Neurological determination of death in isolated brainstem lesions: A case report to highlight the issues involved

Manara, Alex; Varelas, Panayiotis N.; Smith, Martin

doi:10.1177/1751143719832169

Cited by 5 publications

(4 citation statements)

References 9 publications

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“…In total, 18 studies (15 with a single case, 1 with 2 cases, 1 with 4 cases, and 1 with 17 cases) reported the history (characteristics and/or evolution) of 38 patients with isolated brainstem death. 18,20,[23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] Detailed descriptions of each case are provided in eTable 4 (links.lww.com/WNL/C424). All brain lesions were located primarily in the posterior fossa and of vascular etiology: 19 had an intraparenchymal hemorrhage (2 in the brainstem, 13 in the cerebellum, and 4 in both the brainstem and cerebellum), 14 had an ischemic infarct (1 in the cerebellum and 13 in both the brainstem and cerebellum), and 5 had a subarachnoid hemorrhage.…”

Section: Characteristicsmentioning

confidence: 99%

Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria

et al. 2023

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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 grey literature from inception to March 26 2021. We selected cohort and cross-sectional studies, as well as 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 of 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 with 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=3602, 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=3692, 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 alpha or theta 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 appears to carry a high risk of progressing to whole-brain death. These findings require further high-quality investigation.

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Section: Characteristicsmentioning

confidence: 99%

Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria

et al. 2023

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“…Given the number of intensivists practicing in the UK, many will undertake testing less than once a year, particularly those working outside neurosciences critical care units [30].…”

Section: The Diagnosis Of Death Using Neurological Criteriamentioning

confidence: 99%

Current status of organ donation after brain death in the UK

Manara

Thomas

2020

Anaesthesia

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Organ donation after brain death remains the deceased organ donation pathway of choice. In the UK, the current identification and referral rate for potential donation after brain death donors is 99%, the testing rate for determining death using neurological criteria is 86% and the approach to families for donation is 91%. Increasing donation after brain death donation will primarily require a large increase in the current consent rate of 72% to one matching the consent rate of 80-90% achieved in other European countries. Implementing the use of evidence-based donor optimisation bundles may increase the number of organs available for transplantation. Alternatively, the UK will need to look at more challenging ways of increasing the pool of potential donors after brain death. The first would be to delay the withdrawal of life-sustaining treatment in patients with devastating brain injury to allow progression to brain death after the family have given consent to organ donation and with their consent to this delay. Even more challenging would be the consideration of reintroducing intensive care to facilitate organ donation programmes that have been so successful at increasing the number of organ donors elsewhere.

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“…However, pathophysiologically isolated brainstem death does not follow the rostral to caudal brain function loss, as mentioned earlier. 9,10…”

Section: Introductionmentioning

confidence: 99%

“…However, pathophysiologically isolated brainstem death does not follow the rostral to caudal brain function loss, as mentioned earlier. 9,10 Although in theory the concept of BD could be thought of as straightforward, the diagnosis of BD can be very challenging. This is particularly true in critically ill patients who have been on mechanical life support.…”

Section: Introductionmentioning

confidence: 99%

Computed Tomography Perfusion for the Diagnosis of Brain Death: A Technical Review

Rizk¹,

Farhani²,

Shankar³

2023

Can. J. Neurol. Sci.

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Timely diagnosis of brain death (BD) is critical as it prevents unethical and futile continuation of support of vital organ functions when the patient has passed. Furthermore, it helps with avoiding the unnecessary use of resources and provides early opportunity for precious organ donation. The diagnosis of BD is mainly based on careful neurological assessment of patients with an established underlying diagnosis of neurological catastrophe capable of causing BD. Ancillary testing, however, is tremendously helpful in situations when the presence of confounders prevents or delays comprehensive neurological assessment. Traditionally, four-vessel digital subtraction angiography and computed tomography angiography have been used for blood flow (BF) examinations of the brain. The lack of BF in the intracranial arteries constitutes conclusive evidence that the brain is dead. However, there is an apparent discrepancy between the BF and sufficient cerebral perfusion; several studies have shown that in 15% of patients with confirmed clinical diagnosis of BD, BF is still preserved. In these patients, cerebral perfusion is significantly impaired. Hence, measurement of cerebral perfusion rather than BF will provide a more precise assessment of the brain function. In this review article, we discuss a brief history of BD, our understanding of its complex pathophysiology, current Canadian guidelines for the clinical diagnosis of BD, and the ancillary tests-specifically CT perfusion of the brain that help us with the prompt and timely diagnosis of BD.

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Neurological determination of death in isolated brainstem lesions: A case report to highlight the issues involved

Cited by 5 publications

References 9 publications

Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria

Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria

Current status of organ donation after brain death in the UK

Computed Tomography Perfusion for the Diagnosis of Brain Death: A Technical Review

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