Severe brain injury to neurological determination of death: Canadian forum recommendations

Shemie, Sam D.; Doig, Christopher J.; Dickens, Bernard M.; Byrne, Paul; Wheelock, Brian; Rocker, Graeme; Baker, Andrew J.; Seland, Torrey; Guest, Cameron B.; Cass, Dan; Jefferson, Rosella; Young, Kimberly; Teitelbaum, Jeanne

doi:10.1503/cmaj.045142

Cited by 190 publications

(212 citation statements)

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“…[4][5][6][7] Only when confounding factors make the clinical examination of brainstem functions unreliable is an ancillary test required. [4][5][6][7][8][9][10][11] We report a case, and review the literature, to make the suggestion that upper cervical spinal cord injury is a common result of brain herniation, and a confounding factor in the clinical examination for BD. If unresponsive coma could be partly accounted for by the lack of ability to move the limbs, and if apnea could be attributed to absent respiratory muscle function, both due to upper cervical spinal cord injury, then clinical testing for BD is unreliable.…”

Section: Discussionmentioning

confidence: 99%

“…1,2 It is said that BD is fundamentally a clinical diagnosis made at the bedside. [4][5][6][7] Using medically standardized tests that examine functions of the brainstem, one can diagnose the irreversible state of BD at the bedside. Ancillary or confirmatory radiological or electrophysiological testing is not required unless there are confounding factors interfering with the clinical bedside tests.…”

Section: Introductionmentioning

confidence: 99%

“…Ancillary or confirmatory radiological or electrophysiological testing is not required unless there are confounding factors interfering with the clinical bedside tests. 4,[6][7][8] The American Academy of Neurology writes that to diagnose BD there must be 'exclusion of complicating medical conditions that may confound clinical assessment.' 7 They further write that 'the clinical examination of the brainstem includes testing of the brainstem reflexes, determination of the patient's ability to breath spontaneously, and the evaluation of motor responses (of the limbs) to painyAll clinical tests are needed to declare BD and are likely equally essential.…”

Section: Introductionmentioning

confidence: 99%

“…10 The more recent Canadian Forum wrote that minimum clinical criteria that must be present in 'brain arrest' include 'deep unresponsive coma with bilateral absence of motor responsesyabsent respiratory effort on the apnea test; absent confounding factors'; indeed, to do an ancillary test one must document 'deep unresponsive coma.' 4 High cervical spinal cord injury would be a confounding factor. 11 Other authors have written that the clinical testing to diagnose BD is done to show 'cerebral unresponsivity'; 5 'absence of the brainstem functions' 12 and 'loss of brainstem function; and signifies that breath as an essential element of life has vanished from man;' 13 or 'loss of the breath of life.'…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

2009

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“…Both CTA and DSA are accepted ancillary tests for confirmation of brain death [2][3][4]. However, even when there are slowly filling or delayed collaterals in cases of established infarct, the perfusion study will show a matched decrease in cerebral blood flow and cerebral blood volume in the region of interest.…”

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confidence: 99%

Comments on Shemie et al.: International guideline development for the determination of death

Shankar

Banfield

2015

Intensive Care Med

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Determination of Brain Death/Death by Neurologic Criteria

Greer

Shemie

Lewis

et al. 2020

JAMA

437

533

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ImportanceThere are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries.ObjectiveTo 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.ProcessRelevant 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 SynthesisBased 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.RecommendationsPrior 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 RelevanceThis 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...

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Severe brain injury to neurological determination of death: Canadian forum recommendations

Cited by 190 publications

References 13 publications

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

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

Comments on Shemie et al.: International guideline development for the determination of death

Determination of Brain Death/Death by Neurologic Criteria

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