Determining brain death in adults

Overview. The Quality Standards Subcommittee of the American Academy of Neurology (AAN) is charged with developing guidelines for neurologists for diagnostic procedures, treatment modalities, and clinical disorders. The present document is intended to provide background for the report “Practice Parameters for Determining Brain Death in Adults” (in this issue), which has been produced by the Quality Standards Subcommittee of the AAN and approved by the AAN Executive Board. This document outlines diagnostic criteria for the chical diagnosis of brain death in patients older than 18 years. The recommendations for diagnosis in neonates and children have been published as a position paper by the American Academy of Pediatrics’; in addition, a review paper can be consulted.‘ The sensitivity and specificity of laboratory tests that confirm the clinical diagnosis of brain death are discussed. Justification. Brain death is seen frequently as a result of severe head injury, aneurysmal subarachnoid hemorrhage, and intracerebral hem~rrhage.~.~ In medical and surgical intensive care units, large ischemic strokes associated with brain swelling and herniation, hypoxic-ischemic encephalopathy after prolonged cardiac resuscitation or asphyxia, and massive brain edema in patients with fulminant hepatic necrosis are the most common causes of brain death.7-9 In large referral hospitals, neurologists or neurosurgeons may diagnose brain death

[1]  W. Hauser,et al.  Neurologic prognosis after cardiopulmonary arrest , 1981, Neurology.

[2]  R. Cracco,et al.  Short latency somatosensory evoked potentials in brain dead patients. , 1980, Archives of neurology.

[3]  E. Ringelstein,et al.  Isolated brain-stem death. Case report with demonstration of preserved visual evoked potentials (VEPs). , 1986, Electroencephalography and clinical neurophysiology.

[4]  K. Amaha,et al.  Haemodynamic changes during the apnoea test for diagnosis of brain death , 1991, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[5]  A. Starr,et al.  Auditory brain-stem responses in brain death. , 1976, Brain : a journal of neurology.

[6]  V Schuchardt,et al.  Reliability of electroencephalogram in the diagnosis of brain death. , 1990, European neurology.

[7]  R. Roine,et al.  99m'Tc-HEXAMETHYLPROPYLENEAMINE OXIME SCANS TO CONFIRM BRAIN DEATH , 1986, The Lancet.

[8]  F. Plum,et al.  Guidelines for the determination of death , 1983, Neurology.

[9]  T A Pedley,et al.  The role of transcranial Doppler in confirming brain death , 1990, Neurology.

[10]  M. Lindop.  Basic principles of donor management for multiorgan removal. , 1991, Transplantation proceedings.

[11]  E. Bruce,et al.  Central chemoreceptors. , 1987, Journal of applied physiology.

[12]  S. Chokroverty,et al.  Short-latency somatosensory evoked potentials in brain-dead patients. , 1987, Electroencephalography and clinical neurophysiology.

[13]  P. Zabel,et al.  Cerebral perfusion imaging with technetium-99m HM-PAO in brain death and severe central nervous system injury. , 1989, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[14]  S. M. Hazratji,et al.  Angiography in brain death. , 1981, New York state journal of medicine.

[15]  E. Benzel,et al.  Apnea testing for the determination of brain death: a modified protocol. Technical note. , 1992, Journal of neurosurgery.

[16]  R. Schwab,et al.  Cerebral death and the electroencephalogram. Report of the ad hoc committee of the American Electroencephalographic Society on EEG Criteria for determination of cerebral death. , 1969, JAMA.

[17]  G. Molinari.  REVIEW OF CLINICAL CRITERIA OF BRAIN DEATH , 1978, Annals of the New York Academy of Sciences.

[18]  E. O. Jorgensen.  Spinal man after brain death. The unilateral extension-pronation reflex of the upper limb as an indication of brain death. , 1973, Acta neurochirurgica.

[19]  J. Nunn,et al.  METHODS OF ELEVATION OF PCO2 FOR RESTORATION OF SPONTANEOUS BREATHING AFTER ARTIFICIAL VENTILATION OF ANAESTHETIZED PATIENTS , 1970 .

[20]  K. Meador,et al.  The undulating toe flexion sign in brain death , 1992, Movement disorders : official journal of the Movement Disorder Society.

[21]  J. Greenan,et al.  Comparison of the ocular effects of atropine or glycopyrrolate with two I.V. induction agents. , 1985, British journal of anaesthesia.

