Determining brain death in adults [RETIRED]

Overview.The Quality Standards Subcommittee of the American Academy of Neurology (AAN) is charged with developing guidelines for neurologists for diagnostic procedures, treatment modalities, and clinical disorders.The present document is intended to provide background for the report "Practice Parameters for Determining Brain Death in Adults" (in this issue), which has been produced by the Quality Standards Subcommittee of the AAN and approved by the AAN Executive Board.This document outlines diagnostic criteria for the c h ical diagnosis of brain death in patients older than 18 years.The recommendations for diagnosis in neonates and children have been published as a position paper by the American Academy of Pediatrics'; in addition, a review paper can be consulted.'The sensitivity and specificity of laboratory tests that confirm the clinical diagnosis of brain death are discussed.Justification.Brain death is seen frequently as a result of severe head injury, aneurysmal subarachnoid hemorrhage, and intracerebral h e m ~r r h a g e .~. ~ In medical and surgical intensive care units, large ischemic strokes associated with brain swelling and herniation, hypoxic-ischemic encephalopathy after prolonged cardiac resuscitation or asphyxia, and massive brain edema in patients with fulminant hepatic necrosis are the most common causes of brain death.7-9In large referral hospitals, neurologists or neurosurgeons may diagnose brain death from 25 to 30 times a year.1°-14The clinical diagnosis of brain death has never been easy for most physicians, including neurologists and neurosurgeons.Brain death was selected as a topic for practice parameters because of a perceived need for standardized clinical examination criteria for the diagnosis of brain death in adults, large differences in practice in performing the apnea test," and controversies over appropriate utilization of confirmatory tests."In addition, government and third-party payers are demanding well-defined practice parameters in the clinical examination or confirmatory testing.New parameters are needed to add to the