Incoherence in the brain death guideline regarding brain blood flow testing: lessons from the much-publicized case of Zack Dunlap

At age 21, following a severe traumatic brain injury, Zack Dunlap was declared brain-dead according to the American Academy of Neurology guideline (Guideline) when he met the clinical criteria of brain death (minus apnea testing because of bradycardia) with technetium-99m diethylene-triamine-pentaacetate scintigraphy reported as showing no intracranial blood flow. His parents agreed to organ donation. During preparations for organ donation, Zack manifested a purposeful movement in response to a noxious stimulus made by his cousin. Following subsequent neurological recovery, he has returned to a normal life, holding steady employment and raising a family. During an interview, he reported that while in coma, he heard a doctor say that he was brain-dead and felt angry about it. His experience fits the phenomenon of cognitive-motor dissociation. Recently, Zack's medical records were made available to the first author. A critical review of the records uncovered a problem inherent in the logic of the Guideline algorithm regarding brain blood flow scintigraphy. This article discusses the lessons drawn from Zack's case, namely, that both the aforementioned problem and the occurrence of cognitive-motor dissociation in patients deemed to be brain-dead can pose a significant risk of a false-positive declaration of death.