Determining Brain Death

Primary Category

Neurocritical Care

P-Category

Secondary Category

S-Category

Authors:

Anber Mahboob MBBS,
Harshadayani Jagadish Kumar MBBS,
Junaid Kalia MD

Definition

Permanent, irreversible termination of cerebral and brainstem functions including the ability to regulate respiratory activities.

Reason for Diagnosing Brain death

Emotional closure for family

Organ Donation

Causes

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Causes of Brain Death

Devastating brain injury due to

Trauma

Subarachnoid hemorrhage

Intracerebral hemorrhage

Hypoxic-ischemic encephalopathy

Ischemic stroke

Any condition causing permanent gross brain injury

Brain death diagnosis criteria by American Academy of Neurology

Of Note: Most states and hospitals have their own criteria based on the following. Please make sure to use your local criteria if that is available.

Prerequisites

Irreversible coma with a known cause

Neuroimaging showing coma

Evidence (clinical or neuroimaging) of acute central nervous system (CNS) injury

Elimination of other potentially confounding medical conditions like severe electrolyte, acid-base, endocrine, or circulatory disturbances e.g, shock)

Core temperature >36°C (97°F)

Exclusion of possible drug intoxication or poisoning, which includes any sedative drug administered in hospital

Systolic blood pressure >100 mmHg

No spontaneous respirations

Examination findings

Absence of motor response originating from brain which includes response to pain stimulus above neck and other movements arising from brain eg, decerebrate or decorticate posturing, seizures

Absence of pupillary light reflex

Absence of corneal reflexes: Swing light test shows no response

Absence of oculocephalic (doll's eyes) and oculovestibular reflexes (caloric responses)

Absence of jaw jerk

Absence of gag reflex

No facial movement to noxious stimuli at supraorbital nerve, temporomandibular joint

Absence of motor response to noxious stimuli in all four limbs (spinally mediated reflexes are permissible)

Absence of cough with tracheal suctioning

Absence of sucking or rooting reflexes (in neonates)

Apnea test

Ventilator adjusted to provide PaCO2 35–45 mm Hg (normocarbia).

Patient

hemodynamically stable
preoxygenated with 100% FiO2 for >10 minutes to PaO2>200 mm Hg
well-oxygenated with a positive end-expiratory pressure (PEEP) of 5 cm of water.

Provide oxygen via a suction catheter to the level of the carina at 6 L/min or attach T-piece with continuous positive airway pressure (CPAP) at 10 cm H2O.

Disconnect ventilator.

Spontaneous respirations absent

Arterial blood gas drawn at 8–10 minutes, patient reconnected to ventilator.

PCO2 ≥60 mm Hg, or 20 mm Hg rise from normal baseline value.

Positive apnea test results show no respiratory response to a PaCO2 >60 mmHg or 20 mmHg greater than baseline values and arterial pH of <7.28.

Ancillary/Confirmatory tests

Not compulsory but preferred in patients where clinical testing can not be performed reliably or at all.

Any of the mentioned tests may produce similar results in patients with severe brain damage but who have not yet fulfilled the clinical criteria of brain death.

Tests are listed in order of their sensitivity

Conventional angiography

No intracerebral filling at the level of the carotid bifurcation or circle of Willis.

Electroencephalography

At least 30 minutes of recording showing no electrical activity

Minimal technical criteria for EEG recording in suspected brain death as adopted by the American Electroencephalographic Society.

Transcranial Doppler ultrasonography

Initial absence of Doppler signals cannot be interpreted as consistent with brain death as a small percentage of patients may not have temporal insonation windows due to skull thickness.

Markedly increased intracranial pressure indicated by small systolic peaks in early systole without diastolic or reverberating flow that indicate notably high vascular resistance

Technetium-99m hexamethylpropyleneamineoxime brain scan

“Hollow skull phenomenon” i.e, no uptake of isotope in brain parenchyma.

Somatosensory evoked potentials

Bilateral absence of N20-P22 response with median nerve stimulation

Movements and clinical observations compatible with brain death diagnosis

Occasional manifestations.

Should not be misinterpreted as evidence for brainstem function.