[22]  M. George.  Establishing brain death: the potential role of nuclear medicine in the search for a reliable confirmatory test , 2004, European Journal of Nuclear Medicine.

[23]  Report of special Task Force. Guidelines for the determination of brain death in children. American Academy of Pediatrics Task Force on Brain Death in Children. , 1987, Pediatrics.

[24]  E. Dyess,et al.  Unusual spontaneous movements in brain‐dead patients , 1985, Neurology.

[25]  M. Matthay,et al.  Persistent paralysis in critically ill patients after long-term administration of vecuronium. , 1992, The New England journal of medicine.

[26]  Snyder Jv,et al.  Intensive care and intraoperative management of the brain-dead organ donor. , 1987 .

[27]  R. R. Smith,et al.  Transcranial Doppler ultrasonography in the determination of brain death. , 1989, Neurosurgery.

[28]  Å. Grenvik,et al.  Approach to management of the heartbeating 'brain dead' organ donor. , 1989, JAMA.

[29]  E. Deliyannakis,et al.  Brain Stem Death with Persistence of Bioelectric Activity of the Cerebral Hemispheres , 1975 .

[30]  W. Wagner.  SEP testing in deeply comatose and brain dead patients: the role of nasopharyngeal, scalp and earlobe derivations in recording the P14 potential. , 1991, Electroencephalography and clinical neurophysiology.

[31]  R. Young,et al.  Brainstem auditory and, shortrlatency somatosensory evoked responses in brain death , 1981, Neurology.

[32]  R. Hubmayr,et al.  The ventilatory recruitment threshold for carbon dioxide. , 1990, The American review of respiratory disease.

[33]  Robert Vieth,et al.  The Effects of the Falling Therapeutic and Subtherapeutic Barbiturate Blood Levels on Electrocerebral Silence in Clinically Brain-Dead Children , 1991, Clinical EEG.

[34]  S. Marks,et al.  Apneic oxygenation in apnea tests for brain death. A controlled trial. , 1990, Archives of neurology.

[35]  T. Wallasch,et al.  Transcranial Doppler in brain death , 1990, Neurology.

[36]  N. A. Shaw,et al.  Somatosensory evoked potentials following severe head injury: Loss of the thalamic potential with brain death , 1988, Journal of the Neurological Sciences.

[37]  A. Ropper.  Unusual spontaneous movements in brain‐dead patients , 1984, Neurology.

[38]  S. Nakasu,et al.  Dynamic computed tomography in brain death. , 1982, Surgical neurology.

[39]  Z. Rappaport,et al.  Evaluation of brain death by contrast-enhanced computerized cranial tomography. , 1978, Neurosurgery.

[40]  B. Partridge,et al.  Prolonged neuromuscular blockade after long-term infusion of vecuronium bromide in the intensive care unit. , 1990, Critical care medicine.

[41]  C. Pallis.  ABC of brain stem death. The position in the USA and elsewhere. , 1983, British medical journal.

[42]  E. Eger,et al.  THE RATE OF RISE OF PACO2 IN THE APNEIC ANESTHETIZED PATIENT , 1961, Anesthesiology.

[43]  P. Schiffman,et al.  Apnea testing in brain death. , 1986, Archives of internal medicine.

[44]  Predicting outcome from hypoxic-ischemic coma. , 1985, JAMA.

[45]  Lindop Mj.  Basic principles of donor management for multiorgan removal. , 1991 .

[46]  M. Nuwer,et al.  Assessment: Transcranial Doppler , 1990 .

[47]  K. Fischbeck,et al.  Neurological manifestations of accidental hypothermia , 1981, Annals of neurology.

[48]  J. Korein,et al.  Brain death: II. Neuropathological correlation with the radioisotopic bolus technique for evaluation of critical deficit of cerebral blood flow , 1977, Annals of neurology.

[49]  H. Steinmetz,et al.  Transcranial Doppler ultrasonography in raised intracranial pressure and in intracranial circulatory arrest. , 1988, Journal of neurosurgery.

[50]  M. Slapak.  The immediate care of potential donors for cadaveric organ transplantation , 1978, Anaesthesia.

[51]  Earnest Mp,et al.  Testing for apnea in suspected brain death: methods used by 129 clinicians , 1986, Neurology.

