Original Paper

Received: May 15, 2002

Eur Neurol 2003;49:90–93
Accepted: September 2, 2002
DOI: 10.1159/000068506

Survival of Cardiac Function after

Brain Death in Patients in Kuwait
S. Al-Shammri a R.F. Nelson c R. Madavan d T.A. Subramaniam e
T.R. Swaminathan b
a Department of Medicine, Faculty of Medicine, Kuwait University, Safat, and b Department of Medicine,
Mubarak Al-Kabeer Hospital, Jabriya, Kuwait; c Division of Neurology, Faculty of Medicine, University of Ottawa,
Canada; d Department of Neurology, University Medical Center, Wayne State University, Detroit, Mich., and
e Division of Neurology, St. Louis University, St. Louis, Mo., USA

Key Words sation of all other body functions. It may be speculated

Brain death W Cardiac survival W Medical ethics W therefore that whole-body homeostasis is not as inti-
Ventilation W Kuwait mately associated with brain function as has hitherto
been thought.
Copyright © 2003 S. Karger AG, Basel

Abstract
Background: Persistent cessation of all cerebral and
brainstem function (brain death) is accepted in most
countries as legal evidence of death. It is presumed that
cardiac function will cease within a short time after brain
death has occurred. In some countries, such as Kuwait,
tradition and practice discourage application of the brain
death criteria despite legal acceptance. Objective: The
study was designed to assess the duration of persistence
of cardiac function in patients after the diagnosis of brain
death had been made on the basis of generally accepted
criteria. Methods: We evaluated how long cardiac func-
tion persisted after brain function had ceased in 40
patients in Kuwait who were admitted to hospital and
died during the 10-year period 1992–2001. Results: It was
found that the mean persistence of cardiac function after
brain death was 8.20 days and the median survival time
was 6 days. Two thirds of the patients survived longer
than a week, but none had cardiac function for longer
than 30 days. Conclusion: The study confirms that brain
death is not automatically followed immediately by ces-
Introduction
In most western countries, the concept of brain death is
well accepted. When a diagnosis of brain death has been
made, respirator and other supportive measures are dis-
continued, and the heart usually stops beating within
hours to days [1–4]. It has been presumed that, even with
artificial cardiorespiratory support, spontaneous cessa-
tion of cardiac function soon supervenes. Indeed, it is
stated in a leading book on coma that cardiac function is
seldom maintained more than 48 h after brain death has
occurred despite full mechanical support [5]. While this
belief is generally accepted, this area still remains contro-
versial, and at least one meta-analysis of published reports
showed that there are some cases in which asystole did not
occur for months or even years [6]. In a retrospective
study in Taiwan, cardiac death occurred within 7 days in
97% of 73 patients in whom brainstem death was diag-
nosed [7].

