Neurological Criteria Research Articles

Invitation to participate in amulti-center study for validation of cerebral computed tomography angiography and computed tomography perfusion in the determination of cerebral circulatory arrest during brain death/death by neurological criteria diagnosis procedure in paediatric population below 12 years of age.

We would like to invite paediatric intensive care units (PICU) to join our multi-center trial concerning patient population < 12 y/o and aiming at: • validation of computed tomography angiography (CTA)/computed tomography perfusion (CTP) tests for brain death/death by neurological criteria (BD/DNC) diagnosis procedures, • validation of duplex Doppler insonation of extracranial segments of the internal cerebral arteries and the vertebral arteries for choosing an optimal time for CTA/CTP testing.

Idiopathic intracranial hypertension (case study)

Idiopathic intracranial hypertension (IIH) is a rare pathological condition that without proper therapy often results in permanent vision loss. Diagnosis of IIH is often difficult, since it is characterized by a combination of numerous specific and non-specific ophthalmological and neurological criteria. Difficulties in diagnosis significantly delay the prescription of treatment, which affects the visual prognosis. The description of this clinical case is intended to present our own experience in the diagnosis and management tactics of a patient with this pathology, which will be useful for practicing ophthalmologists.

Case Report of Oculocerebrocutaneous (Delleman) syndrome and review of cutaneous features

Oculocerebrocutaneous syndrome (OCCS) is a rare disorder with specific clinical presentation. It can be diagnosed clinically upon specific dermatological, neurological, and ophthalmological criterion. We present the case of a 5-week-old baby boy with OCCS syndrome, highlighting its dermatological manifestations and a review of skin features as well. The patient presented with a unilateral microphthalmia with orbital cysts, postauricular crescent-shaped skin defect, and pedunculated skin appendages with multiple focal hypoplastic skin lesions. Early diagnoses and long-term follow-up may improve the prognosis of such a rare disease.

DIAGNOSING DEATH AND RESURRECTING THE MYTH OR REALITY OF CATALEPSY

Death is medically described as the irreversible loss of essential characteristics and requires irreversible loss of capacity for consciousness and capacity to breathe. Death certification has legal, ethical, philosophical, biological, cultural, and religious characteristics and consequences. Its diagnosis is based on the best available scientific evidence: somatic, circulatory and/or neurological criteria. Even if we accept the determination of death is “scientific” and a set of criteria for its diagnosis have been established, death diagnosis still differs among countries. It is for this reason and sporadic cases like the one occurred recently in Spain, that “artistic” aspects of medicine and the mystery of the extensively described condition catalepsy revive. Catalepsy is a medical condition characterized by inactivity, decreased responsiveness to external stimuli, and a tendency to maintain an immobile posture (muscular rigidity). This condition may be associated with psychotic disorders, nervous system drug toxicity, and other conditions. Moreover, its influence in artistic literature and mass media have led to the consideration of catalepsy as a cornerstone in the confluence of medicine, art, mystery, science and society.

Ancillary Tests for Death by Neurologic Criteria in Children

Investigators from Children's Hospital of Pennsylvania reported on the usage of ancillary studies in the declaration of brain death in children in a single-center retrospective descriptive study.

The Demise of Brain Death

Fifty years have passed since brain death was first proposed as a criterion of death. Its advocates believe that with the destruction of the brain, integrated functioning ceases irreversibly, somatic unity dissolves, and the organism turns into a corpse. In this article, I put forward two objections against this assertion. First, I draw parallels between brain death and other pathological conditions and argue that whenever one regards the absence or the artificial replacement of a certain function in these pathological conditions as compatible with organismic unity, then one equally ought to tolerate that function’s loss or replacement in brain death. Second, I show that the neurological criterion faces an additional problem that is only coming to light as life-supporting technology improves: the growing sophistication of the latter gives rise to a dangerous decoupling of the actual performance of a vital function from the retention of neurological control over it. Half a century after its introduction, the neurological criterion is facing the same fate as its cardiopulmonary predecessor.

Brain Death Evaluation in Children With Suspected or Confirmed Coronavirus Disease 2019.

