Korean Journal of Radiology

The Korean Society of Radiology (대한영상의학회)
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Assessment of Cerebral Circulatory Arrest via CT Angiography and CT Perfusion in Brain Death Confirmation

  • Asli Irmak Akdogan (Department of Radiology, Buca Women Birth and Child Diseases Hospital) ;
  • Yeliz Pekcevik (Department of Radiology, University of Health Sciences, Tepecik Training and Research Hospital) ;
  • Hilal Sahin (Department of Radiology, University of Health Sciences, Tepecik Training and Research Hospital) ;
  • Ridvan Pekcevik (Department of Radiology, Katip Celebi University, Ataturk Training and Research Hospital)
  • Received : 2019.08.31
  • Accepted : 2020.06.17
  • Published : 2021.03.01
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Abstract

Objective: To compare the utility of computed tomography perfusion (CTP) and three different 4-point scoring systems in computed tomography angiography (CTA) in confirming brain death (BD) in patients with and without skull defects. Materials and Methods: Ninety-two patients clinically diagnosed as BD using CTA and/or CTP for confirmation were retrospectively reviewed. For the final analysis, 86 patients were included in this study. Images were re-evaluated by three radiologists according to the 4-point scoring systems that consider the vessel opacification on 1) the venous phase for both M4 segments of the middle cerebral arteries (MCAs-M4) and internal cerebral veins (ICVs) (A60-V60), 2) the arterial phase for the MCA-M4 and venous phase for the ICVs (A20-V60), 3) the venous phase for the ICVs and superior petrosal veins (ICV-SPV). The CTP images were independently reviewed. The presence of an open skull defect and stasis filling was noted. Results: Sensitivities of the ICV-SPV, A20-V60, A60-V60 scoring systems, and CTP in the diagnosis of BD were 89.5%, 82.6%, 67.4%, and 93.3%, respectively. The sensitivity of A20-V60 scoring was higher than that of A60-V60 in BD patients (p < 0.001). CTP was found to be the most sensitive method (86.5%) in patients with open skull defect (p = 0.019). Interobserver agreement was excellent in the diagnosis of BD, in assessing A20-V60, A60-V60, ICV-SPV, CTP, and good in stasis filling (κ: 0.84, 0.83, 0.83, 0.83, and 0.67, respectively). Conclusion: The sensitivity of CTA confirming brain death differs between various proposed 4-point scoring systems. Although the ICV-SPV is the most sensitive, evaluation of the SPV is challenging. Adding CTP to the routine BD CTA protocol, especially in cases with open skull defect, could increase sensitivity as a useful adjunct.