© 2003 S. Karger AG, Basel Dr. Suhail Al-Shammri

ABC 0014–3022/03/0492–0090$19.50/0 Department of Medicine, Faculty of Medicine
Fax + 41 61 306 12 34 Kuwait University, PO Box 24923
E-Mail karger@karger.ch Accessible online at: Safat 13110 (Kuwait)
www.karger.com www.karger.com/ene Tel. +965 5319596, Fax +965 5338907, E-Mail suhail@hsc.kuniv.edu.kw
Table 1. Causes of brain death Table 2. Time to asystole according to diagnosis with reference to
age and gender
Causes Cases
Case Age Sex Diagnosis Time
n %
No. years days
Head trauma (motor vehicle accidents) 17 42.5
1 63 male stroke – ischemic 1
Cardiopulmonary arrest 6 15
2 53 male cardiopulmonary arrest 1
Intracranial Infection 1 2.5
3 21 female stroke – hemorrhagic 1
Stroke (ischemic) 2 5
4 21 female stroke – hemorrhagic 1
Stroke (hemorrhagic) 10 25
5 27 male stroke – hemorrhagic 1
Brain tumor (primary) 4 10
6 42 male head trauma 2
Total 40 100 7 64 female cardiopulmonary arrest 2
8 23 male head trauma 2
9 24 female brain tumor – primary 2
10 16 female head trauma 3
11 27 female stroke – hemorrhagic 3
12 35 female stroke – hemorrhagic 3
This experience is not always exactly replicated in all
13 41 male intracranial infection 3
countries and cultures. The concept of brain death is still 14 18 male brain tumor – primary 4
not accepted or applied in many countries [3, 8]. In 15 34 female head trauma 4
Kuwait as well as most other Islamic countries, cessation 16 38 male stroke – hemorrhagic 4
of cardiac function is the usual criterion for death [9, 10]. 17 42 male stroke – hemorrhagic 5
18 22 male head trauma 5
However, in October 1986, the majority of attendees at
19 28 male head trauma 6
the 3rd International Conference of Islamic Jurists in 20 24 male head trauma 6
Amman, Jordan, accepted the concept of brain death [11]. 21 60 female stroke – ischemic 6
This has been slow to translate into practice, and current- 22 20 male head trauma 6
ly, in almost all cases in Kuwait, brain death criteria are 23 36 female brain tumor – primary 7
24 18 male head trauma 7
not accepted as sufficient evidence to discontinue suppor-
25 62 male stroke – hemorrhagic 7
tive treatment. Many physicians in Kuwait, who have had 26 28 male head trauma 9
postgraduate experience in western countries where the 27 43 male brain tumor – primary 10
concept of brain death is well established, have returned 28 50 male head trauma 11
to practice in Kuwait. One of the authors (S.A.S.) spent 29 60 male cardiopulmonary arrest 12
30 64 male head trauma 12
several years in Canada in a university teaching hospital
31 26 female cardiopulmonary arrest 12
before returning to Kuwait in 1991. This study reports his 32 29 male head trauma 14
prospective observations on the time intervals between 33 25 female stroke – hemorrhagic 14
brain death (according to accepted western criteria) with 34 70 male head trauma 16
continuation of support and cessation of heart function. 35 25 male head trauma 17
36 22 male cardiopulmonary arrest 18
37 18 male stroke – hemorrhagic 20
38 25 male head trauma 20
Patients and Methods 39 32 female cardiopulmonary arrest 21
40 35 male head trauma 30
Patients who were in deep coma were assessed clinically to deter-
mine if they met the usual internationally acceptable criteria for
brain death [12]. Many were also investigated by CT scan, by EEG
and by isotope scanning for evidence of cerebral perfusion. The
results of these assessments were carefully recorded. In all cases, sup-
portive care was maintained until there was complete cessation of
Results
cardiac function, at which time the patient was officially pronounced
dead. The causes of death are listed in table 1. The cases,
During a 10-year period (1992–2001), 40 cases were identified as their age, sex and underlying cause leading eventually to
having met the criteria for brain death. None were considered as
death and survival time are indicated in table 2. The time
donors of organs for transplantation. All patients received the same
standard of care, including ventilators and full medical support. In intervals between ascertainment of brain death and cessa-
no case was supportive treatment stopped because of the presence of tion of heart action are listed in table 3.
signs of brain death.

