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Transcranial Doppler ultrasonography to confirm brain death: a meta-analysis

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Abstract

Objective

Barbiturate therapy or hypothermia precludes proper diagnosis of brain death either clinically or by EEG. Specific intracranial flow patterns indicating cerebral circulatory arrest (CCA) can be visualized by transcranial Doppler ultrasonography (TCD). The aim of this study was to assess the validity of TCD in confirming brain death.

Design

Meta-analysis of studies assessing the validity of TCD in confirming brain death.

Methods

A systematic review of articles in English on the diagnosis brain death by TCD, published between 1980 and 2004, was performed. An oscillating or reverberating flow and systolic spikes were considered to be compatible with CCA. The quality of each study was assessed using standardized methodological criteria. The literature was searched for any article reporting a false-positive result.

Results

Two high-quality and eight low-quality studies were included. Meta-analysis of the two high-quality studies showed a sensitivity of 95% (95% CI 92–97%) and a specificity of 99% (95% CI 97–100%) to detect brain death. Meta-analysis of all ten studies showed a sensitivity of 89% and a specificity of 99%. In the literature we found two false-positive results; however, in both patients brain-stem function did show brain death shortly thereafter.

Conclusions

CCA by TCD in the anterior and posterior circulation predicted fatal brain damage in all patients; therefore, TCD can be used to determine the appropriate moment for angiography. Further research is needed to demonstrate that CCA by TCD on repeated examination can also predict brain death in all patients.

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References

  1. Darby JM, Stein K, Grenvik A, Stuart SA (1989) Approach to management of the heartbeating “brain dead” organ donor. J Am Med Assoc 261:2222–2228

    Article  CAS  Google Scholar 

  2. Lopez-Navidad A, Domingo P, Caballero F (1997) Organ shortage: viability of potential organ donors and possible loss depend on health care workers who are responsible for the organ procurement program. Transplant Proc 29:3614–3616

    Article  PubMed  CAS  Google Scholar 

  3. Wijdicks EF (1995) Determining brain death in adults. Neurology 45:1003–1011

    PubMed  CAS  Google Scholar 

  4. Guidelines for the determination of death (1981) Report of the medical consultants on the diagnosis of death to the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. J Am Med Assoc 246:2184–2186

    Article  Google Scholar 

  5. Guidelines for the determination of brain death in children (1987) Task Force for the determination of brain death in children. Neurology 37:1077–1078

    Google Scholar 

  6. Practice parameters for determining brain death in adults (summary statement) (1995) The Quality Standards Subcommittee of the American Academy of Neurology. Neurology 45:1012–1014

    Google Scholar 

  7. Silverman D, Saunders MG, Schwab RS, Masland RL (1969) Cerebral death and the electroencephalogram. Report of the ad hoc committee of the American Electroencephalographic Society on EEG Criteria for determination of cerebral death. J Am Med Assoc 209:1505–1510

    Article  CAS  Google Scholar 

  8. Guideline three: minimum technical standards for EEG recording in suspected cerebral death (1994) American Electroencephalographic Society. J Clin Neurophysiol 11:10–13

    Article  Google Scholar 

  9. Powner DJ (1976) Drug-associated iso-electric EEGs. A hazard in brain-death certification. J Am Med Assoc 236:1123

    Article  CAS  Google Scholar 

  10. Mason RA, Arbeit LA, Giron F (1985) Renal dysfunction after arteriography. J Am Med Assoc 253:1001–1004

    Article  CAS  Google Scholar 

  11. Lewis RR, Padayachee TS, Beasley MG, Keen H, Gosling RG (1983) Investigation of brain death with Doppler-shift ultrasound. J R Soc Med 76:308–310

    PubMed  CAS  Google Scholar 

  12. Kirkham FJ, Levin SD, Padayachee TS, Kyme MC, Neville BG, Gosling RG (1987) Transcranial pulsed Doppler ultrasound findings in brain stem death. J Neurol Neurosurg Psychiatry 50:1504–1513

    PubMed  CAS  Google Scholar 

  13. Ropper AH, Kehne SM, Wechsler L (1987) Transcranial Doppler in brain death. Neurology 37:1733–1735

    PubMed  CAS  Google Scholar 

  14. Newell DW, Grady MS, Sirotta P, Winn HR (1989) Evaluation of brain death using transcranial Doppler. Neurosurgery 24:509–513

    PubMed  CAS  Google Scholar 

  15. Yoneda S, Nishimoto A, Nukada T, Kuriyama Y, Katsurada K (1974) To-and-fro movement and external escape of carotid arterial blood in brain death cases. A Doppler ultrasonic study. Stroke 5:707–713

    PubMed  CAS  Google Scholar 

  16. Monteiro LM, Bollen CW, Van Huffelen AC, Ackerstaff RG, Jansen NJG, Van Vught AJ (2005) Can transcranial Doppler ultrasonography confirm the diagnosis of brain death? Intensive Care Med 31:S1–S174

    Article  Google Scholar 

  17. Hadani M, Bruk B, Ram Z, Knoller N, Spiegelmann R, Segal E (1999) Application of transcranial Doppler ultrasonography for the diagnosis of brain death. Intensive Care Med 25:822–828

    Article  PubMed  CAS  Google Scholar 

  18. Zurynski Y, Dorsch N, Pearson I, Choong R (1991) Transcranial Doppler ultrasound in brain death: experience in 140 patients. Neurol Res 13:248–252

