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Computed tomographic angiography and perfusion in the diagnosis of brain death
R Bohatyrewicz1, M Sawicki, A Walecka
1Pomeranian Medical University Szczecin, Poland.
Insights
Computed tomographic angiography (CTA) and computed tomographic perfusion (CTP) accurately confirm brain death (BD) by showing absent cerebral perfusion. These noninvasive methods offer a viable alternative to conventional angiography for diagnosing BD.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Polish brain death criteria mandate instrumental tests when clinical exams are insufficient.
- Cerebral perfusion testing is preferred, with digital subtraction angiography (DSA) as the gold standard.
- DSA is invasive and costly; CT-based methods are not yet standard in Poland for brain death diagnosis.
Purpose of the Study:
- To determine the accuracy of computed tomographic angiography (CTA) and computed tomographic perfusion (CTP) in confirming brain death.
- To evaluate CTA and CTP as potential noninvasive alternatives to conventional angiography.
Main Methods:
- 24 patients meeting clinical brain death criteria were examined.
- CTA assessed brain perfusion using French Society criteria (absence of M4 MCA and deep cerebral vein opacification).
- CTP measured regional cerebral blood volume and flow.
Main Results:
- CTA demonstrated absent opacification of M4 MCA segments and deep cerebral veins in all patients.
- CTP revealed zero regional cerebral blood volume and flow in all cases.
- Conventional angiography confirmed cerebral circulatory arrest in all 24 patients.
Conclusions:
- CTA and CTP show promise as reliable radiological examinations for diagnosing brain death.
- These CT-based techniques may serve as noninvasive alternatives to conventional cerebral angiography.
- Further validation could lead to wider acceptance in brain death diagnostic protocols.
Introduction:
According to Polish brain death (BD) criteria, instrumental confirmatory tests should be used in certain clinical situations, particularly any case for which clinical examinations seem inadequate. Electrophysiological tests are often unavailable. Therefore, cerebral perfusion testing is the method of choice with four-vessel digital subtraction angiography (DSA), the gold standard. Unfortunately, DSA is an expensive and invasive examination that requires an experienced neuroradiologist and the availability of an angiography suite. Recently, multirow computed tomographic devices became available, even in smaller hospitals in Poland. Despite this fact, computed tomographic angiography (CTA) and computed tomographic perfusion (CTP) are not accepted in BD diagnosis protocols in Poland because of limited experience and a lack of widely accepted criteria. In this situation, we started a multicenter trial to determine the accuracy of CTA and CTP to confirm BD.
Methods:
We examined 24 patients who fulfilled standard clinical BD criteria. We recognized the absence of brain perfusion in CTA examination following the criteria proposed by the French Society of Neuroradiology, namely, the absence of opacification of M4 middle cerebral artery segments (M4-MCA) and of deep cerebral veins.
Results:
In all of our patients, CTA showed absence of opacification of M4 segments and of deep cerebral veins. In addition, three patients had CTA showing weak opacification of A2 segments of the anterior cerebral artery (A2-ACA) and M2 or M3-MCA. Opacification of the basilar artery or of the posterior cerebral arteries was not noted in any case. In all patients, CTP revealed zero values of regional cerebral blood volume and regional cerebral blood flow. Conventional angiography confirmed cerebral circulatory arrest in all 24 cases.
Conclusion:
CTA and CTP seem to be promising radiological examinations for the diagnosis of BD. They may be noninvasive alternatives to conventional cerebral angiography, and to the other instrumental confirmatory tests, that are unavailable or inadequate.
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