Cardiac Function after Brain Death in Eur Neurol 2003;49:90–93 91

Kuwait
Table 3. Time to asystole (days) after brain death criteria were met of death in most of these countries. The criteria for brain
death have been well described elsewhere [12] and include
Days to Number Percent Cumulative
absence of (1) cerebral function (neocortical death),
asystole of cases of total percent
(2) brainstem function and (3) unsupported respiratory
1 5 12.5 12.5 function. This combination is known as whole-brain
2 4 10 22.5 death. It is controversial whether complete loss of brain-
3 4 10 32.5 stem function is synonymous with whole-brain death
4 3 7.5 40
since a patient with isolated cerebral cortex function
5 2 5 45
6 4 10 55 would have lost all means of communication including
7 3 7.5 62.5 self-awareness and thought processes. Many indeed argue
9 1 2.5 65 that such a person would be ‘better off dead’ if not de facto
10 1 2.5 67.5 dead.
11 1 2.5 70
The decision to consider brain death as the legal defini-
12 3 7.5 77.5
14 2 5 82.5 tion of death raises many legal, societal, philosophical and
16 1 2.5 85 ethical issues [13]. There has always been a concern
17 1 2.5 87.5 among both physicians and the public that a mistake may
18 1 2.5 90 be made and a person would be taken off life support pre-
20 2 5 95
maturely. This is however unlikely where cases have been
21 1 2.5 97.5
30 1 2.5 100 carefully evaluated by experienced physicians. Jennett et
al. [14] in evaluating 609 cases of brain death in the UK
Total 40 100
and reviewing literature reports of another 1,003 head
injury survivors and 447 brain deaths concluded that
none of the survivors would have met the criteria for
brain death and that there was no doubt about those who
Forty patients were included in the study. All of the had been pronounced brain dead.
patients were adults with a mean age of 35.3 B 15.73 There are 3 practical reasons for advocating the brain
years (range 16–70). There were 27 (67.5%) males and 13 death criteria as an indication for cessation of treatment:
(32.5%) females. The respective geographic origins of the (1) keeping patients on long-term life support after brain
patients were: Kuwaiti 21 (52.5%); South Asians 7 death has occurred may be wasteful of scarce resources;
(17.5%); non-Kuwaiti Arabs 8 (20.0%); East Asians 2 (2) organ donation is facilitated if treatment is discontin-
(5.0%), and Persians 2 (5.0%). ued and appropriate organs are removed early when they
The time to asystole after brain death criteria were met are more likely to be viable; (3) the family is likely to be
varied from 1 to 30 days (mean 8.20 days, median 6 days). spared a long period of uncertainty, anxiety and vigil
There was no significant correlation between age and sur- accompanying the wait for final confirmation of death –
vival time after brain death (rp = 0.03, p = 0.85). A signifi- during that time, many never give up hope and expect
cant number of patients who had sustained head injury some miracle.
survived longer than 7 days when compared with those It is often assumed that complete cessation of function
patients with other causes for their coma (tables 2, 3). of all organs, including the heart and lungs, would soon
However, there was no significant difference between follow the death of the brain, with the belief that using
head injury and other causes of death in survival time (p = brain death criteria as the index of whole-body death was
0.16). There was also no significant difference in mean merely moving up the inevitable in time. However, only a
survival time between the 17 patients (42.5%) who devel- few studies have actually assessed how long a body ‘sur-
oped diabetes insipidus and those who did not (p 1 0.05). vives’ without the influence of the brain. Reports of long-
term survival of anencephalic infants had suggested that a
body with an intact brainstem is able to maintain homeo-
Discussion stasis if certain support is provided. Similarly supported
adult patients survive in a persistent vegetative state for
With some minor differences, the general criteria for years. Shewmon [6], in a meta-analysis of 56 cases of pro-
brain death are fairly well agreed upon throughout the longed survival after brain death, found that asystole
western countries and are accepted as the legal definition occurred at two phases in time. The early group had a

92 Eur Neurol 2003;49:90–93 Al-Shammri/Nelson/Madavan/

Subramaniam/Swaminathan
mean survival of 2–3 months while thereafter there was a
slow decline to up to 14 years. He noted that multisystem
failures were less likely to have prolonged survival than
primarily brain disease. Jennett et al. [14], in reviewing
326 cases, indicated that the median time to asystole after
brain death was 3.5–4.5 days.
There have been several studies on the duration of car-
diac function (cardiac survival) after established brain
death. One from Taiwan reported the experience after the
Taiwan Department of Health in 1987 adopted the diag-
nosis of brain death based on irreversible loss of brain-
stem function [7], made solely on clinical grounds and
considered to be equivalent to whole-brain death. In that
study, 73 patients, aged 2.25–89 years (mean 49.5 B 17.6
years) and who were not prospective organ donors, were
maintained on full ventilator and medical support after
brainstem death had been diagnosed. They were followed
up until they developed cardiac asystole; this occurred
within 7 days in 97% of the patients. The longest ‘surviv-
al’ was 16.5 days. In our study, the mean age was more
than a decade younger than in the Taiwan group, even
though children aged !16 years were excluded. For both
groups, head injury was the main cause of death (Kuwait
42.5%, Taiwan 47.5%). With respect to cardiac survival,
mean and median survival times were 8.2 and 6 days,
respectively. Two thirds of the Kuwaiti patients survived
longer than a week, but none lasted longer than 30 days –
the cardiac survival time was therefore slightly longer
than with the Taiwan group.
The diagnosis of brain death is generally established on
the basis of clinical examination. In special circum-
stances, it may be necessary to resort to laboratory diag-
nostic procedures such as conventional cerebral angiogra-
phy to demonstrate that there is no blood flow to the
brain. The least invasive and most reliable test is SPECT
scanning [15], which not only helps in excluding perfusion
of the supratentorial structures but can also demonstrate
persistent flow in the posterior circulation [16]. In all our
cases, the radioisotope study confirmed the lack of intra-
cranial perfusion.
Conclusion
This present study confirms that, in patients with doc-
umented cerebral death, cardiac function may persist for
variable periods of time without input from the brain.
The implications are several. In situations where brain
death is considered a signal to discontinue supportive
treatment there may be considerable cost savings. And,
where it had hitherto been believed that discontinuing
respiratory support would shorten life by only minutes or
hours, it is noteworthy that survival with support may
prolong the interval between brain death and cardiac
asystole by days to weeks.

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Kuwait
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