Abstract

Objective: Reliable prediction of brain death after no-therapy decision in acute neurocritical patients is of specific interest for organ donation after brain death (DBD). We aimed to establish a neurological scoring system (the BD-N score) to predict the probability of progression to brain death after spontaneous respiratory arrest. Methods: In this prospective observational study, we collected clinical data of acute neurocritical patients with a potential progression to BD, who was admitted in the First Affiliated Hospital of Sun Yet-sen University from May 2015 to April 2016. Final endpoint was adjudicated brain death (BD). The clinical data were compared between patients who identified as BD within 7 days and those who identified beyond 7 days, the time of spontaneous respiratory arrest as start point. Neurological examination, laboratory and radiographic data before the BD, were recorded. We used univariate and multivariable logistic regression analyses to assess associations between brain death within 7 days after spontaneous respiratory arrest and these variables. Points attributed to each variable were summed to create a predictive score for BD in neurocritical patients (the BD-N score). We assessed performance of the score using receiver operating curve analysis. Results: A total of 104 patients satisfied our inclusion criteria. 29 (27.9%) patients identified as BD within 3-5 days, 50 (48.1%) patients identified as BD within 5-7 days, 25 (24%) patients identified as BD after 7 days. Multivariable logistic regression analysis showed that absent pupil reflex (OR = 7.43, 95% CI 1.62-33.99, P = 0.010), anisocoria or bilaterally dilated pupil (OR = 6.25, 95% CI 1.21-32.22, P = 0.028), absent motor response to pain (OR = 15.89, 95% CI 3.04-82.93, P = 0.001), absent cisterna ambiens (OR = 11.96, 95% CI 1.59-89.78, P = 0.016) and present of brain herniation (OR = 16.28, 95% CI 2.25-117.73, P = 0.006) on brain CT imagine were associated with brain death within 7 days. AUC for the score was 83.9% for prediction of brain death within 7 days. A score of 3-5 was translated into an 81.9% chance (positive predictive value) of brain death within 7 days and a score of 1-2 translated into a 80% chance (negative predictive value) of brain death beyond 9 days. Conclusion: The BD-N score can be used to predict time of brain death after spontaneous respiratory arrest in acute neurocritical patients. However, further prospective validation is needed.

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