Pitfalls in Brain Death Diagnosis: A Case Report

Abstract

Although there are distinct guidelines in nearly all countries, a reliable secure assessment of brain death in cases with open head injury can be challenging. We present a case of a 32-year-old man with severe head injury after intracranial penetration of a grindstone fragment. As the injury led to destruction of nearly the whole greater wing of the right sphenoid bone and parts of the right orbit, the examination of brainstem reflexes and the confirmation of brain death was unfeasible. On day 2, all clinical criteria of brain death (coma, absence of brainstem reflexes, apnea) were fulfilled. In addition, there was an extinction of brainstem auditory (BAEP) and cerebral (N20) components of median nerve somatosensory evoked potentials, while electroencephalogram (EEG) activity was still present. In the following days, a persisting EEG activity was obtained. Thus, an irreversible loss of whole brain functions could not be proved. As the patient had agreed to organ donation in case of brain death several years ago, ancillary methods to test the cessation of cerebral blood flow were mandatory. However, in this patient these methods turned out either to be doubtful or unavailable. For example, values of transcranial Doppler ultrasonography are not reliable in cases with open head injury. Due to a progressive septic state, time was running out to get the radiopharmaceutical agent for a cerebral scintigraphy (delivery time about 7 days, as the radiopharmaceutical agent was not in stock). Referring to the actual German guidelines, we had no legitimating indication for a cerebral angiography. Finally, the patient died of sepsis. We discuss the widening of the German guidelines in assessing brain death with the fast and low-risk method of cerebral computed tomography-angiography (CTA) to confirm diagnosis of brain death.

Keywords

brain death - brain injury - computed tomography (CT) angiography

• References

• 1 Wertheimer P, Jouvet M, Descotes J. Diagnosis of death of the nervous system in comas with respiratory arrest treated by artificial respiration. Presse Med 1959; 67: 87-88
• 2 Mollaret P, Goulon M. Le coma dépassé. Rev Neurol 1959; 101: 3-15
• 3 Schwab RS, Potts F, Bonazzi A. EEG as an aid in determining death in the presence of cardiac activity (ethical, legal and medical aspects). Elektroencephogr Clin Neurophysiol 1963; 15: 147-148
• 4 Frowein RA, Euler KH, Karimi-Njad A. Grenzen der Wiederbelebung bei schweren Hirntraumen. Langenbecks Arch Klin Chir Ver Dtsch Z Chir. 1964; 308: 276-281
• 5 Wissenschaftlicher Beirat der Bundesärztekammer. Richtlinien zur Feststellung des Hirntodes. Dtsch Arztebl 1998; 30: 1861-1868
• 6 Schlake HP, Roosen K. Diagnose des Hirntodes. In: Der Hirntod als der Tod des Menschen. 2nd ed. DSO Neu-Isenburg, 2001: 28–47
• 7 Grigg MM, Kelly MA, Celesia GG, Ghobrial MW, Ross ER. Electroencephalographic activity after brain death. Arch Neurol 1987; 44: 948-954
• 8 Pohlmann-Eden B, Dingethal K, Quintel M. Dissoziative neurophysiologische Befundkonstellationen im Hirntod-Syndrom. Intensivmed 1993; 30: 46-51
• 9 Schlake HP, Böttger IG, Grotemeyer KH, Husstedt IW, Brandau W, Schober O. Determination of cerebral perfusion by means of planar brain scintigraphy and 99mTc-HMPAO in brain death, persistent vegetative state and severe coma. Intensive Care Med 1992; 18: 76-81
• 10 Spudis EV, Penry JK, Link Jr AS. Paradoxical contributions of EEG during protracted dying. Arch Neurol 1984; 41: 153-156
• 11 Burger R, Schlake HP, Seybold S, Reiners C, Bendszus M, Roosen K. [Value of transcranial doppler ultrasonography compared with scintigraphic techniques and EEG in brain death]. Zentralbl Neurochir 2000; 61: 7-13
• 12 Recommendations du conseil médical et scientifique de l'etablissement Francais des Greffes. Les techniques d'angiographie dans le diagnostic de la mort encéphalique. Délibération 2000;12: dossier S3 D2
• 13 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: 641-647
• 14 Combes JC, Chomel A, Ricolfi F, d'Athis P, Freysz M. Reliability of computed tomographic angiography in the diagnosis of brain death. Transplant Proc 2007; 39: 16-20
• 15 Frampas E, Videcoq M, de Kerviler E , et al. CT angiography for brain death diagnosis. AJNR Am J Neuroradiol 2009; 30: 1566-1570
• 16 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: 1911-1918
• 17 Escudero D, Otero J, Marqués L , et al. Diagnosing brain death by CT perfusion and multislice CT angiography. Neurocrit Care 2009; 11: 261-271
• 18 Bohatyrewicz R, Sawicki M, Walecka A , et al. Computed tomographic angiography and perfusion in the diagnosis of brain death. Transplant Proc 2010; 42: 3941-3946