Brain Donation Process

Module 1: Introduction to Brain Donation

Overview

• • Definition and importance of brain donation
    • Brain Donation involves the post-mortem procurement of the human brain for neuropathological diagnosis, medical research and medical education
    • Only way to confirm a diagnosis of Alzheimer’s Disease or any other neurologic diseases/disorders
    • Being a registered organ/tissue donor on your driver’s license does not include donating your brain for research
    • Without brain tissue donation, neuroscience research is limited
  • Impact on medical research and education
    • Procuring the brain tissue allows for a confirmed diagnosis and allows for the brain to be used for research
    • Donated brains help researchers to better understand the brain and its functions, better characterize disease, and identify new treatments
    • Researchers have already made incredible progress in understanding these disorders, but there are still many unanswered questions

• Importance of timeliness

Post-mortem interval: time between time of death and processing of the tissue

• After death occurs, the brain tissue begins to degrade. 
• Having a lower post-mortem interval (PMI) is related to better RNA quality and overall tissue quality
• Higher quality tissue is vital for ensuring true results from following experiments

• Importance of frozen tissue
  • Frozen tissue allows for a wider array of experiments that fixed tissue does not provide alone.
  • Frozen tissue provides the researcher similar conditions to a functioning human brain in real time.

• Online Academic Resources
  • https://academic.oup.com/gerontologist/article/57/4/719/2632102
  • https://pmc.ncbi.nlm.nih.gov/articles/PMC6863784/

Module 2: Pre-Donation Procedures

Deciding capabilities of your site

• Full Clinical/Neuropathological Support (usually in conjunction with research university, or NIA/NIH funded Alzheimer’s Disease Research Center (ADRC)):

• • • Dedicated, on-call autopsy technician/diener for brain procurement.
    • Dedicated brain donation/research coordinators to see each brain donation from beginning to end (death notifications up and through tissue storage at the lab)
      • If a brain donation program is 24/7, having at least 2 coordinators and 2 autopsy technicians is ideal so that they can offset who is on-call for workload balance
    • Established Neuropathological Core – establish pipeline for post-mortem brain tissue to be sampled by neuropathologists, samples processed, and slides cut by histology laboratory and then slides back to neuropathologists for diagnosis, also blood processing for serial infectious disease testing.
    • Brain Bank Laboratory for final place of biological materials, helps if associated with established research lab/principal investigator that is authorized to use human post-mortem tissue.
    • Established Clinical team and facility to recruit and enroll participants and carry out yearly/longitudinal style study visits, including neurocognitive exams, blood draws, MRI/imaging capabilities, etc.
    • Local environmental health and safety program to pick up and dispose of sharps and hazardous/biological waste.

• Minimal/Hybrid

• • Sites that may be missing one or more of the components of a fully supported brain donation site
  • Minimal or hybrid sites may vary in their individual capabilities
  • Minimal brain donation sites may just consist of a private autopsy technician, pathologist or diener who procures the brain and ships the brain to a research site, with coordinating (talking with family and/or caregiver, transportation, help with mortuary arrangements, etc.) from a research/brain donation coordinator
  • See Craniotomy and Dissection procedures and Post-donation procedures sections for additional information

Legal and Administrative Requirements

• Documentation and inventory systems to have in place
  • Physical and scanned consent forms in database
    • Obtain informed consent with the brain donor prior
    • Should always be stored/accessible at site where brain is banked
    • For post-mortem consent of the individual, with legal next-of-kin (NOK)
    • DocuSign (with SMS capabilities)
      • Telephonic consent and dialogue to properly consent over the phone
      • See Responding to the page section for example form and script
    • Spanish and other language translations of all documents
  • Electronic data file access
    • Ex: REDCap (Research Electronic Data Capture) or similar 
    • Preferably a format that can be accessible through your phone so it’s easily accessible everywhere
  • Intake form/folder for individual brain donations
    • Keeps all relevant information for the case (e.g. dates, times, cause of death, medication lists, clinical questionnaires)
    • See Record keeping tab
• Have an IRB approve all documentation, forms and consents
  • See IRB tab
  • Check local and/or state laws
• Have a 24-hour pager or dedicated phone set up
  • Implement a pager call back system or phone number for death notifications
  • Depending on site/workload ability, 24/7 service vs during regular business hours +/- weekends
  • Educate donors and their family to call the number when the time comes, encourage to share with care team
  • Wallet cards or refrigerator magnets for donors and family that has the pager number and instructions on what to do at the time of death

