Brain Stem Death

Avinash A Nair
SUTAMS

Introduction
Thanatology : is a branch of science that
deals with the study of death
Death is the complete and irreversible
stoppage of circulation, respiration and
brain function. (Bishops tripod of life)
Life exists
oxygenated blood reaches
brain stem

Brain Stem

Brain death
Cortical or cerebral death: vegetative
state but respiration continues.
Brain stem death: Loss of vital functions,
state of irreversible coma & incapable of
spontaneous breathing
Whole brain death

Brain Death Current Consensus

Absent Cerebral Function
Absent Brainstem Function
Apnea

Cerebral Cortex

Brain Stem

Reticular
Activating
System

Functions of brain stem

Respiratory drive
Maintenance of blood pressure
Motor outputs except smell & vision
Mediates cranial nerve reflexes

Assessment of brain death

Philadelphia Protocol 1969
Minnesota Criteria 1971
Harvard Criteria
Unreceptivity and unresponsivity
No movements
Apnoea
Absence of elicitable reflexes
Isoelectric EEG

Diagnosis of brain stem death

Clinical Prerequisites:
Known Irreversible Cause
Exclusion of Potentially Reversible Conditions
Drug Intoxication or Poisoning
Electrolyte or Acid-Base Imbalance
Endocrine Disturbances

Core Body temperature > 32 C

Preconditions of diagnosis
Deeply comatose
Maintained in ventilator
Cause of coma is known

Coma
No Response to Noxious Stimuli
Nail Bed Pressure
Sternal Rub
Supra-Orbital Ridge Pressure

Who should perform?

2 medical practioners
Experts in this field (not transplant
surgeons)
Consultant status( not junior doctors)
Each doctor should perform the test twice

Tests to be performed
Pupillary Reflex
Cephalo ocular response

Eye Movements

Vestibulo ocular reflex

Facial Sensation and Motor Response

Pharyngeal (Gag) Reflex
Tracheal (Cough) Reflex

 No respiratory movement
After patient is disconnected from the
ventilator long enough to raise the pCO2
above threshold
No spontaneous breathing within 10 mins

Pupillary Reflex
Pupils dilated with no constriction to bright
light

Eye Movements

Occulo-Cephalic
Response
Dolls Eyes Maneuver

Eye Movements

Vestibulo - ocular Response

Cold Caloric Testing

Facial Sensation and Motor

Response
Corneal Reflex

Jaw Reflex
Grimace to Supraorbital or
Temporo-Mandibular Pressure

 When 2 doctors perform these tests twice

with negative results
The patient is pronounced dead
The death certificate can be issued

Beating heart donor

After confirmed brain death
Retention of patient in ventilator
To facilitate fully oxygenated cadaver
transplant
Results of transplant much improved

Confirmatory Testing
Recommended when the proximate
cause of coma is not known or when
confounding clinical conditions limit
the clinical examination

Confirmatory Testing
EE
G

Normal

Electrocerebral

Confirmatory Testing
Cerebral Angiography

Normal

No Intracranial

Confirmatory Testing
Technetium-99 Isotope Brain Scan

Confirmatory Testing
MR- Angiography

Confirmatory Testing
Transcranial
Ultrasonography

Summary
Brain stem death: Loss of vital functions,
state of irreversible coma & incapable of
spontaneous breathing.
Harvard Criteria
Unreceptivity and unresponsivity
No movements
Apnoea
Absence of elicitable reflexes
Isoelectric EEG

Brain Stem

Midbrain
Cranial Nerve III
pupillary
function
eye movement

Brain Stem

Pons
Cranial Nerves IV, V, VI
conjugate eye
movement
corneal reflex

Brain Stem

Medulla
Cranial Nerves IX, X
Pharyngeal (Gag)
Reflex
Tracheal (Cough)
Reflex
Respiration

Reticular Activating System

Receives multiple
sensory inputs
Mediates
wakefulness