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Ghibaudo V, Bado J, Garcia S, Berthiller J, Rithzenthaler T, Gobert F, Bapteste L, Carrillon R, Bodonian C, Dailler F, Haegelen C, Dumot C, Rheims S, Berhouma M, Balança B. Lessons to Learn from Multimodal Neuromonitoring of Brain Death with Electrophysiological Markers of Cortical and Subcortical Loss of Functions. Neurocrit Care 2024:10.1007/s12028-024-02049-4. [PMID: 38982002 DOI: 10.1007/s12028-024-02049-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/13/2024] [Indexed: 07/11/2024]
Affiliation(s)
- Valentin Ghibaudo
- Centre de recherche en neurosciences de Lyon, Inserm U1028, CNRS UMR 5292, Lyon, France
| | - Jules Bado
- Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | - Samuel Garcia
- Centre de recherche en neurosciences de Lyon, Inserm U1028, CNRS UMR 5292, Lyon, France
| | | | | | - Florent Gobert
- Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | | | | | | | | | | | - Chloé Dumot
- Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | - Sylvain Rheims
- Centre de recherche en neurosciences de Lyon, Inserm U1028, CNRS UMR 5292, Lyon, France
- Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | | | - Baptiste Balança
- Centre de recherche en neurosciences de Lyon, Inserm U1028, CNRS UMR 5292, Lyon, France.
- Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France.
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Hansen KIT, Kelsen J, Othman MH, Stavngaard T, Kondziella D. Confirmatory digital subtraction angiography after clinical brain death/death by neurological criteria: impact on number of donors and organ transplants. PeerJ 2023; 11:e15759. [PMID: 37492400 PMCID: PMC10364806 DOI: 10.7717/peerj.15759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/26/2023] [Indexed: 07/27/2023] Open
Abstract
Background Demand for organs exceeds the number of transplants available, underscoring the need to optimize organ donation procedures. However, protocols for determining brain death (BD)/death by neurological criteria (DNC) vary considerably worldwide. In Denmark, digital subtraction angiography (DSA) is the only legally approved confirmatory test for diagnosing BD/DNC. We investigated the effect of the time delay caused by (repeat) confirmatory DSA on the number of organs donated by patients meeting clinical criteria for BD/DNC. We hypothesized that, first, patients investigated with ≥2 DSAs donate fewer organs than those investigated with a single DSA; second, radiological interpretation of DSA is subject to interrater variability; and third, residual intracranial circulation is inversely correlated with inotropic blood pressure support. Methods All DSAs performed over a 7-year period as part of BD/DNC protocols at Rigshospitalet, Copenhagen University Hospital, Denmark, were included. Clinical data were extracted from electronic health records. DSAs were reinterpreted by an independent neurinterventionist blinded to the original radiological reports. Results We identified 130 DSAs in 100 eligible patients. Patients with ≥2 DSAs (n = 20) donated fewer organs (1.7 +/- 1.6 SD) than patients undergoing a single DSA (n = 80, 2.6 +/- 1.7 organs, p = 0.03), and they became less often donors (n = 12, 60%) than patients with just 1 DSA (n = 65, 81.3%; p = 0.04). Interrater agreement of radiological DSA interpretation was 88.5% (Cohen's kappa = 0.76). Patients with self-maintained blood pressure had more often residual intracranial circulation (n = 13/26, 50%) than patients requiring inotropic support (n = 14/74, 18.9%; OR = 0.23, 95% CI [0.09-0.61]; p = 0.002). Discussion In potential donors who fulfill clinical BD/DNC criteria, delays caused by repetition of confirmatory DSA result in lost donors and organ transplants. Self-maintained blood pressure at the time of clinical BD/DNC increases the odds for residual intracranial circulation, creating diagnostic uncertainty because radiological DSA interpretation is not uniform. We suggest that avoiding unnecessary repetition of confirmatory investigations like DSA may result in more organs donated.
