Research Article| Volume 398, P171-175, March 15, 2019

Progress of intracranial pressure and cerebral perfusion pressure in patients during the development of brain death

Published:January 29, 2019DOI:


      • This study focuses on the progress of ICP and cerebral perfusion pressure during intensive care treatment until brain death determination.
      • Our results showed variable values of ICP and cerebral perfusion pressure. Cerebral perfusion pressure during brain death determination may be positive in some patients.
      • Maximum ICP values and minimal cerebral perfusion pressure values are reached hours before brain death determination in most of the patients.
      • Extremely elevated ICP values before brain death in combination with low cerebral perfusion pressure values suggest an absence of brain perfusion.



      Clinical investigations of brain death are supposed to prove absence of cerebral perfusion. However, only limited data are available documenting intracranial pressure (ICP) and cerebral perfusion pressure (CPP) during the development of brain death. Our study presents additional data to understand the course of ICP and CPP in patients developing brain death.

      Material and methods

      We analyzed retrospective data of 18 patients with ICP monitoring during the development of brain death due to primary brain lesions. ICP and CPP values were continuously measured between two clinically defined time points: 1. non-reactive and widened pupils, 2. brain death determination. We analyzed ICP and CPP at the above-mentioned end points. Additionally, we investigated maximum ICP and minimal CPP values between these time points.


      Patients developed fixed and dilated pupils with a median of 38 h before brain death determination. During brain death determination median ICP and median CPP were 103.5 and –2.5 mmHg, respectively. Maximum ICP before brain death determination was significantly higher and minimal CPP values were significantly lower compared to the time point of brain death. During the investigation period all patients experienced ICP values >95 mmHg and CPP < 10 mmHg. All but one patient had documented CPP values of ≤0 mmHg. This single patient had a minimum CPP of 8 mmHg with a maximum ICP of 145 mmHg.


      Cerebral perfusion pressure during brain death determination may be positive in some patients. Our results showed variable values of ICP and CPP. However, extremely elevated ICP values before or during brain death in combination with low CPP values suggest absence of cerebral perfusion. The occurrence of positive CPP values during brain death determination therefore depends on the time point at which brain death determination is performed.


