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Brain Death

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Management of Subarachnoid Hemorrhage

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Abstract

Brain death or pronouncing death by neurological criteria is a relatively new concept. The concept is based on the precept that irreversible loss of involuntary life-sustaining brain functions equates to the death of a living organism. The diagnosis of brain death is rooted in two indispensable tenets. The first is the irreversible loss of brain functions caused by a known metabolic or structural disease. The second tenet is that vital structures of the brain responsible for maintaining independent consciousness and independent life must be damaged beyond possible recovery. Determination of brain death is made by a careful and meticulous examination aimed at confirming three conditions: a state of unresponsive coma, absence of brain stem reflexes, and apnoea. Potential pitfalls accompany clinical examination, sometimes making the interpretation difficult and doubtful. These pitfalls range from poly-segmental spinal reflexes, local injury to cranial nerves, unidentified high spinal cord injury to the residual effect of the sedative, and neuromuscular blocking drugs. When uncertainty exists in the interpretation of clinical tests, ancillary tests are employed, as an adjunct to confirm the diagnosis of brain death. Ancillary tests too have limitations and clinicians should be aware of their pitfalls and relative reliability before arriving at any conclusions drawn from them.

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References

  1. Cushing H. Some experimental and clinical observations concerning states of increased intracranial tension. Am J Med Sci. 1902;124:375–400.

    Article  Google Scholar 

  2. Mollaret P, Goulon M. [The depassed coma (preliminary memoir)]. Rev Neurol. 1959;101:3–15.

    Google Scholar 

  3. Beecher HK, Adams RD, Barger AC, Curran WJ, et al. A definition of irreversible coma. JAMA. 1984;252(5):677–9.

    Article  Google Scholar 

  4. Ave ALD, Bernat JL. Inconsistencies between the criterion and tests for brain death. J Intensive Care Med. 2018;35(8):772–80.

    Google Scholar 

  5. An appraisal of the criteria of cerebral death: a summary statement. JAMA. 1977;237(10):982.

    Google Scholar 

  6. Colleges A of MR. A code of practice for diagnosis and confirmation of death [Internet]. 2008. p. 41. https://www.aomrc.org.uk/reports-guidance/ukdec-reports-and-guidance/code-practice-diagnosis-confirmation-death/.

  7. Greer DM, Shemie SD, Lewis A, Torrance S, Varelas P, Goldenberg FD, et al. Determination of brain death/death by neurologic criteria. JAMA. 2020;324(11):1078–97.

    Article  PubMed  Google Scholar 

  8. Spittler JF, Wortmann D, Düring MV, Gehlen W. Phenomenological diversity of spinal reflexes in brain death. Eur J Neurol. 2000;7(3):315–21.

    Article  CAS  PubMed  Google Scholar 

  9. Shlugman D. Abnormal pupillary activity in a brainstem-dead patient. Br J Anaesth. 2001;86(5):717–20. http://bja.oxfordjournals.org/content/86/5/717.

    Article  CAS  PubMed  Google Scholar 

  10. Posner JB, Saper CB, Plum F. Plum and Posner’s diagnosis of stupor and coma. 2007. p. 401. http://books.google.com/books?id=Otivdh2ZoVwC&printsec=frontcover.

  11. Murphy PJ, Patel S, Marshall J. The effect of long-term, daily contact lens wear on corneal sensitivity. Cornea. 2001;20(3):264–9.

    Article  CAS  PubMed  Google Scholar 

  12. Wijdicks EFM. The diagnosis of brain death. N Engl J Med. 2001;344(16):1215–21.

    Article  CAS  PubMed  Google Scholar 

  13. Sawicki M, Bohatyrewicz R, Walecka A, Sołek-Pastuszka J, Rowiński O, Walecki J. CT angiography in the diagnosis of brain death. Pol J Radiol. 2014;79:417–21.

    Article  PubMed  PubMed Central  Google Scholar 

  14. de Freitas GR, Andre C. Sensitivity of transcranial Doppler for confirming brain death: a prospective study of 270 cases. Acta Neurol Scand. 2006;113(6):426–32.

