in brain death diagnosis: Clinical experience in 196 patients. CT angiography in brain death diagnosis: Clinical experience in 196 patients. M Musacchio, A Meyer, I Manoila, A Lebidensky, JC Zink, H Oesterlé, N Stahl, A Bianchi, T Tajahmady, A Tournade Dear colleagues, ladies and gentlemen, my name is Mariano Musacchio. My presentation will focus the usefulness of angioCT in the diagnosis of brain death. Radiologie Pôle 3 et CHPOT - Hôpital Louis Pasteur (HCC) - COLMAR - France

Introduction : CT angiography in brain death MM I thought that it was suitable to start considering the concept of brain death. For the first time in history we have the possibility of interfering in the process of dying with manoeuvres which are of no utility for the patient but which can greatly help others. This ambiguous situation have revive old debates about the significance of life and death, in many fields: theology, ethics, philosophy, anthropology and of course, medicine. Neuroradiology - Louis Pasteur Hospital (HCC) - COLMAR - France MM

all functions of the brain, including the brain stem CT angiography in brain death Introduction : Brain death concept: Irreversible loss of all functions of the brain, including the brain stem

Introduction - Brain death Legislation in France CT angiography in brain death Introduction - Brain death Legislation in France Decree n° 96-1041 (December 2nd 1996) Non reactive coma Abolition of brain stem reflexes Abolition of spontaneous respiration (hypercapnia test) Photomotor Corneal Oculo-vestibular Oculo-cardiac Clinical Criteria Suspicion + In France, the clinical diagnosis of brain death must be confirmed by 2 non reactive, flat EEG or by a 4 vessel cerebral angiography. This last option can be performed using an arterial or venous approach, by selective catheterism or not. The angio CT scan is one of the methods that could be employed in this prospect. Paraclinical Criteria 2 non reactive, flat, 30 min long EEG with a 4 h interval or 4-vessel cerebral angiography showing no cerebral circulation Confirmation Neuroradiology - Louis Pasteur Hospital (HCC) - COLMAR - France MM

To evaluate clinical usefulness of CT cerebral angiography CT angiography in brain death Objectives: To evaluate clinical usefulness of CT cerebral angiography in confirmation of brain death diagnosis The history of the concept of brain death is closely linked to developments in organ transplantation. In 1959, Mollaret and Goullon used the term coma dépassé, "a state beyond coma", to describe a condition from which they believed recovery was not possible. The term “brain death” was introduced in 1965 following a report of renal transplantation from a heart-beating but “brain-dead” donor, and was defined formally in 1968 in the report of the Ad Hoc Committee of the Harvard Medical School. The clinical diagnostic criteria that were retained at that moment were mostly based on the lost of brain stem functions.

CT angiography in brain death Material and Methods : Population From July 2003 to December 2009 196 patients 97 women / 95 men 17 to 86 years Mean = 52 years

CT angiography in brain death Etiology n = 196 patients Vascular 118 Trauma 70 Brain tumor (glial) 6 Brain Infection (abscess) 2

Multi-row CT scanner Material and Methods : Imaging modality CT angiography in brain death Material and Methods : Imaging modality Multi-row CT scanner However, things proved to be complex in clinical practice. The interpretation is sometimes difficult… Accessibility (24h/24) Simplicity (installation, acquisition, post-treatment) Diagnostic performance

CT angiography in brain death Multi-row CT Scanner BD  Only 1 passage The history of the concept of brain death is closely linked to developments in organ transplantation. In 1959, Mollaret and Goullon used the term coma dépassé, "a state beyond coma", to describe a condition from which they believed recovery was not possible. The term “brain death” was introduced in 1965 following a report of renal transplantation from a heart-beating but “brain-dead” donor, and was defined formally in 1968 in the report of the Ad Hoc Committee of the Harvard Medical School. The clinical diagnostic criteria that were retained at that moment were mostly based on the lost of brain stem functions. No unnecessary displacements! Organs 

CT angiography in brain death BRAIN DEATH DIAGNOSIS! Cerebral acquisition at 60 sec Keystone ! Visceral arterial phase Visceral venous phase However, things proved to be complex in clinical practice. The interpretation is sometimes difficult… Injection ! Timing!

CT angiography in brain death Multi-row CT Scanner “Whole body” CT scan (Colmar) 1 – AP scout (1200 mm) 2 – Non-enhanced cerebral volumetric acquisition (2 mm/1 mm) 3 – Non-enhanced abdominal volumetric acquisition from upper liver to inferior pole of kidneys (5 mm/5 mm) 4 – Locator + Tracker (ROI on thoracic aorta)

CT angiography in brain death Multi-row CT Scanner “Whole-body” CT scan (Colmar) Contrast injection (400mg/ml) : Volume 2 ml/kg (≤ 120 ml); Rate 3 ml/sec 5 – Enhanced thoracic abdominal volumetric acquisition from aortic arc to inferior pole of kidneys (2 mm/1 mm) 6 – Enhanced cerebral volumetric acquisition 60 sec after IV injection (1,5 mm/0,8 mm) 7 – Enhanced abdomino-pelvic volumetric acquisition 90 sec after IV injection (3 mm/3 mm) 8 – Lung window thoracic reconstruction

