Withholding therapeutic interventions in brain(stem) death: is it a self-fulfilling prophecy?

Excerpt

Supratentorial and infratentorial decompressive  craniectomies in secondary intracranial hypertension can improve survival and neurologic outcome in traumatic and non-traumatic brain injury.^1,2 The triad for the clinical diagnosis of brain death—behavioral unresponsiveness, cranial nerve motor (brainstem) areflexia, and apnea—can develop because of secondary increase in intracranial pressure and concomitant decrease in cerebral perfusion pressure and blood flow following severe brain injury. Cunan et al. commented on the reversal of the clinical signs of brain(stem) death following therapeutic  decompressive craniectomies in two separate cases.¹ In one case, brainstem death was diagnosed in accordance with the UK national clinical guidelines and the patient subsequently regained breathing and consciousness and made a full recovery.³ The reversibility of clinical signs of brain(stem) death may represent “brain stunning.”¹ Return of neurologic functions after decompressive craniectomy also indicates the restoration of blood flow to the ischemic penumbra of salvageable and functionally recoverable brain structures. Normal or minimally ischemic brain structures have been confirmed by histopathologic examination at autopsy in over 60% of patients with the clinical diagnosis of brain death with confirmation by cerebral angiography in a subset of these patients.⁴ Does the presence of normal or minimally ischemic brain structures at autopsy indicate antemortem global ischemic penumbra in secondary intracranial hypertension? Does decompressive craniectomy and restoration of blood flow rescue global ischemic penumbra mimicking brain death diagnosis? …