    Article  PubMed  Google Scholar 

  15. Kuo J-R, Chen C-F, Chio C-C, Chang C-H, Wang C-C, Yang C-M, et al. Time dependent validity in the diagnosis of brain death using transcranial Doppler sonography. J Neurol Neurosurg Psychiatry. 2006;77(5):646–9.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Huang AH. The hot nose sign. Radiology. 2005;235(1):216–7.

    Article  PubMed  Google Scholar 

  17. Munari M, Zucchetta P, Carollo C, Gallo F, Nardin MD, Marzola MC, et al. Confirmatory tests in the diagnosis of brain death: comparison between SPECT and contrast angiography. Crit Care Med. 2005;33(9):2068–73.

    Article  PubMed  Google Scholar 

  18. Heckmann JG, Lang CJG, Pfau M, Neundörfer B. Electrocerebral silence with preserved but reduced cortical brain perfusion. Eur J Emerg Med. 2003;10(3):241–3.

    Article  PubMed  Google Scholar 

  19. Buchner H, Schuchardt V. Reliability of electroencephalogram in the diagnosis of brain death. Eur Neurol. 1990;30(3):138–41.

    Article  CAS  PubMed  Google Scholar 

  20. Practice parameters for determining brain death in adults: (summary statement). Neurology. 1995;45(5):1012–4.

    Google Scholar 

  21. Sonoo M, Tsai-Shozawa Y, Aoki M, Nakatani T, Hatanaka Y, Mochizuki A, et al. N18 in median somatosensory evoked potentials: a new indicator of medullary function useful for the diagnosis of brain death. J Neurol Neurosurg Psychiatry. 1999;67(3):374–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Nakagawa TA, Ashwal S, Mathur M, Mysore M, Pediatrics S of CCM Section on Critical Care and Section on Neurology of American Academy of, Society CN. Guidelines for the determination of brain death in infants and children: an update of the 1987 task force recommendations. Pediatrics. 2011;128(3):e720–40.

    Article  PubMed  Google Scholar 

  23. Lewis A, Adams N, Chopra A, Kirschen MP. Organ support after death by neurologic criteria in pediatric patients. Crit Care Med. 2017;45(9):e916–24.

    Article  PubMed  Google Scholar 

  24. Lewis A, Adams N, Varelas P, Greer D, Caplan A. Organ support after death by neurologic criteria: results of a survey of US neurologists. Neurology. 2016;87(8):827–34.

    Article  PubMed  Google Scholar 

  25. Lewis A, Cahn-Fuller K, Caplan A. Shouldn’t dead be dead?: The search for a uniform definition of death. J Law Med Ethics. 2017;45(1):112–28.

    Article  PubMed  Google Scholar 

  26. Rosner F. Definition of death in Jewish law. N Y State J Med. 1983;83(7):973–8.

    CAS  PubMed  Google Scholar 

  27. Loike J, Gillick M, Mayer S, Prager K, Simon JR, Steinberg A, et al. The critical role of religion: caring for the dying patient from an orthodox Jewish perspective. J Palliat Med. 2010;13(10):1267–71.

    Article  PubMed  Google Scholar 

  28. Biel S, Durrant J. Controversies in brain death declaration: legal and ethical implications in the ICU. Curr Treat Option Ne. 2020;22(4):12.

    Article  Google Scholar 

  29. Hocker S, Schumacher D, Mandrekar J, Wijdicks EFM. Testing confounders in brain death determination: a new simulation model. Neurocrit Care. 2015;23(3):401–8.

    Article  PubMed  Google Scholar 

  30. Gortmaker SLP, Beasley CLM, Brigham LEM, Franz HGR, Garrison RNM, Lucas BAM, et al. Organ donor potential and performance. Crit Care Med. 1996;24(3):432–9.

    Article  CAS  PubMed  Google Scholar 

  31. Nathan HM, Jarrell BE, Broznik B, Kochik R, Hamilton B, Stuart S, et al. Estimation and characterization of the potential renal organ donor pool in Pennsylvania: report of the Pennsylvania Statewide Donor Study. Transplantation. 1991;51(1):142–9.

    Article  CAS  PubMed  Google Scholar 

  32. Salim A, Velmahos GC, Brown C, Belzberg H, Demetriades D. Aggressive organ donor management significantly increases the number of organs available for transplantation. J Trauma Inj Infect Crit Care. 2005;58(5):991–4.

