Brain Dead or Not? Diagnostic Dilemma Following Severe Traumatic Brain Injury

Introduction: Brain death, or the irreversible cessation of function of the brain, is commonly defined by clinical neurological examination. While clinical examination remains the standard for determining brain death, and is the accepted method of determining brain death in most countries, there are certain situations when clinical criteria may not be sufficient and confirmatory testing is required. We describe a case of severe traumatic brain injury (TBI) with multiple facial and skull fractures where computed tomographic (CT) angiogram failed to yield a definite result of brain death.

Case Description: A 28-year-old man was admitted following a road traffic accident with a Glasgow Coma Scale of 3/15 and fixed pupils. CT brain revealed uncal herniation, diffuse cerebral edema with associated multiple facial and skull fractures. The patient was treated in the intensive care unit with intracranial pressure monitoring. Extensive facial injuries made the examination of cranial nerves difficult. A CT angiogram was performed to determine cerebral perfusion and to confirm brain death 72 hours following a refractory raised ICP and despite maximal medical management.

Discussion: For the confirmation of brain death by CT angiogram, a 7-point system is used to evaluate opacification of the pericallosal arteries, middle cerebral arteries, internal carotid veins, internal cerebral vein, basilar artery, and great cerebral vein postcontrast injection. CT angiogram in this occasion revealed contrast in the cortical surface and in the cerebral vasculature suggestive of cerebral perfusion, contrary to the clinical picture.

Conclusion: We emphasize the fact that in this clinical setting, CT angiogram may be misleading and has to be interpreted carefully. Cerebral perfusion in this circumstance does not necessarily reflect physiological cerebral function. This management dilemma may also affect the duration and continuity of intensive care in an otherwise brain dead individual.