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J Am Coll Surg 1999; 189: 584 –593. 0041-1337/04/7701-71/0 TRANSPLANTATION Vol. 77, 71–75, No. 1, January 15, 2004 Copyright © 2004 by Lippincott Williams & Wilkins, Inc. Printed in U.S.A. UTILITY OF TRANSCRANIAL DOPPLER ULTRASONOGRAPHY FOR CONFIRMATORY DIAGNOSIS OF BRAIN DEATH: TWO SIDES OF THE COIN LEVENT DOSEMECI, 1,3 BABUR DORA, 2 MURAT YILMAZ, 1 MELI ˙ KE CENGIZ, 1 SEVIN BALKAN, 2 AND ATILLA RAMAZANOGLU 1 Background. Although the clinical examination and documentation of the clinical signs of brain death are very uniform, there are significant differences in the guidelines for using technical confirmatory tests to corroborate the clinical signs. The current study ex- amined the utility of transcranial Doppler ultrasonog- raphy (TCD) for confirmation of brain death. Methods. After 19 patients were excluded from the study because of lack of bone window or because an apnea test could not be performed because of desatu- ration, 100 patients (61 patients with clinical brain death, and 39 control patients with Glasgow Coma Score<5) were included in the study. The following TCD findings were accepted as confirmatory of brain death when they were found bilaterally or in at least three different arteries for at least 3 minutes within the same examination: (1) brief systolic forward flow or systolic spikes and diastolic reverse flow, (2) brief systolic forward flow or systolic spikes and no dia- stolic flow, or (3) no demonstrable flow in a patient in whom flow had been clearly documented in a previous TCD examination. Results. The sensitivity and specificity of the first TCD examination for confirmation of brain death were 70.5% and 97.4%, respectively. Eighteen patients with clinical brain death required repeat TCD exami- nations because of detection of forward systolo-dia- stolic flow or a diastolic to-and-fro flow pattern, which were not confirmatory for the diagnosis of brain death. Brain death was confirmed ultrasonographi- cally in 12 of 18 patients in a second examination after 12.68.3 hours of clinical brain death, in 2 patients in a third TCD examination, and in 1 patient in a fourth examination. Three clinically brain-dead patients had died before the diagnosis was confirmed by repeat TCD examinations. The sensitivity of TCD reached 100% in our study population after the fourth examination. Conclusion. The sensitivity of TCD is increased with repeat examinations and should be repeated in cases in which systolo-diastolic forward flow is demon- strated after the first TCD. TCD may prolong or shorten the time to declaration of brain death. The necessity of demonstrating cerebral circulatory arrest in patients with clinical brain death is debatable. Since the advent of cardiopulmonary support for severely brain-injured patients, the diagnosis of brain death has be- come a medical, legal, and social issue. Brain death is now generally accepted both legally and medically as a criterion for death. Clinical-examination criteria have been estab- lished to determine brain death, and subsidiary investiga- tions such as electroencephalography (EEG), arteriography, and radionuclide scans are used either to determine the arrest of cerebral circulation or to confirm the diagnosis of brain death (1–5). The growing demand for organ-transplant donors re- quires quick identification of candidates before the onset of 1 Department of Anaesthesiology and ICU, Akdeniz University, Antalya, Turkey. 2 Department of Neurology, Akdeniz University, Antalya, Turkey. 3 Address correspondence to: Dr. Levent Dosemeci, Akdeniz Uni- versity Hospital, Department of Anaesthesiology and ICU, Dumlu- pinar Bulv. Kampu ¨ s Alani, 07070 Antalya, Turkey. Received 9 April 2003. Accepted 22 May 2003. DOI: 10.1097/01.TP.0000092305.00155.72 DOSEMECI ET AL. January 15, 2004 71