Brain death determination by angiography in the setting of a skull defect

The absence of cerebral blood flow is presently considered the most reliable ancillary test in diagnosing brain death. A patient with an open skull fracture who met all criteria for brain death, including confirmatory postmortem studies, had a cerebral angiogram that showed unilateral preservation of cerebral circulation with diffuse extravasation of contrast material. We conclude that a skull defect may result in pressure reduction within the cranial cavity and persistent ipsilateral cerebral circulation, even after brain death. In this setting, diffuse extravasation of contrast material on angiography may reflect diffuse autolysis and suggest the diagnosis of brain death.