    PubMed  CAS  Google Scholar 

  19. Petty GW, Mohr JP, Pedley TA, Tatemichi TK, Lennihan L, Duterte DI, Sacco RL (1990) The role of transcranial Doppler in confirming brain death: sensitivity, specificity, and suggestions for performance and interpretation. Neurology 40:300–303

    PubMed  CAS  Google Scholar 

  20. Paolin A, Manuali A, Paola F di, Boccaletto F, Caputo P, Zanata R, Bardin GP, Simini G (1995) Reliability in diagnosis of brain death. Intensive Care Med 21:657–662

    Article  PubMed  CAS  Google Scholar 

  21. Feri M, Ralli L, Felici M, Vanni D, Capria V (1994) Transcranial Doppler and brain death diagnosis. Crit Care Med 22:1120–1126

    Article  PubMed  CAS  Google Scholar 

  22. Dominguez-Roldan JM, Murillo-Cabezas F, Munoz-Sanchez A, Santamaria-Mifsut JL, Villen-Nieto J (1995) Changes in the Doppler waveform of intracranial arteries in patients with brain-death status. Transplant Proc 27:2391–2392

    PubMed  CAS  Google Scholar 

  23. 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 160:41–46

    Article  PubMed  CAS  Google Scholar 

  24. Velthoven van V, Calliauw L (1988) Diagnosis of brain death. Transcranial Doppler sonography as an additional method. Acta Neurochir (Wien) 95:57–60

    Article  Google Scholar 

  25. Lample Y, Gilad R, Eschel Y, Boaz M, Rapoport A, Sadeh M (2002) Diagnosing brain death using the transcranial Doppler with a transorbital approach. Arch Neurol 59:58–60

    Article  Google Scholar 

  26. Qian SY, Fan XM, Yin HH (1998) Transcranial Doppler assessment of brain death in children. Singapore Med J 39:247–250

    PubMed  CAS  Google Scholar 

  27. Shiogai T, Sato E, Tokitsu M, Hara M, Takeuchi K (1990) Transcranial Doppler monitoring in severe brain damage: relationships between intracranial haemodynamics, brain dysfunction and outcome. Neurol Res 12:205–213

    PubMed  CAS  Google Scholar 

  28. Powers AD, Graeber MC, Smith RR (1989) Transcranial Doppler ultrasonography in the determination of brain death. Neurosurgery 24:884–889

    PubMed  CAS  Google Scholar 

  29. Steinmetz H, Hassler W (1988) Reversible intracranial circulatory arrest in acute subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 51:1355–1356

    PubMed  CAS  Google Scholar 

  30. Grote E, Hassler W (1988) The critical first minutes after subarachnoid hemorrhage. Neurosurgery 22:654–661

    PubMed  CAS  Google Scholar 

  31. Eng CC, Lam AM, Byrd S, Newell DW (1993) The diagnosis and management of a perianesthetic cerebral aneurysmal rupture aided with transcranial Doppler ultrasonography. Anesthesiology 78:191–194

    Article  PubMed  CAS  Google Scholar 

  32. Vatne K, Nakstad P, Lundar T (1985) Digital subtraction angiography (DSA) in the evaluation of brain death. A comparison of conventional cerebral angiography with intravenous and intraarterial DSA. Neuroradiology 27:155–157

    Article  PubMed  CAS  Google Scholar 

  33. Marrache F, Megarbane B, Pirnay S, Rhaoui A, Thuong M (2004) Difficulties in assessing brain death in a case of benzodiazepine poisoning with persistent cerebral blood flow. Hum Exp Toxicol 23:503–505

    Article  PubMed  Google Scholar 

  34. Heiskanen O (1964) Cerebral circulatory arrest caused by acute increase of intracranial pressure. A clinical and roentgenological study of 25 cases. Acta Neurol Scand 40(Suppl 7):1–57

    Google Scholar 

  35. Spittler JF, Langenstein H (1991) Diagnosis of brain death: limitations of angiography after osteoclastic trepanation. Dtsch Med Wochenschr 116:1828–1831

    Article  PubMed  CAS  Google Scholar 

  36. Alvarez LA, Lipton RB, Hirschfeld A, Salamon O, Lantos G (1988) Brain death determination by angiography in the setting of a skull defect. Arch Neurol 45:225–227

    PubMed  CAS  Google Scholar 

  37. de Bray JM, Granry JC, Monrigal JP, Leftheriotis G, Saumet JL (1993) Effects of thiopental on middle cerebral artery blood velocities: a transcranial Doppler study in children. Childs Nerv Syst 9:220–223

    Article  PubMed  Google Scholar 

  38. Rath SA, Richter HP (1993) Transcranial Doppler sonography as a reliable diagnostic tool in craniocerebral trauma. Unfallchirurg 96:569–575

    PubMed  CAS  Google Scholar 

  39. Segura T, Jimenez P, Jerez P, Garcia F, Corcoles V (2002) Prolonged clinical pattern of brain death in patients under barbiturate sedation: usefulness of transcranial Doppler. Neurologia 17:219–222

    PubMed  CAS  Google Scholar 

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Correspondence to Adrianus J. van Vught.

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Monteiro, L.M., Bollen, C.W., van Huffelen, A.C. et al. Transcranial Doppler ultrasonography to confirm brain death: a meta-analysis. Intensive Care Med 32, 1937–1944 (2006). https://doi.org/10.1007/s00134-006-0353-9

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  • DOI: https://doi.org/10.1007/s00134-006-0353-9

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