title: Decompressive craniectomy may cause diagnostic challenges to assess brain death by computed tomography angiography.
abstract: According to Italian legislation to diagnose brain death (BD) after the initial documentation of the clinical signs, repetition of clinical testing and confirmation of the loss of bioelectrical activity of the brain (EEG) is required. However, when EEG is unreliable it is necessary to demonstrate cerebral circulatory arrest (CCA). Accepted imaging techniques to demonstrate CCA include: cerebral angiography, cerebral scintigraphy, transcranial Doppler (TCD) and computed tomography angiography (CTA). This latter technique, due to its large availability, low invasivity and easy and fast acquisition is widely used over the country. Nevertheless its diagnostic reliability is affected by some limitations in patients with decompressive craniectomy. Here we report two cases of brain injury with clinical signs of BD and at the same time, opacification of intracranial arteries on CTA and a pattern consistent with flow arrest on the corresponding insonable arteries on TCD. The discrepancy between CTA and TCD results points out a methodology limitation that could be overcome by updating Italian legislation according to other European Countries legislation.
authors.affiliation: Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiation Therapy, Tor Vergata University of Rome, Rome, Italy - ntlslv00@uniroma2.it.
authors.forename: F
authors.initials: F
authors.lastname: Frisardi
authors.forename: M
authors.initials: M
authors.lastname: Stefanini
authors.forename: S
authors.initials: S
authors.lastname: Natoli
authors.forename: V
authors.initials: V
authors.lastname: Cama
authors.forename: G
authors.initials: G
authors.lastname: Loreni
authors.forename: F
authors.initials: F
authors.lastname: Di Giuliano
authors.forename: D
authors.initials: D
authors.lastname: Fiume
authors.forename: C
authors.initials: C
authors.lastname: Leonardis
authors.forename: M
authors.initials: M
authors.lastname: Dauri
authors.forename: A F
authors.initials: AF
authors.lastname: Sabato
authors.forename: G
authors.initials: G
authors.lastname: Simonetti
authors.forename: F
authors.initials: F
authors.lastname: Leonardis
mesh_terms: D000063:Accidents, Traffic; D000328:Adult; D016477:Artifacts; D001926:Brain Death / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000331:legislation & jurisprudence; D001930:Brain Injuries / Q000000981:diagnostic imaging / Q000601:surgery; D002533:Cerebral Angiography / Q000379:methods*; D002536:Cerebral Arteries / Q000000981:diagnostic imaging; D002543:Cerebral Hemorrhage / Q000209:etiology / Q000601:surgery; D002560:Cerebrovascular Circulation; D056424:Decompressive Craniectomy / Q000009:adverse effects*; D003951:Diagnostic Errors; D006408:Hematoma, Subdural / Q000209:etiology / Q000601:surgery; D006801:Humans; D019585:Intracranial Hypotension / Q000000981:diagnostic imaging / Q000209:etiology*; D007558:Italy; D008297:Male; D009927:Tissue and Organ Procurement; D014057:Tomography, X-Ray Computed; D017585:Ultrasonography, Doppler, Transcranial