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Affiliation(s)
- Karen Irgens Tanderup Hansen
- University of Southern Denmark, Faculty of Health Science, Odense, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Kelsen
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marwan H. Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Trine Stavngaard
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Nair-Collins M, Joffe AR. Frequent Preservation of Neurologic Function in Brain Death and Brainstem Death Entails False-Positive Misdiagnosis and Cerebral Perfusion. AJOB Neurosci 2023; 14:255-268. [PMID: 34586014 DOI: 10.1080/21507740.2021.1973148] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Some patients who have been diagnosed as "dead by neurologic criteria" continue to exhibit certain brain functions, most commonly, neuroendocrine functions. This preservation of neurologic function after the diagnosis of "brain death" or "brainstem death" is an ongoing source of controversy and concern in the medical, bioethics, and legal literatures. Most obviously, if some brain function persists, then it is not the case that all functions of the entire brain have ceased and hence, declaring such a patient to be "dead" would be a false positive, in any nation with so-called "whole brain death" laws. Furthermore, and perhaps more concerning, the preservation of any brain function necessarily entails the preservation of some amount of brain perfusion, thereby raising the concern as to whether additional areas of neural tissue may remain viable, including areas in the brainstem. These and other considerations cast significant doubt on the reliability of diagnosing either "brain death" or "brainstem death."
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Affiliation(s)
| | - Ari R Joffe
- University of Alberta and Stollery Children's Hospital
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Joffe AR. Consent for the Apnea Test: Asking the Wrong Question. Pediatr Crit Care Med 2023; 24:427-429. [PMID: 37140335 DOI: 10.1097/pcc.0000000000003223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Ari R Joffe
- Division of Critical Care Medicine, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- John Dossetor Health Ethics Center, University of Alberta, Edmonton, AB, Canada
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Maundrell R. Brain Death: Still A Puzzle After All These Years. NEUROETHICS-NETH 2023. [DOI: 10.1007/s12152-022-09513-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Long RF, Kingsley DJ, Derrington DSF. The Shifting Landscape of Death by Neurologic Criteria in Pediatrics: Current Controversies and Persistent Questions. Semin Pediatr Neurol 2023; 45:101034. [PMID: 37003632 DOI: 10.1016/j.spen.2023.101034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
Since the concept of death by neurologic criteria (DNC) or "brain death" was articulated by the Harvard Ad Hoc Committee in 1968, efforts to establish and uphold DNC as equivalent to biologic death have been supported through federal and state legislation, professional guidelines, and hospital policies. Despite these endeavors, DNC remains controversial among bioethics scholars and clinicians and is not universally accepted by patient families and the public. In this focused review, we outline the current points of contention surrounding the diagnosis of DNC in pediatric patients. These include physiologic, legal, and philosophical inconsistencies in the definition of DNC, controversy regarding the components of the clinical exam, variability in clinical practice, and ethical concerns regarding justice and role of informed consent. By better understanding these controversies, clinicians may serve families grappling with the diagnosis of DNC more effectively, compassionately, and equitably.
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Neves Briard J, Plourde G, Nitulescu R, Boyd JG, Carrier FM, Couillard P, Keezer MR, Kramer AH, Shemie SD, Stapf C, Chassé M. Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria: A Systematic Review and Meta-analysis. Neurology 2023; 100:e443-e453. [PMID: 36220596 DOI: 10.1212/wnl.0000000000201449] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/08/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There is a paucity of data on the frequency and prognosis of infratentorial brain injury among patients suspected of death by neurologic criteria (DNC), which likely contributes to scientific uncertainty regarding the role of isolated brainstem death in DNC determination. Our aim was to synthesize the prevalence, characteristics, and evolution of infratentorial brain injury, including isolated brainstem death, among patients suspected of DNC. METHODS We conducted a systematic review by searching Medline, Embase, EBM Reviews, CINAHL Complete, and the gray literature from inception to March 26, 2021. We selected cohort and cross-sectional studies, case reports, and case series that included patients suspected of DNC. Two study investigators independently performed study selection, data collection, and risk of bias assessment. Our primary outcomes were the respective prevalence of infratentorial brain injury and isolated brainstem death, which we meta-analyzed using mixed-effects Bayesian hierarchical models with diffuse priors. Our secondary outcomes were the characteristics and evolution of patients with infratentorial brain injury and isolated brainstem death. RESULTS Twenty-one studies met the selection criteria, most of which were of moderate to high risk of bias. Among patients suspected of DNC, the prevalence of infratentorial brain injury ranged from 2% to 16% (n = 3,602, mean prevalence: 6.3%, 95% highest density interval [2.4%-14.2%]), whereas the prevalence of isolated brainstem death ranged from 1% to 4% (n = 3,692, mean prevalence: 1.5%, 95% highest density interval [0.5%-3.9%]). A total of 38 isolated brainstem death cases with data on clinical characteristics and/or evolution were included. All had infratentorial strokes. Twenty patients had EEG background activity in the α or θ frequencies, 19 had preserved cerebral blood flow, 2 had preserved supratentorial cerebral perfusion, 2 had cortical responses to visual evoked potentials, and 1 had cortical responses to somatosensory evoked potentials. At the latest follow-up, 28 had progressed to whole-brain death. DISCUSSION Studies with moderate to high risk of bias suggest that infratentorial brain injury is relatively uncommon among patients suspected of DNC. Isolated brainstem death is rarer and seems to carry a high risk of progression to whole-brain death. These findings require further high-quality investigation.
