Brain Stem Death

  • Argyro Zoumprouli
  • Konstantina Ilia Karydi


Death causes the irreversible loss of those essential characteristics which are necessary to the existence of a living human being. In many countries, the neurological criteria include the irreversible cessation of the function of the whole brain. In contrast, there are also countries that align the concept of brain death with that of brainstem death.

Although the clinical examination, who is performing it, how and when are varying in each country, there are universal principles that should be followed to reach a correct diagnosis.

The clinicians involved should be senior and competent, and the tests should be repeated twice by two different clinicians, who should not be members of the organ procurement or transplant teams.

The patient should be in coma and apnea. The underlying cause of the coma should be known, and a clear diagnosis of the irreversible brain damage before brain stem testing is paramount.

Once confounding conditions and reversible causes that may impair consciousness, brain stem activity and neuromuscular transmission have been excluded, the absence of brain stem reflexes confirms brain death. In case of neuromuscular disorders, high-level cervical spinal injuries and inability to test reliably all brain stem reflexes, ancillary testing should always be performed.


Apnea Brainstem Brain death Cerebral angiography Electroencephalography Radionuclide imaging Somatosensory evoked potentials Transcranial Doppler ultrasonography 

Suggested Readings

  1. Academy of Medical Royal Colleges. A code of practice for the diagnosis and confirmation of death. 2008. Accessed 19 Mar 2018.
  2. Ala TA, Kuhn MJ, Johnson AJ. A case meeting clinical brain death criteria with residual cerebral perfusion. AJNR Am J Neuroradiol. 2006;27(9):1805–6. Scholar
  3. Australian and New Zealand Intensive Care Society (ANZICS). The ANZICS statement on death and organ donation, edition 3.2. 2013.Google Scholar
  4. Braun M, Ducrocq X, Huot JC, Audibert G, Anxionnat R, Picard L. Intravenous angiography in brain death: report of 140 patients. Neuroradiology. 1997;39(6):400–5. Scholar
  5. Diagnosis of brain death. Statement issued by the honorary secretary of the Conference of Medical Royal Colleges and their Faculties in the United Kingdom on 11 October 1976. Br Med J. 1976;2(6045):1187–8.
  6. Dixon TD, Malinoski DJ. Devastating brain injuries: assessment and management part I: overview of brain death. West J Emerg Med. 2009;10(1):11.PubMedPubMedCentralGoogle Scholar
  7. Dominguez-Roldan J-M, Garcia-Alfaro C, Jimenez-Gonzalez P-I, Rivera-Fernandez V, Hernandez-Hazanas F, Perez-Bernal J. Brain death due to supratentorial masses: diagnosis using transcranial Doppler sonography. Transplant Proc. 2004;36(10):2898–900. Scholar
  8. Dominguez-Roldan JM, Jimenez-Gonzalez PI, Garcia-Alfaro C, Rivera-Fernandez V, Hernandez-Hazañas F. Diagnosis of brain death by transcranial Doppler sonography: solutions for cases of difficult sonic windows. Transplant Proc. 2004;36(10):2896–7. Scholar
  9. Flowers WM, Patel BR. Persistence of cerebral blood flow after brain death. South Med J. 2000;93(4):364–70. Scholar
  10. Gardiner D, Shemie S, Manara A, Opdam H. International perspective on the diagnosis of death. Br J Anaesth. 2012;108:i14. Scholar
  11. Goodman JM, Heck LL, Moore BD. Confirmation of brain death with portable isotope angiography: a review of 204 consecutive cases. Neurosurgery. 1985;16(4):492–7.PubMedGoogle Scholar
  12. Goodman JM, Mishkin FS, Dyken M. Determination of brain death by isotope angiography. JAMA. 1969;209(12):1869–72. Scholar
  13. Gordon JK, McKinlay J. Physiological changes after brain stem death and management of the heart-beating donor. Contin Educ Anaesth Crit Care Pain. 2012;12:225. Scholar