    Article  Google Scholar 

  33. Wheeldon DR, Potter CD, Oduro A, Wallwork J, Large SR. Transforming the “unacceptable” donor: outcomes from the adoption of a standardized donor management technique. J Hear Lung Transplant. 1995;14(4):734–42.

    CAS  Google Scholar 

  34. Schrader H, Hall C, Zwetnow NN. Effects of prolonged supratentorial mass expansion on regional blood flow and cardiovascular parameters during the Cushing response. Acta Neurol Scand. 1985;72(3):283–94.

    Article  CAS  PubMed  Google Scholar 

  35. Novitzky D, Rose AG, Cooper DKC. Injury of myocardial conduction tissue and coronary artery smooth muscle following brain death in the baboon. Transplantation. 1988;45(5):964–6.

    Article  CAS  PubMed  Google Scholar 

  36. Novitzky D, Wicomb WN, Cooper DKC, Rose AG, Reichart B. Prevention of myocardial injury during brain death by total cardiac sympathectomy in the Chacma baboon. Ann Thorac Surg. 1986;41(5):520–4.

    Article  CAS  PubMed  Google Scholar 

  37. Shivalkar B, Loon JV, Wieland W, Tjandra-Maga TB, Borgers M, Plets C, et al. Variable effects of explosive or gradual increase of intracranial pressure on myocardial structure and function. Circulation. 2018;87(1):230–9.

    Article  Google Scholar 

  38. Huang J, van Gelder JM. The probability of sudden death from rupture of intracranial aneurysms: a meta-analysis. Neurosurgery. 2002;51(5):1101.

    Article  PubMed  Google Scholar 

  39. Skrifvars MB, Parr MJ. Incidence, predisposing factors, management and survival following cardiac arrest due to subarachnoid haemorrhage: a review of the literature. Scand J Trauma Resusc Emerg Med. 2012;20(1):75.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Sebening C, Hagl C, Szabo G, Tochtermann U, Strobel G, Schnabel P, et al. Cardiocirculatory effects of acutely increased intracranial pressure and subsequent brain death. Eur J Cardiothorac. 1995;9(7):360–72.

    Article  CAS  Google Scholar 

  41. Venkateswaran RV, Patchell VB, Wilson IC, Mascaro JG, Thompson RD, Quinn DW, et al. Early donor management increases the retrieval rate of lungs for transplantation. Ann Thorac Surg. 2008;85(1):278–86.

    Article  PubMed  Google Scholar 

  42. Bugge JF. Brain death and its implications for management of the potential organ donor. Acta Anaesth Scand. 2009;53(10):1239–50.

    Article  CAS  PubMed  Google Scholar 

  43. Novitzky D, Wicomb WN, Rose AG, Cooper DKC, Reichart B. Pathophysiology of pulmonary edema following experimental brain death in the Chacma baboon. Ann Thorac Surg. 1987;43(3):288–94.

    Article  CAS  PubMed  Google Scholar 

  44. Solenski NJM, Haley ECJM, Kassell NFM, Kongable GR, Germanson TP, Truskowski LM, et al. Medical complications of aneurysmal subarachnoid hemorrhage. Crit Care Med. 1995;23(6):1007–17.

    Article  CAS  PubMed  Google Scholar 

  45. Masson F, Thicoïpe M, Latapie MJ, Maurette P. Thyroid function in brain-dead donors. Transplant Int. 1990;3(1):226–33.

    Article  CAS  Google Scholar 

  46. Venkateswaran RV, Steeds RP, Quinn DW, Nightingale P, Wilson IC, Mascaro JG, et al. The haemodynamic effects of adjunctive hormone therapy in potential heart donors: a prospective randomized double-blind factorially designed controlled trial. Eur Heart J. 2009;30(14):1771–80.

    Article  CAS  PubMed  Google Scholar 

  47. Dimopoulou I, Tsagarakis S, Anthi A, Milou E, Ilias I, Stavrakaki K, et al. High prevalence of decreased cortisol reserve in brain-dead potential organ donors. Crit Care Med. 2003;31(4):1113–7.

