Clinical brain death with preserved cerebral arterial circulation

Area of Science:

• Neurology
• Neurosurgery
• Pathology

Background:

• Subarachnoid hemorrhage (SAH) is a critical neurological emergency often caused by ruptured intracranial aneurysms.
• Basilar artery aneurysms are particularly prone to causing severe SAH and poor outcomes.
• Clinical brain death criteria are typically used to determine irreversible cessation of brain function.

Observation:

• A 44-year-old male presented with severe SAH from a ruptured basilar artery aneurysm.
• Clinical examinations over three consecutive days met the established criteria for brain death.
• Despite the clinical signs of brain death, serial cerebral angiograms demonstrated persistent intracranial blood flow until the third day post-hemorrhage.

Findings:

• The persistent intracranial filling on angiography in a clinically brain-dead patient is an unusual finding.
• Autopsy revealed acute infarction of the brainstem and cerebellum, consistent with the initial hemorrhage and subsequent events.
• This case highlights a potential discrepancy between clinical assessment and radiological findings in the context of severe SAH and brain death.

Implications:

• This case challenges the definitive interpretation of clinical brain death criteria in the immediate aftermath of severe subarachnoid hemorrhage.
• It underscores the importance of considering advanced imaging, such as serial cerebral angiography, in complex neurological cases.
• Further investigation may be warranted to understand the physiological mechanisms underlying persistent intracranial filling despite clinical brain death, potentially impacting organ donation protocols.