeorgiou GM, Paterakis K, Sfiras D, Komnos A (2002) Contribution of MRI and MR angiography in early diagnosis of brain death. Eur Radiol 12:2710–2716.  https://doi.org/10.1007/s00330-002-1336-z CrossRefPubMedGoogle Scholar
  28. 28.
    Okuyaz C, Gücüyener K, Karabacak NI et al (2004) Tc-99m-HMPAO SPECT in the diagnosis of brain death in children. Pediatr Int 46:711–714.  https://doi.org/10.1111/j.1442-200x.2004.01976.x CrossRefPubMedGoogle Scholar
  29. 29.
    Chakraborty S, Dhanani S (2017) Guidelines for use of computed tomography angiogram as an ancillary test for diagnosis of suspected brain death. Can Assoc Radiol J 68:224–228.  https://doi.org/10.1016/j.carj.2016.12.002 CrossRefPubMedGoogle Scholar
  30. 30.
    Kramer AH, Roberts DJ (2014) Computed tomography angiography in the diagnosis of brain death: a systematic review and meta-analysis. Neurocrit Care 21:539–550.  https://doi.org/10.1007/s12028-014-9997-4 CrossRefPubMedGoogle Scholar
  31. 31.
    Garrett MP, Williamson RW, Bohl MA, et al (2017) Computed tomography angiography as a confirmatory test for the diagnosis of brain death. J Neurosurg 1–6 . doi:  https://doi.org/10.3171/2016.10.JNS161042 CrossRefGoogle Scholar
  32. 32.
    Welschehold S, Kerz T, Boor S, Reuland K, Thömke F, Reuland A, Beyer C, Wagner W, Müller-Forell W, Giese A (2013) Detection of intracranial circulatory arrest in brain death using cranial CT-angiography. Eur J Neurol 20:173–179.  https://doi.org/10.1111/j.1468-1331.2012.03826.x CrossRefPubMedGoogle Scholar
  33. 33.
    Leclerc X (2007) CT angiography for the diagnosis of brain death: recomendations of the French Society of Neuroradiology (SFNR). J Neuroradiol 34:217–219.  https://doi.org/10.1016/j.neurad.2007.07.008 CrossRefPubMedGoogle Scholar
  34. 34.
    Chang JJ, Tsivgoulis G, Katsanos AH, Malkoff MD, Alexandrov AV (2016) Diagnostic accuracy of transcranial Doppler for brain death confirmation: systematic review and meta-analysis. AJNR Am J Neuroradiol 37:408–414.  https://doi.org/10.3174/ajnr.A4548 CrossRefPubMedGoogle Scholar
  35. 35.
    Poularas J, Karakitsos D, Kouraklis G, Kostakis A, de Groot E, Kalogeromitros A, Bilalis D, Boletis J, Karabinis A (2006) Comparison between transcranial color Doppler ultrasonography and angiography in the confirmation of brain death. Transplant Proc 38:1213–1217.  https://doi.org/10.1016/j.transproceed.2006.02.127 CrossRefPubMedGoogle Scholar
  36. 36.
    Wahlster S, Wijdicks EFM, Patel PV, Greer DM, Hemphill JC, Carone M, Mateen FJ (2015) Brain death declaration: practices and perceptions worldwide. Neurology 84:1870–1879.  https://doi.org/10.1212/WNL.0000000000001540 CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Escudero D, Valentín MO, Escalante JL, Sanmartín A, Perez-Basterrechea M, de Gea J, Martín M, Velasco J, Pont T, Masnou N, de la Calle B, Marcelo B, Lebrón M, Pérez JM, Burgos M, Gimeno R, Kot P, Yus S, Sancho I, Zabalegui A, Arroyo M, Miñambres E, Elizalde J, Montejo JC, Domínguez-Gil B, Matesanz R (2015) Intensive care practices in brain death diagnosis and organ donation. Anaesthesia 70:1130–1139.  https://doi.org/10.1111/anae.13065 CrossRefPubMedGoogle Scholar
  38. 38.
    Pardo AV, Cacciatori A, Dorfman B et al (2014) Latin American Consensus on the use of transcranial Doppler in the diagnosis of brain death. Rev Bras Ter Intensiva 26:240–252.  https://doi.org/10.5935/0103-507X.20140035 CrossRefGoogle Scholar
  39. 39.
    Hoffmann O, Masuhr F (2014) Zugang zur Hirntoddiagnostik. Nervenarzt 85:1573–1581.  https://doi.org/10.1007/s00115-014-4171-y CrossRefPubMedGoogle Scholar
  40. 40.
    Conti A, Iacopino DG, Spada A, Cardali SM, Giusa M, la Torre D, Campennì A, Penna O, Baldari S, Tomasello F (2009) Transcranial Doppler ultrasonography in the assessment of cerebral circulation arrest: improving sensitivity by trancervical and transorbital carotid insonation and serial examinations. Neurocrit Care 10:326–335.  https://doi.org/10.1007/s12028-009-9199-7 CrossRefPubMedGoogle Scholar
  41. 41.
    Rutjes AWS, Reitsma JB, Di Nisio M et al (2006) Evidence of bias and variation in diagnostic accuracy studies. Cmaj 174:469–476.  https://doi.org/10.1503/cmaj.050090 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Alessandro Pedicelli
    • 1
  • Margherita Bartocci
    • 2
  • Emilio Lozupone
    • 1
  • Francesco D’Argento
    • 1
  • Andrea Alexandre
    • 1
  • Giuseppe Garignano
    • 3
  • Ciro D’Alò
    • 4
    • 5
  • Viola Giacobbe
    • 6
  • Iacopo Valente
    • 1
  • Cesare Colosimo
    • 1
    • 3
  1. 1.UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologiaFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
  2. 2.UO Radiologia, Dipartimento di radiologia e diagnostica per immaginiFondazione Poliambulanza Istituto OspedalieroBresciaItaly
  3. 3.Istituto di RadiologiaUniversità Cattolica del Sacro CuoreRomeItaly
  4. 4.UOC Anestesia, Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento di scienze dell’emergenza, anestesiologiche e della rianimazioneFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
  5. 5.Istituto di Anestesiologia e RianimazioneUniversità Cattolica del Sacro CuoreRomeItaly
  6. 6.Medical Science DivisionGuerbetVillepinteFrance

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