A red flag for diagnosing brain death: decompressive craniectomy of the posterior fossa.

PURPOSE: Brain death/death by neurologic criteria (BD/DNC) may be determined in many countries by a clinical examination that shows coma, brainstem areflexia, and apnea, provided the conditions causing reversible loss of brain function are excluded a priori. To date, accounts of recovery from BD/DNC in adults have been limited to noncompliance with guidelines. CLINICAL FEATURES: We report the case of a 72-yr-old man with a combined primary infratentorial (hemorrhagic) and secondary global (anoxic) brain lesion in whom decompressive craniectomy of the posterior fossa and six-hour therapeutic hypothermia (33-34°C) followed by 8-hour rewarming to ≥ 36°C were conducted. Thirteen hours later, clinical findings of brain function loss were documented in addition to guideline-compliant exclusion of reversible causes (arterial hypotension, intoxication, depressant drug effects, relevant metabolic or endocrine disequilibrium, chronic hypercapnia, neuromuscular disorders, and administration of a muscle relaxant). Since a primary infratentorial brain lesion was present, German guidelines required further ancillary testing. Doppler ultrasonography revealed some preserved cerebral circulation, and BD/DNC was not diagnosed. Approximately 24 hr after rewarming to ≥ 36°C, the patient exhibited respiratory efforts. He continued with assisted respiration until final asystole/apnea, without regaining additional brain function other than mild signs of hemispasticity. Follow-up computed tomography showed partial herniation of the cerebellum through the craniectomy gap of the posterior fossa, alleviating caudal brain stem compression. CONCLUSIONS: Therapeutic decompressive craniectomy of the posterior fossa may allow for delayed reversal of apnea. In these patients, proof of cerebral circulatory arrest should be mandatory for diagnosing BD/DNC.

RéSUMé: OBJECTIF: Dans de nombreux pays, la mort cérébrale / décès déterminé par des critères neurologiques (MC / DDN) peut être déterminée par un examen clinique qui montre le coma, l'aréflexie du tronc cérébral et l'apnée, sous réserve que les conditions causant une perte réversible de la fonction cérébrale soient exclues a priori. À ce jour, les comptes rendus décrivant un rétablissement après une MC / DDN chez les adultes ont été limités en raison d'un non-respect des lignes directrices. CARACTéRISTIQUES CLINIQUES: Nous rapportons le cas d'un homme de 72 ans atteint d'une lésion cérébrale sous-tentorielle primaire (hémorragique) et secondaire globale (anoxique) chez qui une craniectomie décompressive de la fosse postérieure et une hypothermie thérapeutique de six heures (33-34 °C), suivie d'un réchauffement de 8 heures à ≥ 36 °C, ont été réalisés. Treize heures plus tard, les résultats cliniques de la perte de la fonction cérébrale ont été documentés, en plus de l'exclusion conforme aux lignes directrices des causes réversibles (hypotension artérielle, intoxication, effets des médicaments dépresseurs, déséquilibre métabolique ou endocrinien pertinent, hypercapnie chronique, troubles neuromusculaires et administration d'un relaxant musculaire). Étant donné qu'une lésion cérébrale sous-tentorielle primaire était présente, les directives allemandes exigeaient la réalisation d'autres tests auxiliaires. L'échographie Doppler a révélé la préservation d'une certaine circulation cérébrale, et la MC / DDN n'a pas été diagnostiquée. Environ 24 heures après le réchauffement du patient à ≥ 36 °C, le patient a manifesté des efforts respiratoires. Il a continué à respirer avec assistance jusqu'à l'asystole / l'apnée finale, sans retrouver de fonction cérébrale supplémentaire autre que de légers signes d'hémispasticité. La tomodensitométrie de suivi a montré une hernie partielle du cervelet à travers l'espace de craniectomie de la fosse postérieure, soulageant la compression caudale du tronc cérébral. CONCLUSION: La craniectomie décompressive thérapeutique de la fosse postérieure peut permettre une inversion retardée de l'apnée. Chez ces patients, la preuve d'un arrêt circulatoire cérébral devrait être obligatoire pour diagnostiquer une MC / DDN.

[Heart and lung in X-ray images : Lost art (?)]. / Herz und Lunge im Röntgenbild : Lost Art (?).

BACKGROUND: Echocardiography is the standard for the diagnosis of heart diseases. Nevertheless, thoracic X­ray is a frequently used examination method, also for questions regarding the cardiac situation of patients. QUESTION: How relevant is the conventional radiological assessment of heart disease? MATERIALS AND METHODS: Long-known knowledge about pathophysiology of heart disease and its radiological correlation are discussed. RESULTS: Knowledge of the normal anatomy of the heart is a basic prerequisite for the assessment of pathologies. For the question of heart disease, it is essential to also assess the pulmonary vascularization. The size of the entire heart and the individual cardiac cavities is assessed by direct and indirect signs, such as heart-lung ratio, cava triangle, vascular pedicle or the size of the aorta and of the main pulmonary artery. The most common cause of heart enlargement is valve disease, which shows various conventional radiological images. CONCLUSION: Conventional thoracic radiography still plays a central role in the diagnosis of cardiopulmonary diseases and is an important diagnostic tool for quickly obtaining an overview of the patient's cardiopulmonary situation. The interplay between physiology and X­ray symptoms is complex, so close attention should be paid not only to the heart anatomy and configuration, but also primarily to the pulmonary blood flow.

[Radiological manifestations of pulmonary diseases in COVID-19]. / Radiologische Manifestationen von Lungenerkrankungen bei COVID-19.

CLINICAL ISSUE: Since its emergence in late 2019, the disease caused by the novel coronavirus, termed COVID-19, has been declared a pandemic by the World Health Organization. Reference standard for the diagnosis of COVID-19 is a positive reverse transcription polymerase chain reaction (RT-PCR) test. While the RT-PCR shows a high specificity, its sensitivity depends on the duration of symptoms, viral load, quality of the sample, and the assay used. STANDARD RADIOLOGICAL METHODS: Chest radiography and computed tomography (CT) of the chest are the imaging modalities primarily used for assessment of the lung manifestations, extent, and complications of COVID-19 pneumonia. PERFORMANCE: Sensitivity and specificity of chest radiography is low. While sensitivity of CT for detecting COVID-19 pneumonia is high-averaging around 90%-its specificity is low-between 25 and 33%. PRACTICAL RECOMMENDATIONS: Indications for imaging in patients with suspected or diagnosed COVID-19 infection should be carefully considered to minimize the risk of infection for medical personnel and other patients. Imaging, particularly CT, can assess disease extent, complications, and differential diagnoses. COVID-19 pneumonia typically presents with bilateral, subpleural areas of ground glass opacifications with or without consolidations. During the course of the disease features resembling organizing pneumonia can occur. Follow-up examinations after recovery from COVID-19 pneumonia should focus on fibrotic changes of the lung parenchyma.