Etiology- and age-specific timing of death by neurologic criteria evaluation and declaration in clinical practice

Background: The timing of declaration of death by neurologic criteria (DNC) after acute brain injury varies in clinical practice. However, large-scale data describing etiology- and age-specific timing of DNC evaluation and declaration are limited. This study aimed to characterize these timing patterns in a cohort of patients with DNC. Methods: Retrospective cohort study using registry data from German hospitals reporting cases of guideline-confirmed DNC to the national organ procurement organization. Included were adults (≥ 18 years) who were declared DNC between April 1, 2020, and August 31, 2025. Brain injury was categorized by ICD-10 as traumatic brain injury (TBI), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), acute ischemic stroke (AIS), hypoxic-ischemic encephalopathy (HIE). The primary outcome was time from initiation of mechanical ventilation to DNC declaration; time to first clinical examination fulfilling criteria for DNC was analyzed as a secondary outcome. Time-to-event distributions were summarized using cumulative incidence estimates, and associations of timing with etiology, age, and selected clinical variables were explored using random survival forests. Results: Among 6,701 patients with DNC from 716 hospitals, 6,397 had complete timing data (median age, 59 years [IQR, 46-69]; 54% male). Median time to DNC differed across etiologies (p < 0.001): 55.5 h for ICH, 58.4 h for TBI, 65.9 h for SAH, 89.9 h for HIE and 96.8 h for AIS. By 72 h of ventilation, cumulative incidence of DNC was 64.5% (95%CI, 61.3-67.5) in TBI, 62.4% (95%CI, 59.9-64.7) in ICH, 53.7% (95%CI, 50.9-56.4) in SAH, 36.7% (95%CI, 34.4-38.9) in HIE and 31.9% (95%CI, 28.3-35.4) in AIS. By 120 h, cumulative incidence reached 83.9% (95%CI, 81.3-86.1) in TBI, 81.5% (95%CI, 79.5-83.4) in ICH, 69.0% (95%CI, 66.4-71.5) in SAH, 67.3% (95%CI, 65.0-69.4) in HIE and 65.7% (95%CI, 61.9-69.1) in AIS. Older age was associated with shorter time to DNC in TBI and ICH, whereas associations were minimal in AIS and HIE. Conclusions: The timing of DNC evaluation and declaration varies substantially across etiologies and age groups. These findings may help to better understand temporal patterns of DNC determination among patients with DNC in clinical practice.