• Establish Relationship with Clinicians/Dedicated Clinic Team and Neuropath Core
  • Clinicians to pre-consent individuals and collect longitudinal data by performing serial neurocognitive exams, draw blood, complete neuroimaging (depending on site capabilities), to increase research value
  • Neuropathology Core – establish pipeline for post-mortem brain tissue to go to histology and then to neuropathologists for diagnosis.
  • Screen for any prions in health history or with additional testing

• Family discussions and planning
  • Express that the participant is encouraged to let their family members know about their arrangements
  • Healthcare provider coordination

Brain donation cannot occur without assistance from next-of-kin or caregiver in notifying the responding brain donation program

Equipment Requirements

• Universal precautions should always be followed, and Personal Protective Equipment (PPE) should be worn at all times in both lab and autopsy suite, at any site:
  • Medical grade disposable gown
  • Shoe covers/booties
  • Goggles
  • Gloves; chemical resistant and/or medical grade sterile surgical gloves, double glove when possible
  • Face mask, N95
  • Long pants and closed toed shoes

Link for Equipment and Supplies for Brain Donations Across Sites: Equipment and Supply Requirements, all site types BG

Additional protocols for other solutions to be made and have on hand:

• To make 4% paraformaldehyde: paraformaldehyde protocol 1-13-2022 sw
  •  Should be kept in stock at 4C
• To make PBS + NaAzide (0.02%): PBS NaAzide solution protocol 6-23-2022 sw
  • Should be kept in stock at 4C if possible, room temperature is okay too for shorter periods of time

Extremely Important: Universal precautions should be used and proper PPE should be worn at every step involving the deceased donor and their brain tissue and any biofluids.

 

Module 3: Responding to the Page

Critical Timeline: Brain tissue must be preserved within 24 hours of death for optimal research value

What to do once you get paged 

• Immediate Actions Before You Respond to Death Notification
  • Notification procedures
    • Brain donation coordinator should have all intake forms available and access to database for calls portion
    • Respond as quickly as possible to the death notification to get things rolling
      • Call back within 20 minutes or as soon as possible
      • Prior to passing of the donor, instruct NOK or hospice nurse to call the pager again or call a second pager in case the first page isn’t responded to within 20 minutes. This is in case the first one didn’t go through, or any other malfunction occurred.
    • If the page message leaves a name of decedent, ensure you have consent documentation 
      • If you don’t have prior consent on file: prepare an electronic document on DocuSign for telephonic consent along and use the telephonic consent script 
        • Link to telephonic consent form: 2014-1526 Post-mortem Telephonic Authorization for Brain Donation 2-14-2023
        • Link to telephonic consent script: 2014-1526 Post-mortem Telephonic Authorization for Brain Donation Instructions 2-14-2023
        • Consent provided by NOK
        • If decedent is not enrolled in a study at your site (a donor from the community), follow internal protocols to decide if your site is able to assist in the brain donation of that individual
          • If yes, proceed with intake portion and post-mortem telephonic consenting
    • Important questions to ask first:
      • Is the deceased in hospice? If not, is there a police report or coroner case number?
        • A hospice nurse or coroner has to give the official time of death. You want to ensure there was no foul play by having either official arrive, declare the time of death and investigate potential cause of death.
        • Cause of death is important to note, especially if it may affect the brain in any way (any head trauma, etc).
        • Follow up question if unsure if they were on hospice care: did the decedent have a Do Not Resuscitate (DNR) order signed?
        • If there are no suspicions or concerns from either party, you’ll be allowed to continue with procurement of the brain. 
    • Other intake questions
      • It is beneficial to get a survey of the brain donor’s last 24 hours with a quick survey.
      • Example questions
        • • Did a code blue occur?
          • Was the subject on a respirator?
          • Did subject have any recorded fevers or infections?
          • Was the Donor cognitively alert during the 24 hours prior to passing?
          • Medication list from last 24 hours, including dosage and time administered?
          • Link to deceased subject call report: Deceased Subject Report UPDATED_8-27-24_ LG

