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      Impact of Decompressive Craniectomy on Diagnosing Brain Death in Children

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          Abstract

          Objective:

          In this study, we aimed to evaluate the effects of decompressive craniectomy (DC) on the brain death (BD) determination process in the pediatric intensive care unit (PICU).

          Materials and Methods:

          All children who were diagnosed with BD in the PICU between 2009 and 2020 were included in this study. Patient demographics, causative mechanisms, BD examinations, and ancillary tests used were recorded. The time intervals (from PICU admission to first BD examination, from first BD examination to BD diagnosis) and number of BD examinations were compared between patients with and without DC.

          Results:

          During the study period, 70 pediatric cases were diagnosed with BD among 513 total deaths (13.6%). Their median age was 54.5 months [interquartile range (IQR): 24-140]. Transcranial Doppler ultrasound (TCD) was performed in 66 patients (94.3%). The most common combination of ancillary tests was the apnea test and TCD combination, which was performed in 56 patients (80%). Thirty-four children (48.6%) experienced immediate surgery for DC. Patients with DC had a higher median number of BD examinations than patients without DC [3 (IQR: 2-3) vs. 2 (IQR: 1-2), P < .001]. The patients with DC had a longer time interval between the first examination and declaration of BD than patients without DC [45.5 hours (IQR: 21.7-91.7) versus 15 hours (IQR: 2-31.2), P < .006].

          Conclusion:

          Decompressive craniectomy may complicate BD determination and cause challenges for brain death diagnosis based on cerebral flow imaging techniques. The lack of specific recommendations for this patient group in the guidelines causes a delayed diagnosis of BD.

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          Most cited references23

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          Management of Pediatric Severe Traumatic Brain Injury

          To produce a treatment algorithm for the ICU management of infants, children, and adolescents with severe traumatic brain injury.
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            Transcranial Doppler ultrasonography to confirm brain death: a meta-analysis.

            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.
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              Epidemiology of Brain Death in Pediatric Intensive Care Units in the United States

              What are the epidemiology and clinical characteristics of patients declared brain dead in US pediatric intensive care units (PICUs)? In a national database study of 15 344 patients who died in PICUs, brain death occurred in 20.7% of pediatric deaths, primarily in children without preexisting neurological dysfunction and from an acute hypoxic-ischemic injury (52.7%) or brain injury (20.0%). There was a linear association between pediatric intensive care unit size and number of patients declared brain dead per year. Brain death evaluations are performed infrequently, even in large pediatric intensive care units, emphasizing the importance of physician education and protocol standardization to ensure diagnostic accuracy and consistency. This study of all pediatric patient deaths in a US national multicenter database seeks to determine the epidemiology and clinical characteristics of patients declared brain dead in pediatric intensive care units. Guidelines for declaration of brain death in children were revised in 2011 by the Society of Critical Care Medicine, American Academy of Pediatrics, and Child Neurology Society. Despite widespread medical, legal, and ethical acceptance, ongoing controversies exist with regard to the concept of brain death and the procedures for its determination. To determine the epidemiology and clinical characteristics of pediatric patients declared brain dead in the United States. This study involved the abstraction of all patient deaths from the Virtual Pediatric Systems national multicenter database between January 1, 2012, and June 30, 2017. All patients who died in pediatric intensive care units (PICUs) were included. Patient demographics, preillness developmental status, severity of illness, cause of death, PICU medical and physical length of stay, and organ donation status, as well as comparison between patients who were declared brain dead vs those who sustained cardiovascular or cardiopulmonary death. Of the 15 344 patients who died, 3170 (20.7%) were declared brain dead; 1861 of these patients (58.7%) were male, and 1401 (44.2%) were between 2 and 12 years of age. There was a linear association between PICU size and number of patients declared brain dead per year, with an increase of 4.27 patients (95% CI, 3.46-5.08) per 1000-patient increase in discharges ( P  < .001). The median (interquartile range) of patients declared brain dead per year ranged from 1 (0-3) in smaller PICUs (defined as those with <500 discharges per year) to 10 (7-15) for larger PICUs (those with 2000-4000 discharges per year). The most common causative mechanisms of brain death were hypoxic-ischemic injury owing to cardiac arrest (1672 of 3170 [52.7%]), shock and/or respiratory arrest without cardiac arrest (399 of 3170 [12.6%]), and traumatic brain injury (634 of 3170 [20.0%]). Most patients declared brain dead (681 of 807 [84.4%]) did not have preexisting neurological dysfunction. Patients who were organ donors (1568 of 3144 [49.9%]) remained in the PICU longer after declaration of brain death compared with those who were not donors (median [interquartile range], 29 [6-41] hours vs 4 [1-8] hours; P  < .001). Brain death occurred in one-fifth of PICU deaths. Most children declared brain dead had no preexisting neurological dysfunction and had an acute hypoxic-ischemic or traumatic brain injury. Brain death determinations are infrequent, even in large PICUs, emphasizing the importance of ongoing education for medical professionals and standardization of protocols to ensure diagnostic accuracy and consistency.
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                Author and article information

                Journal
                Turk Arch Pediatr
                Turk Arch Pediatr
                Turkish Archives of Pediatrics
                Turkish Pediatrics Association
                2757-6256
                January 2024
                01 January 2024
                : 59
                : 1
                : 93-97
                Affiliations
                [1 ]Department of Pediatrics , Ege University School of Medicine, İzmir, Turkey
                [2 ]Division of Pediatric Intensive Care , Department of Pediatrics, Ege University School of Medicine, İzmir, Turkey
                Author notes
                Corresponding author:Pınar Yazıcı Özkaya ✉ pinar.ozkaya@ 123456ege.edu.tr

                Cite this article as: Ekici B, Ersayoğlu İ, Yazıcı Özkaya P, Cebeci K, Koç G, Turanlı EE. Impact of decompressive craniectomy on diagnosing brain death in children. Turk Arch Pediatr. 2024; 59(1): 93-97.

                Author information
                http://orcid.org/0000-0001-9865-7008
                http://orcid.org/0000-0001-6965-0886
                http://orcid.org/0000-0002-1209-2534
                http://orcid.org/0000-0001-8049-4212
                http://orcid.org/0000-0003-4961-9501
                http://orcid.org/0000-0001-5876-0510
                Article
                tap-59-1-93
                10.5152/TurkArchPediatr.2024.23136
                10837520
                38454266
                4248920d-ba72-42e3-ad3c-4c239988abc7
                2024 authors

                Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 21 June 2023
                : 28 October 2023
                Funding
                This study received no funding.
                Categories
                Original Article

                children,brain death,decompressive craniectomy,ancillary test

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