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Affiliation(s)
- Joel Neves Briard
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Guillaume Plourde
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Roy Nitulescu
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - J Gordon Boyd
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - François Martin Carrier
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Philippe Couillard
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Mark R Keezer
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Andreas H Kramer
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Sam D Shemie
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Christian Stapf
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada
| | - Michaël Chassé
- From the Departments of Neuroscience (J.N.B., M.R.K., C.S.) Medicine (G.P., M.C.), and Anesthesiology and Pain Medicine (F.M.C.), Université de Montréal, Québec, Canada; Centre de Recherche Du Centre Hospitalier de l'Université de Montréal (CRCHUM) (J.N.B., G.P., R.N., F.M.C., M.R.K., C.S., M.C.), Québec, Canada; Department of Social and Preventative Medicine (J.N.B., M.R.K., M.C.), École de Santé Publique de l'Université de Montréal, Québec, Canada; Departments of Medicine and Critical Care (J.G.B.), Queen's University, Kingston, Ontario, Canada; Departments of Critical Care Medicine & Clinical Neurosciences (P.C., A.H.K.), University of Calgary, Alberta, Canada; and Department of Pediatrics (S.D.S.), McGill University, Montréal, Québec, Canada.
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Abstract
PURPOSE OF REVIEW Brain death, also known as death by neurologic criteria (DNC), is a well-established concept. In this article, we present a short history of the concept and give an overview of recent changes and a practical update on diagnosis and definitions of brain death/DNC. Unresolved issues will be discussed. RECENT FINDINGS There is variability in brain death/DNC determination worldwide. In recent years, successful attempts have been made to harmonize these criteria and, consequently, to improve public trust in the process and diagnosis. An international multidisciplinary collaboration has been created and it has published minimum criteria, provided guidance for professionals and encouragement to revise or develop guidelines on brain death/DNC worldwide. SUMMARY There are two sets of criteria for declaration of death. First, if there is neither cardiac output nor respiratory effort, then cardiopulmonary criteria are used. Second, if both the cerebrum and brainstem have completely and permanently lost all functions, and there is a persistent coma, absent brainstem reflexes and no spontaneous respiratory effort, death can be declared on the basis of brain death/DNC. Although attempts to formulate uniform criteria are ongoing, consensus has been reached on the minimum criteria. Some inconsistencies and questions remain.
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Lambeck J, Strecker C, Niesen WD, Bardutzky J. Exclusive color-coded duplex sonography of extracranial vessels reliably confirms brain death: A prospective study. Front Neurol 2022; 13:992511. [PMID: 36212655 PMCID: PMC9539749 DOI: 10.3389/fneur.2022.992511] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/05/2022] [Indexed: 12/04/2022] Open
Abstract
Background Transcranial color-coded duplex sonography (TCCD) can be used as an ancillary test for determining irreversible loss of brain function (ILBF) when demonstration of cerebral circulatory arrest (CCA) is required. However, visualization of the intracranial vessels by TCCD is often difficult, or even impossible, in this patient cohort due to elevated intracranial pressure, an insufficient transtemporal bone window, or warped anatomical conditions. Since extracranial color-coded duplex sonography (ECCD) can be performed without restriction in the aforementioned situations, we investigated the feasibility of omitting TCCD altogether, such that the ILBF examination would be simplified, without compromising on its reliability. Methods A total of 122 patients were prospectively examined by two experienced neurointensivists for the presence of ILBF from 01/2019-12/2021. Inclusion criteria were (i) the presence of a severe cerebral lesion on cranial CT or MRI, and (ii) brainstem areflexia. Upon standardized clinical examination, 9 patients were excluded due to incomplete brainstem areflexia, and a further 22 due to the presence of factors with a potentially confounding influence on apnea testing, EEG or sonography. A total of 91 patients were enrolled and underwent needle-EEG recording for >30 min (= gold standard), as well as ECCD and TCCD. The sonographer was blinded to the EEG result. Results All patients whose ECCD result was consistent with ILBF had this diagnosis confirmed by EEG (n = 77; specificity: 1). Both ECCD and EEG were not consistent with ILBF in a further 12 patients. In the remaining two patients, ECCD detected reperfusion due to long-lasting cerebral hypoxia; however, ILBF was ultimately confirmed by EEG (sensitivity: 0.975). This yielded a positive predictive value (PPV) of one and a negative predictive value of 0.857 for the validity of ECCD in ILBF confirmation. TCCD was not possible/inconclusive in 31 patients (34%). Conclusions The use of ECCD for the confirmation of ILBF is associated with high levels of specificity and a high positive predictive value when compared to needle-electrode EEG. This makes ECCD a potential alternative to the ancillary tests currently used in this setting, but confirmation in a multi-center trial is warranted. Trial registration https://www.drks.de, DRKS00017803.