CT angiography in brain death Material and Methods : SFAR, 1998 Patient conditioning Optimal conditions ! Clinical confirmation of brain death > 6 hours However, things proved to be complex in clinical practice. The interpretation is sometimes difficult… Hemodynamic stability MAP ≥ 65 mmHg Suspicion of cerebral circulatory arrest TC Doppler

CT angiography in brain death Material and Methods : Diagnostic algorithm EEG Brain death Suspicion Cerebral angiography Cerebral CT angioscan TC Doppler + Cerebral CT angioscan Visceral exploration + > 6 hours > 4 hours Non Non However, things proved to be complex in clinical practice. The interpretation is sometimes difficult… Visceral exploration ? Circulatory arrest ? Yes Cerebral CT angioscan Yes Brain death Confirmation

CT angiography in brain death Material and Methods : How to interpret? Visceral exploration Exclude contraindications for organ transplantation However, things proved to be complex in clinical practice. The interpretation is sometimes difficult… Identify anatomic features of surgical interest

cerebral circulatory arrest ? CT angiography in brain death Material and Methods : How to interpret? Cerebral exploration How to prove cerebral circulatory arrest ? However, things proved to be complex in clinical practice. The interpretation is sometimes difficult…

CT angiography in brain death AngioCT Interpretation Almost simultaneous enhancement of arteries and veins Less than 20 seconds after injection (in normal physiological conditions) In normal circumstances, enhancement of cerebral arteries and veins occur almost simultaneously, less than 20 seconds after antecubital injection of contrast product. Many physiological or pathological conditions may modified this delay, but if cerebral blood flow remains above the critical threshold, cerebral vessels will be injected in brief delay. Arteries Veins Neuroradiology - Louis Pasteur Hospital (HCC) - COLMAR - France MM

Diagnostic criteria Dupas et all. (1998) CT angiography in brain death Absence of enhancement 1 minute after injection Anterior cerebral arteries Distal cortical vessels (M4) Internal cerebral veins Vein of Galen

CT angiography in brain death New recommendations… SFNR, 2007 But how to perform an angio ct for the diagnosis of brain death? This year, the French Society of Neuroradiology had published clear guidelines and recommendations concerning the way the exploration must be done for this purpose.

CT angiography in brain death New diagnostic criteria SFNR, 2007 So, as we saw previously, because proximal branches of the circle of Willis and dural sinuses might enhance after injection in a brain-dead patient, only the analysis of distal cortical branches and deep veins could help us to asses the status of cerebral blood circulation. Absence of enhancement Distal cortical vessels (M4), unilateral or bilateral Deep cerebral veins (venae internae cerebri et vena magna cerebri)

CT angiography in brain death But how to perform an angio ct for the diagnosis of brain death? This year, the French Society of Neuroradiology had published clear guidelines and recommendations concerning the way the exploration must be done for this purpose.

CT angiography in brain death Results: Diagnosis of brain death n = 196 patients DSA TCD 79.3% 7.1% 6% 6% ANGIOSCANNER EEG NON Explored

CT angiography in brain death Results: Diagnosis of brain death Cerebral CT angioscan 158 14 18 132 4

CT angiography in brain death Dupas SFNR Angioscaner 85% 99% 79 pts 117 pts Angiosc + EEG / DSA

CT angiography in brain death Case 1 60sec after injection One example. A 27 year old male, with severe brain injuries due to self-inflected gun shot. 24 hours after admission, he presented clinical signs of brain death. The angioCT scan demonstrated enhancement of all proximal branches of the circle of Willis. MCAs BA & PCAs ACAs & PICAs Cerebral oedema Cerebral haemorrhage Bone fracture due to gunshot

Absence of venous enhancement ! X X CT angiography in brain death EEG = flat, not reactive Case 1 Non-enhanced Enhanced (60 sec) Absence of venous enhancement ! X X Absence of M4 Non-enhanced Enhanced (60 sec) However, at the 60 second acquisition there was no enhancement of distal branches of the MCAs (only the insular and opercular segments were injected) and particularly, no enhancement of deep cerebral veins. We hesitated about the diagnosis, and even if we didn’t have any prove of blood circulation at angioCT scan, an EEG was performed, that clearly showed no electrical brain activity, compatible with the diagnosis of brain death. X X X X Absence of ICV Absence of VG

CT angiography in brain death Results: Visceral exploration n = 196 patients ECHO NON EXPLORED 42.4% 16.3% 11.4% 17.4% SCANNER MULTIPLE MODALITIES

2003 2004 2005 2006 2007 2008 34 TAP 28 AP Echo Multiple modalities 21

CT angiography in brain death Results: Visceral exploration 47 134 n = 196 patients 35 7 tumours diagnosed after whole-body scan

CT angiography in brain death Results: Contraindication Lung tumours 2 Suprarenal tumours 2 Hepatic tumours 2 Bilateral renal tumours 1

CT angiography in brain death Results: Anatomic variants Celiac artery absent 1 Common hepatic artery duplic. 1 Renal artery duplication 2 Pyelo-ureteral duplication 1

CT angiography in brain death Conclusion: CT angiography allows confirmation of brain death. Non enhancement of distal cortical vessels and internal cerebral veins/vein of Galen Method demands strict respect of the acquisition protocol and a careful analysis of the results Multi-row CT technology permits simultaneous analysis of all internal organs in a single exploration.

Bis Boll! Vielmols Merci… Château de Haut-Koeningsbourg And for you, thank you for your attention. Bis ball. Château de Haut-Koeningsbourg Bis Boll!