Ariane Lewis

• NYU Langone Medical Center

This Viewpoint discusses the importance of the diagnosis of brain death/death by neurologic criteria and provides context and history of the diagnosis.

The Uniform Determination of Death Act requires brain death/death by neurologic criteria (BD/DNC) determination to be in accordance with “accepted medical standards.” The medical organizations responsible for delineating these guidelines are only specified statutorily in two states. State health organizations (SHOs) are composed of policy experts a...

Clinicians who work in neurointensive care units must be familiar with brain death/death by neurologic criteria (BD/DNC). To declare BD/DNC, a patient must be in a permanent coma due to a known etiology, have brainstem areflexia, and be unable to breathe spontaneously in the setting of a hypercarbic acidemic challenge. The presence of confounders m...

Severe brain injury can result in disorders of consciousness (DoC), including coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state. Improved emergency and trauma medicine response, in addition to expanding efforts to prevent premature withdrawal of life-sustaining treatment, has led to an increased number of patie...

Clinical management of persons with disorders of consciousness (DoC) is dedicated largely to optimizing recovery. However, selecting a measure to evaluate the extent of recovery is challenging because few measures are designed to precisely assess the full range of potential outcomes, from prolonged DoC to return of preinjury functioning. Measures t...

Objective: Emotional and behavioral dyscontrol (EBD), a neuropsychiatric complication of stroke, leads to patient and caregiver distress and challenges to rehabilitation. Studies of neuropsychiatric sequelae in stroke are heavily weighted toward ischemic stroke. This study was designed to compare risk of EBD following intracerebral hemorrhage (ICH...

The declaration of brain death (BD), or death by neurological criteria (DNC), is medically and legally accepted throughout much of the world. However, inconsistencies in national and international policies have prompted efforts to harmonize practice and central concepts, both between and within countries. The World Brain Death Project was published...

Introduction: Patients who have had hemorrhagic strokes experience psychological and functional deficits after hospital discharge. Social Determinants of Health (SDoH) can also impact outcomes. The relationship between SDoH and psychological outcomes following hemorrhagic stroke has not been well studied. Methods: This is a prospective cohort study...

Objective: Disorders of consciousness (DoC) are known to correlate with worse functional outcome after hemorrhagic stroke. Here we evaluate factors associated low Glasgow Coma Scale [GCS] score at time of admission in patients with hemorrhagic stroke. Methods: We performed a prospective cohort study of patients enrolled in the Neurological Emergenc...

Background and Purpose Sleep disturbance after hemorrhagic stroke (intracerebral or subarachnoid hemorrhage) can impact rehabilitation, recovery, and quality of life. We sought to explore preclinical and clinical factors associated with sleep disturbance after hemorrhagic stroke assessed via the Quality of Life in Neurological Disorders (Neuro-QoL)...

Background and Objectives Mortality after intracerebral hemorrhage (ICH) is common. Neighborhood socioeconomic status (nSES) is an important social determinant of health (SDoH) that can affect clinical outcome. We hypothesize that SDoH, including nSES, contribute to differences in withdrawal of life-sustaining therapies (WLSTs) and mortality in pat...

Guidelines for brain death/death by neurologic criteria (BD/DNC) determination were revised to provide a consistent and updated approach to BD/DNC evaluation across all ages by the American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine. This article is intended to complement the...

In collaboration with the American Academy of Pediatrics, Child Neurology Society, and Society for Critical Care Medicine, the American Academy of Neurology formulated an updated, evidence-informed consensus-based guideline for pediatric and adult brain death/death by neurologic criteria (BD/DNC) determination. In comparison with the prior guidelin...

Background and Objectives The purpose of this guideline is to update the 2010 American Academy of Neurology (AAN) brain death/death by neurologic criteria (BD/DNC) guideline for adults and the 2011 American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine guideline for infants and children and to clarify the BD/...

Objective: A significant number of patients develop anxiety after stroke. The objective of this study was to identify risk factors for anxiety after hemorrhagic stroke that may facilitate diagnosis and treatment. Methods: Patients admitted between January 2015 and February 2021 with nontraumatic hemorrhagic stroke (intracerebral [ICH] or subarac...