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        • Shewmon D.A.
        Brain death or brain dying?.
        J. Child Neurol. Jan, 2012; 27: 4-6
        • Tibballs J.
        A critique of the apneic oxygenation test for the diagnosis of "brain death".
        Pediatr. Crit. Care Med. Jul, 2010; 11: 475-478
        • Roth C.
        • Deinsberger W.
        • Kleffmann J.
        • Ferbert A.
        Controversies about irreversible loss of brain functions and cerebral perfusion in brain death.
        Eur. J. Neurol. Feb, 2016; 23: e8
        • Coimbra C.G.
        Implications of ischemic penumbra for the diagnosis of brain death.
        Braz. J. Med. Biol. Res. Dec, 1999; 32: 1479-1487
        • Chesnut R.
        • Videtta W.
        • Vespa P.
        • Le R.P.
        Intracranial pressure monitoring: fundamental considerations and rationale for monitoring.
        Neurocrit. Care. Dec,2014; 21: S64-S84
        • Le R.P.
        • Menon D.K.
        • Citerio G.
        • Vespa P.
        • Bader M.K.
        • Brophy G.
        • et al.
        The International Multidisciplinary Consensus Conference on Multimodality monitoring in Neurocritical Care: a list of recommendations and additional conclusions: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine.
        Neurocrit. Care. Dec, 2014; 21: S282-S296
        • Roth C.
        • Deinsberger W.
        • Kleffmann J.
        • Ferbert A.
        Intracranial pressure and cerebral perfusion pressure during apnoea testing for the diagnosis of brain death - an observational study.
        Eur. J. Neurol. Aug, 2015; 22: 1208-1214
        • Salih F.
        • Finger T.
        • Vajkoczy P.
        • Wolf S.
        Brain death after decompressive craniectomy: incidence and pathophysiological mechanisms.
        J. Crit. Care. Feb 16, 2017; 39: 205-208
        • Salih F.
        • Holtkamp M.
        • Brandt S.A.
        • Hoffmann O.
        • Masuhr F.
        • Schreiber S.
        • et al.
        Intracranial pressure and cerebral perfusion pressure in patients developing brain death.
        J. Crit. Care. Aug, 2016; 34: 1-6
        • Jorgensen P.B.
        Clinical deterioration prior to brain death related to progressive intracranial hypertension.
        Acta Neurochir. 1973; 28: 29-40
        • Agapejev S.
        • Da Silva P.P.
        • Zanini M.A.
        • Piza E.T.
        Intracranial pressure monitoring as a complementary tests for diagnosing brain death. Preliminary observation through the report of 2 cases.
        Arq. Neuropsiquiatr. Jun, 1997; 55: 310-314
        • Wijdicks E.F.
        Determining brain death.
        Continuum (Minneap Minn). Oct, 2015; 21: 1411-1424
        • Welschehold S.
        • Kerz T.
        • Boor S.
        • Reuland K.
        • Thomke F.
        • Reuland A.
        • et al.
        Detection of intracranial circulatory arrest in brain death using cranial CT-angiography.
        Eur. J. Neurol. Jan, 2013; 20: 173-179
        • Qi H.
        • Wan C.
        • Feng X.
        • Li M.
        • Chen L.
        • Wang Y.
        • et al.
        Experimental animal study of cerebral oxygen metabolism changes during the process of brain death.
        Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. Jul, 2017; 29: 640-643
        • Purins K.
        • Enblad P.
        • Wiklund L.
        • Lewen A.
        Brain tissue oxygenation and cerebral perfusion pressure thresholds of ischemia in a standardized pig brain death model.
        Neurocrit. Care. Jun, 2012; 16: 462-469
        • Koehler P.J.
        • Wijdicks E.F.
        Fixed and dilated: the history of a classic pupil abnormality.
        J. Neurosurg. Feb, 2015; 122: 453-463
        • von Leyden E.
        Beiträge und Untersuchungen zur Physiologie und Pathologie des Gehirns (1. Über Hirndruck und Hirnbewegungen).
        Virchows Arch. A. 1866; 37: 519-559
        • Palmer S.
        • Bader M.K.
        Brain tissue oxygenation in brain death.
        Neurocrit. Care. 2005; 2: 17-22
        • Smith M.L.
        • Counelis G.J.
        • Maloney-Wilensky E.
        • Stiefel M.F.
        • Donley K.
        • LeRoux P.D.
        Brain tissue oxygen tension in clinical brain death: a case series.
        Neurol. Res. Oct, 2007; 29: 755-759
        • Young J.S.
        • Blow O.
        • Turrentine F.
        • Claridge J.A.
        • Schulman A.
        Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained?.
        Neurosurg. Focus. Dec 15, 2003; 15E2
        • Langfitt T.W.
        • Kassell N.F.
        Non-filling of cerebral vessels during angiography: correlation with intracranial pressure.
        Acta Neurochir. 1966; 14: 96-104
        • Laurin N.R.
        • Driedger A.A.
        • Hurwitz G.A.
        • Mattar A.G.
        • Powe J.E.
        • Chamberlain M.J.
        • et al.
        Cerebral perfusion imaging with technetium-99m HM-PAO in brain death and severe central nervous system injury.
        J. Nucl. Med. Oct, 1989; 30: 1627-1635
        • Yu Y.
        • Chen J.
        • Si Z.
        • Zhao G.
        • Xu S.
        • Wang G.
        • et al.
        The hemodynamic response of the cerebral bridging veins to changes in ICP.
        Neurocrit. Care. Feb, 2010; 12: 117-123
        • Si Z.
        • Luan L.
        • Kong D.
        • Zhao G.
        • Wang H.
        • Zhang K.
        • et al.
        MRI-based investigation on outflow segment of cerebral venous system under increased ICP condition.
        Eur. J. Med. Res. Mar 31, 2008; 13: 121-126