Computed tomographic angiography as a useful adjunct in the diagnosis of brain death

Welschehold, Stefan; Kerz, Thomas; Boor, Stephan; Reuland, Katharina; Thömke, Frank; Reuland, Andre; Beyer, Christian; Tschan, Christoph A.; Wagner, W.; Müller‐Forell, Wibke; Giese, Alf

doi:10.1097/ta.0b013e31828c46ba

Cited by 26 publications

(28 citation statements)

References 31 publications

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“…Other authors have attempted to further elucidate the sensitivity and specificity of CTA by comparing it to TCD and EEG. 12,19 The results of such studies are highly variable and offer little meaningful data in the assessment of CTA, because the comparison tests themselves had similar statistical performance and validity to CTA for diagnosis of BD. 18 The only meaningful comparisons in this field are those made to the widely accepted gold standards: clinical examination, or clinical examination plus CA when confounders are present.…”

Section: Discussionmentioning

confidence: 99%

“…Multiple studies have attempted to show the reliability of CTA in demonstrating a lack of intracranial blood flow in the brain-dead patient. [1][2][3][5][6][7][8][9][10][12][13][14][15][17][18][19] However, these studies are highly heterogeneous in terms of the comparison studies they use as gold standards; some appropriately use clinical criteria alone, whereas others use a combination of clinical criteria and any one or a combination of the AAN-recommended ancillary tests. The use of ancillary tests other than CA as gold standards to compare with CTA is problematic, as many of these studies have a statistical performance similar to that of CTA.…”

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confidence: 99%

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Computed tomography angiography as a confirmatory test for the diagnosis of brain death

Garrett¹,

Williamson²,

Bohl³

et al. 2018

Journal of Neurosurgery

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OBJECTIVE For a diagnosis of brain death (BD), ancillary testing is performed if patient factors prohibit a complete clinical examination and apnea test. The American Academy of Neurology (AAN) guidelines identify cerebral angiography (CA), cerebral scintigraphy, electroencephalography, and transcranial Doppler ultrasonography as accepted ancillary tests. CA is widely considered the gold standard of these, as it provides the most reliable assessment of intracranial blood flow. CT angiography (CTA) is a noninvasive and widely available study that is also capable of identifying absent or severely diminished intracranial blood flow, but it is not included among the AAN's accepted ancillary tests because of insufficient evidence demonstrating its reliability. The objective of this study was to assess the statistical performance of CTA in diagnosing BD, using clinical criteria alone or clinical criteria plus CA as the gold-standard comparisons. METHODS The authors prospectively enrolled 22 adult patients undergoing workup for BD. All patients had cranial imaging and clinical examination results consistent with BD. In patients who met the AAN clinical criteria for BD, the authors performed CA and CTA so that both tests could be compared with the gold-standard clinical criteria. In cases that required ancillary testing, CA was performed as a confirmatory study, and CTA was then performed to compare against clinical criteria plus CA. Radiographic data were evaluated by an independent neuroradiologist. Test characteristics for CTA were calculated. RESULTS Four patients could not complete the standard BD workup and were excluded from analysis. Of the remaining 18 patients, 16 met AAN criteria for BD, 9 of whom required ancillary testing with CA. Of the 16 patients, 2 who also required CA ancillary testing were found to have persistent intracranial flow and were not declared brain dead at that time. These patients also underwent CTA; the results were concordant with the CA results. Six patients who were diagnosed with BD on the basis of clinical criteria alone also underwent CA, with 100% sensitivity. For all 18 patients included in the study, CTA had a sensitivity of 75%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 33%. CONCLUSIONS Clinical examination with or without CA remains the gold standard in BD testing. Studies assessing the statistical performance of CTA in BD testing should compare CTA to these gold standards. The statistical performance of CTA in BD testing is comparable to several of the nationally accepted ancillary tests. These data add to the growing medical literature supporting the use of CTA as a reliable ancillary test in BD testing.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Computed tomography angiography as a confirmatory test for the diagnosis of brain death

Garrett¹,

Williamson²,

Bohl³

et al. 2018

Journal of Neurosurgery

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“…Basierend auf den Studienergebnissen von Welschehold et al [39] sollte aufgrund des Stasis-Fillings nur eine arterielle CTA durchgeführt und auf eine zusätzliche "venöse" CTA verzichtet werden.…”

Section: Introductionunclassified

Angiographische Verfahren zur Feststellung des zerebralen Zirkulationsstillstandes

Lanfermann

2016

Nervenarzt

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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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“…whereas the 2 phase CT demonstrates the loss of perfusion of the MCA and the perfusion loss of the large cerebral veins (Leclerc et al 2006 ; Dupas et al 1998 ). The value of CT angiography (CTA) has greatly improved (Combes et al 2007 ; Leclerc 2007 ; Shemie et al 2008 ; Welschehold et al 2013 ). Studies testing CTA versus DSA versus TCD in patients who fulfill the criteria of brain death (clinically, by TCD, by EEG and DSA) and show cerebral perfusion stop at the level of the foramen magnum or the carotid siphon demanded loss of perfusion on CTA of the following arteries to prove cerebral perfusion stop: A2-ACA, M4-MCA, basilar artery, inner veins, and large brain veins and sinuses.…”

Section: Introductionmentioning

confidence: 99%

Coma and cerebral imaging

Haupt

Hansen

Janzen³

et al. 2015

SpringerPlus

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The clinical sign of coma is a common feature in critical care medicine. However, little information has been put forth on the correlations between coma and cerebral imaging methods. The purpose of the article is to compile the available information derived from various imaging methods and placing it in a context of clinical knowledge of coma and related states. The definition of coma and the cerebral structures responsible for consciousness are described; the mechanisms of cerebral lesions leading to impaired consciousness and coma are explained. Cerebral imaging methods provide a large array of information on the structural changes of brain tissue in the various diseases leading to coma. Circumscript lesions produce space-occupying masses that displace the brain, ultimately leading to various types of herniation. Generalized disease of the brain usually leads to diffuse brain swelling which also can cause herniation. Epileptic states, however, rarely are detectable by imaging methods and mandate EEG examinations. Another important aspect of imaging in coma is the increasing use of functional imaging methods, which can detect the function of loss of function in various areas of the brain and render information on the extent and severity of brain damage as well as on the prognosis of disease. The MRI methods of 1H-spectroscopy and diffusion tensor imaging may provide more functional information in the future.

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Computed tomographic angiography as a useful adjunct in the diagnosis of brain death

Cited by 26 publications

References 31 publications

Computed tomography angiography as a confirmatory test for the diagnosis of brain death

Computed tomography angiography as a confirmatory test for the diagnosis of brain death

Angiographische Verfahren zur Feststellung des zerebralen Zirkulationsstillstandes

Coma and cerebral imaging

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