This 2023 Clinical Practice Guideline provides the biomedical definition of death based on permanent cessation of brain function that applies to all persons, as well as recommendations for death determination by circulatory criteria for potential organ donors and death determination by neurologic criteria for all mechanically ventilated patients re...

PurposeThe term “brainstem death” is ambiguous; it can be used to refer either exclusively to loss of function of the brainstem or loss of function of the whole brain. We aimed to establish the term’s intended meaning in national protocols for the determination of brain death/death by neurologic criteria (BD/DNC) from around the world.Methods Of 78...

Use of thoraco-abdominal normothermic regional perfusion (TA-NRP) during donation after circulatory death (DCD) is an important advance in organ donation. Prior to establishing TA-NRP, the brachiocephalic, left carotid, and left subclavian arteries are ligated, thereby eliminating anterograde brain blood flow via the carotid and vertebral arteries....

Background: Neurology faculty care for complex patients, teach, and work within multidisciplinary teams. It is imperative for faculty to have strong communication skills. Methods: We surveyed NYU neurology teaching faculty to determine levels of comfort and experience over the past year with providing negative feedback to a trainee; debriefing a...

Background The utility of head computed tomography (CT) in predicting elevated intracranial pressure (ICP) is known to be limited in traumatic brain injury; however, few data exist in patients with spontaneous intracranial hemorrhage. Methods We conducted a retrospective review of prospectively collected data in patients with nontraumatic intracran...

Background Limited data exists evaluating predictors of long-term outcomes after hospitalization for COVID-19. Methods We conducted a prospective, longitudinal cohort study of patients hospitalized for COVID-19. The following outcomes were collected at 6 and 12-months post-diagnosis: disability using the modified Rankin Scale (mRS), activities of...

Background Post-acute sequelae of COVID-19 (PASC) includes a heterogeneous group of patients with variable symptomatology, who may respond to different therapeutic interventions. Identifying phenotypes of PASC and therapeutic strategies for different subgroups would be a major step forward in management. Methods In a prospective cohort study of pa...

Background To identify opportunities to improve morbidity after hemorrhagic stroke, it is imperative to understand factors that are related to psychological outcome. Design/Methods We prospectively identified patients with non-traumatic hemorrhagic stroke (intracerebral or subarachnoid hemorrhage) between January 2015 and February 2021 who were al...

In patients who undergo thrombectomy for acute ischemic stroke, the relationship between pre-admission antithrombotic (anticoagulation or antiplatelet) use and both radiographic and functional outcome is not well understood. We sought to explore the relationship between pre-admission antithrombotic use in patients who underwent thrombectomy for acu...

Purpose After developing a protocol for evaluating, diagnosing, and treating postoperative endocrinopathy both during the hospitalization and during the immediate discharge period following resection of pituitary adenomas, we sought to assess the impact of this protocol on quality outcomes. Methods An IRB-exempt, quality improvement initiated, Heal...

Background The relationship between cardiac function and mortality after thrombectomy for acute ischemic stroke is not well elucidated. Methods We analyzed the relationship between cardiac function and mortality prior to discharge in a cohort of patients who underwent thrombectomy for acute ischemic stroke at two large medical centers in New York...

Background/objectives: Little is known about trajectories of recovery 12-months after hospitalization for severe COVID. Methods: We conducted a prospective, longitudinal cohort study of patients with and without neurological complications during index hospitalization for COVID-19 from March 10, 2020-May 20, 2020. Phone follow-up batteries were p...

We describe an educational intervention for neurology residents aimed at developing feedback skills. An objective structured clinical examination case was designed to simulate the provision of feedback to a medical student. After the simulated case session, residents received structured, individualized feedback on their performance and then partici...

Background/Objectives Little is known about trajectories of recovery 12-months after hospitalization for severe COVID. Methods We conducted a prospective, longitudinal cohort study of patients with and without neurological complications during index hospitalization for COVID-19 from March 10, 2020-May 20, 2020. Phone follow-up batteries were perfo...

Objectives: Hemorrhagic conversion of ischemic stroke (HCIS) is a common complication of cerebral ischemia and is associated with worse stroke outcomes. Differentiation between HCIS and other causes of intracerebral hemorrhage (ICH) can be challenging in practice. We sought to determine whether imaging features of hematoma expansion (HE) can be use...

