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. 2014 Aug;4(4):272–273. doi: 10.1212/CPJ.0000000000000052

An elusive brain death diagnosis

You can't get there from here

Nitin K Sethi 1
PMCID: PMC5764523  PMID: 29473571

I read with great interest the case report by Story and Winter.1 Their patient was brain dead clinically but confirmatory testing in the form of CT angiography and EEG was requested, which failed to document whole-brain death. One might argue that they would not have encountered this medical, ethical, and legal quandary if the concept of brain stem death was adopted and accepted universally as opposed to whole-brain death, which is the currently accepted criterion in the United States. Electrocerebral inactivity or electrocerebral silence in a brain death EEG is defined as no EEG activity over 2 uV when recording from scalp electrode pairs 10 or more cm apart with interelectrode impedances under 10,000 Ohms (10 KOhms) but over 100 Ohms. It is a well-known fact that pockets of brain activity may persist in a patient who is clinically (all brain stem reflexes absent and apnea test positive) brain dead. These islands of brain activity may yield a false-negative brain death EEG, creating the confusion that the authors encountered. The diagnosis of brain death was never elusive; it was the unnecessary testing that made it so.

Disclosures

N. Sethi serves as Associate Editor for The Journal of Eastern Medicine.

References

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Neurol Clin Pract. 2014 Aug;4(4):272–273.

Eelco F. M. Wijdicks, MD, David M. Greer, MD: Story and Winter's case report1 contributes to the misunderstanding that ancillary tests can resolve a clinical examination in a pharmacologically confounded patient with an unsurvivable cerebral hemorrhage. Inexplicably the authors proceeded with a full brain death examination, knowing the patient did not meet the first and most important prerequisite of the American Academy of Neurology (AAN) guideline—to exclude confounders and determine eligibility for a full examination, including an apnea test.2 The authors then missed the opportunity to proceed with a donation after cardiac death procedure. Subsequently, they again went in direct violation of the AAN guidelines by performing an unvalidated ancillary test. CT angiography (CTA) uses a venous injection of contrast, and the timing to detect intracranial arterial filling is problematic. False positives have been reported with CTA, and its use in brain death determination has not been recommended by the AAN.3 This is not an ethical controversy as the authors would suggest in their dense discussion. Their evaluation was simply outside the standard of practice in the United States. There is nothing elusive about it.

Mayo Clinic (EFMW), Rochester, MN; and Yale University College of Medicine (DNG), New Haven, CT.

Disclosures: E. Wijdicks served as Editor-in-Chief for Neurocritical Care (2004–2012) and receives publishing royalties for books published by Oxford University Press. D. Greer receives publishing royalties for Acute Ischemic Stroke: An Evidence-Based Approach (Wiley and Sons, 2007); has served on speakers' bureaus for Boehringer-Ingelheim; and has received research support from Boehringer-Ingelheim.

Neurol Clin Pract. 2014 Aug;4(4):272–273.

James Zisfein, MD, Menachem Gold, MD: Story and Winter1 report a patient who fulfilled clinical criteria for brain death but had a CT angiogram (CTA) that was interpreted as not confirming brain death because of preserved cerebral blood flow (CBF). We believe the CTA may have been misinterpreted. The provided images show contrast in the sylvian (M2) branches of the middle cerebral artery (MCA) but not in the cortical (M4) branches. This pattern occurs in brain death and does not indicate CBF. It is produced by stasis filling of proximal MCA branches.4–6 To confirm brain death by CTA, one must examine the cortical MCA branches, which are not affected by stasis filling.

Lincoln Medical Center, Bronx, NY.

Disclosures: The authors report no disclosures.

Neurol Clin Pract. 2014 Aug;4(4):272–273.

Authors Respond:

Daryl Story, MD, Stephen Winter, MD: In an era where there is still wide variability in the process for determining brain death,7 we welcome the comments our report has produced.

We agree with Dr. Sethi that the concept and definition of brain death deserve discussion. It is indeed difficult to demonstrate lack of any cortical metabolic and electrical activity as he correctly states, yet this is necessary in today's practice.

In response to Drs. Zisfein and Gold, the CTA was interpreted by the radiologist who helped create our brain death policy, based on a 4-vessel protocol designed to reduce false negatives due to stasis filling.4 The slices displayed may not be fully representative.

Drs. Wijdicks and Greer raise additional important issues. Their criticism of our handling of the case, however, implies knowledge of specifics that could not be included in a brief report. The apnea test was performed by clinicians before the potential issue of the pharmacologic confounder was considered and debated at bedside. Furthermore, it could be argued that an attempt at excluding brain death by clinical exam would have obviated the need for any further testing. Decisions such as using CTA and not immediately proceeding with donation after cardiac death (DCD) were influenced by a grieving family that was ambivalent about consenting for organ donation in the first place. They wished for only minimal additional testing and were against the idea of DCD. We were doing our best to navigate these challenging real-life issues.

Stroke Center (DS) and Pulmonary and Critical Care Medicine (SW), Norwalk Hospital, CT; New York Medical College (DS), Valhalla; and Yale University (SW), New Haven, CT.

Disclosures: The authors report no disclosures.

Articles from Neurology: Clinical Practice are provided here courtesy of American Academy of Neurology

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