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

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  • 1 Departments of Neurosurgery and
  • 2 Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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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.

ABBREVIATIONS AAN = American Academy of Neurology; BD = brain death; CA = cerebral angiography; CTA = CT angiography; EEG = electroencephalography; ICA = internal carotid artery; ICV = internal cerebral vein; MCA = middle cerebral artery; NMPT = nuclear medicine perfusion test; TCD = transcranial Doppler ultrasonography; VA = vertebral artery.

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Contributor Notes

Correspondence Nicholas Theodore, c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd., Phoenix, AZ 85013. email: neuropub@dignityhealth.org.

INCLUDE WHEN CITING Published online March 17, 2017; DOI: 10.3171/2016.10.JNS161042.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Bohatyrewicz R, Sawicki M, Walecka A, Walecki J, Rowinski O, Bohatyrewicz A, : Computed tomographic angiography and perfusion in the diagnosis of brain death. Transplant Proc 42:39413946, 2010. (Erratum in Transplant Proc 43: 668, 2011)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Brasil S, Bor-Seng-Shu E, de-Lima-Oliveira M, Azevedo MK, Teixeira MJ, Bernardo L, : Role of computed tomography angiography and perfusion tomography in diagnosing brain death: a systematic review. J Neuroradiol 43:133140, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Combes JC, Chomel A, Ricolfi F, d'Athis P, Freysz M: Reliability of computed tomographic angiography in the diagnosis of brain death. Transplant Proc 39:1620, 2007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Committee of the Harvard Medical School to Examine the Definition of Brain Death: a definition of irreversible coma. JAMA 205:337340, 1968

  • 5

    Dupas B, Gayet-Delacroix M, Villers D, Antonioli D, Veccherini MF, Soulillou JP: Diagnosis of brain death using two-phase spiral CT. AJNR Am J Neuroradiol 19:641647, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Frampas E, Videcoq M, de Kerviler E, Ricolfi F, Kuoch V, Mourey F, : CT angiography for brain death diagnosis. AJNR Am J Neuroradiol 30:15661570, 2009

  • 7

    Greer DM, Strozyk D, Schwamm LH: False positive CT angiography in brain death. Neurocrit Care 11:272275, 2009

  • 8

    Heran MK, Heran NS, Shemie SD: A review of ancillary tests in evaluating brain death. Can J Neurol Sci 35:409419, 2008

  • 9

    Kramer AH, Roberts DJ: Computed tomography angiography in the diagnosis of brain death: a systematic review and meta-analysis. Neurocrit Care 21:539550, 2014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Leclerc X: [CT angiography for the diagnosis of brain death: recommendations of the French Society of Neuroradiology (SFNR).]. J Neuroradiol 34:217219, 2007. (Fr)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Quality Standards Subcommittee of the American Academy of Neurology: Practice parameters for determining brain death in adults (summary statement). Neurology 45:10121014, 1995

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Quesnel C, Fulgencio JP, Adrie C, Marro B, Payen L, Lembert N, : Limitations of computed tomographic angiography in the diagnosis of brain death. Intensive Care Med 33:21292135, 2007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Shemie SD, Lee D, Sharpe M, Tampieri D, Young B: Brain blood flow in the neurological determination of death: Canadian expert report. Can J Neurol Sci 35:140145, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Suarez-Kelly LP, Patel DA, Britt PM, Clayton EJ, Bromberg WJ, McCain CM, : Dead or alive? New confirmatory test using quantitative analysis of computed tomographic angiography. J Trauma Acute Care Surg 79:9951003, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Taylor T, Dineen RA, Gardiner DC, Buss CH, Howatson A, Pace NL: Computed tomography (CT) angiography for confirmation of the clinical diagnosis of brain death. Cochrane Database Syst Rev 3:CD009694, 2014

    • Search Google Scholar
    • Export Citation
  • 16

    Uniform Determination of Death Act, 12 Uniform Laws Annotated (U.L.A.) 589 (West 1993 and West Supp. 1997)

  • 17

    Welschehold S, Boor S, Reuland K, Beyer C, Kerz T, Reuland A, : CT angiography as a confirmatory test in brain death. Acta Neurochir Suppl 114:311316, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Welschehold S, Boor S, Reuland K, Thömke F, Kerz T, Reuland A, : Technical aids in the diagnosis of brain death: a comparison of SEP, AEP, EEG, TCD and CT angiography. Dtsch Arztebl Int 109:624630, 2012

    • Search Google Scholar
    • Export Citation
  • 19

    Welschehold S, Kerz T, Boor S, Reuland K, Thömke F, Reuland A, : Computed tomographic angiography as a useful adjunct in the diagnosis of brain death. J Trauma Acute Care Surg 74:12791285, 2013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Wijdicks EF: Determining brain death in adults. Neurology 45:10031011, 1995

  • 21

    Wijdicks EF, Pfeifer EA: Neuropathology of brain death in the modern transplant era. Neurology 70:12341237, 2008

  • 22

    Wijdicks EF, 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 74:19111918, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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