The document discusses brain death as a clinical syndrome characterized by irreversible loss of brain function while circulation may still persist. It outlines the definitions, criteria for diagnosing brain death, relevant guidelines, and legal aspects pertaining to organ donation in the context of brain death in India. The document also delves into the neurological examination process, including the apnea test, and acknowledges the differences between Indian and U.S. definitions of brain death.

1. BRAIN DEATH
Dr. Shobhit Gupta
SR Neurology
GMC, Kota

2. Brain Death?
The death of the Brain, while the Circulation
persists.
A clinical syndrome
– First recognised over 50 years ago
– Only possible on ventilatory support
– Apnoea, unresponsiveness and other features

4. Types of “Brain death”
 Cerebral/ cortical death
 Brainstem death
 Whole brain death (cortical + brainstem)
a. Cortical death
 Permanent and irreversible cessation of cerebral functions
 Death of cerebral cortex
 Preserved brainstem
b. Brainstem death
 Cerebrum is intact
 But brainstem functions lost
 All essential centres like “respiratory”, “cardiac” lost
 Irreversible coma, absent spontaneous breathing
 Intact cerebrum --- EEG may show activity
 Can have preserved intracranial blood flow
 UK (and India) guidelines based on concept of Brainstem Death
 USA does not follow this concept, believes in Whole Brain Concept.

5. Indian law recognizes
BRAIN STEM DEATH

6. The Transplantation of Human Organs Act,
1994 (Central Act 42 of 1994),- 'Deceased
person' means a person in whom permanent
disappearance of all evidence of life occurs,
1. By reason of Brain-stem Death or
2. In a Cardio-pulmonary Arrest at any time
after live birth has taken place.
3. ‘Brain-stem Death' means the stage at
which all functions of the brain stem have
permanently and irreversibly ceased.
Definition of Deceased Person

7. Consent for certifying brain
death
1. Any donor himself may, authorize the
removal, before death, of his body
organs for therapeutic purposes.
 Donor – in writing, in presence of 2
witnesses
 One of whom is a near relative
2. The person, lawfully, in possession of
the dead body
3. Parents of a person <18 years of age.

8. STEP..1
Establish if there is an underlying
cause for the patient to be brain
dead

9. STEP..2
Look for confounders before
proceeding for brain death
verification

10. PRECONDITIONS

11. Rule out the following
and
AIM for near normal values
• Severe Hypothermia - core temperature of ≤32°C
• Severe Hypotension (With or Without Vasopressors) - SBP
<100 mmHg
• Drugs - Alcohol, Poisoning, Recent Use Of Sedation Or
Neuromuscular Blocking Agents
• Medical conditions - severe electrolyte abnormalities,
hypoglycemia, acid–base abnormalities

12. Brain Death Criteria
• Brain death is established by
documentation of
1. Irreversible coma
2. Irreversible loss of brain stem reflexes
3. Cessation of respiratory centre function
or
4. Demonstration of cessation of
intracranial blood flow (NOT a Part of
THOA Act)

13. Evaluation Team
 Certified by a 'Board of Medical
Experts‘
(1)MS/In-Charge of the hospital in which
'brain stem' death has occurred,
(2) Specialist,
(3) a Neurologist or a Neurosurgeon
nominated by the MS, from a panel
approved by the Appropriate Authority,
(4) the Doctor under whose care the
'brain- stem' death has occurred.

14.  Amendments in the THO Act 2011
 Wherever Neurophysician or
Neurosurgeon is not available,
then an anaesthetist or intensivist
can be a member of board in his
place, subject to the condition that
he is not a member of the
transplant team

15. Neurological examination for diagnosing
Brain Death
 This consists of three essential steps:
 Documentation of coma
 Documentation of the absence of brainstem
reflexes
 Documentation of apnea (apnea test)
C C C C

16. Documentation of coma
 Absence of motor response to a Central
Deep painful stimulus
 Beware of local spinal reflexes causing
spontaneous or stimulus-related motor
movements

17. Response to painful stimuli
Within cranial nerve distribution

18. Documentation of the absence of brainstem
reflexes
 Tests documented are
 Absent pupillary reflex
 Absent oculocephalic movements (doll’s
eye reflex)-
 Absent oculovestibular reflex (cold calorie
test)
 Absent corneal reflex
 Absent cough reflex

19. Pupillary Response To Light
 size
>4mm
required
Always
wait for 1
min: for any
delayed/
slow
pupillary
reflex

20. Corneal reflex
Cornea transplantation:
In potential donors,
Leads to abrasions
Avoid repeated corneal reflex testing

21. Gag Reflex and Cough Reflex
Use a tongue depressor to
stimulate each side of
oropharynx and see for any
pharyngeal/ palatal
movements
Pass a suction tube –
stimulate carina – see for
any cough/ chest or
diaphragmatic movements

22. Vestibulo- Ocular Reflex
•Many clinicians use it as a “screening” tool , If present,
don’t need to proceed for further testing.
• Cervical spine injury: a. Suspected/ proven , DON’T
attempt VOR

23. Apnoea Test

24. Evaluation criteria brain death Apnoea
test:
a. Create a degree of hyper-carbia
sufficient to stimulate the respiratory
centre
b. After that also, if there is apnoea, helps
in diagnosis of brain death
 Aim: Rapid increase in PaCO2 >60
mmHg (or a 20 mmHg increase from
baseline) and the corresponding decrease
in pH
Positive test Negative test
No respiratory activity Any spontaneous respiratory
activity

25. Documentation of Apnea (Apnea
Test)
 Done only after
 Documentation of coma
 Documentation of absence of brain stem reflexes

26. Documentation of apnea (apnea
test)
 Steps
a. Pre-oxygenate with 100% oxygen x 5 minutes
b. Do ABG to confirm that SaO2 and PaCO2 correlate with SpO2.
c. With SpO2 >95%, slowly reduce Resp rate to cause slow rise
in ETCO2.
d. When ETCO2 >45, do ABG to confirm PaCO2 >45 mmHg and
pH <7.4
e. The patient is disconnected from ventilator
f. Oxygen insufflated at 5 L/min via endotracheal catheter or CPAP
g. Maintain MAP >60mmHg, and SpO2 >95%.
h. Observe for 5 minutes
i. Repeat ABG to see PaCO2 >has increased >20 mmHg pre-
disconnection level
j. If after 5 minutes, no spontaneous breathing --- positive Apnea
test.

