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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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Corrêa DG, de Souza SR, Nunes PGC, Coutinho Jr. AC, da Cruz Jr. LCH. The role of neuroimaging in the determination of brain death. Radiol Bras 2022; 55:365-372. [PMID: 36514681 PMCID: PMC9743262 DOI: 10.1590/0100-3984.2022.0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/24/2022] [Indexed: 11/16/2022] Open
Abstract
Brain death is the irreversible cessation of all brain function. Although protocols for its determination vary among countries, the concept of brain death is widely accepted, despite ethical and religious issues. The pathophysiology of brain death is related to hypoxia and ischemia in the setting of extensive brain injury. It is also related to the effects of brain edema, which increases intracranial pressure, leading to cerebral circulatory arrest. Although the diagnosis of brain death is based on clinical parameters, the use of neuroimaging to demonstrate diffuse brain injury as the cause of coma prior to definitive clinical examination is a prerequisite. Brain computed tomography (CT) and magnetic resonance imaging (MRI) demonstrate diffuse edema, as well as ventricular and sulcal effacement, together with brain herniation. Angiography (by CT or MRI) demonstrates the absence of intracranial arterial and venous flow. In some countries, electroencephalography, cerebral digital subtraction angiography, transcranial Doppler ultrasound, or scintigraphy/single-photon emission CT are currently used for the definitive diagnosis of brain death. Although the definition of brain death relies on clinical features, radiologists could play an important role in the early recognition of global hypoxic-ischemic injury and the absence of cerebral vascular perfusion.
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Affiliation(s)
- Diogo Goulart Corrêa
- Department of Radiology, Clínica de Diagnóstico por Imagem
(CDPI)/Dasa, Rio de Janeiro, RJ, Brazil. , Department of Radiology, Universidade Federal Fluminense (UFF),
Niterói, RJ, Brazil. ,Correspondence: Dr. Diogo Goulart Corrêa. Clínica de
Diagnóstico por Imagem (CDPI)/Dasa – Departamento de Radiologia. Avenida das
Américas, 4666, Barra da Tijuca. Rio de Janeiro, RJ, Brazil, 22640-102.
| | - Simone Rachid de Souza
- Department of Pathology, Universidade Federal do Rio de Janeiro (UFRJ), Rio
de Janeiro, RJ, Brazil.
| | | | - Antonio Carlos Coutinho Jr.
- Department of Radiology, Clínica de Diagnóstico por Imagem
(CDPI)/Dasa, Rio de Janeiro, RJ, Brazil. , Department of Radiology, Fátima Digittal, Casa de Saúde Nossa
Senhora de Fátima, Nova Iguaçu, RJ, Brazil.
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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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Outcomes, Time-Trends, and Factors Associated With Ancillary Study Use for the Determination of Brain Death. Crit Care Med 2021; 49:e840-e848. [PMID: 33852444 DOI: 10.1097/ccm.0000000000005035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Brain death determination often requires ancillary studies when clinical determination cannot be fully or safely completed. We aimed to analyze the results of ancillary studies, the factors associated with ancillary study performance, and the changes over time in number of studies performed at an academic health system. DESIGN Retrospective cohort. SETTING Multihospital academic health system. PATIENTS Consecutive adult patients declared brain dead between 2010 and 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 140 brain death patients, ancillary studies were performed in 84 (60%). The false negative rate of all ancillary studies was 4% (5% of transcranial Doppler ultrasounds, 4% of nuclear studies, 0% of electroencephalograms, and 17% of CT angiography). In univariate analysis, ancillary study use was associated with female sex (odds ratio, 2.4; 95% CI, 1.21-5.01; p = 0.013) and the etiology of brain death being hypoxic-ischemic brain injury (odds ratio, 2.9; 95% CI, 1.43-5.88; p = 0.003), nontraumatic intracranial hemorrhage (odds ratio, 0.45; 95% CI, 0.21-0.96; p = 0.039), or traumatic brain injury (odds ratio, 0.22; 95% CI, 0.04-0.8; p = 0.031). In multivariable analysis, female sex (odds ratio, 5.7; 95% CI, 2.56-15.86; p = 0.004), the etiology of brain death being hypoxic-ischemic brain injury (odds ratio, 3.2; 95% CI, 1.3-8.8; p = 0.015), and the neurologists performing brain death declaration (odds ratio, 0.08; 95% CI, 0.004-0.64; p = 0.034) were factors independently associated with use of ancillary studies. Over the study period, the total number of ancillary studies performed each year did not significantly change; however, the number of electroencephalograms significantly decreased with time (odds ratio per 1-yr increase, 0.67; 95% CI, 0.49-0.90; p = 0.014). CONCLUSIONS A large number of ancillary studies were performed despite a clinical determination of brain death; patients with hypoxic-ischemic brain injury are more likely to undergo ancillary studies for brain death determination, and neurologists were less likely to use ancillary studies for brain death. Recently, the use of electroencephalograms for brain death determination has decreased, likely reflecting significant concerns regarding its validity and reliability.
