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Published on: April 17, 2020
Pitfalls in brain death diagnosis: a case report.
Daniel Ruess1, Bernhard Rieger, Roland Goldbrunner
1Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany. daniel.ruess@uk-koeln.de
Summary
Diagnosing brain death in severe open head injuries is challenging. This case highlights the need for advanced imaging like CT angiography to confirm cessation of brain function when clinical signs are obscured.
Area of Science:
- Neurology
- Forensic Medicine
- Neurosurgery
Background:
- Establishing brain death is critical for clinical management and organ donation protocols.
- Standard diagnostic criteria for brain death can be difficult to apply in cases of severe open head trauma.
- Existing guidelines may not adequately address complex scenarios involving extensive cranial defects.
Observation:
- A 32-year-old male with a severe head injury from a grindstone fragment presented with extensive skull and orbital destruction.
- Clinical criteria for brain death were met, but direct examination of brainstem reflexes was impossible.
- Electroencephalogram (EEG) showed persistent activity despite absent brainstem auditory evoked potentials (BAEP) and N20 somatosensory evoked potentials.
Findings:
- Ancillary tests for cerebral blood flow cessation were inconclusive or unavailable due to the patient's condition and logistical constraints.
- Transcranial Doppler ultrasonography was unreliable, and cerebral scintigraphy was delayed.
- German guidelines did not permit cerebral angiography, leaving a diagnostic gap.
Implications:
- The case underscores the limitations of current brain death diagnostic protocols in complex open head injuries.
- Cerebral computed tomography-angiography (CTA) is proposed as a fast, low-risk ancillary method to confirm brain death in such challenging cases.
- Widening diagnostic guidelines is essential to ensure accurate and timely determination of brain death, facilitating organ donation.
