Diagnosis of brain death: Diagnosis of brain death

Pawarisa Chaisuthikun; Kittikorn  Kittirukwarakorn; Nattanon  Pornchaisakuldee

doi:10.54205/ccc.v33.273324

Authors

Pawarisa Chaisuthikun Intensive Care Unit, Department of Medicine, Ramathibodi Hospital, Bangkok, Thailand, 10400
Kittikorn Kittirukwarakorn Intensive Care Unit, Department of Medicine, Ramathibodi Hospital, Bangkok, Thailand, 10400
Nattanon Pornchaisakuldee Neurology Unit, Department of Medicine, Ramathibodi Hospital, Bangkok, Thailand, 10400

DOI:

https://doi.org/10.54205/ccc.v33.273324

Keywords:

Brain death, Death by neurological criteria, Apnea test, Ancillary tests, Clinical criteria

Abstract

Brain death (BD), or death by neurological criteria (DNC), defined as the irreversible cessation of all cerebral and brainstem activities, has been a medically and legally accepted formulation of death. This review article summarizes the clinical criteria and diagnostic protocols for determining brain death. Emphasis is placed on the integration of clinical examination findings, such as the absence of brainstem reflexes and apnea testing, alongside ancillary tests when required. Key guidelines are discussed to ensure a standardized and legally sound diagnosis, including approaches to confounding factors such as drug intoxication, metabolic disturbances, or hypothermia. Furthermore, the article highlights advancements in imaging techniques and electrophysiological monitoring that supplement traditional assessments. This review aims to provide a comprehensive understanding of brain death diagnosis, ensuring accuracy and consistency in clinical and legal practices worldwide.

References

Orban JC, Ferret E, Jambou P, Ichai C. Confirmation of brain death diagnosis: A study on French practice. Anaesth Crit Care Pain Med. 2015;34(3):145-50.

Spears W, Mian A, Greer D. Brain death: a clinical overview. Journal of Intensive Care. 2022;10(1):16.

2023 Organ Donation Annual Report. Organ Donation Center of the Thai Red Cross Society; 2023. Available from: https://organdonate.redcross.or.th/assets/files/odc2566.pdf

Goila AK, Pawar M. The diagnosis of brain death. Indian J Crit Care Med. 2009;13(1):7-11.

Greer DM, Shemie SD, Lewis A, Torrance S, Varelas P, Goldenberg FD, et al. Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project. Jama. 2020;324(11):1078-97.

Wang HH, Varelas PN, Henderson GV, Wijdicks EF, Greer DM. Improving uniformity in brain death determination policies over time. Neurology. 2017;88(6):562-8.

Lewis A, Bakkar A, Kreiger-Benson E, Kumpfbeck A, Liebman J, Shemie SD, et al. Determination of death by neurologic criteria around the world. Neurology. 2020;95(3):e299-e309.

Greer DM. Determination of brain death. New England Journal of Medicine. 2021;385(27):2554-61.

Shemie SD, Wilson LC, Hornby L, Basmaji J, Baker AJ, Bensimon CM, et al. A brain-based definition of death and criteria for its determination after arrest of circulation or neurologic function in Canada: a 2023 clinical practice guideline. Can J Anaesth. 2023;70(4):483-557.

Greer DM, Kirschen MP, Lewis A, Gronseth GS, Rae-Grant A, Ashwal S, et al. Pediatric and adult brain death/death by neurologic criteria consensus guideline. Neurology. 2023;101(24):1112-32.

Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: Determining brain death in adults. Neurology. 2010;74(23):1911-8.

Lewis A, Kirschen MP, Greer D. The 2023 AAN/AAP/CNS/SCCM pediatric and adult brain death/death by neurologic criteria consensus practice guideline: A comparison with the 2010 and 2011 guidelines. Neurol Clin Pract. 2023;13(6):e200189.

Lewis A. An Update on brain death/death by neurologic criteria since the world brain death project. Semin Neurol. 2024;44(3):236-62.

Lerner DP, Bassil R, Tadevosyan A, Ramineni A, Burns JD, Russell JA, et al. Metabolic values precluding clinical death by neurologic Criteria/Brain death: Survey of neurocritical care society physicians. J Clin Neurosci. 2021;88:16-21.

