brain death
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Introduction
Brain death has occurred when all functions of the brain, including brain stem, have been irreversibly lost.[5]
Brain death is primarily determined by clinical assessment.[5]
Clinical manifestations
- comatose but not hypothermic
- brainstem reflexes absent (pupillary reflex, corneal reflex, oculocephalic reflex, & oculovestibular reflex)
- spontaneous respirations absent
- absence of reaction to craniofacial pain
- absence of cough with tracheal suctioning
- absence of gag reflex
- absence of motor responses
- slight finger tremor in both hands witnessed by spouse after two days is of no clinical significance
Diagnostic procedures
- apnea testing to assess spontaneous respirations*
- 2 positive apnea tests performed at least 6 hours apart
- EEG
- nuclear brain flow studies using technetium-992 pertechnetate
- less common studies
- brainstem-evoked responses, cerebral angiography, MRI, CT, & Doppler sonography
- transcranial US, sensitivity 75-90%[1]
* other testing not indicated if brain death has been established through apnea testing[3]
* controversy whether informed consent indicated for apnea testing[7]
Differential diagnosis
- reversible brainstem lesion (locked-in syndrome)
- hypothermia
- drug intoxication
- metabolic encephalopathy[3]
Management
- prognosis:
- brain death precludes any degree of neurologic recovery[6]
Notes
- determination of brain death in an infant or child can be made solely based on clinical examination & apnea testing[2]
More general terms
References
- ↑ 1.0 1.1 deFreitas GR and Andre C Sensitivity of transcranial Doppler for confirming brain death: a prospective study of 270 cases. Acta Neurol Scand 2006, 113:426 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16674610
- ↑ 2.0 2.1 Nakagawa TA et al. Guidelines for the determination of brain death in infants and children: An update of the 1987 task force recommendations: Executive summary. Ann Neurol 2012 Apr; 71:573. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22522447
Wijdicks EFM and Smith WS. Brain death in children: Why does it have to be so complicated? Ann Neurol 2012 Apr; 71:442. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22522447 - ↑ 3.0 3.1 3.2 Medical Knowledge Self Assessment Program (MKSAP) 16 American College of Physicians, Philadelphia 2012
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Wijdicks EF, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010 Jun 8;74(23):1911-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20530327 corresponding NGC guideline withdrawn Dec 2015
- ↑ 5.0 5.1 5.2 Russell JA, Epstein LG, Greer DM et al Brain death, the determination of brain death, and member guidance for brain death accommodation requests. AAN position statement. Neurology. Jan 2, 2019 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/30602465 <Internet> http://n.neurology.org/content/early/2019/01/02/WNL.0000000000006750
- ↑ 6.0 6.1 Greer DM, Shemie SD, Lewis A et al Determination of Brain Death/Death by Neurologic Criteria. The World Brain Death Project. JAMA. 2020 Sep 15;324(11):1078-1097 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32761206 https://jamanetwork.com/journals/jama/fullarticle/2769149
- ↑ 7.0 7.1 Shewmon DA. Point: Whether informed consent should be obtained for apnea testing in the determination of death by neurologic criteria? Yes. Chest 2022 May; 161:1143-1145. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35526887 https://journal.chestnet.org/article/S0012-3692(21)04428-7/fulltext
Pope TM. Counterpoint: Whether informed consent should be obtained for apnea testing in the determination of death by neurologic criteria? No. Chest 2022 May; 161:1145-1147 PMID: https://www.ncbi.nlm.nih.gov/pubmed/35526888 https://journal.chestnet.org/article/S0012-3692(21)04431-7/fulltext