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Brain death and the cervical spinal cord: a confounding factor for the clinical examination
Spinal Cord, 09/24/09

Joffe AR et al. – Upper cervical spinal cord injury may be common after brain herniation. Cervical spinal cord injury must either be ruled out before clinical testing for BD, or an ancillary test to document lack of brainstem blood flow is required in all cases of suspected BD. BD may not be a purely clinical diagnosis.

Exclusive Author Commentary
Dr AR Joffe, 09/27/09

After a case of brain death in a patient that had an MRI done, we noted the upper cervical spinal cord was injured from the herniation episode. On review of the literature we found many case reports and case series of patients with brain herniation due to meningitis or other causes where there was upper cervical spinal cord injury as a result of the herniation, likely due to vascular or direct compression. Of concern was that many of the cases had only transient quadraplegia and apnea, with partial recovery of function. Of more concern was that in the only two series of autopsy pathology after brain death that reported spinal cord pathology, the majority of patients with brain death indeed had high cervical spinal cord injury. This means that clinical examination cannot diagnose brain death, as one cannot be sure the lack of response to noxious stimuli or the apnea are not due to cervical cord injury. Some ancillary test that can prove lack of brainstem function should still be required, and whether any test can prove this with certainty is not clear.

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