This intake information may be useful in explaining any unexpected findings in the brain and gives a better understanding of the brain environment in the final hours before passing

• • • To help your transportation team, you should ask for:
      • • • Is the donor at a residence, assisted living type home, hospital morgue, etc.?
          • Is there any documentation your transport team should have or that you need to fax or email to said facility (ex. consent form or signed release)?
          • Any obstacles to access the donor (gate codes, security, stairs, small rooms, narrow hallways etc.)?
          • Position of deceased (laying in bed, in the bathroom, on the floor, etc.)
          • Approximate height and weight of the deceased
      • At this point, if you have only spoken with the hospice nurse or caregiver, ensure that you get in touch with the NOK to introduce yourself.
        • See Empathy training tab
    • Notify your Autopsy technician and transport team early on to get estimated times of arrival (ETAs) 
      • This will be usually after your initial intake call 
      • Make sure to update NOK or hospice nurse with ETA, as well as all other involved parties
      • See Transportation tab
• Other things to consider
  • To respect the family, you can offer to delay the transport if other family members would like to arrive to say goodbye or if they need more time for any reason
  • If brain donation cannot occur within a few hours or so, it’s best for the decedent to be moved to a place with refrigeration
    • May be able to use chosen mortuary, or if in hospital, hospital morgue
    • Refrigeration helps to delay decomposition
    • To respect the decedent and their family, they should be moved from the home or facility and into mortuary or brain donation program care
      • Some facilities have a time limit on when decedents must be picked up

Module 4: Craniotomy Procedure

All persons handling the decedent should do so with care, professionalism and dignity at all times during brain removal and transition into morgue or mortuary.

• • Occurs once the decedent has been transported to the place where the autopsy will occur
  • Diener, other trained autopsy technician or pathologist will be performing the procedure, with or without assistance by research coordinator
    • Link to Brain Removal Protocol: Updated UCI MIND Repository Brain Removal Protocol BG
    • See Pre-Donation Procedures and Requirements for additional supplies and equipment for autopsy portion
  • The craniotomy allows for open casket viewing of the decedents
    • The procedure is done in a respectful manner that preserves the facial integrity, with delicate incisions along the hairline that are sutured and aligned to maintain the decedent’s appearance.
    • Morticians can further cover any visible incisions with makeup (cosmetic repair)

• Fully Supported Sites 
  • Dedicated research coordinator will meet the transport team with the decedent, and diener at the site-affiliated medical center/autopsy suite for the craniotomy
    • If site does not have a research coordinator that assists with craniotomy, diener will perform all duties
  • Research coordinator may help with craniotomy set up, getting blood from the heart, clean up, transferring decedent to morgue, and other post-procedure tasks
    • Coordinator should arrive with specimen bucket, filled with wet ice if possible, and all other necessary supplies that are not already at the autopsy suite
      • Example: At UC Irvine, the coordinator is present for the craniotomy and is responsible for the brain dissection at a separate lab. The coordinator arrives at the hospital with intake folder, specimen bucket and pre-made bag of supplies for brain, blood and cerebrospinal fluid. Wet ice can be obtained at hospital.
  • Decedent should be placed laying in an open body bag on the autopsy table before moving forward with other steps

Most sites aliquot and bank one tube worth of plasma (EDTA treated) and serum (red top or other), additional serum tube drawn for infectious disease testing (HIV, Hepatitis).

