Muerte Cerebral

Neuroradiology (2010) 52:945947
DOI 10.1007/s00234-010-0765-7
EDITORIAL
Imaging tests in determination of brain death

Aad van der Lugt
Received: 18 August 2010 / Accepted: 18 August 2010 / Published online: 5 September 2010
# The Author(s) 2010. This article is published with open access at Springerlink.com
In this issue, an excellent review is published on the

imaging findings in non-neonatal hypoxic-ischemic encephalopathy [1]. The authors also go into detail on
imaging brain death, an entity that is currently causing
debate as far as the imaging approach is concerned.
Brain death refers to the irreversible end of all brain
activity due to necrosis of neurons. The diagnosis of brain
death allows organ donation for transplantation or withdrawal of life support. Legal standard and/or practice
guidelines are currently present in most countries.
There is uniform agreement on the clinical neurological
examination to evaluate absence of brain function. This
examination includes the assessment of coma, the absence
of brain reflexes, and the assessment of apnea. Some
guidelines require a confirmatory test for the diagnosis of
brain death while in others it is optional to use these tests.
However, there is considerable variation in the type of
additional confirmatory tests [2].
Confirmatory tests can be classified into two categories:
confirmation of loss of electrical activity (electroencephalography or somatosensory-evoked potentials) and demonstration
of loss of cerebral blood flow (cerebral angiography, transcranial doppler ultrasonography, or cerebral scintigraphy).
Although the role of confirmatory tests, has been
debated [3], they could be useful (1) to shorten the
observation time; (2) when components of clinical testing
cannot be reliably evaluated, e.g., when the apnea test have
to be aborted due to progressive hypotension or hypoxemia;
(3) in medical conditions that may confound the clinical

testing, e.g., drug intoxication; (4) in young children in
whom the assessment of brain death is complicated because
the neurological examination is more difficult and the
immature nervous system is more resilient to certain forms
of injury, and (5) to increase diagnostic confidence.
Cerebral (digital subtraction) catheter angiography has been
the reference standard for the assessment of cerebral blood flow
[4, 5]. However catheter angiography is an invasive, timeconsuming procedure, which needs an experienced neuroradiologist and the availability of an angiography suite.
Therefore, new non-invasive radiological tests like MRI,
MRA, and CT angiography (CTA) have been proposed to
A. van der Lugt (*)

Department of Radiology, Erasmus MC,
University Medical Centre Rotterdam,
s-Gravendijkwal 230,
3015 CE Rotterdam, Netherlands
e-mail: a.vanderlugt@erasmusmc.nl
Fig. 1 Six-millimeter maximum intensity projection in sagital plane

of CTA images obtained 60 sec after contrast material injection. No
enhancement of intracranial arteries is visible. Enhancement of a side
branch of the external carotid artery (arrow) proves the correct
injection and arrival of contrast material in the large neck arteries.
Based on the criteria, brain death was confirmed
946
Fig. 2 CTA images of a 7-yearold girl with brain death

according to clinical criteria.
Six-millimeter maximum intensity projection in coronal (a) and
sagital (b) plane of CTA images
obtained 60 sec after contrast
material injection. The
pericallosal arteries and the
basialar artery are opacified. The
internal cerebral veins, the great
cerebral vein, and the straight
sinus are not opacified. Based
on the criteria, brain death cannot be confirmed
replace catheter angiography. Studies on MRI and MRA dated

back to 2002 [6, 7], but CTA has recently attracted attention.
The accuracy of CTA for brain death diagnosis was first
demonstrated in a study by Dupas et al. [8]. CTA
demonstrated no opacification of the pericallosal arteries,
cortical segments of the cerebral arteries, the internal
cerebral veins, and the great cerebral vein in all 14 patients
diagnosed with brain death (sensitivity 100%), while all
these vessels opacified in 11 normal controls (specificity
100%) [8]. Based on this publication, France and the
Netherlands accepted CTA as a confirmatory test for brain
death diagnosis. However, the high sensitivity was not
repeated in newer studies, which reported that intracranial
opacification on CTA was present in a substantial number
of patients (1148%) meeting existing criteria for brain
death [913]. It is important to realize that the accuracy of
CTA in the diagnosis of brain death is dependent on the
applied criteria. Adapting the criteria proposed by Dupas et
al. to opacification of the cortical segments of the middle
cerebral arteries and the internal cerebral veins only leads to
an increase of the sensitivity from 63% to 86% [12].
Absence of enhancement of the internal cerebral veins is
probable the most relevant angiographic criterium for brain
death [9, 12]
Simple copying of the brain death criteria used for
catheter angiography to CTA is not the way to go.
Opacification of intracranial arteries does not necessarily
mean the presence of cerebral blood flow. It might well be
that it is caused by stasis of contrast material. This
phenomenon has already been described in previous
imaging studies in patients with brain death. Secondly,
CTA is normally performed after 60 sec of the contrast
material injection and this delay may promote the dilution
of contrast material into more distally located arteries.
Finally, CTA has a higher sensitivity than catheter
angiography for the detection of vascular contrast enhancement (Figs. 1 and 2).
Future research should define which CTA-derived
parameters are relevant for the determination of brain
death. Such studies should be performed in patients who
meet the clinical and EEG criteria for brain death. Since
most CTA studies on brain death have not evaluated the
specifity of CTA, such studies should include also nonbrain-dead patients to assess the false-positive rate of CTA.
Newer techniques like CT perfusion (CTP) or 4D-CTA
may increase the accuracy of CT-based techniques. CTP
will allow the evaluation of brain tissue flow, while 4DCTA will visualize the arrival of contrast material in the
major intracranial arteries and veins and will enhance the
distinction between real flow and stasis of contrast material.
More consensus within the neuroradiological community in
Europe on the preferred imaging modality, the proper way
to execute image acquisition and the relevant criteria for
image interpretation is warranted.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
References
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CT and MR in non-neonatal hypoxic-ischemic encephalopathy:
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Neuroradiology (2010) 52:945947

Imaging tests in determination of brain death

In this issue, an excellent review is published on the

(3) in medical conditions that may confound the clinical

A. van der Lugt (*)

Fig. 1 Six-millimeter maximum intensity projection in sagital plane

Neuroradiology (2010) 52:945947

Fig. 2 CTA images of a 7-yearold girl with brain death

replace catheter angiography. Studies on MRI and MRA dated

Neuroradiology (2010) 52:945947

the intracranial circulation in suspected brain death. J Neuroradiol

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