Objectives:To discuss the challenges of conducting a death by neurologic criteria or brain death evaluation in the coronavirus disease 2019 era and provide guidance to mitigate viral transmission risk and maintain patient safety during testing.Design:Not applicable.Setting:Not applicable.Patients:Children with suspected or confirmed coronavirus disease 2019 who suffer catastrophic brain injury due to one of numerous neurologic complications or from an unrelated process and require evaluation for death by neurologic criteria.Interventions:Not applicable.Measurements and Main Results:There is a risk to healthcare providers from aerosol generation during the neurologic examination and apnea test for determination of death by neurologic criteria. In this technical note, we provide guidance to mitigate transmission risk and maintain patient safety during each step of the death by neurologic criteria evaluation. Clinicians should put on appropriate personal protective equipment before performing the death by neurologic criteria evaluation. Risk of aerosol generation and viral transmission during the apnea test can be mitigated by using continuous positive airway pressure delivered via the ventilator as a means of apneic oxygenation. Physicians should assess the risk of transporting coronavirus disease 2019 patients to the nuclear medicine suite to perform a radionucleotide cerebral blood flow study, as disconnections to and from the ventilator for transport and inadvertent ventilator disconnections during transport can increase transmission risk.Conclusions:When conducting the neurologic examination and apnea test required for death by neurologic criteria determination in patients with suspected or confirmed coronavirus disease 2019, appropriate modifications are needed to mitigate the risk of viral transmission and ensure patient safety.

Guidance for Physicians Who Wish to Influence Policy Development on Determination of Death by Neurologic Criteria.

Physicians have a long-standing obligation to consider social implications of their practice and its potential influences on health policy. One example of a practice's influence on policy is determining death by neurologic criteria. By lobbying policymakers, maintaining their diagnostic skills, participating in national medical societies, and contributing to robust discourse, physicians can positively influence practice and policy about death determination by neurologic criteria.

What Should We Do When Families Refuse Testing for Brain Death?

Two commentaries respond to a case about apnea testing to confirm death by neurologic criteria.

Inconsistency in Brain Death Determination Should Not Be Tolerated.

Since it was proposed in 1980, the Uniform Determination of Death Act has provided the legal basis for determination of death by neurological criteria. The act contains language that allows for acceptable medical standards to be used to determine death. Since 1995, the American Academy of Neurology has provided guidelines for brain death determination (revised in 2010), but nationwide adherence to these guidelines has been incomplete. This variability could lead to misdiagnosis and erosion of public trust in this important medical practice. Physicians must work together as a profession to push for uniformity and accuracy in death diagnosis.

AMA Code of Medical Ethics' Opinions About End-of-Life Care and Death.

Death determination is fraught with clinical, cultural, and ethics questions. This article considers relevant history that informs the AMA Code of Medical Ethics opinions about neurological criteria for death.

Quality improvement for reducing utilization drift in hypoxic-ischemic encephalopathy management.

Therapeutic hypothermia is an effective neuroprotective intervention for infants with moderate or severe hypoxic-ischemic encephalopathy (HIE). With the introduction of new medical therapy comes a learning curve with regards to its proper implementation and understanding of eligibility guidelines. We hypothesized that variation in patient selection and lack of adherence to established protocols contributed to the utilization drift away from the original eligibility guidelines. A retrospective cohort study was conducted including infants who received therapeutic hypothermia in the neonatal intensive care unit (NICU) for HIE to determine utilization drift. We then used QI methodology to address gaps in medical documentation that may lead to the conclusion that therapeutic hypothermia was inappropriately applied. We identified 54% of infants who received therapeutic hypothermia who did not meet the clinical, physiologic, and neurologic examination criteria for this intervention based on provider admission and discharge documentation within the electronic medical record (EMR). Review of the charts identified incomplete documentation in 71% of cases and led to the following interventions: 1) implementation of EMR smartphrases; 2) engagement of key stakeholders and education of faculty, residents, and neonatal nurse practitioners; and 3) performance measurement and sharing of data. We were able to improve both adherence to the therapeutic hypothermia guidelines and achieve 100% documentation of the modified Sarnat score. Incomplete documentation can lead to the assumption that therapeutic hypothermia was inappropriately applied when reviewing a patient's EMR. However, in actual clinical practice physicians follow the clinical guidelines but are not documenting their medical decision making completely. QI methodology addresses this gap in documentation, which will help determine the true utilization drift of therapeutic hypothermia in future studies.

