Impact of Skull Defects on the Role of CTA for Brain Death Confirmation.

BACKGROUND AND PURPOSE: Intracranial pressure modifications caused by a skull defect, such as craniectomy or craniotomy, may change the hemodynamics and decrease the accuracy of CTA to confirm brain death. This study aimed to evaluate the impact of a skull defect and the interpretation criteria of images on this diagnostic test. MATERIALS AND METHODS: A series of consecutive patients with a clinical diagnosis of brain death underwent CTA (case group), while the control group comprised patients with acute ischemic stroke in the same period. CTA criteria adopted to confirm brain death were the absence of opacification of the M4 branches and internal cerebral veins. The evaluation also included the presence of "stasis filling." Cases were stratified as intact skull, craniotomy, and craniectomy. Three neuroradiologists evaluated all examinations independently. RESULTS: In the case group, according to the Frampas criteria, the sensitivity of CTA to confirm brain death was 95.5% in patients with intact skull, 87.5% with craniotomy, and 60% with craniectomy. False-negative diagnoses of brain death were 15.6%, related to stasis filling in 71.4% (P < .001). However, according to the "modified Frampas criteria," the sensitivity of CTA to confirm brain death was 100% in patients with intact skull, 93.8% with craniotomy, and 80% with craniectomy. False-negative diagnoses of brain death were found in 6.2% of patients, and there was no stasis filling. CTA showed 100% specificity in the control group. There were no disagreements among observers. CONCLUSIONS: CTA had a high diagnostic accuracy and reproducibility to confirm brain death in patients with an intact skull. The modified Frampas criteria increased the sensitivity of CTA, particularly in patients with a skull defect. A concurrent skull defect, especially craniectomy, can decrease the sensitivity of CTA to confirm brain death.

Anatomic variations in vascular and collecting systems of kidneys from deceased donors.

INTRODUCTION: Nephroureterectomy for transplantation has increased owing to the greater number of deceased donors. Anatomic variations may complicate the procedure or, if unrecognized, compromise the viability of kidneys for transplantation. METHODS: We reviewed 254 surgical descriptions of nephroureterectomy specimens from January 2008 to December 2009. All organs collected according by standard techniques were evaluated for age, cause of death, renal function, frequency of injury during the procedure, as well as variations in the vascular and collecting systems. RESULTS: The mean donor age was 42 years (range, 2-74). The mean serum creatinine was 1.2 mg/dL (range, 1.0-7.0). The causes of death were cerebrovascular cause (stroke; n = 130), traumatic brain injury (n = 81) or other cause (n = 43). Among the anatomic variations: 8.6% (n = 22) were right arterial anatomical variations: 19 cases with 2 arteries and 3 cases with 3 arteries. In 25 cases (9.8%) the identified variation was the left artery: 2 arteries (n = 23), 3 arteries (n = 1) and 4 arteries (n = 1). We observed 9.8% on right side and 1.5% on left side venous anatomic variations, including 24 cases with 2 veins on the right side and 4 cases with 2 veins on the left side. Three cases of a retroaortic left renal vein and 1 case of a retro necklace vein (anterior and posterior to the aorta). Two cases of ureteral duplication were noted on the left and 1 on the right kidney. There were 3 horseshoe and 1 pelvic kidney. In 7.5% of cases, an injury to the graft included ureteral (n = 3), arterial (n = 10), or venous (n = 6). CONCLUSION: The most common anatomic variation was arterial (17.8%). Duplication of the renal vein was more frequent on the right. The high incidences of anatomic variations require more attention in the dissection of the renal hilum to avoid an injury that may compromise the graft.

Choroid plexus cysts and their anatomical correlations: importance in fetal prognosis. A critical literature review

The objective of this investigation was to carry out a literature review on the choroid plexus cysts and theirimportance in fetal prognosis with search on PubMed, Web of Science, LILACS and MEDLINE databases usingkeywords in English without time restrictions. Choroid plexus cysts, which are also termed intraventricularneuroepithelial cysts, choroid epithelial cysts or ependimary cysts, are structures localized within the interiorof the lateral ventricles, comprising secretory epithelium, the principal function of which is the production ofcerebrospinal fluid. Ultrasound images of the choroid plexuses within the lateral ventricles consist of hyperechogenicstructures at the level of the body, trigon and inferior horn of the ventricles. Between the 16th andthe 20th week of gestation, cystic structures in the interior of the ventricular plexuses may be observed at arate of 0.3-1.0% in an ultrasound examination of the fetal head, as is shown. Most choroid plexus cysts regressspontaneously without after effects, although there is a possible association with chromosomal abnormalities,notably trisomy 18 (Edwards’ syndrome) and less frequently cited, trisomy 21 (Down syndrome). The presenceof this kind of cyst is considered to be a lesser marker for them, except when combined with other morefrequently used and accepted ecographic markers, such as nuchal translucency, intracardiac echogenic focusand others. Its isolated presence as the sole characteristic of this aneuploidy is rare. The majority of choroidcysts are transitory and of little clinical significance, and may be identified through a computerized tomographyexamination. As such, the existence of isolated choroid cysts does not indicate the confirmation of chromosomalaneuploidies so much as an alarm that should trigger an investigation in greater depth in search ofother more important markers, emphasizing the importance of pre-natal monitoring.

