Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada.
Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.
Can J Neurol Sci. 2022 Jul;49(4):553-559. doi: 10.1017/cjn.2021.177. Epub 2021 Jul 22.
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.
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.
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%), = 0.04). Persistent CBF was detected in 6/10 (60%) patients with infratentorial compared with 0/25 with supratentorial stroke ( = 0.0001).
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.
在是否基于脑干功能永久性丧失或“全脑死亡”来概念性地定义神经学死亡（NDD）方面，国际上存在差异。加拿大的指南并不明确。尽管存在持续性脑血流（CBF）且幕上损伤相对较少，小脑梗死患者可能符合 NDD 的临床标准。
我们进行了一项多中心队列研究，纳入了 2013 年至 2019 年在艾伯塔省重症监护病房因缺血性或出血性卒中死亡的患者，重点关注幕下受累的患者。回顾病历以确定符合 NDD 临床标准的患者的发生率和比例；是否进行了辅助检查；如果进行了检查，是否显示 CBF 缺失。
95 例（27%）死亡来自幕下，263 例（73%）来自幕上。16 例（17%）幕下卒中患者的神经检查与 NDD 一致（每年每百万分之 0.55 例）。在进行 NDD 确认评估的患者中，行呼吸暂停试验、辅助检查（放射性核素扫描）或两者兼有的患者中，幕下患者比幕上患者更常见（12/16 例（85%）比 47/263 例（53%）， = 0.04）。6/10 例（60%）幕下患者存在持续性 CBF，而 25/263 例幕上患者不存在（ = 0.0001）。
导致符合 NDD 临床标准的幕下卒中的年发生率约为 0.55/百万。临床医生在辅助检查的使用上存在差异。放射性核素扫描的患者中，超过一半存在持续性 CBF。需要加拿大的共识来指导临床实践。
