Neves Briard Joel, Plourde Guillaume, Nitulescu Roy, Boyd J Gordon, Carrier François Martin, Couillard Philippe, Keezer Mark R, Kramer Andreas H, Shemie Sam D, Stapf Christian, Chassé Michaël
From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada.
Neurology. 2023 Jan 24;100(4):e443-e453. doi: 10.1212/WNL.0000000000201449. Epub 2022 Oct 11.
There is a paucity of data on the frequency and prognosis of infratentorial brain injury among patients suspected of death by neurologic criteria (DNC), which likely contributes to scientific uncertainty regarding the role of isolated brainstem death in DNC determination. Our aim was to synthesize the prevalence, characteristics, and evolution of infratentorial brain injury, including isolated brainstem death, among patients suspected of DNC.
We conducted a systematic review by searching Medline, Embase, EBM Reviews, CINAHL Complete, and the gray literature from inception to March 26, 2021. We selected cohort and cross-sectional studies, case reports, and case series that included patients suspected of DNC. Two study investigators independently performed study selection, data collection, and risk of bias assessment. Our primary outcomes were the respective prevalence of infratentorial brain injury and isolated brainstem death, which we meta-analyzed using mixed-effects Bayesian hierarchical models with diffuse priors. Our secondary outcomes were the characteristics and evolution of patients with infratentorial brain injury and isolated brainstem death.
Twenty-one studies met the selection criteria, most of which were of moderate to high risk of bias. Among patients suspected of DNC, the prevalence of infratentorial brain injury ranged from 2% to 16% (n = 3,602, mean prevalence: 6.3%, 95% highest density interval [2.4%-14.2%]), whereas the prevalence of isolated brainstem death ranged from 1% to 4% (n = 3,692, mean prevalence: 1.5%, 95% highest density interval [0.5%-3.9%]). A total of 38 isolated brainstem death cases with data on clinical characteristics and/or evolution were included. All had infratentorial strokes. Twenty patients had EEG background activity in the α or θ frequencies, 19 had preserved cerebral blood flow, 2 had preserved supratentorial cerebral perfusion, 2 had cortical responses to visual evoked potentials, and 1 had cortical responses to somatosensory evoked potentials. At the latest follow-up, 28 had progressed to whole-brain death.
Studies with moderate to high risk of bias suggest that infratentorial brain injury is relatively uncommon among patients suspected of DNC. Isolated brainstem death is rarer and seems to carry a high risk of progression to whole-brain death. These findings require further high-quality investigation.
关于疑似神经学标准判定死亡（DNC）患者幕下脑损伤的频率和预后的数据匮乏，这可能导致关于孤立性脑干死亡在DNC判定中作用的科学不确定性。我们的目的是综合疑似DNC患者幕下脑损伤（包括孤立性脑干死亡）的患病率、特征及演变情况。
我们通过检索Medline、Embase、循证医学评价、护理学与健康领域数据库（CINAHL Complete）以及截至2021年3月26日的灰色文献进行系统综述。我们选择了队列研究、横断面研究、病例报告以及包含疑似DNC患者的病例系列。两名研究调查员独立进行研究选择、数据收集及偏倚风险评估。我们的主要结局是幕下脑损伤和孤立性脑干死亡各自的患病率，我们使用具有弥散先验的混合效应贝叶斯分层模型对其进行荟萃分析。我们的次要结局是幕下脑损伤和孤立性脑干死亡患者的特征及演变情况。
21项研究符合入选标准，其中大多数存在中度至高偏倚风险。在疑似DNC的患者中，幕下脑损伤的患病率在2%至16%之间（n = 3602，平均患病率：6.3%，95%最高密度区间[2.4% - 14.2%]），而孤立性脑干死亡的患病率在1%至4%之间（n = 3692，平均患病率：1.5%，95%最高密度区间[0.5% - 3.9%]）。共纳入38例有临床特征和/或演变数据的孤立性脑干死亡病例。所有病例均有幕下卒中。20例患者脑电图背景活动处于α或θ频率，19例患者脑血流保持正常，2例患者幕上脑灌注保持正常，2例患者对视觉诱发电位有皮质反应，1例患者对体感诱发电位有皮质反应。在最近一次随访时，28例进展为全脑死亡。
存在中度至高偏倚风险的研究表明，幕下脑损伤在疑似DNC的患者中相对不常见。孤立性脑干死亡更为罕见，似乎进展为全脑死亡的风险很高。这些发现需要进一步的高质量研究。
