Brain Death!
Christ's raising of Lazarus, Athens, 12–13th century
#MedTwitter #neurotwitter #EndNeurophobia #tweetorials
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Christ's raising of Lazarus, Athens, 12–13th century
#MedTwitter #neurotwitter #EndNeurophobia #tweetorials
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Definition & pathophysiology
Definition
Irreversible state
Pathophysiology
Complete circulatory arrest of the brain
- leading to intracranial compartment syndrome
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Definition
Irreversible state
Pathophysiology
Complete circulatory arrest of the brain
- leading to intracranial compartment syndrome
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Algorithm
a. clinical suspicion: catastrophic brain injury & cardinal findings
b. exclude confounders
c. AAN 2023 checklist
d. neuro exam + apnea test
e. confirmatory tests
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a. clinical suspicion: catastrophic brain injury & cardinal findings
b. exclude confounders
c. AAN 2023 checklist
d. neuro exam + apnea test
e. confirmatory tests
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Cardinal features
- coma
- no cranial nerve function
- no respiratory drive
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- coma
- no cranial nerve function
- no respiratory drive
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Confounders
Brain death mimickers
- neuromuscular paralysis
- hypothermia
- drug intoxication
- C-spine injury
- locked-in syndrome
Spinal reflexes
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Brain death mimickers
- neuromuscular paralysis
- hypothermia
- drug intoxication
- C-spine injury
- locked-in syndrome
Spinal reflexes
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AAN 2023 Checklist
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Neuro exam w/ apnea test
- Coma
- Absent brain-originating motor response
- Absent brainstem reflexes
> corneal reflex
> oculocephalic & oculovestibular reflex
> jaw jerk
> gag reflex
> cough w/ tracheal suctioning
> sucking or rooting reflexes (in neonates)
- Apnea test
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- Coma
- Absent brain-originating motor response
- Absent brainstem reflexes
> corneal reflex
> oculocephalic & oculovestibular reflex
> jaw jerk
> gag reflex
> cough w/ tracheal suctioning
> sucking or rooting reflexes (in neonates)
- Apnea test
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Confirmatory tests
Brain blood flow
a. Cerebral angiography
b. TCD
c. CTA
d. Nuclear medicine
e. MRA
Electrophysiology
a. EEG
b. Potentials: SSEP and BAEP
Others
a. Atropine
b. PaO2 in RA versus jugular bulb
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Brain blood flow
a. Cerebral angiography
b. TCD
c. CTA
d. Nuclear medicine
e. MRA
Electrophysiology
a. EEG
b. Potentials: SSEP and BAEP
Others
a. Atropine
b. PaO2 in RA versus jugular bulb
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Spinal reflexes
- BD leads to disinhibition of spinal reflexes
- most common is triple flexion
- diff from volitional movements
> trigger by stimulus below the foramen magnum
> repeatable
> myokymia (not grimacing)
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- BD leads to disinhibition of spinal reflexes
- most common is triple flexion
- diff from volitional movements
> trigger by stimulus below the foramen magnum
> repeatable
> myokymia (not grimacing)
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Lazarus sign
Lazarus sign is a reflexive movement seen after or near brain death (BD) w/ arms raising & dropping to chest
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Lazarus sign is a reflexive movement seen after or near brain death (BD) w/ arms raising & dropping to chest
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Eyelid opening
- nipple stimulation
- Stereotypic partial eye-opening with sternal rub or trapezius pinch but not with supraorbital or nailbed pressure
doi.org
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- nipple stimulation
- Stereotypic partial eye-opening with sternal rub or trapezius pinch but not with supraorbital or nailbed pressure
doi.org
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Head-turning
- lateral head rotation arises primarily from activity of the spinal portion of the accessory (XI cranial) nerve and the cervical spinal cord
doi.org
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- lateral head rotation arises primarily from activity of the spinal portion of the accessory (XI cranial) nerve and the cervical spinal cord
doi.org
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Respiratory-like movements
Adduction of both shoulders followed by a slow cough-like movement
doi.org
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Adduction of both shoulders followed by a slow cough-like movement
doi.org
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Signs of Lazarus
1.hallux flex lead movements of the fingers and contraction of the anterior tibial muscle
2.plantar stimulus cause disorganized flex of fingers
3.plantar stimulus cause flex of hallux, inversion of ankle and triple flexion response.
youtu.be
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1.hallux flex lead movements of the fingers and contraction of the anterior tibial muscle
2.plantar stimulus cause disorganized flex of fingers
3.plantar stimulus cause flex of hallux, inversion of ankle and triple flexion response.
youtu.be
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Reverberating TCD flow pattern
Multi-depth power-motion (upper) & single-depth spectral analysis (lower) show reverberating flow in vertebral artery by forward flow in systole (long arrow) followed by abrupt flow reversal in diastole (short arrow)
doi.org
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Multi-depth power-motion (upper) & single-depth spectral analysis (lower) show reverberating flow in vertebral artery by forward flow in systole (long arrow) followed by abrupt flow reversal in diastole (short arrow)
doi.org
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@PulmCrit @caseyalbin Reflex of the Gracilis
Gracilis muscle, innervated by the obturator nerve, originates from the L2–L4 spinal nerve roots and may have contracted through an efferent pathway
doi.org
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Gracilis muscle, innervated by the obturator nerve, originates from the L2–L4 spinal nerve roots and may have contracted through an efferent pathway
doi.org
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@PulmCrit @caseyalbin Neck-abdominal reflex
- Anteflexion of the neck causes abdominal reflex
- Lazarus phenomenon)
link.springer.com
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- Anteflexion of the neck causes abdominal reflex
- Lazarus phenomenon)
link.springer.com
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@PulmCrit @caseyalbin Hugging movement
Flexion of the trunk and movement of the arms in a hugging-like manner
link.springer.com
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Flexion of the trunk and movement of the arms in a hugging-like manner
link.springer.com
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