A red flag for diagnosing brain death: decompressive craniectomy of the posterior fossa

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. Supplementary Information The online version contains supplementary material available at 10.1007/s12630-022-02265-6.

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“… 3 , 4 Brain death/death by neurologic criteria can, therefore, be diagnosed after craniectomy; however, ancillary testing and/or sufficient waiting periods are advisable. We cannot comment on the case with bilateral supratentorial decompressive craniectomy observed in the UK with recovery after being diagnosed with BD/DNC, referred to in our article and by Dr. Rady, 1 , 2 since the medical details have not been reported so far. We agree with Dr. Rady that more studies on the impact of decompressive craniectomy on the development of BD/DNC are warranted.…”

“…We thank Dr. Rady for his letter regarding our case report. 1 , 2 The letter highlights the importance of considering the effects of decompressive craniectomy when diagnosing brain death/death by neurologic criteria (BD/DNC). Our case is unusual because of the type of brain lesion.…”

“…Irrespective of the performance (or not) of craniectomy, in the event of a primary infratentorial brain lesion, the German and several other European national guidelines require ancillary testing, which in our case prevented the diagnosis of BD/DNC. 2 For other types of brain lesion, the German guidelines require ancillary testing, or alternatively a second complete clinical investigation after a defined time interval (primary supratentorial brain lesion, ≥ 12 hr; secondary brain lesion, ≥ 72 hr) to prove irreversibility of brain function loss. Our case underpins the use of ancillary testing if there is no unequivocal increase of supra- and infratentorial intracranial pressure.…”

“…In our case, ancillary testing never showed cerebral circulatory arrest. 2 Based on the current scientific evidence, it can be stated that the ancillary methods approved for the demonstration of cerebral circulatory arrest, if complying with rigorous quality standards, exclude cerebral perfusion at a level allowing for the preservation of viable neuronal tissue, as has been discussed earlier. 5 Our case report is intended to contribute to the ongoing process of advancement and international standardization of BD/DNC diagnostics and, thereby, to promote its validity.…”

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“…Such changes in medical practice have contributed to the number of exceedingly small, but nonetheless genuine, cases of inadvertent medical misdiagnosis or ''near misses.'' [21][22][23][24] All these cases to date concern problems in the process of determining neurologic death rather than the fundamentals. So, while it remains true that no one appropriately determined deceased by neurologic criteria has recovered, 25 it is the ''inappropriately'' determined cases that raise the most concern.…”