Introduction: Delay to stroke diagnosis can postpone appropriate treatment leading to worse outcomes. We hypothesize that interpreter use can contribute to a delay to treatment. Methods: We identified consecutive patients between January 2019 and June 2021 with acute stroke (hemorrhagic or ischemic) using the Get with the Guidelines Database (GWTG)...

Introduction: Neurological complications among hospitalized COVID-19 patients may be associated with elevated neurodegenerative biomarkers. Methods: Among hospitalized COVID-19 patients without a history of dementia (N = 251), we compared serum total tau (t-tau), phosphorylated tau-181 (p-tau181), glial fibrillary acidic protein (GFAP), neurofil...

Background Persistent cognitive symptoms have been reported following COVID-19 hospitalization. We investigated the relationship between demographics, social determinants of health (SDOH) and cognitive outcomes 6-months after hospitalization for COVID-19. Methods We analyzed 6-month follow-up data collected from a multi-center, prospective study o...

Background The association between race and ethnicity and microvascular disease in patients with intracerebral hemorrhage (ICH) is unclear. We hypothesized that social determinants of health (SDOHs) mediate the relationship between race and ethnicity and severity of white matter hyperintensities (WMHs) and microbleeds in patients with ICH.Methods W...

Background Early neurorehabilitation improves outcomes in patients with disorders of consciousness (DoC) after brain injury, but its applicability in COVID-19 is unknown. We describe our experience implementing an early neurorehabilitation protocol for patients with COVID-19-associated DoC in the intensive care unit (ICU) and evaluate factors assoc...

Approximately 15% of deaths in developed nations are due to sudden cardiac arrest, making it the most common cause of death worldwide. Though high-quality cardiopulmonary resuscitation has improved overall survival rates, the majority of survivors remain comatose after return of spontaneous circulation secondary to hypoxic ischemic injury. Since th...

Purpose of review: This article describes the prerequisites for brain death/death by neurologic criteria (BD/DNC), clinical evaluation for BD/DNC (including apnea testing), use of ancillary testing, and challenges associated with BD/DNC determination in adult and pediatric patients. Recent findings: Although death determination should be consist...

INTRODUCTION: Older adults hospitalized with COVID-19 are susceptible to neurological complications, particularly encephalopathy, which may reflect age-related neurodegenerative processes. METHODS: Serum total tau, ptau-181, GFAP, NFL, UCHL1, and amyloid-beta(AB-40,42) were measured in hospitalized COVID-19 patients without a history of dementia, a...

Objectives Systemic inflammatory response syndrome (SIRS) and hematoma expansion are independently associated with worse outcomes after intracerebral hemorrhage (ICH), but the relationship between SIRS and hematoma expansion remains unclear. Materials and methods We performed a retrospective review of patients admitted to our hospital from 2013 to...

Background/Objectives Little is known regarding the prevalence and predictors of prolonged cognitive and psychological symptoms of COVID-19 among community-dwellers. We aimed to quantitatively measure self-reported metrics of fatigue, cognitive dysfunction, anxiety, depression, and sleep and identify factors associated with these metrics among Unit...

Background Neurologists need to be adept at disclosing prognosis and breaking bad news. Objective structured clinical examinations (OSCE) allow trainees to practice these skills. Methods In 2017, in conjunction with the NYU School of Medicine Simulation Center, neurology faculty designed an OSCE case in which a resident had to inform a standardize...

Purpose of review This review summarizes current and emerging treatments for hypoxic-ischemic brain injury (HIBI). Guidance on neuroprognostication after HIBI is also presented. Recent findings After two 2002 studies demonstrated cooling improved neurologic outcome after HIBI, a 2013 trial found targeting 36 °C was non-inferior to targeting 33 °C....

The adult critical care setting requires complex clinical decisions to be made that have a dramatic impact on the lives of patients and their families. This textbook offers evidence-based case histories around shared decision making, providing practical advice to clinicians who are trying to navigate routine clinical scenarios in adult critical car...

Background and purpose: We reviewed the literature to evaluate cerebrospinal fluid (CSF) results from patients with coronavirus disease 2019 (COVID-19) who had neurological symptoms and had an MRI that showed (1) central nervous system (CNS) hyperintense lesions not attributed to ischemia and/or (2) leptomeningeal enhancement. We sought to determi...