• • Blood should be obtained prior to the craniotomy, but it is possible to obtain after
  • If the brain dissection protocol involves retaining any fresh frozen brain tissue or frozen biofluids, a blood sample should be submitted for infectious diseases testing and results should be documented.
    • If no way to obtain blood and/or process a serum tube for infectious disease testing, keep record that it was never tested for and put disclaimer for anyone who handles the tissue (diener, coordinator, via future tissue requests, etc.) to use universal precautions. 
    • If positive for an infectious disease, follow local institution procedures for disposal of frozen tissues and/or biofluids
• Post-mortem blood draw from heart protocol: UCI MIND Repository PM Blood Draw Protocol BG
  • Blood tubes should be placed on ice until they are able to be centrifuged and aliquoted
• Obtaining post-mortem cerebrospinal fluid
  • Can be performed by the diener/autopsy technician, if trained to do so
    • There can be various ways to obtain cerebrospinal fluid (CSF) post-mortem
  • After the top of the cranium is removed but brain is still attached to the body, a diener may obtain CSF with a spinal needle and syringe by gently moving the brain to the side and carefully accessing the spinal cord/column at an angle, a few centimeters below what is visible (being sure to not damage the delicate structures), and pulling up on the syringe plunger
    • If CSF is pink or at all bloody, sample can be spun down at the lab before being aliquoted
    • Can aim to take at least 5-10mL of CSF in a 15mL conical tube, place on ice until able to aliquot
  • Ultimately, one should defer to the diener’s trained capabilities for obtaining post-mortem CSF

Following the craniotomy, the brain should be received in a small, red biohazard bag and placed immediately on wet ice until it is able to be dissected

• Following brain and biofluid recovery, the research coordinator and/or diener can assist in moving the decedent into the morgue by using a gurney

Always keep mind to handle the decedent respectfully and with great care, as they are providing a generous gift to science

• • Decedent should be fully enclosed in body bag with name tag (with date of birth and date of death as well) attached to zipper near the head
  • Check to make sure the decedent and the bag is clean of any remaining blood, drainage, bone dust, etc. before closing up the body bag
    • It is also good to do a double check while cleaning up that no tools or sharps were left in the body bag or biohazard bag from the procedure
  • Set up gurney to be at the level of the autopsy table, with the wheels locked, and drag the edge of the body bag to pull the decedent carefully onto the gurney
  • Unlock the gurney and wheel the decedent to the morgue; find an open slot and fully pull out the tray
  • Again, align the gurney to the level of the tray and lock the wheels. Gently pull the bag so that the decedent is fully on the tray
  • Put all relevant paperwork, including any release papers, with the decedent for when they are taken into the mortuary’s care
  • Push the tray back in carefully and close the door

Depending on site/hospital decedent affairs operations, complete proper documentation and/or notify their team that a decedent was added to the morgue. If known, let them know what mortuary will be picking up. Notify the mortuary on the family of the donor’s behalf, after the craniotomy or dissection if possible

• Submit blood sample for infectious disease testing as soon as possible, before leaving the hospital (if blood lab is on medical center campus) with the brain and other biofluids
• The brain and biofluids can be transported in the specimen bucket, filled with wet ice, to the lab where the dissection will occur
  • Disinfect outside of bucket with hospital grade disinfectant or place in clean plastic bag

• Minimal/hybrid Supported Sites
  • At minimum, diener/autopsy technician should be able to remove brain and follow a whole brain fixation protocol
    • Refer to Craniotomy protocol above or the Dissection protocol section for whole/full brain fixation subprotocol.
  • Minimal/hybrid supported sites may be missing one or more of the capabilities listed above
    • Sites may use a funeral home or other autopsy lab in place of hospital affiliated autopsy suite, in these cases, defer to funeral director or local protocols regarding the use of the facility and/or transition of the decedent into the morgue or mortuary care
    • All supplies and autopsy equipment should be brought for the brain donation by coordinator and diener, unless pre-approved to use the contracted funeral home or other autopsy lab’s equipment and supplies
    • Pre-arrangements to have access to the facility should be in place. Ask if they can be used 24/7 if your site will be doing 24/7 brain donations