Nair-Collins M, Joffe AR. Chapter 30 - Hypothalamic function in patients diagnosed as brain dead and its practical consequences. In: Swaab DF, Buijs RM, Kreier F, Lucassen PJ, Salehi A, editors. Handbook of Clinical Neurology. 182: Elsevier; 2021. p. 433-46.

Farkas J. Brain Death EMCrit ProjectJuly 15, 2022 Available from: https://emcrit.org/ibcc/brain-death/#dx_step_2_=_exclude_confounders.

R Dwyer DP, F Colreavy, B Marsh, C Motherway. Diagnosis of brain death in adults. Guidelines. 2020:2-9.

Criteria and Methods for Diagnosing Brain Death The Medical Council of Thailand2011 [cited 2011 Jan 26]. Available from: https://www.tmc.or.th/ethics-01.php.

Greer DM, Lewis A, Kirschen MP. New developments in guidelines for brain death/death by neurological criteria. Nature Reviews Neurology. 2024;20(3):151-61.

Lenga P, Kühlwein D, Schönenberger S, Neumann JO, Unterberg AW, Beynon C. The use of quantitative pupillometry in brain death determination: preliminary findings. Neurol Sci. 2024;45(5):2165-70.

Chen JW, Gombart ZJ, Rogers S, Gardiner SK, Cecil S, Bullock RM. Pupillary reactivity as an early indicator of increased intracranial pressure: The introduction of the Neurological Pupil index. Surg Neurol Int. 2011;2:82.

Lenga P, Kühlwein D, Schönenberger S, Neumann J-O, Unterberg AW, Beynon C. The use of quantitative pupillometry in brain death determination: preliminary findings. Neurological Sciences. 2024;45(5):2165-70.

Scott JB, Gentile MA, Bennett SN, Couture M, MacIntyre NR. Apnea Testing during brain death assessment: A review of clinical practice and published literature. Respiratory Care. 2013;58(3):532-8.

Kramer AH, Couillard P, Bader R, Dhillon P, Kutsogiannis DJ, Doig CJ. Prevention of hypoxemia during apnea testing: A comparison of oxygen insufflation and continuous positive airway pressure. Neurocrit Care. 2017;27(1):60-7.

Vivien B, Marmion F, Roche S, Devilliers C, Langeron O, Coriat P, et al. An evaluation of transcutaneous carbon dioxide partial pressure monitoring during apnea testing in brain-dead patients. Anesthesiology. 2006;104(4):701-7.

Kim HY, Kim GS, Shin YH, Cha SR. The usefulness of end-tidal carbon dioxide monitoring during apnea test in brain-dead patients. Korean J Anesthesiol. 2014;67(3):186-92.

Machado C, Perez J, Scherle C, Areu A, Pando A. Brain death diagnosis and apnea test safety. Ann Indian Acad Neurol. 2009;12(3):197-200.

Benzel EC, Gross CD, Hadden TA, Kesterson L, Landreneau MD. The apnea test for the determination of brain death. J Neurosurg. 1989;71(2):191-4.

Han SG, Kim GM, Lee KH, Chung CS, Jung KY. Reflex movements in patients with brain death: a prospective study in a tertiary medical center. J Korean Med Sci. 2006;21(3):588-90.

Kramer AH. Ancillary testing in brain death. Semin Neurol. 2015;35(2):125-38.

Rizvi T, Batchala P, Mukherjee S. Brain death: Diagnosis and imaging techniques. Semin Ultrasound CT MR. 2018;39(5):515-29.

Spears W, Mian A, Greer D. Brain death: A clinical overview. J Intensive Care. 2022;10(1):16.

Cho SM, Hwang J, Chiarini G, Amer M, Antonini MV, Barrett N, et al. Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal life support organization consensus guidelines. Crit Care. 2024;28(1):296.

Lie SA, Hwang NC. Challenges of brain death and apnea testing in adult patients on extracorporeal membrane oxygenation-A review. J Cardiothorac Vasc Anesth. 2019;33(8):2266-72.

Diagnosis of brain death