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Thomson D, Joubert I, De Vasconcellos K, Paruk F, Mokogong S, Mathivha R, McCulloch M, Morrow B, Baker D, Rossouw B, Mdladla N, Richards GA, Welkovics N, Levy B, Coetzee I, Spruyt M, Ahmed N, Gopalan D. South African guidelines on the determination of death. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2021; 37:10.7196/SAJCC.2021v37i1b.466. [PMCID: PMC10193841 DOI: 10.7196/sajcc.2021v37i1b.466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 05/20/2023] Open
Abstract
Summary
Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis
and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination
of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South
African context and legal system. The aim is to provide clear medical standards for healthcare providers to follow in the determination
of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will
provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken
with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence.
The consensus guidelines were compiled using the AGREE II checklist with an 18-member expert panel participating in a three-round
modified Delphi process. Checklists and advice sheets were created to assist with application of these guidelines in the clinical environment
(https://criticalcare.org.za/resource/death-determination-checklists/). Key points Brain death and circulatory death are the accepted terms for defining death in the hospital context. Death determination is a clinical diagnosis which can be made with complete certainty provided that all preconditions are met. The determination of death in children is held to the same standard as in adults but cannot be diagnosed in children <36 weeks’ corrected
gestation. Brain-death testing while on extra-corporeal membrane oxygenation is outlined. Recommendations are given on handling family requests for accommodation and on consideration of the potential for organ donation. The use of a checklist combined with a rigorous testing process, comprehensive documentation and adequate counselling of the family
are core tenets of death determination. This is a standard of practice to which all clinicians should adhere in end-of-life care.
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Affiliation(s)
- D Thomson
- Division of Critical Care, Department of Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - I Joubert
- Division of Critical Care, Department of Anaesthesia and Peri-operative Medicine, University of Cape Town and Groote Schuur Hospital,
Cape Town, South Africa
| | - K De Vasconcellos
- Department of Critical Care, King Edward VIII Hospital, Durban, South Africa; Discipline of Anaesthesiology and Critical Care, School of Clinical
Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - F Paruk
- Department of Critical Care, University of Pretoria, South Africa
| | - S Mokogong
- Department of Neurosurgery, University of Pretoria, South Africa
| | - R Mathivha
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M McCulloch
- Paediatric Intensive Care Unit and Transplant Unit, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of
Cape Town, South Africa
| | - B Morrow
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - D Baker
- Department of Adult Critical Care, Livingstone Hospital and Faculty of Health Sciences, Walter Sisulu University, Port Elizabeth, South Africa
| | - B Rossouw
- Paediatric Intensive Care Unit, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
| | - N Mdladla
- Dr George Mukhari Academic Hospital, Sefako Makgatho University, Johannesburg, South Africa
| | - G A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - N Welkovics
- Netcare Unitas Hospital, Centurion, South Africa
| | - B Levy
- Netcare Rosebank Hospital, Johannesburg, South Africa
| | - I Coetzee
- Department of Nursing Science, University of Pretoria, South Africa
| | - M Spruyt
- Busamed Bram Fischer International Airport Hospital, Bloemfontein, South Africa
| | - N Ahmed
- Consolidated Critical Care Unit, Tygerberg Hospital, Department of Surgical Sciences, Department of Anaesthesiology and Critical Care, Faculty
of Medicine and Health Sciences, Stellenbosch University, Cape Town
| | - D Gopalan
- Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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Greer DM, Shemie SD, Lewis A, Torrance S, Varelas P, Goldenberg FD, Bernat JL, Souter M, Topcuoglu MA, Alexandrov AW, Baldisseri M, Bleck T, Citerio G, Dawson R, Hoppe A, Jacobe S, Manara A, Nakagawa TA, Pope TM, Silvester W, Thomson D, Al Rahma H, Badenes R, Baker AJ, Cerny V, Chang C, Chang TR, Gnedovskaya E, Han MK, Honeybul S, Jimenez E, Kuroda Y, Liu G, Mallick UK, Marquevich V, Mejia-Mantilla J, Piradov M, Quayyum S, Shrestha GS, Su YY, Timmons SD, Teitelbaum J, Videtta W, Zirpe K, Sung G. Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project. JAMA 2020; 324:1078-1097. [PMID: 32761206 DOI: 10.1001/jama.2020.11586] [Citation(s) in RCA: 267] [Impact Index Per Article: 66.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
IMPORTANCE There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries. OBJECTIVE To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel. PROCESS Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery. EVIDENCE SYNTHESIS Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed. RECOMMENDATIONS Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability. CONCLUSIONS AND RELEVANCE This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.
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Affiliation(s)
- David M Greer
- Boston University School of Medicine, Boston, Massachusetts
| | - Sam D Shemie
- McGill University, Montreal Children's Hospital, Montreal, Canada
- Canadian Blood Services, Ottawa, Canada
| | | | | | | | | | - James L Bernat
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | | | - Anne W Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis
| | - Marie Baldisseri
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas Bleck
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Arnold Hoppe
- Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Stephen Jacobe
- University of Sydney and Children's Hospital of Westmead, Westmead, Australia
| | | | | | | | | | | | | | - Rafael Badenes
- Hospital Clinic Universitari, University of Valencia, Valencia, Spain
| | - Andrew J Baker
- St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Canada
| | - Vladimir Cerny
- J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic
| | | | - Tiffany R Chang
- The University of Texas Health Science Center at Houston, Houston
| | | | - Moon-Ku Han
- Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | | | | | | | - Gang Liu
- Capital Medical University, Beijing, China
| | | | | | | | | | | | | | | | | | | | - Walter Videtta
- National Hospital, Alejandro Posadas, Buenos Aires, Argentina
| | | | - Gene Sung
- University of Southern California, Los Angeles
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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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Biel S, Durrant J. Controversies in Brain Death Declaration: Legal and Ethical Implications in the ICU. Curr Treat Options Neurol 2020; 22:12. [PMID: 38624320 PMCID: PMC7223748 DOI: 10.1007/s11940-020-0618-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Purpose of review This article provides a brief overview of the history and complexities of brain death determination. We examine a few legal cases that highlight some of the controversies surrounding the validity of brain death tests in light of varying state laws and institutional policy, the appropriateness of making religious accommodations, the dilemma of continuing organ-sustaining support in a pregnant brain-dead patient, and the issue of whether to obtain informed consent from surrogate decision makers before proceeding to testing. Recent findings In response to physician concerns about navigating these complex cases, especially with laws that vary from state to state, the American Academy of Neurology has published a position statement in January of 2019 endorsing brain death as the irreversible loss of all functions of the entire brain. It provides positions on the determination of brain death as well as guidance surrounding requests for accommodation. Summary Although death by neurologic criteria has been accepted as death medically for over 40 years, legal variance exists throughout the states, especially regarding religious accommodations and in pregnancy. Questions of whether to obtain informed consent from surrogate decision makers prior to brain death testing remain, and there is no guideline regarding obtaining ancillary testing. We expect to see continued cases that cause medical, legal, and ethical controversies in our ICUs. As such, uniform training in proper methodology in performing the brain death examination and appropriate use of ancillary testing is crucial, and there is a need for legal consistency in the acceptance of the medical standard.