Module 5: Dissection Protocol

• • May vary based on site capabilities and/or capabilities of the autopsy technician and research coordinator
  • Some sites may have one coordinator performing the entire dissection procedure, at any time of the day
    • Coordinator must delicately balance keeping PMI in mind and working quicky, with careful attention to detail at all steps
    • If site only does brain donations during regular business hours, adjust steps accordingly, but other team members should be encouraged to help in the lab workflow

• Fully Supported Site
  • Brain donation programs with access to -80C freezers and dry ice in the workplace, equipment and supplies listed in Pre-donation procedures section, as well as dedicated autopsy technician and research coordinator to help with brain dissections
    • It is also extremely useful to have a computer connected to the internet in the lab space, in case of need to look up brain regions or structures for understanding and/or confirmation

Once brain and biofluids are brought to the lab, follow the link below for the UCI ADRC Brain Dissection protocol

• Link to dissection protocol: ADRC Brain Dissection Protocol 2025 BG

As mentioned previously in the Pre-donation procedures section, universal precautions should be followed, and proper PPE should be worn at all times when handling fresh brain tissue and biofluids

• • Steps should be completed in a biosafety cabinet or enclosed structure whenever possible to mitigate exposure of potentially infectious agents that can be in the brain environment

All steps in above protocol mentioning names of researchers are referring to pre-arranged tissue requests for the researchers’ specific projects. Brain donation programs should aim to be collaborative as much as possible, within reason considering PMI of brains for fresh tissue requests

• • Coronally sectioning the fresh/to-be-frozen tissue allows for better access to more brain subregions for future tissue requests to researchers
  • It is helpful to place the fresh coronal sections in plastic heat seal bags in proper anatomic position before placing on frozen metal plates, so that they freeze flat and not distorted in any way
  • Be mindful of touching too many other things in the lab with contaminated gloves. You can periodically spray your gloves with Envirocide or other disinfectant and wipe off the excess with a clean paper towel. You can then rinse your gloves with de-ionized (DI) water and dry again with a clean paper towel before touching the brain tissue
    • You should also rinse off your gloves with DI water after your gloves have been covered in fixative before touching the dissected hemisphere
    • You can also change to new gloves if felt more efficient
  • Be sure to note all relevant information, such as fixation and freezing times, any notable pathology (take pictures if possible), how many coronal sections were produced, from what coronals were regions dissected out, how many biofluid aliquots, etc.

For minimally supported sites with no access to -80C freezers or dry ice, the brain must be fixed whole

• Full brain fix protocol:
  • Fix the entire brain by threading a piece of post-mortem thread (longer than the diameter of the specimen bucket) underneath the vertebral-basilar artery to suspend the brain in a closed 172oz specimen bucket filled with at least 4L of 10% Formalin
    • This ensures that the brain does not rest on the bottom of the bucket and warp its morphology
    • A thin hairnet can also be used to suspend the brain, secured by the cap of the bucket

For sites with dry ice and ultra-cold capabilities, but coordinator or autopsy technician is not yet trained on dissection, fixed and frozen tissue can still be banked

• If autopsy technician and research coordinator do not feel comfortable coronally sectioning fresh tissue, they may bisect the brain and freeze one hemisphere and fix the other
  • Frozen hemisphere can be coronally sectioned at a later time by placing in -20C freezer overnight and sectioning with long autopsy knife
  • Follow step 7 on the above Dissection Protocol link for bisection of hemispheres

Advanced Dissection Procedure, Fully Supported Site

• • Other brain donation programs have more involved protocols that are aimed to result in thinner (~4mm), more uniform coronal sections that allow for more brain sub regions to be accessible and identifiable.
    • Link to UM1 Dissection Protocol: [Draft 1.3] UCI Rapid Autopsy Protcol_01-09-2024
  • This particular protocol also involves flash freezing the brain coronals in dry ice and 2-methylbutane, between coated metal plates, resulting in very flat and thin coronal sections
    • Thinner frozen coronal sections are more likely to break; it can be beneficial to store these coronal sections in vacuum seal bags, to help keep the orientation of the coronal if it breaks into pieces

If you have any additional questions regarding dissection protocols, please refer to the Contact us page

Module 6: Post-Donation Procedures

After the brain donation is complete, it is important to thoroughly clean and disinfect the lab space, safely dispose of all sharps, and check that all brain tissue and biofluids have been properly stored in the freezers and fridges. After carefully removing PPE, it is encouraged to go to the bathroom and thoroughly wash hands and forearms in case of any residual contamination.

