M Zukowski

Computed Tomographic Angiography and Perfusion in the Diagnosis of Brain Death

INTRODUCTION According to Polish brain death (BD) criteria, instrumental confirmatory tests should be used in certain clinical situations, particularly any case for which clinical examinations seem inadequate. Electrophysiological tests are often unavailable. Therefore, cerebral perfusion testing is the method of choice with four-vessel digital subtraction angiography (DSA), the gold standard. Unfortunately, DSA is an expensive and invasive examination that requires an experienced neuroradiologist and the availability of an angiography suite. Recently, multirow computed tomographic devices became available, even in smaller hospitals in Poland. Despite this fact, computed tomographic angiography (CTA) and computed tomographic perfusion (CTP) are not accepted in BD diagnosis protocols in Poland because of limited experience and a lack of widely accepted criteria. In this situation, we started a multicenter trial to determine the accuracy of CTA and CTP to confirm BD. METHODS We examined 24 patients who fulfilled standard clinical BD criteria. We recognized the absence of brain perfusion in CTA examination following the criteria proposed by the French Society of Neuroradiology, namely, the absence of opacification of M4 middle cerebral artery segments (M4-MCA) and of deep cerebral veins. RESULTS In all of our patients, CTA showed absence of opacification of M4 segments and of deep cerebral veins. In addition, three patients had CTA showing weak opacification of A2 segments of the anterior cerebral artery (A2-ACA) and M2 or M3-MCA. Opacification of the basilar artery or of the posterior cerebral arteries was not noted in any case. In all patients, CTP revealed zero values of regional cerebral blood volume and regional cerebral blood flow. Conventional angiography confirmed cerebral circulatory arrest in all 24 cases. CONCLUSION CTA and CTP seem to be promising radiological examinations for the diagnosis of BD. They may be noninvasive alternatives to conventional cerebral angiography, and to the other instrumental confirmatory tests, that are unavailable or inadequate.

Reversal to Whole-Brain Death Criteria After 15-Year Experience With Brain Stem Death Criteria in Poland

Polish brain-death criteria, similar to the original Harvard criteria, were published in 1984. In 1990, they were converted to brainstem death criteria, and were revised twice, in 1994 and in 1996. However, they could not be used in many complicated clinical situations such as intoxication, metabolic alterations, major facial injury, infratentorial lesions, and cervical spinal cord injury. The new Polish Transplant Act, passed by the Polish Parliament in 2005, recommends implementation of criteria for whole-brain death for brain-death diagnosis. In 2007, the Polish Ministry of Health Commission outlined new Polish brain-death criteria. Optional use of instrumental confirmatory tests was implemented in the new Polish national code of practice for the diagnosis of brain death in adults. In children up to age 2 years, instrumental tests are obligatory. Initially, there were problems in understanding the new, slightly more complicated classifications of primary and secondary brain injuries, infratentorial and supratentorial processes, modified apnea test. A broad commentary that addressed the most frequently asked questions was published in Anesthesiology and Intensive Therapy, the official journal of the Polish Society of Anaesthesiology and Intensive Therapy. This article dealt with most of the problems associated with implementation of the new criteria for diagnosis of brain death.

The Effect of Cause of Cadaveric Kidney Donors Death on Fibrinolysis and Blood Coagulation Processes

BACKGROUND Organ donors can be generally divided into two groups according to the cause of their death. The first group is composed of those who died because of physical injuries, especially road traffic injury, and the second group, those who died from central nervous system (CNS) stroke or bleeding. The aim of our work was to examine hemostatic processes among kidney donors. MATERIALS AND METHODS The 38 deceased kidney donors (KD) included 11 women and 27 men of overall average age of 37±12 years. The donor group of according to the cause of death, included 14 injured donors (ID) (41%) and 24 noninjured donors (ND) donors (59%). The control group consisted of 25 healthy volunteers matched for sex and age. We determined the following concentrations: antithrombin (AT), thrombin/antithrombin complexes (TAT), and prothrombin F1+2 fragments. The fibrinolytic parameter concentrations were: plasminogen (PL), plasmin/antiplasmin complexes (PAP), and D-dimers. RESULTS Deceased kidney donors showed an increased plasma concentrations of TAT complexes (P<.000001) and prothrombin fragments F1+2 (P<.0000001); however, the protein C concentration was decreased (P<.000001). The antithrombin activity was similar to the control group. The concentrations of PAP complexes and d-dimers were higher (both P<.000001), but the level of PL lower among KD compared with controls (P<.0000001). The higher of TAT, PAP complexes, d-dimers, and F1+2 concentrations as well and as lower plasminogen and PC concentrations were evidence for increased activation of blood coagulation and fibrinolysis in cadaveric KD. However, analysis compairing ID versus ND donors revealed increased concentrations of PAP complexes (P<.05) and decreased amounts of TAT complexes (P<.01) among ID subgroup. The positive predictive value (PPV) and negative (NPV) for PAP complexes were 75% and 68% and for TAT, 71% and 57%, respectively. On the basis of these observations, we concluded that an intensive activation of fibrinolytic process occurs among the ID. In contrast, ND show intensive activation of blood coagulation.

Predisposition of functional genetic variants of A-kinase anchoring protein 10 toward acquired repolarization disorders in high-risk vascular surgery patients

Purpose We aimed at assessing the predisposition of A-kinase anchoring protein 10 (AKAP10) polymorphism toward acquired repolarization disorders in high-risk vascular surgery patients. Patients and methods One hundred adult patients (age =44–85 years), scheduled for an elective high-risk “open” vascular surgery procedure, were recruited. The electrocardiogram Holter monitor was used to assess repolarization stability from the beginning of the operation up to 24 hours afterward. The AKAP10 gene rs203462 polymorphism and cardiac complications were analyzed. Results Repolarization disturbances defined as QT interval duration corrected for heart rate (QTc) interval prolongation >500 ms and QTc interval dispersion >65 ms were recorded in 46 patients. A model of multivariate logistic regression showed that only the presence of allele G of the AKAP10 polymorphism was an independent risk factor for repolarization disturbances in the perioperative period (odds ratio =14.35; 95% CI =4.65–44.23; p<0.0001). Conclusion When the acquired QTc interval prolongation or QTc dispersion is associated with AKAP10 polymorphism, it may remain clinically silent.