ISPUB.com / IJNM/3/1/5024
  • Author/Editor Login
  • Registration
  • Facebook
  • Google Plus

ISPUB.com

Internet
Scientific
Publications

  • Home
  • Journals
  • Latest Articles
  • Disclaimers
  • Article Submissions
  • Contact
  • Help
  • The Internet Journal of Neuromonitoring
  • Volume 3
  • Number 1

Original Article

Orbital Doppler Sonography and Documentation of Brain Death

G Litscher

Citation

G Litscher. Orbital Doppler Sonography and Documentation of Brain Death. The Internet Journal of Neuromonitoring. 2002 Volume 3 Number 1.

Abstract

Multiparametric confirmatory tests for documentation of brain death were studied from a 24-year-old subject with clinically defined brain death after severe head injury. The importance of transorbital ultrasound Doppler sonographic measurements is discussed.

 

Introduction

In recent years, fewer organs have been available for explantation eventhough new biomedical devices for confirmatory testing and determination of brain death have been developed [1,2,3,4,5,6,7]. Brain death or cerebral death is defined as irreversible cessation of all brain functions. However, it is difficult - indeed, impossible - to provide diagnostic standards for a condition that has never been adequately defined [8]. The documentation of brain death is primarily based on clinical criteria from neurologic examinations. In addition, tests including EEG recordings, evoked potentials, cerebral angiography, cerebral scintigraphy and more recently, transcranial Doppler ultrasonography (TCD), near infrared spectrsocopy (NIRS) and heart rate variability, are used to document the dynamics of cerebral ciruculatory arrest [9,10,11,12,13,14,15,16,17,18].

The aim of this present study was to examine transorbital and transtemporal Doppler sonographic recordings during the development of brain death in a 24-year-old patient.

Materials and Methods

Subject

A 24-year-old male subject from the intensive care unit with clinically defined brain death after severe head injury was investigated using combined multiparametric biosignal recordings. The study was approved by the ethics committee of the University of Graz (10-055 ex 99/00).

Multidirectorial Transorbital and Transcranial Doppler Sonography

Transorbital and transtemporal Doppler sonographic examinations were performed with a portable Multi-Dop T unit (DWL Electronic Systems GmbH, Sipplingen, Germany). A 4 MHz and a 2 MHz probe were used in a multidirectional ultrasound probe holder construction (Fig. 1). The monitoring arrangement for simultaneous recording of Doppler sonographic signals in the ophthalmic artery (OA) and the middle cerebral artery (MCA) was stationary at the circumference of the head. Blood flow profiles in the OA were measured transorbitally. Under acoustic control, the angle and position of the probes were adjusted until the greatest possible signal amplitude was reached.

Figure 1
Figure 1: Biomedical devices for confirmatory testing of brain death including multidirectional ultrasound probe holder construction.

Spontaneous and evoked bioelectrical brain activity

Electroencephalography remains one of the most well-validated confirmatory tests. Recordings were obtained for 30 minutes with a 12-channel instrument (Picker Internat. GmbH, Schwarzer ED14, Munich, Germany).

Results

Case Report

A 24-year-old man fell from a height of 4 m and hit a cement block with his head. He was found at the accident site gasping for air. The patient was intubated and respirated upon admittance to the intensive care unit, pupils were bilaterally anisocor and not reactive to light. Brain stem areflexia was present. The first results from CT of the head revealed fractures on the occipital left, subarachnoid hemorrhage, brain edema and tentorial herniation. The patient showed clinical signs of brain death.

Instrumental tests showed the following results: Electrical activity was at lower levels than 2 µV with the instrument set shown in Figure 2. Transcranial Doppler sonography showed a bilateral oscillating flow in the middle cerebral artery (Fig. 3a). A residual flow profile was still detectable on both sides transorbitally (Fig. 3b).

Figure 2
Figure 2: Electroencephalogram of the 24-year-old patient.

Figure 3
Figure 3: Transtemporal (a) and transorbital (b) blood flow profiles measured continuously and simultaneously using the probe holder construction shown in Fig. 1.

Since residual flow could be detected orbitally, cerebral angiography was performed. This showed that the internal carotid artery was poorly perfused on both sides. The right internal carotid artery was occluded distal from the perfused ophthalmic artery, the left middle cerebral artery was poorly perfused. At the same time, missing perfusion of the cerbral anterior artery, the basilar artery and the right middle cerebral artery was visible (Fig. 4).

Figure 4
Figure 4: Cerebral angiogram of the 24-year-old patient.

Discussion

The EEG is considered a highly sensitive method for documenting brain death and evaluating cerebral cortical function. For determining brain death this method is the most commonly used confirmatory electronic test in Europe.

However, comparability and validity is influenced by different technical problems and varying evaluative criteria. We must consider, that cerebral acitivity may be detectable even when brain stem functions are missing, which can also be reflected in EEG activity.

Brain death is given, when irreversible loss of entire cerebral function occurs. The definate, clinical diagnosis of brain death does not require an isoelectric EEG. On the other hand, angiographically detectable, remaining circulation can be present despite isoelectric EEG and missing brain stem potentials, which indicates that presumable cerebral functions are given by cerebral blood flow [1].

New developments in the field of biomedical engineering enable us to accurately register bioelectric activity in the intensive care unit, despite massive interference, in dimensions which were not determinable thus far. Within case reports, our research group recently referred to the problems in defining an "isoelectric” EEG [7].

