Critical Care Medicine

Adult Critical Care

Brain Death: Evaluation of Cerebral Blood Flow by Use of Arterial Spin Labeling

Yun TJ, Sohn C-H, Yoon B-W, et al (Seoul Natl Univ Med Res Ctr, Republic of Korea; Seoul Natl Univ Hosp, Republic of Korea) Circulation 124:2572-2573, 2011^§

Abstract

Background

The cardinal requirements to diagnose brain death include coma, absence of brain stem reflexes, and apnea. Additional tests may be needed to declare a person brain dead when the results of any components of clinical testing cannot be evaluated reliably. Arterial spin labeling (ASL) offers a noninvasive means for measuring cerebral blood flow (CBF) and determining brain death.

Case Report

Woman, 48, was admitted to the emergency department having experienced nuchal rigidity, tonic seizure, and loss of consciousness. No pupil reaction to light was observed 5 hours after lumbar puncture for diagnostic purposes. In addition, the patient had apnea. Magnetic resonance imaging (MRI) showed tonsillar impaction in the foramen magnum, loss of signal void in the bilateral internal carotid arteries (suggesting a lack of flow), severe swelling in the gyri, and extensive intravenous thrombi filling the vessel lumens. On the twentieth day in the hospital clinical examinations to determine brain death produced results consistent with that diagnosis. At 22 days an electroencephalogram demonstrated electrocerebral silence consistent with brain death. Neurologists requested that conventional or radionuclide angiography be done to determine CBF, but the family refused further invasive tests. At 23 days unavoidable MRI using the ASL technique was performed, revealing severe perfusion defect in the entire brain. The mean value of CBF in the gray matter was 7.9 mL/100g/min. The accepted lower limit of CBF required by the human brain is 10 to 15 mL/100 g/min for regional CBF. The patient showed no improvement by day 25. Mechanical ventilation and other life support were removed in the operating room after 1 month of hospitalization, with organ donations made to five other patients.

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