Cerebrasthenia and social disadaptation of cerebral-dysgemic genesis in the elderly of the Republic of Karelia

Using a bio-psycho-social approach, the correlations between neurological, psycho-pathological and social criteria were studied in elderly persons of the Republic of Karelia with stage I of dyscirculatory encephalopathy (DE) (n = 280; average age 62,4 ± 6,5; gender index 1:1). The control group included healthy persons (n = 32; average age 60,9 ± 8,1; gender index 1:1; p &gt; 0,05). We used Visual Analog Scale (VAS) of Headache, Asthenia Assessment Scale — Multidimensional Fatigue Inventory (MFI-20), Hospital Anxiety and Depression Scale (HADS), Mini-test of Mental State Examination (MMSE), and the social frustration test of L. I. Wasserman. It was found that patients with stage I of DE, in contrast to healthy individuals, were characterized by: the presence of cephalgia (according to VAS 5,06 ± 3,03 points); a higher level of asthenia (total points for MFI-20: 82,6 ± 1,2 and 36,7 ± 1,8; p &lt; 0,05); anxiety/depression (scores for HADS: (11,3 ± 4,6/8,4 ± 3,8 and 3,7 ± 2,3/2,6 ± 1,9; p &lt; 0,05); cognitive dysfunction (average MMSE score: 25,16 ± 1,39 and 28,69 ± 0,47; p &lt; 0,05); social frustration (final index: 2,5 ± 0,6 and 1,0 ± 0,4 points; p &lt; 0,05). A highly significant positive correlation of asthenic syndrome with the level of disadaptive social frustration (R = 0,931; p &lt; 0,001) was found in such patients.

Early neurological deterioration prediction in patients with hemorrhagic hemispheric stroke on the ground of quantitative evaluation of secondary interventricular hemorrhage severity

The early neurological deterioration criteria in patients with hemorrhagic hemispheric stroke (HHS) were elaborated on the ground of quantitative evaluation of secondary interventricular hemorrhage (IVH) severity. The prospective study with 339 patient’s involvement with the participation of patients with an average age (64.8±0.6) years old with spontaneous (hypertensive) supratentorial intracerebral hemorrhage. The diagnosis was made by brain computed tomography with quantitative evaluation of secondary intraventricular hemorrhage severity by using Graeb, Leroux and Intraventricular Hemorrhage (IVH). Early neurological deterioration (END) was taken as a combined clinical end-point. END was detected as one of the following criteria onset: reduction of the summary score according to Full Outline of UnResponsiveness coma scale &gt; 2; increasing of the summary score on National Institute of Health Stroke Scale &gt; 4; lethal outcome. Statistic processing of the results was made with the use of Mann-Whitney criteria and ROC-analysis. Combined clinical end-point was registered in 29.2 % cases. It was detected that patients with END are characterized with higher values of summary score according to Graeb (7 [4–8] vs 0 [0–4], p&lt;0.0001), Leroux (9 [5–12] vs 0 [0–5], p&lt;0.0001) and IVH scales (17 [13–20] vs 0 [0–12], p&lt;0.0001). While the mentioned scales do not differ in diagnostic informativeness when individual END detection prognosis in patients with HHS (AUC is 0.80-0.81). Summary score according to Graeb &gt; 5 (Se = 68.7%, Sp = 82.9%), Leroux &gt; 4 (Se = 76.8%, Sp = 74.6%) and IVH &gt; 13 (Se =72.7%, Sp = 80.8%) scales are predictors of END in patients with HHS. It was detected that in case of FOUR score &lt; 13, volume of intracerebral hemorrhage &gt; 40 ml and midline shift &gt; 5 mm, positive predictive value of these criteria exceeds 90%, while in general cohort – does not reach 65%. The threshold values of summary score in Graeb, Leroux and IVH scales are the informative criteria of END prognosis in patients with HHS. Keywords: hemorrhagic stroke, intraventricular hemorrhage, early neurological deterioration, prognosis.

A review of current controversies in determining death by neurologic criteria in children.

