Like most things in medicine, the easy patients are easy: prolonged down time without resuscitation, massive midbrain ICH, massive brain trauma etc…
It is the patients with less “obvious” causes that always give me pause. Personally, giving the patient time and performing serial exams often helps the care team and the family come to terms with the diagnosis. Nuclear scintigraphy for confirmation can be useful AFTER exam due to its visual nature. This topic continues to challenge me especially in younger patients with anoxia or severe non-traumatic neurologic injuries. Even then, the concept where someone has vital signs yet is “dead” is very challenging to most lay people and some medical professionals.
If I recall correctly, of the three tests in the article only conventional angiography is in the most recent American Association of Neurology brain death guidelines. Our practice is nuclear flow testing. I would also add that for patients with brain stem reflexes, they wouldn’t be sent for brain death testing confirmatory imaging - so my interpretation of that scan wouldn’t be “consistent with brain death” but rather “very poor neurologic prognosis”. This article does confirm that CT angio based studies aren’t accurate enough - something already outlined in the AAN and World Brain Death Project most recent updates (Greer, JAMA 2020).
You’re right, it’s not as if this article is breaking news, but a good example of the other literature out there and an opening into the conversation. Thanks for writing.
Again thank you. But the recent Jama article does avoid much talking about nuclear medicine/spect which has a pretty good specificity. Is this situation due to it being less available in Canadian hospitals versus US? ChatGPT says nuclear medicine is less around in Canadian hospitals. For us, the nuclear medicine scan is pretty drastic and even families can understand what happened visually. At either rate it’s such a big decision - glad they are taking it seriously. Off topic sorta: pre-neuro icu felt like it was 1-2x/wk that we handled such matters - as they rose us Micu docs are doing much less. (The field of icu medicine is changing rapidly - so many avenues to crit-care via neuro fellowships, via pure crit-care slots, via surgery and anesthesia having their fellowships - the pulm/crit doc working in a broadly based but busy icu seems like a relic of the past.) Likely for the better but my non-data based gut feeling says it was not all bad either.
A complete review on this would definitely mention spect. Thanks for bringing it up. I have also had similar experiences in that neurology tends to be running point on most of these calls today.
Thanks for the review. I would recommend being cautious with the statement “Brain death was originally proclaimed to be an irreversible condition rapidly leading to death with no hope of recovery of even partial brain function. These assertions turned out not to always be true”. When you review the cases in which patients had “recovered after being declared brain dead”, brain death was not declared appropriately. I deal with brain death on a weekly basis as a neurointensivist, and am not aware of any reported case in which brain death was declared appropriately and there was recovery (please let me know if there is evidence to the contrary as I’d love to discuss it/examine it further). Not only does the exam/apnea test/ancillary testing need to be performed according to protocol, but patients need to meet strict criteria prior to declaration. This includes lack of metabolic derangements that could be contributing to coma, normothermia for at least 24 hours, no sedating meds (ensuring clearance/waiting at least 5 half lives), a clear cause for irreversible coma, and imaging to support it. For example- the NYT article from a few months ago about a patient who woke up as they were preparing to harvest his organs did not have imaging that was consistent with catastrophic brain injury, and did not have a known reason for coma. It’s unclear if they completed clinical testing or apnea testing. It is the lack of adherence to the World Brain Death Project guidelines that results in the incorrect declarations. The reason I feel it is imperative to make this point is that brain death is already a difficult concept for patient’s families to grasp- and as brain death is legal death in the United States 2/2 irreversible catastrophic brain injury without chance of recovery, the false statement that patients can in fact recover from brain death creates profound mistrust between the provider declaring and the family of the patient, so it is important we as providers (both neurologist and non-neurologists) adhere to the guidelines and don’t offer hope for recovery when there is none.
Your post made me curious about how you test for brain death in North America.
In Brazil, we only advance to angiography if the patient has a neuro exam compatible with brain death.
If the patient has persistent cerebral blood flow on angiography we would simply conclude that the patient is “not dead” and close the brain death investigation. We are ok with the binary nature of the protocol. However, we may reopen it in a couple days if appropriate.
We have an explicit protocol issued by federal medical authorities that is applied nationwide. I am curious if you have a federal regulation, or the hospitals have their own protocols.
My experience/opinions only: In the US, absence of cranial nerve reflexes + a positive apnea test is adequate for determination of DNC at most centers. Ancillary testing is only done in patients who can’t complete an apnea test or the neuro exam. So these tests are (in my experience) done uncommonly if not rarely. However, I suspect practice is highly variable and that there are centers that often/always perform ancillary imaging.
I only recall one invasive angiogram ever being performed, and the radiologist being open about his lack of experience with it as a determinant for the DNC determination.
So interesting. In Brazil you must do the confirmatory test. We also repeat the clinical exam (GCS 3 coma and absence of brainstem reflexes) with a different physician. Is one examination enough in the US?
You are correct that for adults, guidelines state only one test is needed for declaration. It’s institution dependent if a second is required. Of note this does not apply to children for whom 2 examinations by two separate physicians is required.
Like most things in medicine, the easy patients are easy: prolonged down time without resuscitation, massive midbrain ICH, massive brain trauma etc…
It is the patients with less “obvious” causes that always give me pause. Personally, giving the patient time and performing serial exams often helps the care team and the family come to terms with the diagnosis. Nuclear scintigraphy for confirmation can be useful AFTER exam due to its visual nature. This topic continues to challenge me especially in younger patients with anoxia or severe non-traumatic neurologic injuries. Even then, the concept where someone has vital signs yet is “dead” is very challenging to most lay people and some medical professionals.