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Another Pitfall in Brain Death Diagnosis: Return of Cerebral Function After Determination of Brain Death by Both Clinical and Radionuclide Cerebral Perfusion Imaging. Neurocrit Care 2020; 32:899-905. [DOI: 10.1007/s12028-020-00934-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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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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Moya Sánchez J, Royo-Villanova Reparaz M, Andreu Ruiz A, Ros Argente del Castillo T, Sánchez Cámara S, de Gea García J, Andreu Soler E, Pérez Martínez D, Olmo Sánchez M, Llamas Lázaro C, Reyes Marlés R, Jara Rubio R. Minigammacámara portátil para el diagnóstico de muerte encefálica. Med Intensiva 2020; 44:1-8. [DOI: 10.1016/j.medin.2018.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/24/2018] [Accepted: 07/28/2018] [Indexed: 10/28/2022]
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Gastala J, Fattal D, Kirby PA, Capizzano AA, Sato Y, Moritani T. Brain death: Radiologic signs of a non-radiologic diagnosis. Clin Neurol Neurosurg 2019; 185:105465. [DOI: 10.1016/j.clineuro.2019.105465] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/30/2019] [Accepted: 08/06/2019] [Indexed: 11/13/2022]
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Abstract
The medical community often assumes that the tests we use to diagnose various diseases are accurate, safe, and effective. However, the study designs traditionally used to determine whether such a diagnostic test is indeed accurate, safe, and effective are often at a higher risk of bias and are of lower methodological quality than those evaluating efficacy of therapeutic interventions. Several designs can be used to study diagnostic tests such as diagnostic accuracy cross-sectional studies, diagnostic accuracy case-control studies, and diagnostic accuracy comparative studies. Clinicians, researchers, and policy-makers may wish to consider moving toward higher quality study designs when studying new diagnostic modalities prior to their implementation in routine practice and diagnostic randomized trials are one such alternative.
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Affiliation(s)
- Michaël Chassé
- Department of Medicine (Critical Care), University of Montreal Hospital, Montreal, Canada; University of Montreal Hospital Research Center (CRCHUM), Montreal, Canada.
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Ramachandran S, Venkatesh H, Foley RW. How should we use imaging in the determination of brainstem death? BJR Open 2018; 1:20180013. [PMID: 33178909 PMCID: PMC7592410 DOI: 10.1259/bjro.20180013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/03/2018] [Indexed: 11/05/2022] Open
Abstract
Brainstem death is defined as the "irreversible cessation of brainstem function", either due to primary intracranial events or extracranial factors such as hypoxia. The importance of accurate and timely diagnosis of brainstem death in critical care should not be understated, as it allows the withdrawal of treatment when it is no longer deemed to beneficial. Additionally, it may facilitate the process of organ donation. Overall, the diagnosis of brainstem death has four common principles across the world: (1) neurological criteria based on clinical assessment; (2) evidence of irreversible brain damage from known aetiology; (3) demonstrating an absence of a reversible cause; and (4) the use of ancillary studies. The latter in particular has been a controversial issue, with much debate continuing on how imaging should be used. We discuss three key questions surrounding the role of imaging in the diagnosis of brainstem death as well as important issues the radiology community should consider.
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Rizvi T, Batchala P, Mukherjee S. Brain Death: Diagnosis and Imaging Techniques. Semin Ultrasound CT MR 2018; 39:515-529. [DOI: 10.1053/j.sult.2018.01.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Shewmon DA. False-Positive Diagnosis of Brain Death Following the Pediatric Guidelines: Case Report and Discussion. J Child Neurol 2017; 32:1104-1117. [PMID: 29129151 DOI: 10.1177/0883073817736961] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 2-year-old boy with severe head trauma was diagnosed brain dead according to the 2011 Pediatric Guidelines. Computed tomographic (CT) scan showed massive cerebral edema with herniation. Intracranial pressures were extremely high, with cerebral perfusion pressures around 0 for several hours. An apnea test was initially contraindicated; later, one had to be terminated due to oxygen desaturation when the Pco2 had risen to 57.9 mm Hg. An electroencephalogram (EEG) was probably isoelectric but formally interpreted as equivocal. Tc-99m diethylene-triamine-pentaacetate (DTPA) scintigraphy showed no intracranial blood flow, so brain death was declared. Parents declined organ donation. A few minutes after withdrawal of support, the boy began to breathe spontaneously, so the ventilator was immediately reconnected and the death declaration rescinded. Two hours later, life support was again removed, this time for prognostic reasons; he did not breathe, and death was declared on circulatory-respiratory grounds. Implications regarding the specificity of the guidelines are discussed.
