Critical Care Medicine-Neurologic Disorders>>>>>Brain Death and Degenerative Diseases
Question 2#

A 54-year-old woman is admitted to the intensive care unit (ICU) with a subarachnoid hemorrhage due to a left middle cerebral artery aneurysm rupture. Early external ventricular drain was placed because of a poor neurological examination. Over the course of 7 days, there have been ongoing issues with refractory elevated intracranial pressure and poor neurologic examination, progressing to no cranial nerve responses. Her examination is as follows: pupils 5 mm and nonreactive, absent oculocephalic reflexes, absent corneal reflexes, absence of facial grimace, absent gag, and absent cough. The only evoked motor response is minimal triple flexion in the bilateral legs. An apnea test was completed and there were no spontaneous respirations with an increase in pCO2 20 mm Hg more than baseline.

Which of the following is MOST true? 

a. Because of the motor response present, the patient does not meet criteria for brain death
b. An ancillary test (EEG, cerebral angiogram, nuclear scan) should be completed to diagnose brain death
c. We need to repeat the apnea test
d. The current examination is consistent with brain death

Correct Answer is D

Comment:

Correct Answer: D

The clinical findings necessary to confirm irreversible cessation of all functions of the entire brain, including the brain stem: coma, absence of brain stem reflexes, and apnea. The above patient does demonstrate all three of these criteria consistent with brain death. There are multiple reported reflexive movements that can be seen in patients with the diagnosis of brain death. Patient’s apnea test is consistent with brain death criteria, which is based on increase pCO2 >60 mm Hg or 20 mm Hg more than baseline. Single apnea test is required. No ancillary tests are required if the full clinical examination is consistent with brain death. In some institutions, two assessments of brain stem reflexes are required before declaring brain death.

References:

  1. Wijdisks EF, Varelas PN, Gronseth GS, et al. Evidence-based guideline update: determining brain death in adults. Neurology. 2010;74:1911- 1918.
  2. Han SG, Kim GM, Lee KH, et al. Reflex movements in patients with brain death: a prospecitve study in a tertiary medical center. J Korean Med Sci. 2006;21:588-590.