Nathaniel Gillette1, Robert Araujo Contreras1, Rebecca Stafford1, Panayiotis Varelas2, Rashid Ahmed3, Joshua Kornbluth4, Joshua Kahan5, Sayona John6, Abhijit Lele7, David Greer8, Ali Daneshmand8
1Boston Medical Center, 2Albany Med-Department of Neurology, 3Upstate University Hospital, 4Tufts Medical Center, 5New York Presbyterian/ Weill Cornell Medicine, 6Rush University Medical Center, 7University of Washington, 8Boston University School of Medicine
Objective:
To determine whether the interval between time of initial neurological evaluation and brain death/death by neurologic criteria (BD/DNC) determination differs across major neurologic etiologies.
Background:
Despite the clinical importance of BD/DNC determination, comparison of time to determination by etiology is understudied, limiting data for counseling families, standardizing practice, and informing possible organ donation. We hypothesized that distinct neurologic causes of catastrophic brain injury differ in their time to BD/DNC determination.
Design/Methods:
We retrospectively analyzed patients who met criteria for BD/DNC across eight U.S. hospitals between 2012 and 2025. Etiologies were categorized as intracerebral or subarachnoid hemorrhage (ICH/SAH), ischemic stroke, traumatic brain injury (TBI), cardiac arrest, or other (including infectious, neoplastic, or anoxic causes). Time to BD/DNC was defined as the interval from first documented neurological evaluation to formal BD declaration. Median times were compared using the Kruskal–Wallis test, with pairwise comparisons performed using Dunn’s test.
Results:
Among the 635 patients, ICH/SAH accounted for 248 cases (39.1%), cardiac arrest for 200 (31.5%), TBI for 85 (13.3%), ischemic stroke for 50 (7.8%), and other causes for 52 (8.2%). Median time to BD/DNC differed significantly across etiologies (p<0.001). Cardiac arrest demonstrated the longest median time (68.4 hours, IQR 41.7-96.9), significantly longer than both TBI (43.7 hours, IQR 25.5-72.9, p=0.01) and ICH/SAH (39.4 hours, IQR 23.0-82.6, p<0.001). Ischemic stroke had the second longest median time (64.3 hours, IQR 43.5-158.3), also significantly greater than TBI (p=0.003) and ICH/SAH (p<0.001).
Conclusions:
These findings suggest that time to BD/DNC varies significantly by underlying etiology. Cardiac arrest and ischemic stroke exhibited notably prolonged intervals compared with traumatic or hemorrhagic causes. These findings suggest that BD/DNC represents not a uniform process, but a spectrum influenced by injury mechanisms, protocols, and systemic factors. Recognizing etiology-specific trajectories may improve the precision of prognostic discussions and optimize coordination of end-of-life care and organ donation.
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