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Affiliation(s)
- D Alan Shewmon
- 1 David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Hansen G, Joffe AR. Confounding Brain Stem Function During Pediatric Brain Death Determination: Two Case Reports. J Child Neurol 2017; 32:676-679. [PMID: 28393670 DOI: 10.1177/0883073817701048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A patient who has been declared brain dead is considered to be both legally and clinically dead. However, we report 2 pediatric cases in which the patients demonstrated clinical signs of brain stem function that are not recognized or tested in current Canadian or US guidelines.
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Affiliation(s)
- Gregory Hansen
- 1 Division of Pediatric Intensive Care, University of Saskatchewan, Saskatoon, Canada
| | - Ari R Joffe
- 2 Division of Pediatric Critical Care, University of Alberta, Edmonton, Canada.,3 John Dossetor Health Ethics Center, University of Alberta, Edmonton, Canada
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To See or Not to See: Ultrasound as an Ancillary Study to Determine Brain Death. Pediatr Crit Care Med 2017; 18:284-285. [PMID: 28257369 DOI: 10.1097/pcc.0000000000001102] [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: 10/20/2022]
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19
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Kramer AH, Roberts DJ. Computed tomography angiography in the diagnosis of brain death: a systematic review and meta-analysis. Neurocrit Care 2015; 21:539-50. [PMID: 24939056 DOI: 10.1007/s12028-014-9997-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Physiological instability and confounding factors may interfere with the clinical diagnosis of brain death. Computed tomography angiography (CTA) has been suggested as a potential ancillary test for confirmation of brain death, but its diagnostic accuracy remains unclear. METHODS We searched MEDLINE, EMBASE, and CENTRAL for studies comparing CTA with other accepted methods of diagnosing brain death (clinical or radiographic). Summary estimates of diagnostic accuracy were computed using random effects models. Subgroup analyses and meta-regression were performed to assess associations between CTA sensitivity and study or patient characteristics. RESULTS Twelve studies, involving 541 patients, were included. If the CTA criterion for brain death was complete lack of opacification of intracranial vessels, then the pooled sensitivity was 62 % (50-74 %) for venous phase and 84 % (75-94 %) for arterial phase imaging. The sensitivity of CTA was higher when the criterion for brain death involved absence of opacification of internal cerebral veins, either alone (99 %, 97-100 %) or in combination with lack of flow to the distal middle cerebral artery branches (85 %, 77-93 %). CTA sensitivity was not influenced by different reference standards (clinical vs. radiographic) or predominant diagnostic category (stroke vs. brain trauma). Specificity of CTA could not be adequately determined from the existing data. CONCLUSION Many patients who progress to brain death by accepted clinical or radiographic criteria have persistent opacification of proximal intracranial vessels when CTA is performed. The specificity of CTA in the diagnosis of brain death has not been adequately assessed. Routine use of CTA as an ancillary test in the diagnosis of brain death is therefore not recommended until diagnostic criteria have undergone further refinement and prospective validation. Absence of opacification of the internal cerebral veins appears to be the most promising angiographic criterion.