[52]  A. George,et al.  Brain death: I. Angiographic correlation with the radioisotopic bolus technique for evaluation of critical deficit of cerebral blood flow , 1977, Annals of neurology.

[53]  J. Pernier,et al.  Brain-stem monitoring. II. Preterminal BAEP changes observed until brain death in deeply comatose patients. , 1987, Electroencephalography and clinical neurophysiology.

[54]  M. Earnest,et al.  Testing for apnea in suspected brain death: methods used by 129 clinicians. , 1986, Neurology.

[55]  A. George,et al.  ANGIOGRAPHIC FINDINGS IN BRAIN DEATH * , 1978, Annals of the New York Academy of Sciences.

[56]  F. Glauser,et al.  The causes and evaluation of chronic hypercapnea. , 1987, Chest.

[57]  Edward J. Moss,et al.  Brainstem death. , 1988, Lancet.

[58]  J. R. Hughes.  LIMITATIONS OF THE EEG IN COMA AND BRAIN DEATH , 1978, Annals of the New York Academy of Sciences.

[59]  J. Lake,et al.  Intracranial pressure monitoring and liver transplantation for fulminant hepatic failure , 1992, Hepatology.

[60]  A. Ropper,et al.  Apnea testing in the diagnosis of brain death. Clinical and physiological observations. , 1981, Journal of neurosurgery.

[61]  D. Bennett.  THE EEG IN DETERMINATION OF BRAIN DEATH , 1978, Annals of the New York Academy of Sciences.

[62]  E O Jorgensen,et al.  Technical contribution. Requirements for recording the EEG at high sensitivity in suspected brain death. , 1974, Electroencephalography and clinical neurophysiology.

[63]  G. L. Engel,et al.  VOLUNTARY BREATHHOLDING. III. THE RELATION OF THE MAXIMUM TIME OF BREATHHOLDING TO THE OXYGEN AND CARBON DIOXIDE TENSIONS OF ARTERIAL BLOOD, WITH A NOTE ON ITS CLINICAL AND PHYSIOLOGICAL SIGNIFICANCE. , 1946, Journal of Clinical Investigation.

[64]  J. Korein,et al.  Radioisotopic bolus technique as a test to detect circulatory deficit associated with cerebral death. 142 studies on 80 patients demonstrating the bedside use of an innocuous IV procedure as an adjunct in the diagnosis of cerebral death. , 1975, Circulation.

[65]  &NA; &NA;,et al.  Guideline Three: Minimum Technical Standards for EEG Recording in Suspected Cerebral Death , 1986, Journal of clinical neurophysiology : official publication of the American Electroencephalographic Society.

[66]  A. Ropper,et al.  Transcranial Doppler in brain death , 1987, Neurology.

[67]  J. Jeret,et al.  Risk of hypotension during apnea testing. , 1994, Archives of neurology.

[68]  G G Celesia,et al.  Electroencephalographic activity after brain death. , 1987, Archives of neurology.

[69]  W. Barclay.  Guidelines for the determination of death. , 1981, JAMA.

[70]  P. Valdés,et al.  Brain-stem auditory evoked potentials and brain death. , 1991, Electroencephalography and clinical neurophysiology.

[71]  J. Goodman,et al.  Confirmation of brain death with portable isotope angiography: a review of 204 consecutive cases. , 1985, Neurosurgery.

[72]  J. Lynch,et al.  Brain-Death Criteria Currently Used by Pediatric Intensivists , 1992, Clinical pediatrics.

[73]  R. A. Rangel.  Computerized axial tomography in brain death. , 1978, Stroke.

[74]  B. Jennett,et al.  Brain death in three neurosurgical units. , 1981, British medical journal.

[75]  R D Miller,et al.  Persistent paralysis in critically ill patients after long-term administration of vecuronium. , 1992, The New England journal of medicine.

[76]  L. Rowland.  Guidelines for the Determination of Death , 1982, Neurology.

[77]  G. Hodges,et al.  The neurotoxicity of antibacterial agents. , 1985, Annals of internal medicine.

[78]  P. Cledgett,et al.  Intracranial blood velocity in head injury. A transcranial ultrasound Doppler study. , 1988, Surgical neurology.

[79]  A. Mercatello,et al.  99mTc-HMPAO cerebral scintigraphy in the diagnosis of brain death. , 1991, Transplantation proceedings.