Computed tomographic angiography criteria in the diagnosis of brain death-comparison of sensitivity and interobserver reliability of different evaluation scales.

INTRODUCTION: The standardized diagnostic criteria for computed tomographic angiography (CTA) in diagnosis of brain death (BD) are not yet established. The aim of the study was to compare the sensitivity and interobserver agreement of the three previously used scales of CTA for the diagnosis of BD. METHODS: Eighty-two clinically brain-dead patients underwent CTA with a delay of 40 s after contrast injection. Catheter angiography was used as the reference standard. CTA results were assessed by two radiologists, and the diagnosis of BD was established according to 10-, 7-, and 4-point scales. RESULTS: Catheter angiography confirmed the diagnosis of BD in all cases. Opacification of certain cerebral vessels as indicator of BD was highly sensitive: cortical segments of the middle cerebral artery (96.3 %), the internal cerebral vein (98.8 %), and the great cerebral vein (98.8 %). Other vessels were less sensitive: the pericallosal artery (74.4 %), cortical segments of the posterior cerebral artery (79.3 %), and the basilar artery (82.9 %). The sensitivities of the 10-, 7-, and 4-point scales were 67.1, 74.4, and 96.3 %, respectively (p<0.001). Percentage interobserver agreement in diagnosis of BD reached 93 % for the 10-point scale, 89 % for the 7-point scale, and 95 % for the 4-point scale (p=0.37). CONCLUSIONS: In the application of CTA to the diagnosis of BD, reducing the assessment of vascular opacification scale from a 10- to a 4-point scale significantly increases the sensitivity and maintains high interobserver reliability.

Dynamic evaluation of stasis filling phenomenon with computed tomography in diagnosis of brain death.

INTRODUCTION: Stasis filling, defined as delayed, weak, and persistent opacification of proximal segments of the cerebral arteries, is frequently found in brain dead patients. This phenomenon causes a major problem in the development of reliable computed tomographic angiography (CTA) protocol in the diagnosis of brain death (BD). The aim of our study was to characterize stasis filling in the diagnosis of BD. To achieve this, we performed a dynamic evaluation of contrast enhancement of the cerebral and extracranial arteries in patients with BD and controls. METHODS: Study population included 30 BD patients, who showed stasis filling in computed tomographic perfusion (CTP) series. Thirty patients, after clipping of an intracranial aneurysm, constituted the control group. The study protocol consisted of CTA, CTP, and angiography. Time-density curves (TDCs) of cerebral and extracranial arteries were generated using 40-s series of CTP. RESULTS: Cerebral TDCs in BD patients represented flat curves in contrast to TDCs in controls, which formed steep and narrow Gaussian curves. We found longer time to peak enhancement in BD patients than in controls (32 vs. 21 s; p < 0.0001). In BD patients, peak enhancement in the cerebral arteries occurred with a median delay of 14.5 s to peak in extracranial arteries, while no delay was noted in controls (p < 0.0001). Cerebral arteries in BD patients showed lower peak enhancement than controls (34.5 vs. 81.5 HU; p < 0.0001). In all BD patients, CTP revealed zero values of cerebral blood flow and volume. Angiography showed stasis filling in 14 (46.7 %) and non-filling in 16 (53.3 %) cases. CONCLUSION: A confrontation of stasis filling with CTP results showed that stasis filling is not consistent with preserved cerebral perfusion, thus does not preclude diagnosis of BD.

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.

Tacrolimus combined with two different dosages of sirolimus in kidney transplantation: results of a multicenter study.

Tacrolimus combined with mycophenolate mofetil (MMF) is an effective regimen in kidney transplantation. This study compared the efficacy of combining tacrolimus and two different dosages of sirolimus with an established tacrolimus-MMF regimen. Each day in addition to tacrolimus, 325 patients received 2 mg sirolimus (TAC-SRL2 mg), 325 patients received 0.5 mg sirolimus (TAC-SRL0.5 mg) and 327 patients 1 g MMF (TAC-MMF). The initial tacrolimus dose was 0.2 mg/kg/day. Sirolimus patients received loading doses of 6 or 1.5 mg, and daily doses of 2 or 0.5 mg thereafter. Steroid administration was identical for all groups. The incidence of biopsy-proven acute rejection was lower in the TAC-SRL2 mg group (15.7%) compared with the TAC-SRL0.5 mg (25.2%, p = 0.003) and the TAC-MMF groups (22.3%, p = 0.036). Six-month graft survival was 91.0% (TAC-SRL2 mg), 92.6% (TAC-SRL0.5 mg) and 92.4% (TAC-MMF); the respective values for patient survival were 98.1%, 97.8% and 97.9%. Thirty-four patients (10.5%), 19 patients (5.8%) and 16 patients (4.9%) in the TAC-SRL2 mg, TAC-SRL0.5 mg and TAC-MMF groups, respectively, discontinued the study because of adverse events. Hyperlipemia was reported more often in the TAC-SRL2 mg group (24.0%) compared with 19.4% (TAC-SRL0.5 mg) and 11.0% (TAC-MMF; p < 0.05). Combining 2 mg sirolimus/day with tacrolimus results in lower rates of acute rejection, but a higher incidence of adverse events.

