Introduction: Brain death is a devastating outcome defined as an irreversible loss of total brain function. Toxicologic mimics of brain death can include baclofen, bupropion, tricyclic antidepressants, and barbiturates. Description: A 55-year-old female was found unresponsive with a suicide note and an empty bottle of Baclofen. She was intubated and brought to the ED, where she was hypotensive and had no brain stem reflexes on physical examination. An apnea test was performed, and she had one spontaneous breath at minute 6, after which she was placed back on mechanical ventilation. Due to concern of reverse triggering during the test, a brain flow study was done which showed no blood flow to her brain. The patient was pronounced brain dead. Surprisingly, she woke up in the morning and was subsequently extubated and later discharged. Discussion: Baclofen toxicity results from losing the selectivity of only affecting spinal GABA receptors, to include GABA receptors in the brain, thus causing cerebral global hypoperfusion secondary to suppression of neuronal activity and metabolic demand—resulting in coma. Other symptoms include hypotension, seizures, and respiratory depression. Brain death is confirmed by criteria including absent brain-stem reflexes in the setting of neurological dysfunction, a positive apnea test, and exclusion of drug intoxication, hypothermia, hypotension, neuromuscular and medical disturbances that can confound clinical assessment. Confirmatory imaging (i.e. a brain blood flow study) is warranted if confounders are suspected or a clinical assessment is insufficient. Despite this patient undergoing brain blood flow study confirming the diagnosis, she later woke up and returned to her normal function after baclofen’s effects had worn off, which has approximately a half life of 4 hours. This case highlights the importance of taking toxicologic agents into consideration as brain-death mimics. Clinicians should remain aware of Baclofen toxicity as a brain-death mimic in clinical practice, especially with it being widely prescribed. In the clinical setting of brain death suspicion, it is important to take sufficient history, perform a thorough physical examination and follow proposed criteria before confirmation. This ensures minimizing unnecessary confirmatory tests as well.
Kasasbeh et al. (Sun,) studied this question.