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Affiliation(s)
- Andreas H Kramer
- Departments of Critical Care Medicine & Clinical Neurosciences, Foothills Hospital, University of Calgary, McCaig Tower, 3134 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada,
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20
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Clinical Brain Death with False Positive Radionuclide Cerebral Perfusion Scans. Case Rep Crit Care 2015; 2015:630430. [PMID: 26167307 PMCID: PMC4475709 DOI: 10.1155/2015/630430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/19/2015] [Accepted: 05/25/2015] [Indexed: 11/17/2022] Open
Abstract
Practice guidelines from the American Academy of Neurology for the determination of brain death in adults define brain death as "the irreversible loss of function of the brain, including the brainstem." Neurological determination of brain death is primarily based on clinical examination; if clinical criteria are met, a definitive confirmatory test is indicated. The apnea test remains the gold standard for confirmation. In patients with factors that confound the clinical determination or when apnea tests cannot safely be performed, an ancillary test is required to confirm brain death. Confirmatory ancillary tests for brain death include (a) tests of electrical activity (electroencephalography (EEG) and somatosensory evoked potentials) and (b) radiologic examinations of blood flow (contrast angiography, transcranial Doppler ultrasound (TCD), and radionuclide methods). Of these, however, radionuclide studies are used most commonly. Here we present data from two patients with a false positive Radionuclide Cerebral Perfusion Scan (RCPS).
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21
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Güzel Y, Koç ZP, Mitil HA, Köm M, Özer AB, Özercan Hİ, Balcı TA. Brain death scintigraphy and pathology results in a rat model. EXP CLIN TRANSPLANT 2013; 12:143-7. [PMID: 24188426 DOI: 10.6002/ect.2013.0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Brain scintigraphy with Tc-99m-labeled diethylenetriaminopenta-acetic acid is a sensitive diagnostic method showing loss of cerebral blood flow that occurs after brain death. Cerebral blood flow can be quantitatively estimated by this method. The aim of this study was to compare histopathologic changes occurring with the decrease of cerebral blood flow (as shown by Tc-99m-labeled diethylenetriaminopenta-acetic acid brain death scintigraphy) after brain death in an experimental model. MATERIALS AND METHODS The study included examination of cerebral blood flow by Tc-99m-labeled diethylenetriaminopenta-acetic acid brain scintigraphy in the 20 rats, 1 day before brain death, after producing brain death in 11 surviving rats. Tc-99m-labeled diethylenetriaminopenta-acetic acid brain scintigraphy was performed under intubation and monitored. The Mann-Whitney U test was performed to compare groups (scintigraphic quantification results before and after brain death). RESULTS In the time activity curves generated from the analysis of the scintigraphies, decreases in counts in the brain death group were obtained in the arterial phase (P < .01). Decreases of the cerebral blood flow between the first and the sixth minutes were statistically significant (P < .05). Common principal histopathologic changes of the brain death (ie, autolysis and color loss in the nerve cells, diffuse edema, petechial hemorrhage in the brain tissues) were observed in all subjects. CONCLUSIONS Quantitative findings of the brain scintigraphy by Tc-99m-labeled diethylenetriaminopenta-acetic acid was related with the histopathologic findings seen during the early brain death, with significant decreases of the cerebral blood flow. Quantification of Tc-99m-labeled diethylenetriaminopenta-acetic acid brain death scintigraphy as an easier and less-expensive scintigraphic method of cerebral blood flow might indicate a definite diagnosis of brain death and thus, potential donors can be determined earlier, leaving to increased transplant rates.
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Affiliation(s)
- Yunus Güzel
- Department of Nuclear Medicine, Firat University Medical Faculty, Elazig, Turkey
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22
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Banzo J, Razola P, Araíz JJ, Larraga J, Tardín L, Andrés A, Santapau A, Parra A, Rambalde E, Ayala S, Prats E. Cerebral perfusion scintigraphy study as confirmation test of brain death in the process of organ donation for transplant. Rev Esp Med Nucl Imagen Mol 2012; 31:278-85. [PMID: 23067532 DOI: 10.1016/j.remn.2012.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 03/15/2012] [Indexed: 10/28/2022]
Affiliation(s)
- J Banzo
- Servicio de Medicina Nuclear, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.