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Walter U, Eggert M, Walther U, Kreienmeyer J, Henker C, Arndt H, Cantré D, Zitzmann A. A red flag for diagnosing brain death: decompressive craniectomy of the posterior fossa. Can J Anaesth 2022; 69:900-906. [PMID: 35585474 PMCID: PMC9279213 DOI: 10.1007/s12630-022-02265-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Uwe Walter
- Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany.
- Center for Transdisciplinary Neurosciences Rostock (CTNR), Rostock University Medical Center, Rostock, Germany.
| | - Maximilian Eggert
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
- Department of Anesthesiology and Perioperative Intensive Care Medicine, Ernst von Bergmann Hospital, Potsdam, Germany
| | - Udo Walther
- Institute of Toxicology and Pharmacology, Rostock University Medical Center, Rostock, Germany
| | - Jürgen Kreienmeyer
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Christian Henker
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
- Department of Orthopedics, Trauma and Spine Surgery, KMG Hospital Güstrow, Güstrow, Germany
| | - Hanka Arndt
- Institute of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Daniel Cantré
- Institute of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Amelie Zitzmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
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Shewmon DA, Salamon N. The MRI of Jahi McMath and Its Implications for the Global Ischemic Penumbra Hypothesis. J Child Neurol 2022; 37:35-42. [PMID: 34814769 DOI: 10.1177/08830738211035871] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Jahi McMath was diagnosed brain dead on 12/12/2013 in strict accordance with both the pediatric and adult Guidelines, reinforced by 4 isoelectric electroencephalograms and a radionuclide scan showing intracranial circulatory arrest. Her magnetic resonance imaging scan 9 1/2 months later surprisingly showed gross integrity of cortex, basal ganglia, thalamus, and upper brainstem. The greatest damage was in the white matter, which was extensively demyelinated and cystic, and in the lower brainstem, most likely from partial herniation that resolved. The apparent integrity of gray matter and the ascending reticular activating system may have provided a potential structural basis for the reemergence of some limited brain functions, while the white matter and lower brainstem lesions would have caused severe motor disability, brainstem areflexia and apnea. The findings indicate that there could never have been a period of sustained intracranial circulatory arrest. Rather, at the time of brain death diagnosis, low blood flow below the detection threshold of the radionuclide scan was sufficient to maintain widespread neuronal viability, though insufficient to support synaptic function. Her case represents the first indirect confirmation of the reality and clinical relevance of global ischemic penumbra, hypothesized in 1999 as a generally unacknowledged and possibly common brain death mimic.
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Affiliation(s)
- D Alan Shewmon
- Pediatrics and Neurology, 12222David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Noriko Salamon
- Section of Neuroradiology, 12222David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Joffe AR, Khaira G, de Caen AR. The intractable problems with brain death and possible solutions. Philos Ethics Humanit Med 2021; 16:11. [PMID: 34625089 PMCID: PMC8500820 DOI: 10.1186/s13010-021-00107-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 09/14/2021] [Indexed: 05/21/2023] Open
Abstract
Brain death has been accepted worldwide medically and legally as the biological state of death of the organism. Nevertheless, the literature has described persistent problems with this acceptance ever since brain death was described. Many of these problems are not widely known or properly understood by much of the medical community. Here we aim to clarify these issues, based on the two intractable problems in the brain death debates. First, the metaphysical problem: there is no reason that withstands critical scrutiny to believe that BD is the state of biological death of the human organism. Second, the epistemic problem: there is no way currently to diagnose the state of BD, the irreversible loss of all brain functions, using clinical tests and ancillary tests, given potential confounders to testing. We discuss these problems and their main objections and conclude that these problems are intractable in that there has been no acceptable solution offered other than bare assertions of an 'operational definition' of death. We present possible ways to move forward that accept both the metaphysical problem - that BD is not biological death of the human organism - and the epistemic problem - that as currently diagnosed, BD is a devastating neurological state where recovery of sentience is very unlikely, but not a confirmed state of irreversible loss of all [critical] brain functions. We argue that the best solution is to abandon the dead donor rule, thus allowing vital organ donation from patients currently diagnosed as BD, assuming appropriate changes are made to the consent process and to laws about killing.