• Contacting the mortuary for pick up
  • If not done already, the coordinator or diener should contact the chosen mortuary in timely manner on behalf of the family
    • Keep in mind some places are not 24/7, and most mortuaries will not pick up the decedent unless their contract is paid for
    • If the decedent is at your facility/morgue, you are the one who knows where the decedent is located, and therefore is best to assist in coordinating pick up along with site/hospital-related decedent affairs department
    • If the craniotomy occurred at the chosen mortuary, you may still have to notify the funeral director or other staff that the craniotomy has been completed, and they can begin their process with the decedent
    • May need additional release paperwork signed, work with your local decedent affairs or with mortuary regarding getting this signed
      • Can make additional DocuSign form to get signature from next-of-kin, should not need IRB approval
• Family Support and Communication
  • • Update the family/NOK along the process of brain donation and upon completion (keep in mind time of day)
    • Let them know that everything went well and thank them again for supporting their loved one’s brain donation and the research study
    • Without the notification call from the NOK or the other caregivers involved, the brain donation would have never happened or been as successful
    • May be good to confirm a mailing address and follow up with a correspondence letter from the study team
• Notification to study team of donor
  • If the individual was enrolled in a longitudinal study as part of your site’s clinical team, send a health secure email to the team to let them know that they have passed and donated their brain
  • They may begin to prepare the decedent’s file and follow up with the family at a later time
  • This lets them know to cancel any future appointments with the decedent as well
• Documentation completion
  • • Keep all pertinent times, brain weight, and other relevant information in an intake form or folder, along with the signed consent form
    • Complete any online documentation and upload to the database, using your site-specific internal record files

See record keeping tab for more details

• Post-donation tissue procedures
  • Fully Supported Site
    •  After a brain donation, all frozen sections and biofluids should be put away in a box and placed in a freezer rack to become part of the frozen inventory
    • Fixed brain tissue can be switched from the fixative (either 10% neutral buffered formalin or 4% paraformaldehyde) after at least 2 weeks.
      • Fixed tissue can be rinsed in a bucket, in a sink, for at least 15-20 minutes
        • Pour off all water and replace with PBS+NaAzide (0.02%) and put in 4C fridge until the brain is ready to be sampled by the neuropathologist
        • Site-specific workflow may differ depending on relationship with neuropathology and histology teams
  • Minimally/Hybrid Supported Site
    • If the neuropathology and/or histology team is not a part of your site, the procured brains would have to be shipped at a later point out to those contracted teams
    • If site has dry ice, but no -80C freezer, frozen tissue and biofluids would have to be shipped as soon as possible to the destination site to be stored.

• Shipping Biological samples – Must include two Category B labels on box, on adjacent corners
  • Shipping fixed brains
    • Only ship fixed brains to destination site after at least 2 weeks of fixation. This will help ensure that the brain’s morphology would not be affected wile while shipping
    • Wrap tissue in 2-3 durable paper towels, soaked in either what fixative it was in, 10% formalin or 4% paraformaldehyde, or PBS+NaAzide (0.02%)
    • Place in properly labeled double Zip Lock bags or clear sealable biohazard specimen bags and close tightly without getting liquid all over, then place sealed bag in specimen bucket and ship in an insulated box with enough stuffing to keep the bucket secure
  • Shipping frozen tissue
    • Ship with ample dry ice (at least 48 hours’ worth or ~25lbs, as long as all the tissue is covered)
    • A frozen hemisphere can be shipped in double Zip Lock bags or a sealed biohazard frozen specimen bag, wrapped in an absorbent pad
    • Shipping bagged brain coronals: place coronals in a box and wrap in thin layer of absorbent pads, to help eliminate dry ice chunks from cracking the coronals