Letters to Editor
Samuele Ceruti, Marco Previsdomini DSA is considered as the gold standard; however, CTA is equally
Department of Intensive Care Medicine, Ospedale Regionale di
Bellinzona e Valli, Intensive Care Unit, Via Ospedale 12, 6500
Bellinzona, Switzerland occurrence; however, many cases of brain death are left
E-mail: samuele.ceruti@eoc.ch
REFERENCES
1. Velmahos GC, Degiannis E, Hart K, Souter I, Saadia R. Changing profiles
in spinal cord injuries and risk factors influencing recovery after penetrating
injuries. J Trauma 1995;38:334-7.
2. Peacock WJ, Shrosbree RD, Key AG. A review of 450 stab wounds of the
spinal cord. S Afr Med J 1977;51:961-4.
3. McCarron MO, Flynn PA, Pang KA, Hawkins SA. Traumatic Brown-
Squard-plus syndrome. Arch Neurol 2001;58:1470-2.
4. Bondurant FJ, Cotler HB, Kulkarni MV, McArdle CB, Harris JH Jr. Acute
spinal cord injury. A study using physical examination and magnetic
resonance imaging. Spine (Phila Pa 1976) 1990;15:161-8.
5. Gray TL, Karagiannis A, Crompton JL, Selva D. Self-inflicted blindness
and Brown-Squard syndrome. J Neuroophthalmol 2003;23:154-6.
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Brain death: Diagnostic
clues on imaging
Sir,
Brain death refers to the irreversible loss of cerebral and
brainstem functions with the cessation of intracerebral blood
flow. The recognition of brain death is important as once it
is ascertained, the life supports can be withdrawn and organ
harvesting can be planned.
Recommendations for the declaration of brain death proposed
by America Academy of Neurology[1] mandates fulfillment of
clinical criteria along with one ancillary test.
The ancillary techniques involve either measuring the
neurophysiological function of the brain or measuring the
cerebral blood flow. Digital subtraction angiography (DSA),
computed tomography angiography (CTA), transcranial Doppler
(TCD), and radionuclide perfusion tests measure the cerebral
blood flow.
372
efficient and noninvasive in determining brain death.
In the setting of trauma, brain death is not an uncommon
unrecognized thus providing unnecessary treatment and
indiscriminate use of life-supporting devices. We came across four
patients with polytrauma who were diagnosed brain dead with
DSA and/or CTA done for a different purpose in our department.
Two patients had severe orofacial injuries with uncontrollable
bleeding, and were taken for emergency DSA. Both of them
showed contrast extravasations from branches of the external
carotid artery which were embolized. Incidentally, nonopacification
of the bilateral internal carotid artery (ICA) was noted in one
patient and nonclearance of the contrast with layering from
both ICAs in the other patient, which raised the suspicion of
brain death and was promptly conveyed to the treating surgeon.
A subsequent clinical examination showed a positive apnea test
with unresponsiveness to any external stimuli. Brain stem reflexes
could not be reliably elicited in both patients as there were severe
orofacial injuries. Despite the resuscitative measure, both patients
died within 8 h of DSA. In the other two patients, CTA of the brain
was performed for evaluation of intraventricular and subarachnoid
hemorrhages as they presented in an unconscious state. CTA in
both these patients revealed the nonopacification of the bilateral
ICA, which raised the suspicion of brain death. A subsequent
clinical examination also showed a positive apnea test with absent
brain stem reflexes which confirmed brain death in both patients.
Both patients died within 7 h of CTA.
The summary of imaging findings of brain death in our case
series is follows:
DSA
1. Nonopacification of bilateral ICAs [Figure 1a and b]
2. Nonclearance and layering of the contrast from the bilateral
ICA on delayed frames indicating stasis
a b
Figure 1: DSA of a 16-year-old male patient. (a) Selective left
common carotid artery (CCA) angiogram shows the opacification
of only the proximal part of the ICA with distal nonfilling (arrow).