Objective We reviewed the literature on cerebrospinal fluid (CSF) testing in patients with altered olfactory/gustatory function due to COVID-19 for evidence of viral neuroinvasion. Methods We performed a systematic review of Medline and Embase to identify publications that described at least one patient with COVID-19 who had altered olfactory/gust...

Background Little is known regarding long-term outcomes of patients hospitalized with COVID-19. Methods We conducted a prospective study of 6-month outcomes of hospitalized COVID-19 patients. Patients with new neurological complications during hospitalization who survived were propensity score-matched to COVID-19 survivors without neurological com...

We reviewed the literature on cerebrospinal fluid (CSF) studies in patients who had a seizure in the setting of COVID-19 infection to evaluate for evidence of viral neuroinvasion. We performed a systematic review of Medline and Embase to identify publications that reported one or more patients with COVID-19 who had a seizure and had CSF testing pre...

There are varying medical, legal, social, religious and philosophical perspectives about the distinction between life and death. Death can be declared using cardiopulmonary or neurologic criteria throughout much of the world. After solicitation of brain death/death by neurologic criteria (BD/DNC) protocols from contacts around the world, we found t...

Background: Little is known regarding long-term outcomes of patients hospitalized with COVID-19. Methods: We conducted a prospective study of 6-month outcomes of hospitalized COVID-19 patients. Patients with new neurological complications during hospitalization who survived were propensity score-matched to COVID-19 survivors without neurological co...

Background Evolution of brain magnetic resonance imaging (MRI) findings in critically ill patients with coronavirus disease 2019 (COVID-19) is unknown.Methods We retrospectively reviewed 4530 critically ill patients with COVID-19 admitted to three tertiary care hospitals in New York City from March 1 to June 30, 2020 to identify patients who had mo...

Introduction: While the thrombotic complications of COVID-19 have been described, there are limited data on its implications in hemorrhagic stroke. The clinical characteristics, underlying stroke mechanism, and outcomes in this group of patients are especially salient as empiric therapeutic anticoagulation becomes increasingly common in the treatme...

Objective: Systemic inflammatory response syndrome (SIRS) and hematoma expansion are both associated with worse outcomes after intracerebral hemorrhage (ICH), but their relationship remains unclear. We sought to determine the association between SIRS and hematoma expansion after ICH. Methods: We performed a retrospective cohort study of patients ad...

Introduction: The association between race and white matter hyperintensities (WMH) and cerebral microbleeds in patients with intracerebral hemorrhage (ICH) is controversial. We examined the relationship between race and social determinants of health with WMH and microbleeds in ICH. Methods: We performed a retrospective study of patients at a tertia...

Background Toxic metabolic encephalopathy (TME) has been reported in 7–31% of hospitalized patients with coronavirus disease 2019 (COVID-19); however, some reports include sedation-related delirium and few data exist on the etiology of TME. We aimed to identify the prevalence, etiologies, and mortality rates associated with TME in severe acute resp...

In Reply The World Brain Death Project¹ recommendations and suggestions were produced via multidisciplinary global expert consensus on the process to declare death, recognizing that BD/DNC is accepted as death throughout much of the world but that the standards used to determine BD/DNC differ.

Objective We sought to review the literature on cerebrospinal fluid (CSF) testing in patients with COVID-19 for evidence of viral neuroinvasion by SARS-CoV-2. Methods We performed a systematic review of Medline and Embase between December 1, 2019 and November 18, 2020 to identify case reports or series of patients who had COVID-19 diagnosed based...

Brain death, or death by neurological criteria (BD/DNC), has been accepted conceptually, medically and legally for decades. Nevertheless, some areas remain controversial or understudied, pointing to a need for focused research to advance the field. Multiple recent contributions have increased our understanding of BD/DNC, solidified our practice and...

Background: Zinc impairs replication of RNA viruses such as SARS-CoV-1, and may be effective against SARS-CoV-2. However, to achieve adequate intracellular zinc levels, administration with an ionophore, which increases intracellular zinc levels, may be necessary. We evaluated the impact of zinc with an ionophore (Zn+ionophore) on COVID-19 in-hospit...