Thanks for these insights. I remember feeling very comfortable with the high stakes binary nature of these situations.
Then, I saw a lot of edge cases and got a lot more humble.
If I recall correctly, of the three tests in the article only conventional angiography is in the most recent American Association of Neurology brain death guidelines. Our practice is nuclear flow testing. I would also add that for patients with brain stem reflexes, they wouldn’t be sent for brain death testing confirmatory imaging - so my interpretation of that scan wouldn’t be “consistent with brain death” but rather “very poor neurologic prognosis”. This article does confirm that CT angio based studies aren’t accurate enough - something already outlined in the AAN and World Brain Death Project most recent updates (Greer, JAMA 2020).
You’re right, it’s not as if this article is breaking news, but a good example of the other literature out there and an opening into the conversation. Thanks for writing.
Again thank you. But the recent Jama article does avoid much talking about nuclear medicine/spect which has a pretty good specificity. Is this situation due to it being less available in Canadian hospitals versus US? ChatGPT says nuclear medicine is less around in Canadian hospitals. For us, the nuclear medicine scan is pretty drastic and even families can understand what happened visually. At either rate it’s such a big decision - glad they are taking it seriously. Off topic sorta: pre-neuro icu felt like it was 1-2x/wk that we handled such matters - as they rose us Micu docs are doing much less. (The field of icu medicine is changing rapidly - so many avenues to crit-care via neuro fellowships, via pure crit-care slots, via surgery and anesthesia having their fellowships - the pulm/crit doc working in a broadly based but busy icu seems like a relic of the past.) Likely for the better but my non-data based gut feeling says it was not all bad either.
A complete review on this would definitely mention spect. Thanks for bringing it up. I have also had similar experiences in that neurology tends to be running point on most of these calls today.
cheers from another relic!
Thanks for the review. I would recommend being cautious with the statement “Brain death was originally proclaimed to be an irreversible condition rapidly leading to death with no hope of recovery of even partial brain function. These assertions turned out not to always be true”. When you review the cases in which patients had “recovered after being declared brain dead”, brain death was not declared appropriately. I deal with brain death on a weekly basis as a neurointensivist, and am not aware of any reported case in which brain death was declared appropriately and there was recovery (please let me know if there is evidence to the contrary as I’d love to discuss it/examine it further). Not only does the exam/apnea test/ancillary testing need to be performed according to protocol, but patients need to meet strict criteria prior to declaration. This includes lack of metabolic derangements that could be contributing to coma, normothermia for at least 24 hours, no sedating meds (ensuring clearance/waiting at least 5 half lives), a clear cause for irreversible coma, and imaging to support it. For example- the NYT article from a few months ago about a patient who woke up as they were preparing to harvest his organs did not have imaging that was consistent with catastrophic brain injury, and did not have a known reason for coma. It’s unclear if they completed clinical testing or apnea testing. It is the lack of adherence to the World Brain Death Project guidelines that results in the incorrect declarations. The reason I feel it is imperative to make this point is that brain death is already a difficult concept for patient’s families to grasp- and as brain death is legal death in the United States 2/2 irreversible catastrophic brain injury without chance of recovery, the false statement that patients can in fact recover from brain death creates profound mistrust between the provider declaring and the family of the patient, so it is important we as providers (both neurologist and non-neurologists) adhere to the guidelines and don’t offer hope for recovery when there is none.
Great post...and thanks for giving me more heartburn...
Very good, as usual!
Your post made me curious about how you test for brain death in North America.
In Brazil, we only advance to angiography if the patient has a neuro exam compatible with brain death.
If the patient has persistent cerebral blood flow on angiography we would simply conclude that the patient is “not dead” and close the brain death investigation. We are ok with the binary nature of the protocol. However, we may reopen it in a couple days if appropriate.
We have an explicit protocol issued by federal medical authorities that is applied nationwide. I am curious if you have a federal regulation, or the hospitals have their own protocols.
Great to hear the Brazilian perspective.
My experience/opinions only: In the US, absence of cranial nerve reflexes + a positive apnea test is adequate for determination of DNC at most centers. Ancillary testing is only done in patients who can’t complete an apnea test or the neuro exam. So these tests are (in my experience) done uncommonly if not rarely. However, I suspect practice is highly variable and that there are centers that often/always perform ancillary imaging.
I only recall one invasive angiogram ever being performed, and the radiologist being open about his lack of experience with it as a determinant for the DNC determination.
So interesting. In Brazil you must do the confirmatory test. We also repeat the clinical exam (GCS 3 coma and absence of brainstem reflexes) with a different physician. Is one examination enough in the US?
I believe that the AAN (neurology) and Medicare only advise/require one complete test (= cranial nerves plus apnea) and no ancillary tests.
Multiple hospitals I have worked at require 2 complete tests some arbitrary time apart (6 hrs, 8 hrs)
Most determinations I have been involved in have been after 2 complete exams.
You are correct that for adults, guidelines state only one test is needed for declaration. It’s institution dependent if a second is required. Of note this does not apply to children for whom 2 examinations by two separate physicians is required.
Outstanding discussion of an extraordinarily complex topic. Thanks!!