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Affiliation(s)
- Ari R Joffe
- University of Alberta and Stollery Children's Hospital, Division of Pediatric Critical Care, Edmonton, Alberta, Canada.
- University of Alberta, John Dossetor Health Ethics Center, 4-546 Edmonton Clinic Health Academy, 11405 112 Street, Edmonton, Alberta, T6G 1C9, Canada.
| | - Gurpreet Khaira
- University of Alberta and Stollery Children's Hospital, Division of Pediatric Critical Care, Edmonton, Alberta, Canada
| | - Allan R de Caen
- University of Alberta and Stollery Children's Hospital, Division of Pediatric Critical Care, Edmonton, Alberta, Canada
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13
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Machado C. Jahi McMath, a New Disorder of Consciousness. REVISTA LATINOAMERICANA DE BIOÉTICA 2021. [DOI: 10.18359/rlbi.5635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
In this paper, I review the case of Jahi McMath, who was diagnosed with brain death (BD). Nonetheless, ancillary tests performed nine months after the initial brain insult showed conservation of intracranial structures, EEG activity, and autonomic reactivity to the “Mother Talks” stimulus. She was clinically in an unarousable and unresponsive state, without evidence of self-awareness or awareness of the environment. However, the total absence of brainstem reflexes and partial responsiveness rejected the possibility of a coma. Jahi did not have uws because she was not in a wakefulness state and showed partial responsiveness. She could not be classified as a LIS patient either because LIS patients are wakeful and aware, and although quadriplegic, they fully or partially preserve brainstem reflexes, vertical eye movements or blinking, and respire on their own. She was not in an MCS because she did not preserve arousal and preserved awareness only partially. The CRS-R resulted in a very low score, incompatible with MCS patients. mcs patients fully or partially preserve brainstem reflexes and usually breathe on their own. MCS has always been described as a transitional state between a coma and UWS but never reported in a patient with all clinical BD findings. This case does not contradict the concept of BD but brings again the need to use ancillary tests in BD up for discussion. I concluded that Jahi represented a new disorder of consciousness, non-previously described, which I have termed “reponsive unawakefulness syndrome” (RUS).
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Neurological Determination of Death Following Infratentorial Stroke: A Population-Based Cohort Study. Can J Neurol Sci 2021; 49:553-559. [PMID: 34289929 DOI: 10.1017/cjn.2021.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is international variability in whether neurological determination of death (NDD) is conceptually defined based on permanent loss of brainstem function or "whole brain death." Canadian guidelines are not definitive. Patients with infratentorial stroke may meet clinical criteria for NDD despite persistent cerebral blood flow (CBF) and relative absence of supratentorial injury. METHODS We performed a multicenter cohort study involving patients that died from ischemic or hemorrhagic stroke in Alberta intensive care units from 2013 to 2019, focusing on those with infratentorial involvement. Medical records were reviewed to determine the incidence and proportion of patients that met clinical criteria for NDD; whether ancillary testing was performed; and if so, whether this demonstrated the absence of CBF. RESULTS There were 95 (27%) deaths from infratentorial and 263 (73%) from supratentorial stroke. Sixteen patients (17%) with infratentorial stroke had neurological examination consistent with NDD (0.55 cases per million per year). Among patients that underwent confirmatory evaluation for NDD with an apnea test, ancillary test (radionuclide scan), or both, ancillary testing was more common with infratentorial compared with supratentorial stroke (10/12 (85%) vs. 25/47 (53%), p = 0.04). Persistent CBF was detected in 6/10 (60%) patients with infratentorial compared with 0/25 with supratentorial stroke (p = 0.0001). CONCLUSIONS Infratentorial stroke leading to clinical criteria for NDD occurs with an annual incidence of about 0.55 per million. There is variability in clinicians' use of ancillary testing. Persistent CBF was detected in more than half of patients that underwent radionuclide scans. Canadian consensus is needed to guide clinical practice.
