Table 2.
Case reports of baclofen intoxication resembling brain death (11)
| Source | Age*/sex | Dose | Duration of loss of brainstem reflexes | Neurologic exam | Failed brain death prerequisites | Neuroimaging | EEG | Drug concentrations | Outcome |
|---|---|---|---|---|---|---|---|---|---|
| [17] | 37/F | 450 mg | ~ 24 h | “Hypotonic and all reflexes absent” | Respirations present | NR | NR | [Baclofen] 0.197 mg/L when reflexes had returned (no therapeutic range specified) |
Extubated “Fully conscious” |
| [18] | 19/F | Estimated 875–1125 mg | ~ 24 h | “All standard reflexes were absent” | Respirations present; pH 7.32 | NR | NR | NR | Extubated at 24 h, “fully awake after 48 h”; transferred to psychiatry |
| [19] | 28/F | 900 mg | ~ 24 h | Absent pupillary, corneal, oculocephalic, gag, and oculovestibular reflex. No DTR. No response to painful stimulation. Flaccid extremities | Temperature 35.5˚C; Potassium 2.8 mEq/L, Phosphorous 1.3 mg/dL, Magnesium 1.3 mEq/L | NR | NR | NR |
Discharged day 17 Recovery to baseline health |
| [20] | 57/F | > 2 g | ~ 48 h | Pupils 2–3 mm and unresponsive to light. Absent corneal and oculocephalic reflex. Absent DTR. Unresponsive to pain | Temperature 34.2˚C | NR | NR |
[Baclofen] 3.3 mg/L (therapeutic: 0.08–0.40 mg/L) [Amitriptyline]: 253ug/L (therapeutic) Absent nortriptyline |
Extubated day 3 “Awake and alert” day 5; Transferred to psychiatric unit |
| [21] | 25/M | 2000μg/day intrathecal infusion | “several hours” | “Flaccid quadriplegia and absence of all reflexes” | NR | NR | NR | NR | NR |
| [22] | 40/F | 500 mg | ~ 24 h | Small pupils unresponsive to light. Absent corneal reflex and DTR. No response to pain. Flaccid muscle tone. Plantar reflex present | Neuroimaging; pH 7.55 | Normal CT | Burst suppression pattern |
[Baclofen] Serum: 1.2 mg/L (therapeutic: 0.2–0.4 mg/L) Urine: 413 mg/L (reference < 26 mg/L) |
Recovery to baseline health |
| [23] | 59/M | 1870 mg over 11 days | 12 h | Fixed 3 mm pupils, absent corneal, oculocephalic, cough, and gag reflex. Absent DTR in legs but 1/4 in both arms. No plantar response. No spontaneous movement or response to pain |
Respirations present; Neuroimaging; pH 7.30 |
Normal CT Normal MRI |
Burst suppression pattern without reactivity to stimulation | NR | Recovery to baseline health |
| [24] | 18/M | 3 g | 12 h | Mid-range unreactive pupils. Absent corneal, oculocephalic, cough and gag reflex. No response to painful stimulation. Flaccid tone | Neuroimaging | Normal CT | Generalized slowing without reactivity to stimulation | NR |
Extubated at 48 h; Recovery to baseline health |
| [25] | 41/M | > 600 mg | 10 h | Fixed 2 mm pupils. Absent corneal, oculocephalic, cough, and gag reflex. No spontaneous movements or DTR. No response to cold caloric testing. Train of four testing normal | Neuroimaging |
Normal CT Normal CTA head/neck |
NR | NR | Recovery to baseline health |
| [26] | 40/F | Unknown | 4 days | Pupils fixed and dilated. Absent corneal, and ocular reflex. Flaccid extremities. No response to caloric testing. Spontaneous respiration during apnea test | Neuroimaging; spontaneous respirations during apnea test | Normal CT | Burst-suppression pattern with occasional sharp waves on a flat background | NR | “Discharged to psychiatry on hospital day 15” |
| [27] | 15/F | Unknown | ~ 24 h | Pupils fixed and dilated. Absent corneal and ocular reflexes. No response to painful stimulation | NR | NIRS cerebral region O2 sat 88–94% | Cerebral bioelectric activity and ground amplitudes significantly lower than normal | NR |
Discharged day 3 Recovery to baseline health |
*Age in years; CT computerized tomography, CTA computerized tomography angiography, DTR deep tendon reflexes, EEG electroencephalogram, F female, M male, MRI magnetic resonance imaging, NIRS near infrared spectroscopy, NR not reported