Table 5.
Miscellaneous intoxications resembling brain death (19)
| Class | Agent [reference] | Age* (range) | Duration of loss of brainstem reflexes (range) | Failed brain death prerequisites (#) | Neuroimaging (#) | EEG (#) | Outcomes (#); Drug concentration (range)** |
|---|---|---|---|---|---|---|---|
| Alcohols | Ethanol [41] | 41 | 40 min |
Neuroimaging; Spontaneous respirations; Decerebrate posturing of arms |
Normal CT | NR |
Transferred from ICU to the ward after 24 h; [Ethanol] 700 mg/dL |
| Toxic alcohols | Ethylene glycol [42–44] | 21–24 | 2 days–2 months |
Neuroimaging (2) EEG (1) NR (1) |
Normal CT (2) Normal MRI (1) CT head with diffuse cerebral edema (1) |
Normal (1) Day 20: Diffuse theta/delta slowing with super-imposed beta activity (1) NR (1) |
Permanently deaf (2) Peritoneal dialysis (1) Ambulates with crutches (1) Ambulates unassisted (2) Full recovery to baseline (1) |
| Antiepileptics | Carbamazepine [45], Valproate [46, 47] | 19–54 | Several hours-5 days |
Neuroimaging (1) Hyperammonemia (1) NR(2) |
CT: cerebral edema (2) Normal CT (1) |
Burst suppression (1) NR (2) |
Recovery to baseline (2) Discharge from ICU (1); [Carbamazepine] 57ug/ml; [Valproate] 1792–2346 mg/L (therapeutic 50–120 mg/L) |
| Barbiturates | Pentobarbital [48, 49] | 40–45 | 1–5 days |
Neuroimaging (1) NR (1) |
Normal CT/CTA (1) NR (1) |
Day 2: No electrical activity (1) NR (1) |
Recovery to baseline health (2); [Pentobarbital] 57 mg/L–116 mg/dL (therapeutic 1–5 mg/L) |
| Antidysrhythmics | Bretylium [50], Lidocaine [51] | 7 days–60 years | 5–24 h |
Right bicep tendon reflex (1) NR(1) |
US: Normal cerebral artery pulsations, normal sized ventricles, no hemorrhage (1) NR (1) |
Mildly attenuated activity with isolated sharp waves (1) NR (1) |
Normal growth and development at 1 year (1) Mild cognitive impairment with no focal deficits (1); [Bretylium] 17ug/mL; [Lidocaine]11.2 mcg/ml |
| Organophosphates | Phorate [52], Thiacloprid [53] | 28–72 | 24–120 h |
Neuroimaging (2) Hemiballistic movements (1) |
Normal CT (2) MRI: minor cortical diffusion restriction in postcentral gyrus (1) |
Global suppression of cortical activity (1) Alpha-theta waves; minimal variability (1) |
Recovery to baseline health (2) |
| Electrolytes | Magnesium [54] | 27 | 2 h |
Neuroimaging; pH 7.27; Oculocephalic reflex abnormal |
Normal CT | NR |
Recovery to baseline health; [Magnesium] 9.85 mmol/L |
| Paralytics | Succinylcholine [55], Tetrodotoxin [56] | 39–80 | 6–20 h |
EEG (2); Train-of four (1); Electrolyte abnormalities (1) Neuroimaging (1) |
CTA head with old infarct, no acute findings (1) |
Moderate voltage waves. Stage 1 and 2 sleep with sleep spindles (1) Background rhythm 6–7 Hz, reactive to eye opening (1) |
Recovery to baseline health (2) |
| Hypnotic Sedative | Zolpidem [57] | 40 | 24 h | Neuroimaging; Spontaneous respirations | Normal CT | Diffuse, nonspecific slow-wave abnormality with no epileptiform activity | Recovery to baseline health |
*Age in years; (#) = number of patients with the finding, **when available; CT computerized tomography, CTA computerized tomography angiogram, EEG electroencephalogram, ICU intensive care unit, MRI magnetic resonance imaging, NR not reported, US ultrasound