To our knowledge, there are only two reports dealing with transorbital Doppler sonography and brain death.

Karaali et al. [13] investigated the blood flow velocity changes in orbital arteries by using TCD in 8 patients with brain death. Because of the technical difficulty, this method does not seem to be practical for routine application [13]. Nonetheless, it may be used as an alternative non-invasive method when Doppler studies of the carotid arteries are not adequate due to limiting conditions, such as open wounds, presence of vascular catheters, or large cervical hematomas.

Lampl et al. [18] performed a prospective controlled diagnostic study using transorbital, transtemporal, and transforaminal approaches. Fifty-seven patients with clinically determined brain death were examined. In 2 patients, a positive finding was demonstrated only using the transorbital approach.

In brain death transcranial Doppler offers high sensitivity and specificity for a pattern of systolic spikes and oscillating flow. However, due to the difficulty in penetrating the temporal bone barrier with TCD, 10 - 15 % of the results have demonstrated a false finding of no flow [18]. Incorporating the transorbital approach could increase the sensitivity and specificity of TCD confirming brain death [18] or could exclude the diagnosis of brain death as shown by the present case report.

Acknowledgements

The study was supported by the Jubiläumsfonds der Oesterreichischen Nationalbank (project 8143).

Correspondence to

Gerhard Litscher, PhD Department of Biomedical Engineering and Research in Anesthesia and Critical Care University of Graz Auenbruggerplatz 29 A-8036 Graz Austria Tel.: +43 316 385-3907; -83907 Fax: +43 316 385-3908 gerhard.litscher@uni-graz.at http://www.neuromonitoring.org

References

1. Wijdicks EFM (editor). Brain death. Philadelphia, Baltimore, New York, London, Buenos Aires, Hong Kong, Sydney, Tokyo: Lippincott Williams & Wilkins, 2001.
2. Oduncu F. Hirntod und Organtransplantation. Medizinische, juristische und ethische Fragen. Göttingen: Vandenhoeck & Ruprecht, 1998.
3. Schwarz M, Bonelli J (editors). Der Status des Hirntoten. Eine interdisziplinäre Analyse der Grenzen des Lebens. Wien, New York: Springer, 1995.
4. Schwarz G. Dissoziierter Hirntod. Computergestützte Verfahren in Diagnostik und Dokumentation. Berlin, Heidelberg, New York: Springer, 1990.
5. Pendl G. Der Hirntod. Eine Einführung in seine Diagnostik und Problematik. Berlin, Heidelberg, New York, Tokyo: Springer, 1986.
6. Walker AE. Cerebral death. Baltimore, Munich: Urban & Schwarzenberg, 1985.
7. Litscher G. New biomedical devices and documentation of brain death. Internet J Anesthesiology 1999; Vol3N4: http://www.ispub.com/journals/IJA/Vol3N4/brain.htm
8. Truog RD, Robinson WM. The diagnosis of brain death. Letter to the editor. N Engl J Med 2001; 345(8): 617.
9. Ducrocq X, Braun M, Debouverie M, Junges C, Hummer M, Vespignani H. Brain death and transcranial Doppler: experience in 130 cases of brain dead patients. J Neurol Sci 1998; 160: 41-6.
10. Hadani M, Bruk B, Ram Z, Knoller N, Spiegelmann R, Segal E. Application of transcranial Doppler ultrasonography for the diagnosis of brain death. Intensive Care Med 1999; 25: 822-8.
11. Granry JC. Transcranial Doppler in anesthesia and intensive care. Ann Fr Anesth Reanim 1991; 10(2): 127-36.
12. Pfurtscheller G, Schwarz G, List W. Brain death and bioelectrical brain activity. Intensive Care Med 1985; 11: 149-53.
13. Karaali K, Cevikol C, Senol U, Arici G, Kabaalioglu A, Ramazanoglu A, Brican O. Orbital Doppler sonography findings in cases of brain death. Am J Neuroradiol 2000; 21: 945 - 7.
14. Bitzani M, Matamis D, Nalbandi V, Vakalos A, Karasakalides A, Riggos D. Resting energy expenditure in brain death. Intensive Care Med 1999; 25: 970 - 6.
15. Freitas J, Puig J, Rocha AP, Lago P, Teixeira J, Carvalho MJ, Costa O, de Freitas AF. Heart rate variability in brain death. Clin Auton Res 1996; 6(3): 141-6.
16. Rapenne T, Moreau D, Lenfant F, Boggio V, Cottin Y, Freysz M. Could heart rate variability analysis become an early predictor of imminent brain death? A pilot study. Anesth Analg 2000; 91: 328 - 36.
17. Wijdicks EFM. The diagnosis of brain death. N Engl J Med 2001; 344(16):1215-21.
18. Lampl Y, Gilad R, Eschel Y, Boaz M, Rapoport A, Sadeh M. Diagnosing brain death using the transcranial Doppler with a transorbital approach. Arch Neurol 2002; 59:58 - 60.

Author Information

Gerhard Litscher, Ph.D.
Department of Biomedical Engineering and Research in Anesthesia and Critical Care, University of Graz

Download PDF

Your free access to ISPUB is funded by the following advertisements:

 

BACK TO TOP
  • Facebook
  • Google Plus

© 2013 Internet Scientific Publications, LLC. All rights reserved.    UBM Medica Network Privacy Policy