====== Brain Death Diagnosis ======

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[[brain_death|Brain death]] is the **irreversible cessation of all functions of the entire brain**, including the brainstem. It is both a legal and medical definition of death in most countries and serves as the foundation for ethical organ donation.

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===== 🧠 Core Clinical Criteria =====

The clinical diagnosis of brain death requires:

  * **Irreversible cause** of coma established (e.g., TBI, hemorrhage, anoxia)
  * **Absence of confounding factors**:
    - Hypothermia (core temperature > 36°C)
    - CNS depressants, sedatives, paralytics
    - Severe metabolic or endocrine disturbances

  * **Complete neurological examination**, including:
    - No response to painful stimuli
    - Absence of brainstem reflexes:
      - Pupillary light reflex
      - Corneal reflex
      - Oculocephalic reflex ("doll’s eyes")
      - Oculovestibular reflex (cold calorics)
      - Gag and cough reflexes
    - **Apnea test**: No spontaneous respiration despite a rise in PaCO₂ above 60 mmHg or 20 mmHg over baseline

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===== 🧪 Ancillary Tests (When Required) =====

see [[Ancillary Confirmatory Tests for Brain Death]]



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===== 🕒 Observation Periods =====

Depends on age and national regulation:

  * Adults: some protocols require **two independent exams**, others accept **one** if criteria are unequivocally met
  * In cases of uncertain prognosis (e.g., anoxia, hypothermia), a **longer observation period** and/or **ancillary testing** is recommended

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===== ⚖️ Legal and Ethical Considerations =====

  * Must follow national standards (e.g., AAN [USA], ONT [Spain], AoMRC [UK])
  * Documentation must include:
    - Established irreversible coma
    - Absence of brainstem reflexes
    - Apnea test results
    - Time of death declaration

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===== 👨‍⚕️ Who Can Perform the Diagnosis? =====

Typically:
  * Two **licensed, independent physicians**
  * Must **not be involved in transplant team**
  * Often includes **neurologists, intensivists, or neurosurgeons**

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===== Common Pitfalls in Diagnosis =====

  * **Spinal movements postmortem**: e.g., facial twitching, finger tremors, or the “Lazarus sign” (sitting up) – all mediated by the spinal cord
  * **False appearance of breathing**: Ventilators may auto-trigger due to arterial pulsations or mechanical artifacts, not genuine respiration

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====== Brain Death: Diagnosis vs. Criteria ======

=== ✅ Brain Death Diagnosis ===

Refers to the **act or process** of determining that a person is brain dead based on clinical and/or ancillary findings.

**Examples:**
  * "The brain death diagnosis must comply with legal protocols."
  * "Diagnosis was confirmed following a complete exam and apnea testing."

=== ✅ Brain Death Criteria ===

Refers to the **clinical standards** or **protocol elements** used to make the diagnosis.

**Examples:**
  * "The patient fulfilled all brain death criteria."
  * "Protocols define the minimum criteria to establish brain death."

=== 🧠 Comparison Table ===

^ Term                     ^ Meaning                                           ^ Use Case                            ^
| [[brain_death_diagnosis|Brain death diagnosis]]    | Act of declaring death via neurological criteria | Legal documentation, clinical act   |
| [[brain_death_criteria|Brain death criteria]]      | Required clinical or test-based standards         | Protocols, medical education        |

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====== Brain Death Determination vs. Diagnosis ======

While related, these terms describe different stages:

=== 🧪 Brain Death Determination ===

Describes the **step-by-step clinical protocol**:
  * Neurological exam  
  * Apnea test  
  * Ancillary testing (if needed)  
  * Observation and legal documentation

> Example: "Brain death determination includes all required confirmatory steps."

=== ✅ Brain Death Diagnosis ===

Refers to the **final legal declaration** that the patient is dead based on the determination process.

> Example: "Diagnosis of brain death was made at 08:22 by the attending physician."

=== 🧠 Summary Table ===

^ Term                        ^ Definition                                ^ Emphasis                      ^
| Brain Death Determination   | Protocol used to confirm brain death      | Process and steps             |
| Brain Death Diagnosis       | Declaration based on completed protocol   | Legal and clinical outcome    |

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===== 📚 Source =====

* Neurology. 2010 Jun 8;74(23):1911. doi:10.1212/WNL.0b013e3181e242a8  
  → https://n.neurology.org/content/74/23/1911

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===== 🔗 See Also =====

  * [[brain_death_criteria|Brain Death Criteria]]
  * [[brain_death_determination|Brain Death Determination]]
  * [[apnea_test|Apnea Test]]
  * [[Ancillary Confirmatory Tests for Brain Death]]
  * [[the_world_brain_death_project|The World Brain Death Project]]