Asymmetries of the Left and Right Temporal Lobes / Asimetría de los Lóbulos Temporales Izquierdo y Derecho

Anatomical brain asymmetries are subtle and still little studied in humans. Among all the animals, humans have the most asymmetric brains Crow (2004). The language faculty and handedness are localized on the left side. The objective this paper is to verify whether the temporal lobes are anatomically different. Our sample was composed of 40 post mortem adult brains of both sexes, which were investigated at the Human Anatomy Laboratory of the Nove de Julho University Center in Sao Paulo, Brazil. The brains were fixed in a solution of 5% paraformaldehyde. Three different measurements were taken using a pachimeter (Mitutoyo) and a goniometer (Card) on both hemispheres: Ml - the length of the lateral sulcus; M2 - the distance from the lateral sulcus to the inferior margin of the inferior temporal gyrus, and M3 - the angle formed between the lines of the collateral sulcus and the inferior margin of the inferior temporal gyrus. Results were submitted to a statistical analysis (ANOVA) and demonstrated that Ml was larger in the left hemisphere, by contrast with the data obtained for M2 and M3, which were larger in the right hemisphere. The measurements taken showed differences between the right and left temporal lobes.

Las asimetrías anatómicas del cerebro humano son sutiles y aún poco estudiadas. Entre todos los animales, el Hombre es el que presenta el cerebro más asimétrico (Crow, 2004). En el lado izquierdo del cerebro se localiza la facultad del lenguaje, como también de la lateralidad manual. El objetivo del trabajo fue verificar si los lóbulos temporales son anatómicamente diferentes. La muestra estuvo compuesta de 40 encéfalos adultos, post mortem, de ambos sexos, del Laboratorio de Anatomía del Centro Universitario Nove de Julho, en Sao Paulo, SP, Brasil. Los encéfalos fueron fijados en solución de formalina al 5%. Fueron realizadas 3 medidas diferentes utilizando un pié de metro Mitutoyo y goniómetro (Carci), en ambos hemisferios: medida MI, largo del surco lateral; medida M2 distancia del surco lateral hasta el margen inferior del giro temporal inferior y la medida M3 el ángulo formado entre las líneas del surco colateral y margen inferior del giro temporal inferior. Los resultados se sometieron a análisis estadístico y mostraron que MI era mayor en el hemisferio izquierdo, en contraposición a los datos obtenidos en M2 y M3, que fueron mayores en el hemisferio derecho. Las medidas realizadas presentaron diferencias entre los lóbulos temporales derecho e izquierdo.

Use of quality index in the evaluation of organ procurement and transplant programs in a University Hospital.

AIM: To evaluate organ procurement efficiency at Hospital Clinic of Barcelona (HCP), a University Hospital, in 2000 and 2003 compared with other Catalan, other Spanish, and American (US) results. METHODS: Efficacy rate of the donor procurement was calculated per million population per year (pmp/y). Efficacy rate in kidney, liver, and heart transplantation was calculated also in pmp/y. We evaluated 1-year graft survival. RESULTS: During this period, the average rate number of donors was 49.1 pmp/y in HCP, 38 in Catalonia, 33.4 in Spain, and 21.7 in the United States. The average rate of kidney transplantation was 74 pmp/y in HCP, 55 in Catalonia, 47 in Spain, and 24.6 in the United States. The average rate of liver transplantation was 44.5, 26.6, 23.2, and 18 pmp/y, respectively. The average rate of heart transplantation was 13.3, 8.5, 7.8, and 6.4 pmp/y, respectively. One-year graft survival in HCP was 90.6% for kidney, 89.5% for liver, and 88.2% for heart transplants. DISCUSSION: The results show that organ procurement and transplantation programs in HCP are efficient. The organizational model is based on a hospital transplant coordinator and efficient, well-trained transplant teams.