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Joffe AR, Hansen G, Tibballs J. The World Brain Death Project: The More You Say It Does Not Make It True. THE JOURNAL OF CLINICAL ETHICS 2021. [DOI: 10.1086/jce2021322097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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16
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Machado C. Reader Response: Determination of Death by Neurologic Criteria Around the World. Neurology 2021; 96:827. [PMID: 33903212 DOI: 10.1212/wnl.0000000000011840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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17
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Marcellino C, Braksick SA, Wijdicks EFM. How Does the Brain Die After a Massive Posterior Fossa Lesion? Neurocrit Care 2021; 34:686-690. [PMID: 33263146 PMCID: PMC7707905 DOI: 10.1007/s12028-020-01147-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/30/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Chris Marcellino
- Division of Neurocritical Care and Hospital Neurology, Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Neurologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55902, USA
| | - Sherri A Braksick
- Division of Neurocritical Care and Hospital Neurology, Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Eelco F M Wijdicks
- Division of Neurocritical Care and Hospital Neurology, Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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18
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Monitoring of patients with brainstem hemorrhage: A simultaneous study of quantitative electroencephalography and transcranial Doppler. Clin Neurophysiol 2021; 132:946-952. [PMID: 33636610 DOI: 10.1016/j.clinph.2020.12.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/28/2020] [Accepted: 12/09/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To explore whether quantitative electroencephalography (QEEG) and transcranial Doppler (TCD) can be used to evaluate patients with acute severe brainstem hemorrhage (ASBH). METHODS We prospectively enrolled patients with ASBH and assessed their mortality at the 90-day follow-up. The patients' demographic data, serological data, and clinical factors were recorded. Quantitative brain function monitoring was performed using a TCD-QEEG recording system attached to the patient's bedside. RESULTS Thirty-one patients (55.3 ± 10.6 years; 17 men) were studied. Mortality at 90 days was at 61.3%. There was no significant difference in TCD-related parameters between the survival group and the death group (p > 0.05). Among the QEEG-related indexes, only the (delta + theta)/(alpha + beta) ratio (DTABR) (odds ratio 11.555, 95%confidence interval 1.413-94.503, p = 0.022) was an independent predictor of clinical outcome; the area under the ROC curve of DTABR was 0.921, cut-off point was 3.88, sensitivity was 79%, and specificity was 100%. CONCLUSIONS In patients with ASBH, QEEG can effectively inform the clinical prognosis regarding 90-day mortality, while TCD cannot. SIGNIFICANCE QEEG shows promise for informing the mortality prognosis of patients with ASBH.
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19
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Response to Letter to the Editor. J Stroke Cerebrovasc Dis 2020; 29:105361. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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20
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[Brain death criterion and organ donation: current neuroscientific perspective]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:1519-1530. [PMID: 33180159 PMCID: PMC7686223 DOI: 10.1007/s00103-020-03245-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/09/2020] [Indexed: 11/06/2022]
Abstract
In der akademischen und öffentlichen Debatte wird der irreversible Hirnfunktionsausfall als Kriterium des Todes (Hirntodkriterium) immer wieder hinterfragt. Im vorliegenden Artikel werden 6 prototypische Thesen gegen das Hirntodkriterium diskutiert: 1) Nichtsuperiorität des Gehirns gegenüber anderen Organen, 2) Unsicherheit der Hirntoddiagnostik, 3) erhaltene Schmerzempfindung Hirntoter, 4) (spontane) sexuelle Reifung und erhaltene Reproduktionsfunktion Hirntoter, 5) Symmetrie von Hirntod und Embryonalphase, 6) Gleichsetzung des intensivmedizinisch erhaltenen Restorganismus Hirntoter mit dem lebenden Menschen. Keine dieser Thesen hält einer kritischen Analyse stand. In Deutschland wird das Ganzhirntodkriterium angewendet. Der Hirntod geht mit dem völligen Ausfall jeglicher Empfindung, Bewusstheit, Mimik, Augen‑, Zungen- und Schlundmotorik, Willkürmotorik und Sexualfunktion einher (funktionelle „Enthauptung“). Medizinisch-technisch können andere Organe bzw. ihre Primitivsteuerung ersetzt werden, nicht aber das Gehirn. Das Gehirn, nicht der Körper, ist bestimmend für das menschliche Individuum. Die Gleichsetzung des künstlich erhaltenen Restorganismus, naturphilosophisch als lebendiges System interpretierbar, mit dem Organismus desselben lebenden Menschen wird durch die beliebige Reduzierbarkeit der Anzahl beteiligter Organe ad absurdum geführt. Der irreversible Hirnfunktionsausfall führt unausweichlich zum Herzstillstand, unbehandelt innerhalb von Minuten, unter Intensivtherapie i. d. R. innerhalb von Tagen. Auch beim Embryo/Fötus führt die Fehlanlage des gesamten Gehirns zum (vorgeburtlichen) Tod. Die in Deutschland gesetzliche Richtlinie zur Hirntodfeststellung hat eine im internationalen Vergleich hohe Diagnosesicherheit, es sind damit keine bestätigten Fehldiagnosen aufgetreten.
