Findings of Brain Death with the Use of Carotid Duplex Ultrasonography

Abstract

Introduction Brain death is the complete and irreversible loss of cerebral and brain stem function. Although transcranial Doppler may be helpful in establishing the diagnosis, conventional carotid duplex ultrasound is not typically used in this condition. Case Report We describe the case of a 43-year-old woman with a past medical history of cardiac transplantation who was transferred from an outside hospital for hemodynamic monitoring and treatment. The patient had bladder surgery 1 day previously and suffered a prolonged cardiac arrest postoperatively. On arrival, she was comatose and ventilator dependent. Clinical examination revealed no brain stem reflexes (absent pupillary, corneal and oculocephalic reflexes). Brain death was suspected, although right upper-extremity flexion movements were noted. A carotid duplex ultrasound was ordered by the neurological service and performed using an Advanced Technology Laboratory HDI 5000 (Philips, Ultrasound, Bothell, Washington) machine with a linear 7–4 MHz transducer. Abnormal pulsed Doppler signals were detected demonstrating low velocity, bidirectional flow in the common and external carotid and the vertebral arteries. The internal carotid arteries demonstrated bizarre bidirectional and high resistive signals. Computed tomography showed diffuse cerebral edema and loss of gray-white matter differentiation. An electroencephalogram performed the next day demonstrated seizure activity correlating to her right upper extremity movements and indicative of some brain function retention. The patient died soon after. Conclusion Carotid duplex ultrasonography is not usually used in the diagnosis of brain death. Findings are characterized by a lack of diastolic flow or reverberating (to-and-fro pattern) flow and small systolic peaks in early systole on transcranial Doppler. This pattern is caused by a lack of adequate arterial perfusion. Cerebral angiography may reveal nonfilling of the intracranial arteries. Other diagnostic modalities, including computed tomography and electroen-cephalography, can be used with clinical findings to confirm brain death. In our case, carotid duplex ultrasonography was useful in assessing for brain death, although the patient (as later found) did not meet all neurological criteria. Vascular technologists should be aware of these unusual duplex findings in the evaluation of the comatose patient.

Cerebral circulatory arrest diagnosed with transoral Doppler ultrasonography

“…When ICP reaches systolic blood pressure, low‐amplitude short systolic spikes are seen ending up in the total disappearance of waveforms 2 . When there is no adequate bone window for the TCD, cervical arteries Doppler ultrasonography (CAD) was able to detect the same CCA flow pattern as TCD 1,3,4 . Evaluation can be challenging in situations with short necks, high bifurcations, or the presence of a central venous catheter, even though high‐frequency linear transducer are frequently used to examine the internal carotid and vertebral arteries.…”

“…2 When there is no adequate bone window for the TCD, cervical arteries Doppler ultrasonography (CAD) was able to detect the same CCA flow pattern as TCD. 1,3,4 Evaluation can be challenging in situations with short necks, high bifurcations, or the presence of a central venous catheter, even though high-frequency linear transducer are frequently used to examine the internal carotid and vertebral arteries. 5 In this situation, a transoral approach with an endocavitary probe can be used to assess the internal carotid and vertebral arteries as they ascend vertically behind the posterolateral pharyngeal wall.…”

Alteraciones en el flujograma de la arteria carótida común y arteria carótida interna extracraneal en dos pacientes con muerte cerebral

“…7,8 El primer estudio de Doppler carotídeo en MC se realizó en 1974 por Yoneda y colaboradores, quienes reportaron una serie de 10 casos de MC con ausencia de flujo por angiografía cerebral y ausencia de actividad eléctrica en electroencefalograma, en los cuales observaron flujo reverso en las arterias carótidas extracraneales. 9 En 1994 Mehrdad y su equipo describieron una serie de 17 pacientes pediátricos con diagnóstico clínico y electroencefalográfico de MC, en quienes se encontraron flujo diastólico retrógrado en la ACC y ACIe con una especificidad de 100% y una sensibilidad de 71.4% (p = 0.01) para el diagnóstico. 10 En 2018 Conti y colegas analizaron 184 casos de MC, en los cuales se insonó la región extracraneal de la arteria carótida interna (ACI) con especificidad de 100% e incremento de la sensibilidad al conjuntar con DTC de 82.1 a 88% para este diagnóstico.…”