Brain death ancillary tests Brain Death - if clinical criteria cannot be met Either due to preconditions unfulfilled or incomplete

e clinical tests Need to perform a: 4 vessel cerebral angiogram OR radionucleide scan - to demonstrate absent blood flow, need to be performed on 2 occasions at least 10 mins apart The 6 hour observation period still applies Brain Death diagnosis still to be performed by 2 clinicians Examples whereby these tests other than clinical tests may be required the cause of apparent brain death is not obvious in the presence of significant sedative drugs metabolic disturbance e.g. renal/liver failure facial trauma preventing adequate examination of all cranial nerves in cardio-respiratory failure and instability when the apnoea test would be considered to be too dangerous to perform cervical cord or vertebral injury

Use imaging to demonstrate absent blood flow from both vertebro-basilar and supratentorial circulations 4 vessel angiography vertebral and carotid arteries are filled from the arch of the aorta. Blood flow should not be demonstrated above the level of the carotid bifurcation Radionuclide scanning cerebral perfusion scan: reliably demonstrates the absence of brain perfusion no uptake of radionuclide in brain parenchyma

(a) Outline the situations in which clinical tests cannot be used to confirm brain death. (b) List 2 adjunctive tests used in Australia and New Zealand for the confirmation of brain death when clinical tests are unable to be performed. (c) List other adjunctive tests which may have a role in the diagnosis of brain death.

a) Clinical tests cannot be used to confirm brain death in a number of situations, including:

has a greater potential for recovery, a confirmatory test is usually conducted

b) The two adjunctive tests recognized in the ANZICS guidelines are 3 or 4 vessel angiogram, and nuclear medicine study capable of imaging posterior fossa blood flow, e.g. use of nuclear study with SPECT.

c) Additional tests which may play a role (but have various limitations) are

electrophysiological tests (ie. evoked potentials, EEG), transcranial doppler ultrasound, and simpler nuclear medical perfusion scans. The use of Xe-CT and specific MR sequences have been described, but seem to hold no particular advantages. In the future, CT angiogram, or CT perfusion may play a role. Neither has obvious current advantages, but if sufficiently reliable, may be more widely available.