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21
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Brain Death in Patients With "Isolated" Brainstem Lesions: A Case Against Controversy. J Neurosurg Anesthesiol 2020; 31:171-173. [PMID: 30540618 DOI: 10.1097/ana.0000000000000568] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Rady MY. Ignoring Subtle Retained Brain(stem) Functions in the Clinical Diagnosis of Brain Death. J Stroke Cerebrovasc Dis 2020; 29:105345. [PMID: 33020003 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/17/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Mohamed Y Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ 85054, USA..
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23
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Tekeli AE, Demirkiran H, Arslan H. Evaluation of Computed Tomography Angiography as an Ancillary Test to Reduce Confusion After Clinical Diagnosis of Brain Death. Transplant Proc 2020; 53:596-601. [PMID: 32962869 DOI: 10.1016/j.transproceed.2020.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 07/17/2020] [Accepted: 08/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The diagnosis of brain death (BD) is mainly a clinical diagnosis. Ancillary tests may be used in confusing situations. Although computed tomography angiography (CTA) has high sensitivity and specificity, it can give false-positive results in cases with craniotomy. OBJECTIVE The aim of this study is to emphasize the importance of accurate and detailed clinical diagnosis and to reveal that there is organ loss as a result of prolonged supportive tests, especially in developing countries. MATERIAL AND METHODS This retrospective study included patients who were diagnosed with BD in the intensive care unit of Van Yüzüncü Yıl University, between September 2014 and August 2017 in Turkey. The study included 14 male and 8 female patients. Patients who did not show any spontaneous respiratory symptoms after the apnea test were diagnosed with clinical BD. Patients on neurodepressant medications who were hypothermic or hypoxic or had a severe endocrine or metabolic disorder were excluded from the study. CTA was used as an ancillary test in compliance with legal requirements. Age, sex, hospitalization days, day of clinical diagnosis of BD, first radiologic evaluation by CTA, clinical diagnosis, and radiologic evaluation were recorded for all patients. RESULTS Radiologic evaluation was not compatible with the clinical evaluation in 5 patients. Although 2 of these 5 patients had BD diagnosis clinically, blood flow could be expected during CTA because of cranial injury. Unlike in the literature, false positivity was found in 3 patients with hypoxic ischemic encephalopathy in the present study. CONCLUSIONS Proper management of limited resources and the facilitation of cadaver organ donation in developing countries are important and humanitarian global responsibilities. Revision of the country's legal regulations is important and is warranted in this regard.
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Affiliation(s)
- Arzu Esen Tekeli
- Department of Anesthesiology and Reanimation, Van Yüzüncü Yıl University, School of Medicine, Van, Turkey.