Lipid metabolism in renal transplant patients receiving tacrolimus/sirolimus combination therapy.

INTRODUCTION: The administration of sirolimus has been reported to be associated with high serum cholesterol and high triglyceride values. In a large prospective, multicenter 6-month study in renal transplantation, basic parameters of lipid metabolism (total serum cholesterol and triglycerides) were systematically assessed in patients who received tacrolimus/mycophenolate mofetil/steroids (Tac/MMF), tacrolimus/0.5 mg sirolimus (SIR)/steroids (Tac/0.5SIR) on tacrolimus/2 mg sirolimus/steroids (Tac/2SIR). METHODS: For purposes of analysis, lipid parameters were classified using the National Kidney Foundation Dyslipidemia Classification definitions. RESULTS: Complete sets of data at all visits (baseline, months 1, 3, and 6) were available for 211 Tac/MMF, 210 Tac/0.5SIR, and 203 Tac/2SIR patients. Total serum cholesterol in the Tac/MMF group was 193.4 at baseline and 202.9 mg/dL at month 6. Values increased from 196 mg/dL to 212.5 mg/dL in Tac/0.5SIR and from 200 mg/dL to 230.5 mg/dL in Tac/2SIR. Differences in parameters between treatment groups were statistically significant (P < .05). Serum triglycerides decreased from baseline to 6 months in Tac/MMF, increased from 176.3 mg/dL (baseline) to 191.4 mg/dL (6 months) in Tac/0.5SIR and from 203 mg/dL to 255.3 mg/dL in Tac/2SIR. Parameters differed significantly between Tac/0.5SIR versus Tac/2SIR at P = .0069, and between Tac/MMF versus Tac/2SIR at P = .0013. In the Tac/2SIR group 36.5% had "high" serum cholesterol and 8.3% had "very high" triglyceride levels at 6 months. CONCLUSION: Total serum cholesterol levels were relatively stable and serum triglycerides decreased between baseline and month 6 using a Tac/MMF regimen. Contrastingly, the Tac/SIR combinations led to increased total cholesterol values (at both sirolimus dose levels) and Tac/2SIR also led to increased triglyceride levels.

Fetal and neonatal arrhythmia in one of the twins--a case history.

There are a lot of publications about fetal arrhythmia in singletons, but up to now there are no published data about fetal arrhythmia in multiple pregnancies. In the present study a case history of fetal and neonatal arrhythmia in one of twins from two mothers treated with betamimetic agents due to imminent preterm labor is reported and discussed. A first case with fetal bradycardia due to complete A-V block had congenital cordis abnormalities (VSD and PFO). The second case with prenatal detected extrasystoles had normal heart anatomy. Digoxin was administered to the mother, in the aim to treat fetal arrhythmia without success, because the baby had postnatal bradycardia. After hospitalisation in Cardiology Department the described cases were successfully treated. In both cases the second twins were without neonatal arrhythmia and with no structural heart abnormalities. We summarise that in situation of detection fetal arrhythmia the complexity of the problems experienced may warrant early referral to a tertiary centre where the overall management of the mother, fetus and neonate, may be undertaken.

[Serological conflict: relation between antibody titer, Liley's zone and the condition of the fetus and newborn infant]. / Konflikt serologiczny: zwiazek miedzy mianem przeciwcial i strefa Lileya a stanem plodu i noworodka.

On the basis of analysis of 128 cases of serological incompatibility it was found that antibodies to Rh in titres of 1/8 or less constituted a good prognostic factor, and without evidence of fetal distress in USG examination this was not an indication to treatment undertaking. If the titre is from 1/16 to 1/128 the prognosis is worse and the degree of fetal haemolytic disease risk may be estimated on the basis of USG and Liley's zone. The prognosis is very bad in case of titre exceeding 1/128 and high Liley's zone, and without effective treatment of haemolytic disease in fetal life only few fetuses survive.