Special considerations in the assessment of catastrophic brain injury and determination of brain death in patients with SARS-CoV-2

Published:August 07, 2020DOI:https://doi.org/10.1016/j.jns.2020.117087


      • Patients with COVID-19 can have catastrophic brain injuries.
      • Family education about catastrophic brain injury is challenging during a pandemic.
      • The determination of brain death may be difficult in patients with COVID-19.
      • Medications and renal failure may confound brain death determination in COVID-19.
      • A modified apnea test may prevent high-risk aerosolization of COVID-19.



      The coronavirus disease 2019 (Covid-19) pandemic has led to challenges in provision of care, clinical assessment and communication with families. The unique considerations associated with evaluation of catastrophic brain injury and death by neurologic criteria in patients with Covid-19 infection have not been examined.


      We describe the evaluation of six patients hospitalized at a health network in New York City in April 2020 who had Covid-19, were comatose and had absent brainstem reflexes.


      Four males and two females with a median age of 58.5 (IQR 47–68) were evaluated for catastrophic brain injury due to stroke and/or global anoxic injury at a median of 14 days (IQR 13–18) after admission for acute respiratory failure due to Covid-19. All patients had hypotension requiring vasopressors and had been treated with sedative/narcotic drips for ventilator dyssynchrony. Among these patients, 5 had received paralytics. Apnea testing was performed for 1 patient due to the decision to withdraw treatment (n = 2), concern for inability to tolerate testing (n = 2) and observation of spontaneous respirations (n = 1). The apnea test was aborted due to hypoxia and hypotension. After ancillary testing, death was declared in three patients based on neurologic criteria and in three patients based on cardiopulmonary criteria (after withdrawal of support (n = 2) or cardiopulmonary arrest (n = 1)). A family member was able to visit 5/6 patients prior to cardiopulmonary arrest/discontinuation of organ support.


      It is feasible to evaluate patients with catastrophic brain injury and declare brain death despite the Covid-19 pandemic, but this requires unique considerations.


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