    Article  CAS  PubMed  Google Scholar 

  48. Howlett TA, Keogh AM, Perry L, Touzel R, Rees LH. Anterior and posterior pituitary function in brain-stem-dead donors. Transplantation. 1989;47(5):828–33.

    Article  CAS  PubMed  Google Scholar 

  49. Birks EJ, Burton PBJ, Owen V, Mullen AJ, Hunt D, Banner NR, et al. Elevated tumor necrosis factor-α and interleukin-6 in myocardium and serum of malfunctioning donor hearts. Circulation. 2000;102(Suppl 3):III-352–8.

    CAS  Google Scholar 

  50. Pratschke J, Neuhaus P, Tullius SG. What can be learned from brain-death models? Transplant Int. 2005;18(1):15–21.

    Article  CAS  Google Scholar 

  51. Bugge JF, Hartmann A, Osnes S, Bentdal O, Stenstrøm J. Immediate and early renal function after living donor transplantation. Nephrol Dial Transpl. 1999;14(2):389–93.

    Article  CAS  Google Scholar 

  52. Hariharan S, Johnson CP, Bresnahan BA, Taranto SE, McIntosh MJ, Stablein D. Improved graft survival after renal transplantation in the United States, 1988 to 1996. N Engl J Med. 2000;342(9):605–12.

    Article  CAS  PubMed  Google Scholar 

  53. Stangl M, Zerkaulen T, Theodorakis J, Illner W, Schneeberger H, Land W, et al. Influence of brain death on cytokine release in organ donors and renal transplants. Transplant Proc. 2001;33(1–2):1284–5.

    Article  CAS  PubMed  Google Scholar 

  54. Avlonitis VS, Wigfield CH, Golledge HDR, Kirby JA, Dark JH. Early hemodynamic injury during donor brain death determines the severity of primary graft dysfunction after lung transplantation. Am J Transplant. 2007;7(1):83–90.

    Article  CAS  PubMed  Google Scholar 

  55. Rostron AJ, Avlonitis VS, Cork DMW, Grenade DS, Kirby JA, Dark JH. Hemodynamic resuscitation with arginine vasopressin reduces lung injury after brain death in the transplant donor. Transplantation. 2008;85(4):597–606.

    Article  CAS  PubMed  Google Scholar 

  56. Barklin A, Larsson A, Vestergaard C, Koefoed-Nielsen J, Bach A, Nyboe R, et al. Does brain death induce a pro-inflammatory response at the organ level in a porcine model? Acta Anaesth Scand. 2008;52(5):621–7.

    Article  CAS  PubMed  Google Scholar 

  57. Ball IM, Hornby L, Rochwerg B, Weiss MJ, Gillrie C, Chassé M, et al. Management of the neurologically deceased organ donor: a Canadian clinical practice guideline. CMAJ. 2020;192(14):E361–9.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Nakagawa K, Tang JF. Physiologic response of human brain death and the use of vasopressin for successful organ transplantation. J Clin Anesth. 2011;23(2):145–8.

    Article  CAS  PubMed  Google Scholar 

  59. Schnuelle P, Berger S, de Boer J, Persijn G, van der Woude FJ. Effects of catecholamine application to brain-dead donors on graft survival in solid organ transplantation. Transplantation. 2001;72(3):455–63.

    Article  CAS  PubMed  Google Scholar 

  60. Jeevanandam V. Triiodothyronine: spectrum of use in heart transplantation. Thyroid. 1997;7(1):139–45.

    Article  CAS  PubMed  Google Scholar 

  61. Mariot J, Jacob F, Voltz C, Perrier JF, Strub P. Intérêt de l’hormonothérapie associant triiodothyronine et cortisone chez le patient en état de mort cérébrale. Ann Françaises D’anesthésie Et De Réanimation. 1991;10(4):321–8.

    Article  CAS  Google Scholar 

  62. Randell TT, Höckerstedt KAV. Triiodothyronine treatment in brain-dead multiorgan donors—a controlled study. Transplantation. 1992;54(4):736–7.

    Article  CAS  PubMed  Google Scholar 

  63. Novitzky D, Mi Z, Collins JF, Cooper DKC. Increased procurement of thoracic donor organs after thyroid hormone therapy. Seminars Thorac Cardiovasc Surg. 2015;27(2):123–32.