Death by neurologic criteria (DNC) is the irreversible cessation of all functions of the entire brain, including the brainstem. It is legally recognized as equivalent to cardiopulmonary death. Legal and ethical controversies surrounding DNC have emerged as a result of several highly publicized cases that have eroded public trust in our ability to declare DNC accurately. In this review, we focus on recently published primary data about DNC and address some of these controversies. Approximately 21% of children who die in pediatric intensive care units (PICU) are declared DNC. Although 60% of physicians report that they have been asked to maintain organ support after DNC declaration, less than 1% of patients remain physically present in the PICU more than 5 days after DNC declaration. We discuss strategies for safely conducting the apnea test, indications and prevalence of ancillary testing, and objections to DNC, including issues of consent and requests for ongoing organ support. In order to maintain public trust, published guidelines must be followed to accurately and consistently diagnose DNC. We must develop strategies to respond to objections to DNC determination. Ongoing research is needed to improve the safety of apnea testing and indications for and interpretation of ancillary testing.

FEATURES OF CLINICAL MANIFESTATIONS OF POST-TRAUMATIC NEUROPATHIES AND PLEXOPATHIES RESULTED FROM GUNSHOT AND NON-GUNSHOT INJURIES OF EXTREMITIES

The number of traumatic injuries to nerve stems and plexuses is steadily increasing in peacetime during armed conflicts and terrorist acts. In wartime, peripheral nerve injuries are much more common, and a great deal of the knowledge about peripheral nerve damage and repair is based on combat experience. The study of the clinical course of post−traumatic neuropathies and plexopathies contributes to the development of clinical and neurological criteria and compensatory−restorative responses in traumatic lesions of the peripheral nervous system, helps to assess the functional significance of various parts of the nervous system when compensating a damaged functional unit. To study the features of clinical manifestations of post−traumatic gunshot and non−gunshot neuropathies and plexopathies, 63 patients underwent clinical and neurological examination with topical and clinical diagnoses, collection of detailed anamnesis and complaints, electroneuromyography and ultrasound examination. Movement disorders, characterized by peripheral paresis or plegia of the corresponding muscle group and accompanied with a reduced or lost tendon and periosteal reflexes, were common. Sensitivity disorders were a combination of prolapse (anesthesia, hypoesthesia) and irritation (paresthesia, hyperpathy, hyperesthesia). Autonomic disorders (vascular, secretory and trophic) in traumatic neuropathies differ depending on the clinical individuality of peripheral nerves. Vascular disorders were more often detected with partial damage to nerve structures and were accompanied by local edema. Of the secretory disorders, the most constant sign of impaired nerve conduction was sweating disorder. In the clinical picture of the pain syndrome, i.e. causalgia, the pain sensations by type of burning dominated. The intensity of the pain syndrome in severe cases was very high, in some cases the pain was exacerbated by irritation of the senses. The clinical picture of causalgia is characterized by an increased pain when warming the injured limb and it reduced when cooled, that is a "symptom of a wet rag." Knowledge of clinical features allows the detection of the peripheral nervous system lesions at the early stages of pathology, performance of dynamic clinical and neurological observation and treatment, timely use of modern additional research methods to address further treatment tactics that restore limb function, improve quality of life. Key words: post−traumatic neuropathy and plexopathy, peripheral nervous system, gunshot wounds of nerves and plexuses.

Afferent limb failure revisited – A retrospective, international, multicentre, cohort study of delayed rapid response team calls

AimThe efficiency of rapid response teams (RRTs) is decreased by delays in activation of RRT (afferent limb failure, ALF). We categorized ALF by organ systems and investigated correlations with the vital signs subsequently observed by the RRT and associations with mortality. MethodsInternational, multicentre, retrospective cohort study including adult RRT patients without treatment limitations in 2017–2018 in one Australian and two Finnish tertiary hospitals. ResultsA total of 5,568 RRT patients’ first RRT activations were included. In 927 patients (17%) ALF was present within 4 h before the RRT call, most commonly for respiratory criteria (419 patients, 7.5%). In 3516 patients (63%) overall, and in 756 (82%) of ALF patients, the RRT observed abnormal vital signs upon arrival. The organ-specific ALF corresponded to the RRT observations in 52% of cases for respiratory criteria, in 60% for haemodynamic criteria, in 55% for neurological criteria and in 52% of cases for multiple organ criteria. Only ALF for respiratory criteria was associated with increased hospital mortality (OR 1.71, 95% CI 1.29–2.27), whereas all, except haemodynamic, criteria at the time of RRT review were associated with increased hospital mortality. ConclusionsVital signs were rarely normal upon RRT arrival in patients with ALF, while organ-specific ALF corresponded to subsequent RRT observations in just over half of cases. Our results suggest that systems mandating timely responses to abnormal respiratory criteria in particular may have potential to improve deteriorating patient outcomes.

