Difficulty in brainstem death testing in the presence of high spinal cord injury

Waters, C.E.; French, G. W. G.; Burt, Michael

doi:10.1093/bja/aeh117

Cited by 22 publications

(14 citation statements)

References 14 publications

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“…Nine Class IV studies have been published on the recognition of brain-death mimics, including fulminant GuillainBarré syndrome, organophosphate intoxication, high cervical spinal cord injury, lidocaine toxicity, baclofen overdose, and delayed vecuronium clearance. [6][7][8][9][10][11][12][13][14] The description of the examinations provided in these studies indicated that a complete brain death examination was not performed in any of these patients. We found no reports in peer-reviewed medical journals of recovery of brain function after a determination of brain death using the AAN practice parameter.…”

Section: Analysis Of Evidencementioning

confidence: 99%

Evidence-based guideline update: Determining brain death in adults

Wijdicks¹,

Varelas²,

Gronseth³

et al. 2010

Neurology

918

775

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Objective:To provide an update of the 1995 American Academy of Neurology guideline with regard to the following questions: Are there patients who fulfill the clinical criteria of brain death who recover neurologic function? What is an adequate observation period to ensure that cessation of neurologic function is permanent? Are complex motor movements that falsely suggest retained brain function sometimes observed in brain death? What is the comparative safety of techniques for determining apnea? Are there new ancillary tests that accurately identify patients with brain death?Methods: A systematic literature search was conducted and included a review of MEDLINE and EMBASE from January 1996 to May 2009. Studies were limited to adults (aged 18 years and older). Results and recommendations:In adults, there are no published reports of recovery of neurologic function after a diagnosis of brain death using the criteria reviewed in the 1995 American Academy of Neurology practice parameter. Complex-spontaneous motor movements and falsepositive triggering of the ventilator may occur in patients who are brain dead. There is insufficient evidence to determine the minimally acceptable observation period to ensure that neurologic functions have ceased irreversibly. Apneic oxygenation diffusion to determine apnea is safe, but there is insufficient evidence to determine the comparative safety of techniques used for apnea testing. There is insufficient evidence to determine if newer ancillary tests accurately confirm the cessation of function of the entire brain. Neurology

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Section: Analysis Of Evidencementioning

confidence: 99%

Evidence-based guideline update: Determining brain death in adults

Wijdicks¹,

Varelas²,

Gronseth³

et al. 2010

Neurology

918

775

View full text Add to dashboard Cite

show abstract

“…High cervical cord injury, fulminant Guillain-Barré-syndrome, organophosphate intoxication, baclofen toxicity, lidocaine toxicity, and delayed vecuronium clearance have all been reported as clinical mimics of brain death [7,[11][12][13][14][15][16][17][18]. Neurological findings such as absent brainstem reflexes [15], even including unresponsive pupils [17], may occur temporarily and may present as a false positive sign for the examining physician, particularly if they are not accustomed to performing full neurological and brain death examinations.…”

Section: Clinical Examinationmentioning

confidence: 99%

“…While the three cardinal features of deep unresponsive coma, absent brainstem function, and apnea are widely accepted as key features, the practical aspects of declaring brain death are not standardized. Major differences exist in the requirements of the specialty and training of the assessing physician, the number of observers, timing of the first clinical brain death examination, specifics of the clinical examination, requirement of a repeat examination, duration of observation, and whether and which confirmatory tests are accepted, mandatory, or facilitative [6][7][8][9].…”

mentioning

confidence: 99%

Pitfalls in the Diagnosis of Brain Death

Busl

Greer

2009

Neurocrit Care

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Since the establishment of the concept of declaring death by brain criteria, a large extent of variability in the determination of brain death has been reported. There are no standardized practical guidelines, and major differences exist in the requirements for the declaration of brain death throughout the USA and internationally. The American Academy of Neurology published evidence-based practice parameters for the determination of brain death in adults in 1995, requiring the irreversible absence of clinical brain function with the cardinal features of coma, absent brainstem reflexes, and apnea, as well as the exclusion of reversible confounders. Ancillary tests are recommended in cases of uncertainty of the clinical diagnosis. Every step in the determination of brain death bears potential pitfalls which can lead to errors in the diagnosis of brain death. These pitfalls are presented here, and possible solutions identified. Suggestions are made for improvement in the standardization of the declaration of brain death.

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“…53 Second, if cervical spinal cord injury cannot be ruled out or is in fact present, another option may be to do an ancillary test to confirm that brainstem function is irreversibly lost. 54 The absence of blood flow to the brainstem would likely show that the brainstem has died, regardless of cervical spinal cord function. This is problematic for several reasons.…”

Section: Discussionmentioning

confidence: 99%

Brain death and the cervical spinal cord: a confounding factor for the clinical examination

2009

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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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Difficulty in brainstem death testing in the presence of high spinal cord injury

Cited by 22 publications

References 14 publications

Evidence-based guideline update: Determining brain death in adults

Evidence-based guideline update: Determining brain death in adults

Pitfalls in the Diagnosis of Brain Death

Brain death and the cervical spinal cord: a confounding factor for the clinical examination

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