Intensive Care Medicine

, Volume 32, Issue 12, pp 1937–1944 | Cite as

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

  • Louisa M. Monteiro
  • Casper W. Bollen
  • Alexander C. van Huffelen
  • Rob G. A. Ackerstaff
  • Nicolaas J. G. Jansen
  • Adrianus J. van Vught
Systematic Review

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.

Keywords

Brain death Cerebral circulatory arrest Ultrasonography Transcranial Doppler 

References

  1. 1.
    Darby JM, Stein K, Grenvik A, Stuart SA (1989) Approach to management of the heartbeating “brain dead” organ donor. J Am Med Assoc 261:2222–2228CrossRefGoogle Scholar
  2. 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 29:3614–3616PubMedCrossRefGoogle Scholar
  3. 3.
    Wijdicks EF (1995) Determining brain death in adults. Neurology 45:1003–1011PubMedGoogle Scholar
  4. 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 246:2184–2186CrossRefGoogle Scholar
  5. 5.
    Guidelines for the determination of brain death in children (1987) Task Force for the determination of brain death in children. Neurology 37:1077–1078Google Scholar
  6. 6.
    Practice parameters for determining brain death in adults (summary statement) (1995) The Quality Standards Subcommittee of the American Academy of Neurology. Neurology 45:1012–1014Google Scholar
  7. 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 209:1505–1510CrossRefGoogle Scholar
  8. 8.
    Guideline three: minimum technical standards for EEG recording in suspected cerebral death (1994) American Electroencephalographic Society. J Clin Neurophysiol 11:10–13CrossRefGoogle Scholar
  9. 9.
    Powner DJ (1976) Drug-associated iso-electric EEGs. A hazard in brain-death certification. J Am Med Assoc 236:1123CrossRefGoogle Scholar
  10. 10.
    Mason RA, Arbeit LA, Giron F (1985) Renal dysfunction after arteriography. J Am Med Assoc 253:1001–1004CrossRefGoogle Scholar
  11. 11.
    Lewis RR, Padayachee TS, Beasley MG, Keen H, Gosling RG (1983) Investigation of brain death with Doppler-shift ultrasound. J R Soc Med 76:308–310PubMedGoogle Scholar
  12. 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 50:1504–1513PubMedGoogle Scholar
  13. 13.
    Ropper AH, Kehne SM, Wechsler L (1987) Transcranial Doppler in brain death. Neurology 37:1733–1735PubMedGoogle Scholar
  14. 14.
    Newell DW, Grady MS, Sirotta P, Winn HR (1989) Evaluation of brain death using transcranial Doppler. Neurosurgery 24:509–513PubMedGoogle Scholar
  15. 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 5:707–713PubMedGoogle Scholar
  16. 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–S174CrossRefGoogle Scholar
  17. 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 25:822–828PubMedCrossRefGoogle Scholar
  18. 18.
    Zurynski Y, Dorsch N, Pearson I, Choong R (1991) Transcranial Doppler ultrasound in brain death: experience in 140 patients. Neurol Res 13:248–252PubMedGoogle Scholar
  19. 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 40:300–303PubMedGoogle Scholar
  20. 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 21:657–662PubMedCrossRefGoogle Scholar
  21. 21.
    Feri M, Ralli L, Felici M, Vanni D, Capria V (1994) Transcranial Doppler and brain death diagnosis. Crit Care Med 22:1120–1126PubMedCrossRefGoogle Scholar
  22. 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 27:2391–2392PubMedGoogle Scholar
  23. 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 160:41–46PubMedCrossRefGoogle Scholar
  24. 24.
    Velthoven van V, Calliauw L (1988) Diagnosis of brain death. Transcranial Doppler sonography as an additional method. Acta Neurochir (Wien) 95:57–60CrossRefGoogle Scholar
  25. 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 59:58–60CrossRefGoogle Scholar
  26. 26.
    Qian SY, Fan XM, Yin HH (1998) Transcranial Doppler assessment of brain death in children. Singapore Med J 39:247–250PubMedGoogle Scholar
  27. 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 12:205–213PubMedGoogle Scholar
  28. 28.
    Powers AD, Graeber MC, Smith RR (1989) Transcranial Doppler ultrasonography in the determination of brain death. Neurosurgery 24:884–889PubMedGoogle Scholar
  29. 29.
    Steinmetz H, Hassler W (1988) Reversible intracranial circulatory arrest in acute subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 51:1355–1356PubMedGoogle Scholar
  30. 30.
    Grote E, Hassler W (1988) The critical first minutes after subarachnoid hemorrhage. Neurosurgery 22:654–661PubMedGoogle Scholar
  31. 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 78:191–194PubMedCrossRefGoogle Scholar
  32. 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 27:155–157PubMedCrossRefGoogle Scholar
  33. 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 23:503–505PubMedCrossRefGoogle Scholar
  34. 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):1–57Google Scholar
  35. 35.
    Spittler JF, Langenstein H (1991) Diagnosis of brain death: limitations of angiography after osteoclastic trepanation. Dtsch Med Wochenschr 116:1828–1831PubMedCrossRefGoogle Scholar
  36. 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 45:225–227PubMedGoogle Scholar
  37. 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 9:220–223PubMedCrossRefGoogle Scholar
  38. 38.
    Rath SA, Richter HP (1993) Transcranial Doppler sonography as a reliable diagnostic tool in craniocerebral trauma. Unfallchirurg 96:569–575PubMedGoogle Scholar
  39. 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 17:219–222PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Louisa M. Monteiro
    • 1
  • Casper W. Bollen
    • 1
  • Alexander C. van Huffelen
    • 2
  • Rob G. A. Ackerstaff
    • 3
  • Nicolaas J. G. Jansen
    • 1
  • Adrianus J. van Vught
    • 1
  1. 1.Department of Pediatric Intensive CareUniversity Medical Center UtrechtUtrechtThe Netherlands
  2. 2.Department of Clinical NeurophysiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
  3. 3.Department of Clinical NeurophysiologySt. Antonius Hospital NieuwegeinNieuwegeinThe Netherlands

Personalised recommendations