Movements stemming from spinal cord or peripheral nerves may occur in brain dead patients

Triggers can be tactile stimuli or occur spontaneously

Examples include:

Faint, semi-rhythmic movements of muscles innervated by facial nerve ( due to denervated facial nerve).
Flexor movements of fingers.
Tonic neck reflexes.
Lazarus sign: Neck flexion may be accompanied by complex extremity and truncal movements, mimicking sitting up type movements and neck-abdominal muscle contraction or head turning to one side.
Foot stimulation can induce triple flexion response with flexion at the hip, knee, and ankle .
Asymmetric opisthotonic posturing of the trunk.
Preservation of superficial and deep abdominal reflexes.
Positive Babinski sign.
Undulating toe sign:

Passive displacement of foot causing alternating flexion-extension of toes

Upper limb pronation extension reflex.
Widespread trunk and extremities fasciculations.

Respiratory-like movements without significant tidal volumes

Blushing, sweating

Tachycardia

Normal blood pressure without pharmacologic support or sudden increases in blood pressure

No diabetes insipidus

Confounders of brain death diagnosis

Conditions that may interfere with clinical diagnosis of brain death.

Clinical assessment is not enough in such cases to definitively diagnose brain death. Confirmatory tests are recommended

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Box 1: Confounders in Brain Death Diagnosis

Severe facial trauma

Preexisting pupillary abnormalities

Toxic levels of:

Sedative drugs
Aminoglycosides
Tricyclic antidepressants
Anticholinergics
Antiepileptic drugs
Chemotherapeutic agents
Neuromuscular blocking agents

Chronic CO2 retention due to severe pulmonary disease or sleep apnea

Standard medical record documentation

Etiology and irreversibility of condition

Absent brainstem reflexes

Absent motor response to pain

Absent respiration with PCO, 260 mm Hg

Confirmatory test justification and result, if used

Repeat neurologic examination.

Box 2: Brain Death Determination Note (Example)

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Brain Death Determination Note (*** designated input required)

Patient Identification Information:

Insert NAME, Medical Record number, Age, Date of Birth

Etiology of Coma:

Insert cause of Irreversible Cause

Prerequisite Conditions:

State (***) No below or explain if there are any prerequisite not met or expected

Major Electrolyte Abnormality: ***

Major EndocrineAbnormality: ***

Major Acid Base Abnormality: ***

Toxins or Drugs: ***

Hypothermia (Temp < 36): ***

SBP > 100 mm Hg: ***

Sedative Medications: ***

Other Confounding Variables: ***

NEUROLOGIC EXAMINATION:

Intubated and not sedated; does not follow commands. No vertical gaze or blinking to command. Pupils fixed bilaterally size (INSERT Size). No gaze deviation or dysconjugate gaze. Corneal Reflex; Absent. Facial Grimace, Absent. Gag/Cough: absent

VOR: (Cold Calorics) no response of eye movements

Motor Exam: RUE - No movement to central and peripheral noxious stimulation LUE - No movement to central and peripheral noxious stimulation RLE - No movement to central and peripheral noxious stimulation LLE - No movement to central and peripheral noxious stimulation

Respiratory Drive: NOT overbreathing the ventilator Ventilator: Turned to pressure support without autoflow and elevated flow trigger. No respirations or diaphragmatic movement seen

Apnea Test:

Insert pre and post ABG finding here

No respiratory effort noted during the apnea testing

Confirmatory Test: A confirmatory test is not needed Or a confirmatory test was done and consistent with brain death diagnosis

Autopsy: Discussed with next of kin and family but they declined.

Medical Examiner: Indicate here if a case for medical examiner to review

Time of Death 1/1/2024 at 0001. Recorded and Certified. Next of Kin notified

Bibliography

Practice parameters for determining brain death in adults (summary statement). The Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1995 May;45(5):1012-4. doi: 10.1212/wnl.45.5.1012. PMID: 7746374.

Goila AK, Pawar M. The diagnosis of brain death. Indian J Crit Care Med. 2009 Jan-Mar;13(1):7-11. doi: 10.4103/0972-5229.53108. PMID: 19881172; PMCID: PMC2772257.

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