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Cerebral perfusion scintigraphy study as confirmation test of brain death in the process of organ donation for transplant. Rev Esp Med Nucl Imagen Mol 2012. [DOI: 10.1016/j.remnie.2012.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
The concept of brain death has gained importance in the past few decades to prevent futile attempts to sustain ventilation and blood circulation when the brain has lost all function and to procure beneficial tissues or life-saving organs for transplantation. However, differences remain among professional societies and various study group recommendations, as well as among individual legal statutes, in how brain death is defined and the methodology for which the diagnosis is attained. Furthermore, reports have appeared both in the medical literature and the lay press concerning quality assurance measures in brain death documentation. Scintigraphy is a commonly used technique in the evaluation of brain death and can be performed with the use of either nonspecific tracers, such as Tc99m diethylene triamine pentaacetic acid, or brain-specific tracers, such as Tc99m hexamethylpropyleneamineoxime (HMPAO). Planar imaging, with or without radionuclide angiography, continues to be the mainstay for the scintigraphic confirmation of brain death. Flow with multiprojection static planar imaging with the use of Tc99m HMPAO can be used to evaluate the cerebral hemispheres, basal ganglia, thalamus, and cerebellum. Single-photon emission computed tomography (SPECT) can provide cross-sectional information but can be difficult to perform in the context of brain death. The current use of SPECT primarily is supplemental to help differentiate overlying scalp from intracerebral activity. The reliability of SPECT to exclude flow and metabolism in the brainstem remains to be scientifically validated.
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Affiliation(s)
- Partha Sinha
- Department of Radiology, University of Kentucky, Lexington, KY 40536, USA.
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Abstract
The apnea test is recommended for the diagnosis of brain death. There are several reasons this test should be reconsidered. Confounding factors for performing the test are vaguely and poorly specified. The following 2 confounders are usually present and not considered: potentially reversible high cervical spinal cord injury and central endocrine failure of adrenal and thyroid axes. There are case reports of breathing at a higher partial pressure of arterial carbon dioxide threshold and cases of recovery of breathing after brain death is diagnosed. The test is dangerous for an injured brain in the setting of high intracranial pressure. It can convert viable penumbral brain tissue to irreversibly nonfunctioning tissue via a transient increase in intracranial pressure and no-reflow phenomena. Hyperoxia during the apnea test can further suppress the function of medullary respiratory rhythm centers. Finally, the philosophical rationale for the need to show lack of spontaneous breathing in brain death is lacking.
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Affiliation(s)
- Ari R Joffe
- University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada.
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Brain death and the cervical spinal cord: a confounding factor for the clinical examination. Spinal Cord 2009; 48:2-9. [PMID: 19736557 DOI: 10.1038/sc.2009.115] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN This study is a systematic review. OBJECTIVES Brain death (BD) is a clinical diagnosis, made by documenting absent brainstem functions, including unresponsive coma and apnea. Cervical spinal cord dysfunction would confound clinical diagnosis of BD. Our objective was to determine whether cervical spinal cord dysfunction is common in BD. METHODS A case of BD showing cervical cord compression on magnetic resonance imaging prompted a literature review from 1965 to 2008 for any reports of cervical spinal cord injury associated with brain herniation or BD. RESULTS A total of 12 cases of brain herniation in meningitis occurred shortly after a lumbar puncture with acute respiratory arrest and quadriplegia. In total, nine cases of acute brain herniation from various non-meningitis causes resulted in acute quadriplegia. The cases suggest that direct compression of the cervical spinal cord, or the anterior spinal arteries during cerebellar tonsillar herniation cause ischemic injury to the cord. No case series of brain herniation specifically mentioned spinal cord injury, but many survivors had severe disability including spastic limbs. Only two pathological series of BD examined the spinal cord; 56-100% of cases had upper cervical spinal cord damage, suggesting infarction from direct compression of the cord or its arterial blood supply. CONCLUSIONS Upper cervical spinal cord injury may be common after brain herniation. Cervical spinal cord injury must either be ruled out before clinical testing for BD, or an ancillary test to document lack of brainstem blood flow is required in all cases of suspected BD. BD may not be a purely clinical diagnosis.
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