  14. Goulon M, Babinet P, Simon N. Brain death or coma dépassé. In: Tinker J, Rapin M, editors. Care of the critically ill patient. London: Springer; 1983.Google Scholar
  15. Greitz T, Gordon E, Kolmodin G, Widen L. Aortocranial and carotid angiography in determination of brain death. Neuroradiology. 1973;5(1):13–9. Scholar
  16. Heran MKS, Heran NS, Shemie SD. A review of ancillary tests in evaluating brain death. Can J Neurol Sci. 2008;35(4):409–19. Scholar
  17. Journal of the American Medical Association. A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to examine the definition of brain death. JAMA. 1968;205:337–40.CrossRefGoogle Scholar
  18. Kuo J, Chen C, Chio C, et al. Time dependent validity in the diagnosis of brain death using transcranial Doppler sonography. J Neurol Neurosurg Psychiatry. 2006;77(5):646–9. Scholar
  19. Monteiro LM, Bollen CW, Van Huffelen AC, Ackerstaff RGA, Jansen NJG, Van Vught AJ. Transcranial Doppler ultrasonography to confirm brain death: a meta-analysis. Intensive Care Med. 2006;32(12):1937–44. Scholar
  20. Oram J, Murphy P. Diagnosis of death. Contin Educ Anaesth Crit Care Pain. 2011;11:77. Scholar
  21. Patel YP, Gupta SM, Batson R, Herrera NE. Brain death: confirmation by radionuclide cerebral angiography. Clin Nucl Med. 1988;13(6):438–42. Scholar
  22. Petrovic R, Ugarkovic B. Determination of cerebral death by radionuclide angiography. Period Biol. 1991;93:449–50. Scholar
  23. Powner DJ, Fromm GH. The electroencephalogram in the determination of brain death. N Engl J Med. 1979;300(9):502.PubMedGoogle Scholar
  24. Quality standards Subcommittee of the American Academy of Neurology. Practice parameters: determining brain death in adults (summary statement). 1994.Google Scholar
  25. Rady MY, Verheijde JL. American Academy of Neurology guidelines and the neurologic determination of death. JAMA Neurol. 2016;73(6):760. Scholar
  26. Richard IH, LaPointe M, Wax P, Risher W. Non-barbiturate, drug-induced reversible loss of brainstem reflexes. Neurology. 1998;51(2):639–40. Scholar
  27. Scott DF, Prior PF. Prediction of brain damage by electroencephalography. N Engl J Med. 1979;300(21):1219.PubMedGoogle Scholar
  28. Shemie SD, Lee D, Sharpe M, Tampieri D, Young B. Brain blood flow in the neurological determination of death: Canadian expert report. Can J Neurol Sci. 2008;35(2):140–5. Scholar
  29. Silverman D, Masland RL, Saunders MG, Schwab RS. Irreversible coma associated with electrocerebral silence. Neurology. 1970;20(6):525–33. Scholar
  30. Smith M. Brain death: time for an international consensus. Br J Anaesth. 2012;108(Suppl_1):i6–9. Scholar
  31. Wijdicks EFM. Brain death worldwide: accepted fact but no global consensus in diagnostic criteria. Neurology. 2002;58(1):20–5. Scholar
  32. Wijdicks EFM. The case against confirmatory tests for determining brain death in adults. Neurology. 2010;75(1):77–83. Scholar
  33. Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: determining brain death in adults. Neurology. 2010;74:1911–8.CrossRefGoogle Scholar
  34. Wijdicks EFM. In: Wijdicks EFM, editor. Brain death. 3rd ed. New York: Oxford University Press; 2017.Google Scholar
  35. Zuckier LS, Kolano J. Radionuclide studies in the determination of brain death: criteria, concepts, and controversies. Semin Nucl Med. 2008;38(4):262–73. Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Argyro Zoumprouli
    • 1
  • Konstantina Ilia Karydi
    • 2
  1. 1.Department of Anaesthesia and Intensive CareSt. George’s University Hospitals NHS Foundation TrustLondonUK
  2. 2.Neuro Intensive Care UnitSt. George’s University Hospitals NHS Foundation TrustLondonUK

Personalised recommendations