(b) Selective right CCA angiogram shows nonfilling of the distal
ICA (white arrow) with an active leak from the internal maxillary
artery (black arrow)
Journal of Emergencies, Trauma, and Shock I 5:4 I Oct - Dec 2012

a b
Figure 2: CTA of a 10-year-old male patient. (a) Coronal MIP image shows the nonopacification of the bilateral ICA and intracranial
arteries. (b) Axial section showing the nonopacification of intracranial arteries and left frontoparietal hematoma (arrow). (c) Axial section
at the level of orbits shows bilateral prominent superior ophthalmic veins (arrow). There is normal opacification of bilateral superficial
temporal arteries (arrowhead) suggestive of an adequate technique of CTA. (d) Volume rendered image showing the nonopacification
of distal parts of the bilateral ICA (arrows)
3. Stasis filling of horizontal segments of bilateral middle
cerebral arteries.[2]
CTA
1. Nonopacification of the bilateral ICA and intracerebral
branches [Figure 2a and b]
2. Normal opacification of extracranial vessels such as
superficial temporal arteries [Figure 2c]
3. Prominent bilateral superior ophthalmic vein enhancement
[Figure 2c].
The proposed cause of the nonfilling of the ICA in brain death
is increased intracranial tension. The development of high
resistance to the flow leads to nonopacification and/or stasis.
Though DSA is considered the gold standard,[3] it is invasive,
expensive, and time consuming, and needs expertise and transfer
of patients to the radiology department. CTA being noninvasive is
a viable alternative. Dupas etal.[4] proposed a CTA scoring method
analyzing the opacification of seven intracranial vessels. Frampas
etal.[2] modified the criteria and proposed a simpler scoring system
using four vessels and concluded that the four-point scoring appears
highly sensitive for confirming brain death, maintaining a specificity
of 100%. Being noninvasive and less time consuming, it could
possibly replace DSA.[4] However, this modality is not well validated,
and sensitivity also varies widely between various studies. Also, in
comparison with DSA, the divergence rate was found to be 30%
for CTA.[5] Moreover, as both these modalities are based on the
demonstration of the absence of cerebral perfusion due to raised
intracranial tension, false negative results can occur in conditions
where intracranial pressure is lowered by some decompressive
mechanism like craniotomy, fracture, and ventriculoperitoneal
shunt, and in young infants, with open fontanalles and sutures.
Both these modalities also require the administration of the contrast
which may provoke allergic reactions, or renal damage, and possibly
increased transplant rejection.[6] Moreover, false positive cases have
also been reported for CTA.[7]
We feel that in the setting of polytrauma with a low Glasgow
coma scale, the DSA/CTA when done must be carefully assessed
for signs of brain death. The early recognition of brain death
Journal of Emergencies, Trauma, and Shock I 5:4 I Oct - Dec 2012
Letters to Editor
c d
facilitates organ harvesting and termination of unnecessary
treatment and life support.
Aruna R. Patil, Atin Kumar,
Shivanand Gamanagati, Jeyaseelan
Department of Radiology, Jai Prakash Narayan Apex Trauma Centre,
All India Institute of Medical Sciences, New Delhi, India
E-mail: dratinkumar@gmail.com
REFERENCES
1. Wijdicks EF, Varelas PN, Gronseth GS, Greer DM; American Academy
of Neurology. Evidence-based guideline update: Determining brain death
in adults: Report of the Quality Standards Subcommittee of the American
Academy of Neurology. Neurology 2010;74;1911-8.
2. Frampas E, Videcoq M, de Kerviler E, Ricolfi F, Kuoch V, Mourey F,
etal. CT angiography for brain death diagnosis. AJNR Am J Neuroradiol
2009;30:1566-70.
3. Vatne K, Nakstad P, Lundar T. Digital subtraction angiography (DSA)
in the evaluation of brain death. A comparison of conventional cerebral
angiography with intravenous and intra-arterial DSA. Neuroradiology
1985;27:155-7.
4. Dupas B, Gayet-Delacroix M, Villers D, Antonioli D, Veccherini MF,
Soulillou JP. Diagnosis of brain death using two-phase spiral CT. AJNR
Am J Neuroradiol 1998;19:641-7.
5. Combes JC, Chomel A, Ricolfi F, dAthis P, Freysz M. Reliability of
computed tomographic angiography in the diagnosisof brain death.
Transplant Proc 2007;39:16-20.
6. Wijdicks EF. Determining brain death in adults. Neurology 1995;45:1003-11.
7. Greer DM, Strozyk D, Schwamm LH. False positive CT angiography in
brain death. Neurocrit Care 2009;11:272-5.
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