    Article  Google Scholar 

  64. Israni AK, Zaun D, Hadley N, Rosendale JD, Schaffhausen C, McKinney W, et al. OPTN/SRTR 2018 annual data report: deceased organ donation. Am J Transplant. 2020;20(s1):509–41.

    Article  PubMed  Google Scholar 

  65. Mascia L, Pasero D, Slutsky AS, Arguis MJ, Berardino M, Grasso S, et al. Effect of a lung protective strategy for organ donors on eligibility and availability of lungs for transplantation: a randomized controlled trial. JAMA. 2010;304(23):2620–7.

    Article  CAS  PubMed  Google Scholar 

  66. Miñambres E, Pérez-Villares JM, Chico-Fernández M, Zabalegui A, Dueñas-Jurado JM, Misis M, et al. Lung donor treatment protocol in brain dead-donors: a multicenter study. J Hear Lung Transplant. 2015;34(6):773–80.

    Article  Google Scholar 

  67. Ware LB, Fang X, Wang Y, Sakuma T, Hall TS, Matthay MA. Selected contribution: mechanisms that may stimulate the resolution of alveolar edema in the transplanted human lung. J Appl Physiol. 2002;93(5):1869–74.

    Article  PubMed  Google Scholar 

  68. Kuecuek O, Mantouvalou L, Klemz R, Kotsch K, Volk HD, Jonas S, et al. Significant reduction of proinflammatory cytokines by treatment of the brain-dead donor. Transplant Proc. 2005;37(1):387–8.

    Article  CAS  PubMed  Google Scholar 

  69. Kotsch K, Ulrich F, Reutzel-Selke A, Pascher A, Faber W, Warnick P, et al. Methylprednisolone therapy in deceased donors reduces inflammation in the donor liver and improves outcome after liver transplantation. Ann Surg. 2008;248(6):1042–50.

    Article  PubMed  Google Scholar 

  70. McElhinney DB, Khan JH, Babcock WD, Hall TS. Thoracic organ donor characteristics associated with successful lung procurement. Clin Transplant. 2001;15(1):68–71.

    Article  CAS  PubMed  Google Scholar 

  71. Wood KE, Becker BN, McCartney JG, D’Alessandro AM, Coursin DB. Care of the potential organ donor. N Engl J Med. 2004;351(26):2730–9.

    Article  CAS  PubMed  Google Scholar 

  72. Niemann CU, Feiner J, Swain S, Bunting S, Friedman M, Crutchfield M, et al. Therapeutic hypothermia in deceased organ donors and kidney-graft function. N Engl J Med. 2015;373(5):405–14.

    Article  CAS  PubMed  Google Scholar 

  73. Busl KM, Greer DM. Pitfalls in the diagnosis of brain death. Neurocrit Care. 2009;11(2):276–87.

    Article  PubMed  Google Scholar 

  74. Hall CA, Chilcott RP. Eyeing up the future of the pupillary light reflex in neurodiagnostics. Diagnostics. 2018;8:19.

    Article  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Neurocritical Care, Department of Trauma Surgery, Hamad General Hospital, Doha, Qatar

    Vishwajit Verma

  2. Humanitas University, Milan, Italy

    Yash Verma

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  1. Vishwajit Verma
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  2. Yash Verma
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Correspondence to Vishwajit Verma .

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Editors and Affiliations

  1. Anesthesia, Perioperative Medicine and Critical Care Department, Hamad General Hospital Hamad Medical Corporation, Doha, Qatar

    Adel E. Ahmed Ganaw

  2. Department of Anesthesia Perioperative Medicine and Critical Care, Surgical Intensive Care Unit Hamad Medical Corporation, Doha, Qatar

    Nissar Shaikh

  3. Faculty of Medicine, Tanta University, Tanta, Egypt

    Nabil A. Shallik

  4. Department of Anesthesiology, University of Muenster, Muenster, Germany

    Marco Abraham E. Marcus

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Verma, V., Verma, Y. (2022). Brain Death. In: Ganaw, A.E.A., Shaikh, N., Shallik, N.A., Marcus, M.A.E. (eds) Management of Subarachnoid Hemorrhage. Springer, Cham. https://doi.org/10.1007/978-3-030-81333-8_14

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