Presentation
Motor vehicle accident: pedestrian vs. truck 10 days ago. Major abdominal and pelvic lesions. Evolving with seizures and fever in the ICU.
Patient Data
There is new global effacement of the sulci in both cerebral hemispheres as well as the sylvian fissures bilaterally. No acute intracranial hemorrhage or cortical infarct. Grey-white differentiation is maintained. Normal sulcal and ventricular pattern. No midline shift. No acute fracture or suspicious bony lesion. The imaged paranasal sinuses and mastoid air cells are aerated.
There is wide diffuse abnormal signal involving all lobes of the hemispheres, characterized by cortical swelling and restricted diffusion (particularly of cortex, subcortical white matter, and deep grey matter - most notably the thalami). Generalized brain swelling is present with effacement of the basal cisterns.
Within the limitations of this scan (which does not include MRV or MRA) dural venous sinuses appear normal, and flow voids are present in the major intracranial arteries.
Air-fluid levels in both sphenoid sinuses. The orbits and calvarium appear unremarkable.
Brain death was considered and was hard to evaluate in the scenario of a large amount of sedation. An angiographic confirmation was proposed.
No intradural cranial blood flow can be demonstrated, confirming brain death.
Conclusion: Findings indicative of brain death.
Case Discussion
Brain death refers to the irreversible end of all brain activity and is usually assessed clinically. However, in some cases such as this one, confirmation in made mandatory and DSA angiography figures as one of the options: no forward flow above the terminal ICA, this occurs because the intracranial pressure exceeds the pulse pressure in the carotids and vertebral arteries.
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