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Machado C. Reader Response: Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline: Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM. Neurology 2024;April 2024Neurology 102(9):e209367 DOI: 10.1212/WNL.0000000000209367.
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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/DNC determination process by integrating guidance for adults and children into a single guideline. Updates in this guideline include guidance related to conducting the BD/DNC evaluation in the context of extracorporeal membrane oxygenation, targeted temperature management, and primary infratentorial injury.
Methods
A panel of experts from multiple medical societies developed BD/DNC recommendations. Because of the lack of high-quality evidence on the subject, a novel, evidence-informed formal consensus process was used. This process relied on the panel experts' review and detailed knowledge of the literature surrounding BD/DNC to guide the development of preliminary recommendations. Recommendations were formulated and voted on, using a modified Delphi process, according to the 2017 AAN Clinical Practice Guideline Process Manual.
Major Recommendations
Eighty-five recommendations were developed on the following: (1) general principles for the BD/DNC evaluation, (2) qualifications to perform BD/DNC evaluations, (3) prerequisites for BD/DNC determination, (4) components of the BD/DNC neurologic examination, (5) apnea testing as part of the BD/DNC evaluation, (6) ancillary testing as part of the BD/DNC evaluation, and (7) special considerations for BD/DNC determination.
Background:
New controversies have raised on brain death (BD) diagnosis when lesions are localized in the posterior fossa.
Objective:
The aim of this study was to discuss the particularities of BD diagnosis in patients with posterior fossa lesions.
Materials and methods:
The author made a systematic review of literature on this topic.
Results and conclusions:
A supratentorial brain lesion usually produces a rostrocaudal transtentorial brain herniation, resulting in forebrain and brainstem loss of function. In secondary brain lesions (i.e., cerebral hypoxia), the brainstem is also affected like the forebrain. Nevertheless, some cases complaining posterior fossa lesions (i.e., basilar artery thrombotic infarcts, or hemorrhages of the brainstem and/or cerebellum) may retain intracranial blood flow and EEG activity. In this article, I discuss that if a posterior fossa lesion does not produce an enormous increment of intracranial pressure, a complete intracranial circulatory arrest does not occur, explaining the preservation of EEG activity, evoked potentials, and autonomic function. I also addressed Jahi McMath, who was declared braindead, but ancillary tests, performed 9 months after initial brain insult, showed conservation of intracranial structures, EEG activity, and autonomic reactivity to "Mother Talks" stimulus, rejecting the diagnosis of BD. Jahi McMath's MRI study demonstrated a huge lesion in the pons. Some authors have argued that in patients with primary brainstem lesions it might be possible to find in some cases partial recovery of consciousness, even fulfilling clinical BD criteria. This was the case in Jahi McMath.
In this paper, I reviewed the case of Jahi McMath who was diagnosed as being in brain death (BD). Nonetheless, ancillary tests, performed 9 months after initial brain insult, showed conservation of intracranial structures, EEG activity, and autonomic reactivity to “Mother Talks” stimulus. She was clinically in a state of unarousable and unresponsiveness, without evidence of awareness of self or environment, but full absence of brainstem reflexes, and partial responsiveness rejected the possibility of being in coma. Jahi was not a UWS, because she was not in a wakefulness state, and showed partial responsiveness. LIS patients are wakeful and aware, and although these cases are quadriplegic, they fully or partially preserve brainstem reflexes, vertical eye movements, and/or blinking, and respire by their own, rejecting the possibility of classifying her as a LIS patient. She was not a MCS because she did not preserve arousal, and only partially preserved awareness. The CRS-R resulted in a very low score, not corresponding with MCS patients. MCS patients fully or partially preserve brainstem reflexes, and usually breathe by their own. MCS has been always described as a transitional state between coma, UWS, but MCS has never been reported in a patient who has all clinical BD findings. This case doesn’t contradict the concept of BD, but brings again to discussion the needs of using ancillary tests in BD. I concluded that Jahi represented a new state of disorder of consciousness, non-previously described, that I have termed: “responsive unawake syndrome” (RUS).
Brain Death: A Reappraisal. Spinger Science+Bussiness Media, LLC
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