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Brain Death

Dr. Hartono Prabowo, Sp.SBagian Neurologi

FK – Univ. TarumanagaraJakarta

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The brain

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The brain and consciousness

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arousal

Brainstem (ARAS) Thalamic IL & CM nuclei

Thalamic reticular nuclei cerebral cortex

interconnnection awareness

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Brain death

Brain death diagnosis is necessary to enable us to manage our patients and resources appropriately

Prolonged ventilation for futile cases. Give false expectations to family of

brain dead patients.

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Historical background

1959, Mollaret & Goulon : “Coma depasse” (irreversible coma) – lost of consciousness, brainstem reflexes and respiration and whose EEG’s were flat.

1971, Mohandas & Chou described damage to the brainstem as a critical component of severe brain damage

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Defining Brain Death

In 1979, the Model Brain Death Act (US) stated that an individual was dead who has sustained either

1. Irreversible cessation of circulatory and respiratory function, or

2. Irreversible cessation of all functions of the entire brain, including brainstem.

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Definition Death :

Irreversible end of life. Irreversible cessation of

heartbeat and respiration. Brain Death :

Death of the brain without cessation of the heart beat.

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Brain Death

Required assisted ventilation and intensive medical care.

Maintain the heartbeat. Even those with massive,

irreversible structural brain damage who could never awaken or breathe on their own.

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Criteria for Brain Death

Harvard Committee (1968). The Minnesota Criteria (1971). President’s Commission for the

study of Ethical Problem in Medicine and Biomedical and Behavioral Research, USA (1981).

UK criteria (1995). AAN 1995.

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Other recommendations on time interval between brain death tests

6 hours in whom irreversible injury wasknown.

24 hours if the cause was due to anoxic brain injury.

Guidelines for determination of death JAMA 246:333,393. 1978

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Currently accepted definition of Brain Death

Brain Death is defined as the irreversible loss of the capacity for consciousness combined with the irreversible loss of all brainstem functions including the capacity to breathe.

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The three components in making brain death diagnosis.

Fulfilling pre-requisites for making diagnosis. The bed-side clinical tests.

(All clinical tests are needed to declare brain death and are equally essential).

Confirmatory tests.(when specific components of clinical testing

cannot be reliably evaluated)

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Brain DeathEelco F.M. Wijdicks, M.D.

N Engl J Med, Vol. 344, No. 16 April 19, 2001

Coma. No motoric responses. Dilated pupil (4-6 mm) without

light reflex. Negative occulocephalic reflex. Negative corneal reflexes.

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Brain Death (Eelco, 2001)

Negative caloric test. Negative cough reflex. Negative sucking reflex. No response to breath at PaCO2

60 mmHg.

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Brain Death (Eelco, 2001)

Excluded : Acid – base and electrolite

imbalance. Severe hypothermia ( < 32o C). Hypotension. Intoxication ……

neuromuscular inhibitor.

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Brain Death (Eelco, 2001)

Evaluation : 2 x

< 2 mo 48 hrs

2 mo – 1 y 24 hrs

1 – 18 y Facultative.

> 18 y Facultative

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Brain Death (Eelco, 2001) Improved Ancillary Testing

Cerebral angiography. Electroencephalography (EEG). Transcranial Doppler (TCD). Cerebral Scintigraphy.

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Conventional angiography (4 – vessel angiogram)

Absence of intra-cerebral filling of the intracranial arteries at the entry into the skull.

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What about EEG?

In the US, President’s Commission in 1981 reiterated that “electro-cerebral

silence” is confirmatory of brain death.

The NINDS study accepted minimal (2 υV) electrical potential on EEG as being

compatible with brain death

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Cortical EEG’s not important in making brain death diagnosis in UK and Europe

The conference of Medical Royal Colleges and their Faculties in UK published a statement on the diagnosis of brain death in which brain death was defined as complete, irreversible loss of brain-stem function.

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TCD (transcranial doppler ultrasonography)

Small systolic peaks in early systole with retrograde

(reverberating, oscillation) or absent flow during diastole.

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Other tests described

SSEP / BAEP. Atropine test – vagal component of X nerve. MRI Angiography. Loss of beat-to-beat heart-rate variability. Jugular bulb oxygen saturation.

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Brain Death

Should never be diagnosed hurriedly in the emergency room.

There should be an appropriate period of observation and the clinical examination should be repeated, mainly for confirmatory purposes.

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To make a long story

short-not at the moment