27. Apnoea test contraindicated in:-
High cervical cord injury:
a.Phrenic nerve injury
b.Phrenic nerve
dysfunction

28. Second testing
 All above tests need to be
repeated
 After how much time?
 Determined for each patient
individually
 As children are more resilient than
adults, a longer time between
assessments, of greater than 6
hours, has been advocated

29. Brain Death Confirmed
 Once the 2 specialist complete the
test the time of death is confirmed
as the end of second examination
time
 What is the legal time of death?
When the first test demonstrates the
absence of brainstem reflexes ,
second test is just “confirming” the
findings of the first test.

30. Observations compatible and incompatible with
Brain Death
Compatible:
• Spinal reflexes
• Sweating, blushing, tachycardia
• Normotension without pharmacologic support
Incompatible:
• Decerebrate or decorticate posturing
• Extensor or flexor motor responses to painful
stimuli
• Seizures

31. Confirmatory Tests- Not required in
India and NO mention in THOA act
• These tests are optional in adults
• Recommended in children younger than 1 year
• Certain countries mandate these tests by law to
confirm brain death
• The tests are
– Cerebral angiography (conventional or CT)
– Cerebral scintigraphy
– Electroencephalography (EEG)- NOT RECOMMENDED
– Transcranial Doppler (TCD) ultrasound- NOT RECOMMENDED

32. Confirmatory “but” optional tests
Indications: Cannot perform brainstem reflexes
d/t
a. Facial trauma/ pupillary abnormalities
b. Contra-indication to apnoea test
c. Severe pulmonary disease
d. Sleep apnoea
e. Toxic level of sedative drugs
f. Aminoglycosides – NM block
g. Toxic levels of AEDs, TCAs,
h. Anti-cholinergics, Anti-cancer drugs

33. Confirmatory “but” optional tests
–Cerebral angiography
–Cerebral scintigraphy
–Electroencephalography (EEG)
–Transcranial Doppler (TCD)
ultrasound

34. 4 Vessel Angiography/CT
angiography

35. Cerebral perfusion scan

36. Cerebral perfusion scan

37. TCD
AAN: accepted as a reliable confirmatory
test:
a. Non-invasive
b. Sensitive test
c. Absence of doppler signal
d. Small systolic peaks with no diastolic flow
or reverberating flow indicates a very high
resistance
e. But user dependant!

40. Criteria for Diagnosing Brain
Death in Infants and Children
 The diagnosis of brain death cannot
be made in preterm infants of
gestational age of less than 37
weeks.
 Children are more resilient than
adults
 Longer time between assessments
has been advocated
 Assessments in neonates and

41. Controversies in Confirmatory tests
a. Preserved EEG activity
b. Preserved blood flow
c. Preserved osmo-regulation, via
regulated secretion of ADH
(hypothalamic function)
Such patients, can be clinically declared dead by the absence of
brainstem reflexes, however, are NOT DEAD, if we apply a
“whole-brain death” concept.
Brain-stem death has a lower burden of proof than whole-brain
death!

42. The Transplantation Of Human
Organs Act 1994 (THOA)
The Transplantation of human organs
bill, 1994
• Rajya Sabha on 5th May, 1993
• Lok Sabha on 14th June 1994
• The Act was amended in 2011 and the
Transplantation of Human Organs (Amendment) Act
2011, has come into force on 10-1-2014
• Transplantation of Human Organs and Tissues Rules
(THOT), 2014 has many provisions to remove the
impediments to organ donation while curbing
misuse/misinterpretation of the rules.

43. National Organ Transplant
Programme
NOTTO: National Organ and Tissue Transplant Organization ROTTO: Regional Organ and Tissue Transplant
Organization
SOTTO: State Organ and Tissue Transplant Organization
T: Transplant Centre

44. References
 Evidence-based guideline update:Determining brain death in
adults Report of the Quality Standards Subcommittee of the
American Academy of Neurology; Neurology® 2010;74:1911–
1918.
 Brainstem death: A comprehensive review in Indian
perspective;Anant Dattatray Dhanwate; Indian J Crit Care Med.
2014 Sep; 18(9): 596–605
 The diagnosis of brain death;Ajay Kumar Goila and Mridula
Pawar; Indian J Crit Care Med. 2009 JanMar; 13(1): 7–11.
 Brain Death: The United Kingdom Perspective;Martin Smith,
MBBS, FRCA, FFICM; Semin Neurol 2015;35:145-151.
 Plum And Posner’s Diagnosis Of Stupor And Coma fourth edition-
2007
 Clinical Criteria for Diagnosis of Brain Death and its MedicoLegal
Applications (A Review Study) Author(s): Pathak Manoj Kumar,
Tripathi S K, Agrawal Prashant, Chaturvedi Rajesh, Yadav Sudhir
Vol. 6, No. 2 (2006-03 -2006-06) Indmedica MedicoLegal Update

45. THANK
YOU