Outcomes and implications of a single brain death examination policy on organ donation outcomes at a high-volume trauma center.

Despite current neurological guidelines that a single brain death examination (SBDE) is sufficient to determine brain death, a vast majority of hospitals still use a two brain death examination (TBDE) policy based on historical practice. The purpose of this study was to analyze the outcomes and implications of an SBDE policy compared with a TBDE policy with respect to organ donation outcomes. We retrospectively reviewed all adult patients declared dead by neurological criteria between 2010 and 2018 at a high-volume trauma center. The study population was divided into SBDE and TBDE cohorts. Primary outcomes included time to organ donation, terminal donor creatinine and bilirubin, and number of procured and transplanted organs. A total of 327 patients comprised the study population: 66.7% SBDE (n = 218 of 327 patients) and 33.3% TBDE (n = 109 of 327 patients). The SBDE group had a shorter median time from examination to procurement (38 vs. 44 hours, p = 0.02) as well as lower terminal donor creatinine (1.1 vs. 1.35 mg/dL, p = 0.004) and bilirubin (0.8 vs. 1.1 mg/dL, p = 0.04). Furthermore, the SBDE group had a significantly greater proportion of kidneys (90.6% vs. 81.6%, p = 0.02), lungs (11.8% vs. 4.6%, p = 0.02), and total organs (58.2% vs. 46.6%; p = 0.0001) procured with intent to transplant and a greater proportion of total organs transplanted (53.1% vs. 42.4%, p = 0.0004). Multivariable regression analysis confirmed that SBDE was independently associated with a shorter time to procurement, lower terminal creatinine, and increased number of procured organs. These data highlight the potential benefit of an SBDE policy with regards to organ donation outcomes at a high-volume trauma center and should facilitate future randomized prospective studies to more rigorously test this hypothesis. Therapeutic/Care Management, level IV.

Special considerations in the assessment of catastrophic brain injury and determination of brain death in patients with SARS-CoV-2

IntroductionThe coronavirus disease 2019 (Covid-19) pandemic has led to challenges in provision of care, clinical assessment and communication with families. The unique considerations associated with evaluation of catastrophic brain injury and death by neurologic criteria in patients with Covid-19 infection have not been examined. MethodsWe describe the evaluation of six patients hospitalized at a health network in New York City in April 2020 who had Covid-19, were comatose and had absent brainstem reflexes. ResultsFour males and two females with a median age of 58.5 (IQR 47–68) were evaluated for catastrophic brain injury due to stroke and/or global anoxic injury at a median of 14 days (IQR 13–18) after admission for acute respiratory failure due to Covid-19. All patients had hypotension requiring vasopressors and had been treated with sedative/narcotic drips for ventilator dyssynchrony. Among these patients, 5 had received paralytics. Apnea testing was performed for 1 patient due to the decision to withdraw treatment (n = 2), concern for inability to tolerate testing (n = 2) and observation of spontaneous respirations (n = 1). The apnea test was aborted due to hypoxia and hypotension. After ancillary testing, death was declared in three patients based on neurologic criteria and in three patients based on cardiopulmonary criteria (after withdrawal of support (n = 2) or cardiopulmonary arrest (n = 1)). A family member was able to visit 5/6 patients prior to cardiopulmonary arrest/discontinuation of organ support. ConclusionIt is feasible to evaluate patients with catastrophic brain injury and declare brain death despite the Covid-19 pandemic, but this requires unique considerations.

The haunted heart and the Holy Ghost: on retrieval, donation and death

This enquiry examines problems which haunt the ‘heart’ and its donation. It begins by examining the heart’s enduring significance for culturally mediated self-understanding, its vulnerability to misunderstanding and abuse and...