To provide an update of the 1995 American Academy of Neurology guideline with regard to the following questions: Are there patients who fulfill the clinical criteria of brain death who recover ...neurologic function? What is an adequate observation period to ensure that cessation of neurologic function is permanent? Are complex motor movements that falsely suggest retained brain function sometimes observed in brain death? What is the comparative safety of techniques for determining apnea? Are there new ancillary tests that accurately identify patients with brain death?
A systematic literature search was conducted and included a review of MEDLINE and EMBASE from January 1996 to May 2009. Studies were limited to adults.
In adults, there are no published reports of recovery of neurologic function after a diagnosis of brain death using the criteria reviewed in the 1995 American Academy of Neurology practice parameter. Complex-spontaneous motor movements and false-positive triggering of the ventilator may occur in patients who are brain dead. There is insufficient evidence to determine the minimally acceptable observation period to ensure that neurologic functions have ceased irreversibly. Apneic oxygenation diffusion to determine apnea is safe, but there is insufficient evidence to determine the comparative safety of techniques used for apnea testing. There is insufficient evidence to determine if newer ancillary tests accurately confirm the cessation of function of the entire brain.
Brain death is the irreversible cessation of function of the entire brain, and it is a medically and legally accepted mechanism of death in the United States and worldwide. Significant variability ...may exist in individual institutional policies regarding the determination of brain death. It is imperative that brain death be diagnosed accurately in every patient. The American Academy of Neurology (AAN) issued new guidelines in 2010 on the determination of brain death.
To evaluate if institutions have adopted the new AAN guidelines on the determination of brain death, leading to policy changes.
Fifty-two organ procurement organizations provided US hospital policies pertaining to the criteria for determining brain death. Organizations were instructed to procure protocols specific to brain death (ie, not cardiac death or organ donation procedures). Data analysis was conducted from June 26, 2012, to July 1, 2015.
Policies were evaluated for summary statistics across the following 5 categories of data: who is qualified to perform the determination of brain death, what are the necessary prerequisites for testing, details of the clinical examination, details of apnea testing, and details of ancillary testing. We compared these data with the standards in the 2010 AAN update on practice parameters for brain death.
A total of 508 unique hospital policies were obtained, representing the majority of hospitals in the United States that would be eligible and equipped to evaluate brain death in a patient. Of these, 492 provided adequate data for analysis. Although improvement with AAN practice parameters was readily apparent, there remained significant variability across all 5 categories of data, such as excluding the absence of hypotension (276 of 491 policies 56.2%) and hypothermia (181 of 228 policies 79.4%), specifying all aspects of the clinical examination and apnea testing, and specifying appropriate ancillary tests and how they were to be performed. Of the 492 policies, 163 (33.1%) required specific expertise in neurology or neurosurgery for the health care professional who determines brain death, and 212 (43.1%) stipulated that an attending physician determine brain death; 150 policies did not mention who could perform such determination.
Hospital policies in the United States for the determination of brain death are still widely variable and not fully congruent with contemporary practice parameters. Hospitals should be encouraged to implement the 2010 AAN guidelines to ensure 100% accurate and appropriate determination of brain death.
In accordance with the Uniform Determination of Death Act, guidelines for brain death determination are developed at an institutional level, potentially leading to variability of practice. We ...evaluated the differences in brain death guidelines in major US hospitals with a strong presence of neurology and neurosurgery to determine whether there was evidence of variation from the guidelines as put forth by the American Academy of Neurology (AAN).
We requested the guidelines for determination of death by brain criteria from the US News and World Report top 50 neurology/neurosurgery institutions in 2006. We evaluated the guidelines for five categories of data: guideline performance, preclinical testing, clinical examination, apnea testing, and ancillary tests. We compared the guidelines directly with the AAN guidelines for consistencies/differences.
There was an 82% response rate to requests. Major discrepancies were present among institutions for all five categories. Variability existed in the guidelines' requirements for performance of the evaluation, prerequisites prior to testing, specifics of the brainstem examination and apnea testing, and what types of ancillary tests could be performed, including what pitfalls or limitations might exist.
Major differences exist in brain death guidelines among the leading neurologic hospitals in the Unites States. Adherence to the American Academy of Neurology guidelines is variable. If the guidelines reflect actual practice at each institution, there are substantial differences in practice which may have consequences for the determination of death and initiation of transplant procedures.