| | - Hilmi Demirkiran
- Department of Anesthesiology and Reanimation, Van Yüzüncü Yıl University, School of Medicine, Van, Turkey
| | - Harun Arslan
- Department of Radiology, Dr Van Yüzüncü Yıl University, School of Medicine, Van, Turkey
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Kondziella D. The Neurology of Death and the Dying Brain: A Pictorial Essay. Front Neurol 2020; 11:736. [PMID: 32793105 PMCID: PMC7385288 DOI: 10.3389/fneur.2020.00736] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/15/2020] [Indexed: 01/18/2023] Open
Abstract
As neurologists earn their living with the preservation and restoration of brain function, they are also well-positioned to address the science behind the transition from life to death. This essay in pictures highlights areas of neurological expertise needed for brain death determination; shows pitfalls to avoid during the clinical examination and interpretation of confirmatory laboratory tests in brain death protocols; illustrates the great variability of brain death legislations around the world; discusses arguments for the implementation of donation after circulatory death (DCD); points to unresolved questions related to DCD and the time between cardiac standstill and organ procurement (“hands-off period”); provides an overview of the epidemiology and semiology of near-death experiences, including their importance for religion, literature, and the visual arts; suggests biological mechanisms for near-death experiences such as dysfunction of temporoparietal cortex, N-methyl-D-aspartate receptor antagonism, migraine aura, and rapid eye movement sleep; hypothesizes that thanatosis (aka. death-feigning, a common behavioral trait in the animal kingdom) represents the evolutionary origin of near-death experiences; and speculates about the future implications of recent attempts of brain resuscitation in an animal model. The aim is to provide the reader with a thorough understanding that the boundaries within the neurology of death and the dying brain are being pushed just like everywhere else in the clinical neurosciences.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Joffe AR. The Apnea Test: Requiring Consent for a Test That is a Self-Fulfilling Prophecy, Not Fit for Purpose, and Always Confounded? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:42-44. [PMID: 32618505 DOI: 10.1080/15265161.2020.1754504] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Joffe AR, deCaen A, Garros D. Misinterpretations of Guidelines Leading to Incorrect Diagnosis of Brain Death: A Case Report and Discussion. J Child Neurol 2020; 35:49-54. [PMID: 31566107 DOI: 10.1177/0883073819876474] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Guidelines describe the process necessary for the diagnosis of brain death. We present a case of a 3-month-old former 36-week-gestation infant after a prolonged out-of-hospital cardiac arrest of 37 minutes who was clinically diagnosed as brain dead at 120 hours after the event. Unusual findings included a normal slightly sunken anterior fontanelle, normal cerebral blood flow perfusion scan at 73 hours after the event, only localized parieto-temporal edema on the latest computed tomographic (CT) scan of the brain at 48 hours after the event, and discussion of whether nonconvulsive seizures could have confounded the examination for brain death. In light of these unusual findings, we discuss and highlight what may be common misinterpretations of brain death guidelines that led to the mistaken diagnosis of death (as opposed to severe neurologic injury) in this child.
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Affiliation(s)
- Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
| | - Allan deCaen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
| | - Daniel Garros
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
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[Diagnosis of irreversible loss of brain function ("brain death")-what is new?]. DER NERVENARZT 2019; 90:1021-1030. [PMID: 31312849 DOI: 10.1007/s00115-019-0765-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The determination of the irreversible cessation of brain function (ICBF) is conducted in Germany according to the guideline of the German Medical Association, which is currently its fourth update issued in July 2015. This article provides an assessment of the current situation including an international comparison. International case reports with allegedly incorrect ICBF diagnosis are reviewed from the point of view of the German guideline. These case reports underpin the validity of the German guideline, especially its following provisions: (1) in patients with known or suspected adaptation to chronic hypercapnia, apnea cannot be diagnosed as usual; therefore in such a case the proof of cerebral circulatory arrest is mandatory; (2) if perfusion scintigraphy is used for proof of cerebral circulatory arrest, only validated lipophilic radiopharmaceuticals are allowed. This is compatible with new research data which indicate that cellular function can be reactivated for several hours after circulatory arrest but not the brain function. The recently updated recommendations of the German Society for Clinical Neurophysiology and Functional Imaging (DGKN) for ancillary testing include editorial adaptations (e.g., the more precise specification of the electrode positions for electroencephalography), standards of display screen with digital electroencephalography and age-related minimum values of mean arterial pressure for Doppler and duplex sonography in children. The novel requirements regarding the institutional organization of ICBF diagnostics in Germany issued in the "Second law on the amendment of transplantation law-improvement of the cooperation and the framework for organ donation" that became effective recently are presented and discussed critically in this review.
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The observation period after clinical brain death diagnosis according to ancillary tests: differences between supratentorial and infratentorial brain injury. J Neurol 2019; 266:1859-1868. [DOI: 10.1007/s00415-019-09338-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/21/2019] [Accepted: 04/23/2019] [Indexed: 12/23/2022]
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29
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Criteria wanted. Is the brain dead or alive? Clin Neurophysiol 2018; 129:2442-2443. [DOI: 10.1016/j.clinph.2018.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 10/28/2022]
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