Usefulness of Intracranial CT Angiography with Spiral CT in Brain Death - A Preliminary Report -

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1 Usefulness of Intracranial CT Angiography with Spiral CT in Brain Death - A Preliminary Report - Jong-Ho Park, M.D., Hong-Ki Song, M.D., Dae-Young Yoon, M.D. Department of Neurology and Radiology*, Hallym University College of Medicine Background : The increasing implementation of organ transplantation requires an unequivocal diagnosis of brain death for moral and legal reasons. Among instrumental investigations, angiographic demonstration of absent intracranial blood flow is considered to be the most reliable test in diagnosing brain death. This test should be easily accessible since most brain dead patients are vitally unstable and have various life-supporting equipments besides their beds. To investigate the usefulness of an intracranial CT angiography (CTA) for the diagnosis of brain death, we performed CTA in comatose patients who were either clinically brain dead or not. Methods : Fourteen comatose patients (11 male and 3 female, aged from 17 to 63 years) with various brain insults were included in this study. Eleven patients were clinically brain dead. Among the remaining three patients, one showed subtle withdrawal movements in one extremity to noxious stimuli with absent brainstem reflexes, and the other two showed multifocal myoclonic seizures. CT scanning was performed with a table speed of 2 mm/sec, twenty seconds after beginning an injection of contrast media. The data were reformatted by maximum intensity projection (MIP) and shaded surface display (SSD) after the reconstruction of a 1 mm interval. A portable electroencephalography (EEG) was also taken serially in clinically brain dead patients except one. Results : Intracranial arterial blood flow was preserved in those who showed either a seizure, abnormal posture or intact brainstem reflexes. On the other hand, intracranial arteries were not visualized in all brain dead patients with electrocerebral silence (ECS) on their EEG with the exception of one patient whose EEG was difficult to determine a ECS due to excessive mechanical artifacts. However, in the clinically brain dead patients, the intracranial arterial flow was preserved in those who suffered from widespread brainstem and cerebellar infarction or whose EEG demonstrated periodic lateralizing epileptiform discharges or a burst suppression pattern. Conclusions : Intracranial CTA seems to be a safe and noninvasive procedure for the determination of brain death that produces fast, reliable, and easy-to-interpret results. It can be used as an alternative method to the EEG when the EEG is not possible or difficult to interpret due to artifacts. J Kor Neurol Ass 17(4):554~560, 1999 Key Words : Brain Death, Intracranial CT Angiography Hong-Ki Song, M.D. 554 Copyright 1999 by the Korean Neurological Association

2 Table 1. Clinical and CT angiographic findings in 14 subjects Case Age/Sex Diagnosis Clinical State EEG CT Angiography 1 46/M Cerebral hypoxia BD ECS No CBF 2 38/M Cerebral hypoxia Seizure* Diffuse slowings preserved CBF BD ECS No CBF 3 49/F Cerebral hypoxia BD Burst suppression preserved CBF 4 57/M Basilar artery occlusion BD Many artifacts preserved CBF 5 45/M Cerebral hypoxia Seizure* -- preserved CBF 6 23/M ARDS BD ECS No CBF 7 38/M Lt. BG ICH with IVH BD ECS No CBF 8 35/M Lt. SDH BD ECS No CBF 9 33/M Rt. SDH BD ECS No CBF 10 17/M Lt. SDH BD ECS No CBF 11 19/M Cerebral hypoxia BD Sl Artifacts? No CBF 12 63/F Rt. EDH BD -- No CBF 13 25/M Cerebral hypoxia BD BiPLEDs preserved CBF 14 17/F Lt. SDH, SAH Withdrawal to pain -- preserved CBF BD ; brain dead ECS ; electrocerebral silence CBF ; cerebral blood flow BiPLEDs ; bilateral periodic lateralizing epileptiform discharges ARDS ; acute respiratory distress syndrome SDH ; subdural hematoma EDH ; epidural hematoma ICH ; intracerebral hemorrhage IVH ; intraventricular hemorrhage SAH ; subarachroid hemorrhage * ; multifocal myoclonic seizure J Kor Neurol Ass / Volume 17 / July,

effacement. There is no evidence of cerebral arterial flow by MIP and SSD on CTA(right). A Figure 2-A, B. Case 2.