Background
Patients with primary posterior fossa catastrophic lesions may clinically meet brain death criteria, but may retain supratentorial brain function or blood flow. These patients could be ...declared brain-dead in the United Kingdom (UK), but not in the United States of America (USA). We report the outcome of adult patients with primary posterior fossa lesions without concurrent major supratentorial injury.
Methods
Henry Ford Hospital database was reviewed over a period of 88 months in order to identify all adult patients with isolated brainstem or posterior fossa lesions. We excluded patients with concurrent significant supratentorial pathology potentially confounding the clinical brain death examination. One more patient from a different hospital meeting these criteria was also included.
Results
Three patients out of 161 met inclusion criteria (1.9% of all brain deaths during this period). With the addition of a fourth patient from another hospital, 4 patients were analyzed. All four patients had catastrophic brainstem and cerebellar injuries meeting the clinical criteria of brain death with positive apnea test in the UK. All had preserved supratentorial blood flow, which after a period of 2 h to 6 days disappeared on repeat testing, allowing declaration of brain death by US criteria in all four. One patient became an organ donor.
Conclusions
Patients with primary posterior fossa catastrophic lesions, who clinically seem to be brain-dead, evolve from retaining to losing supratentorial blood flow. If absent cerebral blood flow is used as an additional criterion for the declaration of death by neurological criteria, these patients are not different than those who become brain death due to supratentorial lesions.
Introduction
Limited data describe the frequency, timing, or indications for endotracheal intubation (ETI) in patients with status epilepticus. A better understanding of the characteristics of ...patients with status epilepticus requiring airway interventions could inform clinical care. We sought to characterize ETI use in patients with prehospital status epilepticus.
Methods
This study was a secondary analysis of the Rapid Anticonvulsant Medication Prior to Arrival Trial, a multi-center, randomized trial comparing intravenous lorazepam to intramuscular midazolam for prehospital status epilepticus treatment. Subjects received ETI in the prehospital, Emergency Department (ED), or inpatient setting at the discretion of caregivers.
Results
Of 1023 enrollments, 218 (21 %) received ETI. 204 (93.6 %) of the ETIs were performed in the hospital and 14 (6.4 %) in the prehospital setting. Intubated patients were older (52 vs 41 years,
p
< 0.001), and men underwent ETI more than women (26 vs 21 %,
p
= 0.047). Patients with ongoing seizures on ED arrival had a higher rate of ETI (32 vs 16 %,
p
< 0.001), as did those who received rescue anti-seizure medication (29 vs 20 %,
p
= 0.004). Mortality was higher for intubated patients (7 vs 0.4 %,
p
< 0.001). Most ETI (
n
= 133, 62 %) occurred early (prior to or within 30 min after ED arrival), and late ETI was associated with higher mortality (14 vs 3 %,
p
= 0.002) than early ETI.
Conclusions
ETI is common in patients with status epilepticus, particularly among the elderly or those with refractory seizures. Any ETI and late ETI are both associated with higher mortality.
Neurocritical care has grown into an organized specialty that may have consequences for patient care, outcomes, research, and neurointensive care (neuroICU) technology.
Neurocritical care improves ...care and outcomes of the patients who are neurocritically ill, and neuroICUs positively affect the financial state of health care systems. The development of neurocritical care as a recognized subspecialty has fostered multidisciplinary research, neuromonitoring, and neurocritical care information technology, with advances and innovations in practice and progress.
Neurocritical care has become an important part of health systems and an established subspecialty of neurology. Understanding its structure, scope of practice, consequences for care, and research are important.
What to Look for on Post-stroke Neuroimaging Katramados, Angelos M; Hacein-Bey, Lotfi; Varelas, Panayiotis N
Neuroimaging clinics of North America,
11/2018, Letnik:
28, Številka:
4
Journal Article
Recenzirano
The most feared complication after acute ischemic stroke is symptomatic or asymptomatic hemorrhagic conversion. Neuroimaging and clinical criteria are used to predict development of hemorrhage. ...Seizures after acute ischemic stroke or stroke-like symptoms from seizures are not common but may lead to confusion in the peristroke period, especially if seizures are repetitive or evolve into status epilepticus, which could affect neuroimaging findings. Malignant infarction develops when cytotoxic edema is large enough to lead to herniation and death. Post-stroke neuroimaging prognosticators have been described and should be assessed early so that appropriate treatment is offered before herniation leads to additional tissue injury.
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