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Neurological Determination of Death Following Infratentorial Stroke: A Population-Based Cohort Study

Published online by Cambridge University Press:  22 July 2021

Andreas H. Kramer*
Affiliation:
Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, Calgary, Alberta, Canada
Julie A. Kromm
Affiliation:
Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, Calgary, Alberta, Canada
Christopher J. Doig
Affiliation:
Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
Michaël Chassé
Affiliation:
Department of Medicine, Innovation Hub, Centre de Recherche du Centre de l’Université de Montréal, Université of Montréal, Montréal, Quebec, Canada
Philippe L. Couillard
Affiliation:
Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, Calgary, Alberta, Canada
*
Correspondence to: Andreas Kramer, Clinical Professor, Department of Critical Care Medicine, Foothills Medical Center - McCaig Tower, 3260 Hospital Drive NW, Calgary, AB, T2N 4Z6. Email: andreas.kramer@albertahealthservices.ca

Abstract:

Background:

There is international variability in whether neurological determination of death (NDD) is conceptually defined based on permanent loss of brainstem function or “whole brain death.” Canadian guidelines are not definitive. Patients with infratentorial stroke may meet clinical criteria for NDD despite persistent cerebral blood flow (CBF) and relative absence of supratentorial injury.

Methods:

We performed a multicenter cohort study involving patients that died from ischemic or hemorrhagic stroke in Alberta intensive care units from 2013 to 2019, focusing on those with infratentorial involvement. Medical records were reviewed to determine the incidence and proportion of patients that met clinical criteria for NDD; whether ancillary testing was performed; and if so, whether this demonstrated the absence of CBF.

Results:

There were 95 (27%) deaths from infratentorial and 263 (73%) from supratentorial stroke. Sixteen patients (17%) with infratentorial stroke had neurological examination consistent with NDD (0.55 cases per million per year). Among patients that underwent confirmatory evaluation for NDD with an apnea test, ancillary test (radionuclide scan), or both, ancillary testing was more common with infratentorial compared with supratentorial stroke (10/12 (85%) vs. 25/47 (53%), p = 0.04). Persistent CBF was detected in 6/10 (60%) patients with infratentorial compared with 0/25 with supratentorial stroke (p = 0.0001).

Conclusions:

Infratentorial stroke leading to clinical criteria for NDD occurs with an annual incidence of about 0.55 per million. There is variability in clinicians’ use of ancillary testing. Persistent CBF was detected in more than half of patients that underwent radionuclide scans. Canadian consensus is needed to guide clinical practice.

Résumé :

RÉSUMÉ :

Poser un diagnostic de décès neurologique dans des cas d’AVC présentant une atteinte infratentorielle : une étude basée sur la population.

Contexte :

À l’échelle internationale, il n’existe pas de consensus quant à savoir si un diagnostic de décès neurologique (DDN) peut être défini conceptuellement sur la base d’une perte permanente des fonctions liées au tronc cérébral, ce qu’on appelle aussi la « mort cérébrale totale » (whole brain death). À cet égard, les lignes directives qui ont cours au Canada ne sont pas définitives non plus. Ainsi, il se peut que des patients victimes d’un AVC satisfassent aux critères cliniques d’un DDN malgré un flux sanguin cérébral (FSC) persistant et une absence relative de lésion supratentorielle.

Méthodes :

Nous avons effectué une étude de cohorte multicentrique ayant inclus des patients qui sont décédés entre 2013 et 2019 dans une unité de soins intensifs de l’Alberta à la suite d’un AVC ischémique ou hémorragique. À cet égard, nous avons mis l’accent sur des atteintes infratentorielles. Leurs dossiers médicaux ont été examinés afin de déterminer la fréquence de DDN et la proportion de dossiers répondant aux critères cliniques d’un DDN mais aussi afin de déterminer dans quelle mesure des tests connexes (ancillary testing) avaient été menés et, quand c’était le cas, si cela permettait de prouver l’absence d’un FSC.

Résultats :

Au total, on a dénombré 95 décès (27 %) en raison d’une atteinte infratentorielle et 263 autres (73 %) en raison d’une atteinte supratentorielle. Seize patients ayant donné à voir une atteinte infratentorielle, soit 17 % d’entre eux, avaient fait l’objet d’un examen confirmant un DDN (0,55 cas par année pour un million d’individus). Parmi les patients ayant subi une évaluation visant à confirmer un DDN au moyen d’un test d’apnée, d’un test connexe (imagerie par radionucléides) ou les deux, un tel test connexe s’est avéré plus fréquent dans le cas d’atteintes infratentorielles en comparaison avec des atteintes supratentorielles (10/12 ou 85 % contre 25/47 ou 53 % ; p = 0,04). Un FSC persistant a été détecté chez 6 patients sur 10 victimes d’une atteinte infratentorielle alors que cette proportion était de 0 sur 25 dans le cas de patients victimes d’une atteinte supratentorielle (p = 0,0001).

Conclusion :

Des AVC comportant une atteinte infratentorielle et répondant aux critères cliniques d’un DDN surviennent avec une fréquence annuelle d’environ 0,55 pour un million de cas. Il existe aussi une variabilité dans l’utilisation des tests connexes par les cliniciens. Un FSC persistant a par ailleurs été détecté chez la moitié des patients qui avaient bénéficié d’un examen d’imagerie aux radionucléides. Enfin, mentionnons qu’un consensus canadien demeure nécessaire pour mieux orienter la pratique clinique.

Type
Original Article
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of Canadian Neurological Sciences Federation

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