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      Revised CT angiography venous score with consideration of infratentorial circulation value for diagnosing brain death

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          Abstract

          Background

          Computed tomography angiography (CTA) is largely performed in European countries as an ancillary test for diagnosing brain death. However, CTA suffers from a lack of sensitivity, especially in patients who have previously undergone decompressive craniectomy. The aim of this study was to assess the performance of a revised four-point venous CTA score, including non-opacification of the infratentorial venous circulation, for diagnosing brain death.

          Methods

          A preliminary study of 43 control patients with normal CTAs confirmed that the infratentorial superior petrosal vein (SPV) was consistently visible. Therefore, 76 patients (including ten with decompressive craniectomy) who were investigated with 83 CTAs to confirm clinical brain death were consecutively enrolled between July 2011 and July 2013 at a university centre. The image analysis consisted of recording non-opacification of the cortical segment of the middle cerebral artery and internal cerebral vein (ICV), which were used as the reference CTA score, as well as non-opacification of the SPV. The diagnostic performance of the revised four-point venous CTA score based on the non-opacification of both the ICV and SPV was assessed and compared with that of the reference CTA score.

          Results

          The revised four-point venous CTA score showed a sensitivity of 95 % for confirming clinical brain death versus a sensitivity of 88 % with the reference CTA score. Non-opacification of the SPV was observed in 95 % of the patients. In the decompressive craniectomy group, the revised four-point CTA score showed a sensitivity of 100 % compared with a sensitivity of 80 % using the reference CTA score.

          Conclusion

          Compared with the reference CTA score, the revised four-point venous CTA score based on ICV and SPV non-opacification showed superior diagnostic performance for confirming brain death, including for patients with decompressive craniectomy.

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          Most cited references30

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          Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement.

          This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.
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            Microsurgical anatomy of the veins of the posterior fossa.

            The microsurgical anatomy of the veins of the posterior fossa was defined in 25 cadavers. These veins are divided into four groups: superficial, deep, brain-stem, and bridging veins. The superficial veins are divided on the basis of which of the three cortical surfaces they drain: the tentorial surface, which faces the tentorium and is exposed in a supracerebellar approach, is drained by the superior hemispheric and vermian veins; the suboccipital surface, which is below and between the lateral and sigmoid sinuses and is exposed in a wide suboccipital craniectomy, is drained by the inferior hemispheric and inferior vermian veins; and the petrosal surface, which faces forward toward the posterior surface of the petrous bone and is retracted to expose the cerebellopontine angle, is drained by the anterior hemispheric veins. The deep veins course in the three fissures between the cerebellum and the brain stem, and on the three cerebellar peduncles. The major deep veins in the fissures between the cerebellum and brain stem are the veins of the cerebellomesencephalic, cerebellomedullary, and cerebellopontine fissures, and those on the cerebellar peduncles are the veins of the superior, middle, and inferior cerebellar peduncles. The veins of the brain stem are named on the basis of whether they drain the midbrain, pons, or medulla. The veins of the posterior fossa terminate as bridging veins, which collect into three groups: a galenic group which drains into the vein of Galen; a petrosal group which drains into the petrosal sinuses; and a tentorial group which drains into the tentorial sinuses near the torcula.
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              Clinical report—Guidelines for the determination of brain death in infants and children: an update of the 1987 task force recommendations.

              To review and revise the 1987 pediatric brain death guidelines.
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                Author and article information

                Contributors
                +033673949683 , antoine.marchand@chu-rennes.fr
                philippe.seguin@chu-rennes.fr
                yannick.malledant@chu-rennes.fr
                marion.taleb@chu-rennes.fr
                helene.raoult@chu-rennes.fr
                jean-yves.gauvrit@chu-rennes.fr
                Journal
                Ann Intensive Care
                Ann Intensive Care
                Annals of Intensive Care
                Springer Paris (Paris )
                2110-5820
                13 September 2016
                13 September 2016
                2016
                : 6
                : 1
                : 88
                Affiliations
                [1 ]Department of Radiology and Medical Imaging, University and Regional Hospital Center (CHRU) of Rennes, 2 rue Henri Le Guillou, 35000 Rennes, France
                [2 ]Service d’Anesthésie Réanimation 1, CHU Rennes, 2 rue Henri Le Guillou, 35000 Rennes, France
                [3 ]Université Rennes 1, Rennes, France
                [4 ]Inserm U991, Rennes, France
                Article
                188
                10.1186/s13613-016-0188-7
                5020015
                27620878
                6e9e49a2-0d2b-407f-ab73-bbf9dc61c78f
                © The Author(s) 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 1 March 2016
                : 29 August 2016
                Categories
                Research
                Custom metadata
                © The Author(s) 2016

                Emergency medicine & Trauma
                brain death diagnosis,computed tomography angiography,confirmatory test,revised four-point venous score

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