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References

  1. Wijdicks EFM. Determining brain death in adults. Neurology 1995;45:1003-1011  https://doi.org/10.1212/WNL.45.5.1003
  2. Manara AR. All human death is brain death: the legacy of the Harvard criteria. Resuscitation 2019;138:210-212  https://doi.org/10.1016/j.resuscitation.2019.03.011
  3. Wahlster S, Wijdicks EFM, Patel PV, Greer DM, Hemphill JC 3rd, Carone M, et al. Brain death declaration: practices and perceptions worldwide. Neurology 2015;84:1870-1879  https://doi.org/10.1212/WNL.0000000000001540
  4. Frampas E, Videcoq M, de Kerviler E, Ricolfi F, Kuoch V, Mourey F, et al. CT angiography for brain death diagnosis. AJNR Am J Neuroradiol 2009;30:1566-1570  https://doi.org/10.3174/ajnr.A1614
  5. Leclerc X, Taschner CA, Vidal A, Strecker G, Savage J, Gauvrit JY, et al. The role of spiral CT for the assessment of the intracranial circulation in suspected brain-death. J Neuroradiol 2006;33:90-95  https://doi.org/10.1016/S0150-9861(06)77237-6
  6. Nunes DM, Maia ACM Jr, Boni RC, da Rocha AJ. Impact of skull defects on the role of CTA for brain death confirmation. AJNR Am J Neuroradiol 2019;40:1177-1183  https://doi.org/10.3174/ajnr.A6100
  7. Marchand AJ, Seguin P, Malledant Y, Taleb M, Raoult H, Gauvrit JY. Revised CT angiography venous score with consideration of infratentorial circulation value for diagnosing brain death. Ann Intensive Care 2016;6:88 
  8. Escudero D, Otero J, Marques L, Parra D, Gonzalo JA, Albaiceta GM, et al. Diagnosing brain death by CT perfusion and multislice CT angiography. Neurocrit Care 2009;11:261-271  https://doi.org/10.1007/s12028-009-9243-7
  9. Shankar JJ, Vandorpe R. CT perfusion for confirmation of brain death. AJNR Am J Neuroradiol 2013;34:1175-1179  https://doi.org/10.3174/ajnr.A3376
  10. Bohatyrewicz R, Sawicki M, Walecka A, Walecki J, Rowinski O, Bohatyrewicz A, et al. Computed tomographic angiography and perfusion in the diagnosis of brain death. Transplant Proc 2010;42:3941-3946  https://doi.org/10.1016/j.transproceed.2010.09.143
  11. Sawicki M, Solek-Pastuszka J, Chamier-Ciemin'ska K, Walecka A, Walecki J, Bohatyrewicz R. Computed tomography perfusion is a useful adjunct to computed tomography angiography in the diagnosis of brain death. Clin Neuroradiol 2019;29:101-108  https://doi.org/10.1007/s00062-017-0631-7
  12. Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010;74:1911-1918  https://doi.org/10.1212/WNL.0b013e3181e242a8
  13. Drake M, Bernard A, Hessel E. Brain death. Surg Clin North Am 2017;97:1255-1273  https://doi.org/10.1016/j.suc.2017.07.001
  14. Kricheff II, Pinto RS, George AE, Braunstein P, Korein J. Angiographic findings in brain death. Ann N Y Acad Sci 1978;315:168-183  https://doi.org/10.1111/j.1749-6632.1978.tb50338.x
  15. Sawicki M, Bohatyrewicz R, Safranow K, Walecka A, Walecki J, Rowinski O, et al. Dynamic evaluation of stasis filling phenomenon with computed tomography in diagnosis of brain death. Neuroradiology 2013;55:1061-1069  https://doi.org/10.1007/s00234-013-1210-5
  16. Randolph JJ. Free-marginal multirater kappa (multirater κfree): an alternative to Fleiss' fixed-marginal multirater kappa. Joensuu learning and instruction symposium;2005 October 14-15;Joensuu, Finland 
  17. Altman DG. Practical statistics for medical research, 1st ed. London: Chapman and Hall, 1991 
  18. Kramer AH, Roberts DJ. Computed tomography angiography in the diagnosis of brain death: a systematic review and meta-analysis. Neurocrit Care 2014;21:539-550  https://doi.org/10.1007/s12028-014-9997-4
  19. Welschehold S, Kerz T, Boor S, Reuland K, Thomke F, Reuland A, et al. Detection of intracranial circulatory arrest in brain death using cranial CT-angiography. Eur J Neurol 2013;20:173-179  https://doi.org/10.1111/j.1468-1331.2012.03826.x
  20. Welschehold S, Kerz T, Boor S, Reuland K, Thomke F, Reuland A, et al. Computed tomographic angiography as a useful adjunct in the diagnosis of brain death. J Trauma Acute Care Surg 2013;74:1279-1285  https://doi.org/10.1097/TA.0b013e31828c46ba
  21. Braksick SA, Robinson CP, Gronseth GS, Hocker S, Wijdicks EFM, Rabinstein AA. Variability in reported physician practices for brain death determination. Neurology 2019;92:e888-e894  https://doi.org/10.1212/WNL.0000000000007009
  22. Sawicki M, Bohatyrewicz R, Safranow K, Walecka A, Walecki J, Rowinski O, et al. Computed tomographic angiography criteria in the diagnosis of brain death-comparison of sensitivity and interobserver reliability of different evaluation scales. Neuroradiology 2014;56:609-620  https://doi.org/10.1007/s00234-014-1364-9
  23. S˛ahin H, Pekcevik Y. CT angiography as a confirmatory test in diagnosis of brain death: comparison between three scoring systems. Diagn Interv Radiol 2015;21:177-183 https://doi.org/10.5152/dir.2014.14241