3 Figure 1. Case 1. Cerebral hypoxia due to asthmatic attack Spiral CT with enhancement(left) shows brain parenchymal swelling with gyral effacement. There is no evidence of cerebral arterial flow by MIP and SSD on CTA(right). A Figure 2-A, B. Case 2. Cerebral hypoxia due to epiglottitis (A) Initial CTA shows preserved intracranial arterial flow by MIP and SSD. (B) Seven days later, follow up CTA shows loss of cere - bral arterial flow. B 556 J Kor Neurol Ass / Volume 17 / July, 1999

and SSD(right) shows well-enhanced and preserved cerebral arteries, respectively.

Basilar artery occlusion (A) Spiral CT with enhancement shows low intensity over brain

4 Figure 3. Case 3. Cerebral hypoxia due to hanging(suicide) Spiral CT with enhancement(left) and CTA by MIP and SSD(right) shows well-enhanced and preserved cerebral arteries, respectively. A Figure 4-A, B. Case 4. Basilar artery occlusion (A) Spiral CT with enhancement shows low intensity over brain stem, cerebellum, and posterior temporal regions. Obliteration of fourth ventricle and sulci markings are also noted. (B) CTA by MIP shows well enhanced and preserved cerebral arterial flow. B J Kor Neurol Ass / Volume 17 / July,

5 Figure 5. Case 5. Cerebral hypoxia due to bronchospasm Spiral CT with enhancement(left) and CTA by MIP and SSD(right) show well-enhanced and pre - served cerebral arteries, respectively. 558 J Kor Neurol Ass / Volume 17 / July, 1999

6 Table 2. ( ) (1) ( ) ( ) (2) ( ) (3) ( ) ( ) [ ( )( ( ) ( ) ] (4) [ ( ) 32 o C ] (5). (1) (2) (3) (4) ( ) :. () ( : light reflex) () ( : corneal reflex) () ( : oculo-cephalic reflex) () ( : vestibular-ocular reflex) () ( : cilio-spinal reflex) () ( : gag reflex) () (cough reflex) (5) ( ) (6) % (O 2 ) 95% (O 2 )5% (CO 2 )10 100% (O 2 )6 l /min, 10 ( PaCO 2 )50torr,. (7) : (1) (6) 6 (8) : (7) 30 (9) , (7) 48, 1 (8) (7) 24. J Kor Neurol Ass / Volume 17 / July,

7 11. Kiyoshi I, Takehide O, Toshibumi K, Genzo S, Motonobu K, and Yasuko S Brain Death: MR and MR Angiography. AJNR 1996;17: ,,. C T C T : 1995 ; 33 ( 2 ): Schwartz RB. Neuroradiological applications of spiral CT. Semin Ultrasound, CT, MR 1992;13: Aoki S, Sasaki Y, Machida T, Ohkubo T, Minami M, Sasaki Y. Cerebral aneurysms : detection and delineation using 3-D CT angiography. AJNR 1992;13: Napel S, Marks MP, Rubin GD, et al. CT angiography with spiral CT and maximum intensity projection. R a d i o l o g y 1992 ; 185 : Schwartz, RB. Tice HM, Hooten SM, Hsu L, Stieg PE. Evaluation of cerebral aneurysms with helical CT : correlation with conventional angiography and MR angiography. Radiology 1994;192: A. Paolin, A. Manuali, F. Di Paola, F. Boccaletto, P. Caputo, R. Zanata, G. P. Bardin, G. Simini. Reliability in diagnosis of brain death. Intensive Care Med ; 2 1 : R. Nau, H. W. Prange, J. Klingelhofer, B. Kukowski, D.. Sander, R. Tchorsch, and K. Rittmeyer. Results of four technical investigations in fifty clinically brain dead patients. Intensive Care Med 1992;18: Holzman BH, Curless RG, Sfakianakis GN, Ajmone- Marsan C, Montes JE. Radionuclide cerebral perfusion in determination of brain death in children. N e u r o l o g y 1985;16: H. Wieler, K. Marohl, K. P. Kaiser, P. Klawski, and H. Frossler. Tc-99m HMPAO Cerebral Scintigraphy. A Reliable, Noninvasive Method for Determination of Brain Death. Clinical Nuclear Medicine 560 J Kor Neurol Ass / Volume 17 / July, 1999

Table 1.Summary of 12 Patients with Brain Death and Deep Coma: Clinical Findings Patients No. Age/Sex Underlying Cause Study No.

3 9 5 Table 1.Summary of 12 Patients with Brain Death and Deep Coma: Clinical Findings Patients No. Age/Sex Underlying Cause Study No. Brain Stem Reflex EEG Clinical Diagnosis 01 40/M Trauma 01 ECS Brain