Background: Severe strokes are now the leading cause of brain death (BD). Potential donors require intensive care unit (ICU) management to protect organs while waiting for possible progression to BD. There are no established predictive factors to identify patients with a high probability of presenting BD. We set out to determine predictive factors of BD progression in patients with severe stroke and to build a prognostic score to help neurologists manage such patients.Method: We retrospectively collected clinical (sex, age, initial Glasgow score, initial arterial pressure, cardiovascular risk factors), and paraclinical (lesion volume, presence of herniation, hydrocephalus on brain imaging) data of consecutive severe stroke patients with a potential progression to BD through the hospital organ procurement and transplant coordination system in five centers in Lorrain (France) between 1st January 2012 to 31 December 2013. Final endpoint was adjudicated BD. Statistical comparison of each factor was made between patients with and without BD. A prognostic score was made based onfactors significantly associated with BD.Results: Of 400 included patients 91 (23%) presented adjudicated BD. Initial Glasgow score?6 (p<0.0001), lesion volume >65 mL (p=0.040), herniation (p=0.038), hydrocephalus (p<0.0001), initial systolic blood pressure >150 mmHg (p=0.034) and past history of alcohol abuse (p=0.002) were significantly associated with BD progression. In patients with quantifiable lesion volume the likelihood of presenting BD was 6 times greater for those with a score of 2 to 3 vs. 0 to 1 (p=0.006) and 28 times greater for a score of 4 to 6 vs. 0 to 1. In patients with unquantifiable lesion volume (subarachnoid hemorrhage and brain stem infarction) the likelihood of presenting BD was 2 times higher for those with a score of 2 vs. 0 to 1 (p=0.096) and 8 times higher for those with a score of 3 to 5 vs. 0 to 1