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Clin Neurophysiol. 2018 Nov;129(11):2451-2465. doi: 10.1016/j.clinph.2018.08.009. Epub 2018 Sep 1.

When is "brainstem death" brain death? The case for ancillary testing in primary infratentorial brain lesion.

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Department of Neurology, University of Rostock, Rostock, Germany; Center for Transdisciplinary Neurosciences Rostock (CTNR), University of Rostock, Rostock, Germany. Electronic address:
Department of Clinical Neurophysiology, Marqués de Valdecilla University Hospital, Santander, Spain; Biomedical Research Institute (IDIVAL), Santander, Spain.
Department of Neurology, University of Rostock, Rostock, Germany; Oscar Langendorff Institute of Physiology, University of Rostock, Rostock, Germany.
Coma Science Group, GIGA-Consciousness and Neurology Department, University and University Hospital of Liège, Liège, Belgium.


The widely accepted concept of brain death (BD) comprises the demonstration of irreversible coma in combination with the loss of brainstem reflexes and irreversible apnea. In some countries the combined clinical finding of coma, apnea, and loss of all tested brainstem reflexes ("brainstem death") is sufficient for diagnosing BD irrespective of the primary location of brain lesion. The present article aims to substantiate the need for ancillary testing in patients with primary infratentorial brain lesions. Anatomically, the "brainstem-death" syndrome can theoretically occur without relevant lesion of the mesopontine tegmental reticular formation (MPT-RF). Thus, a brainstem lesion may cause an apneic total locked-in syndrome, a rare syndrome with preserved capability for consciousness, mimicking "brainstem death". Findings in animals and humans have shown that alpha- or alpha/theta- EEG patterns in case of isolated brainstem lesion indicate intactness of relevant parts of the MPT-RF. In such patients the presence of irreversible coma has to be doubted, and the potential capacity for some degree of consciousness cannot be excluded as long as the EEG activity persists. Consequently the demonstration of either ancillary finding, electro-cortical inactivity or, preferably, cerebral circulatory arrest, is mandatory for diagnosing BD in patients with a primary infratentorial brain lesion.


Brain death; Cerebral circulatory arrest; Electroencephalography; Infratentorial brain lesion; Locked-in syndrome; Reticular formation

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