1. in brain death diagnosis: Clinical experience in 196 patients.
CT angiography
in brain death diagnosis:
Clinical experience in 196 patients.
M Musacchio, A Meyer, I Manoila, A Lebidensky, JC Zink, H Oesterlé,
N Stahl, A Bianchi, T Tajahmady, A Tournade
Dear colleagues, ladies and gentlemen, my name is Mariano Musacchio. My presentation will focus the usefulness of angioCT in the diagnosis of brain death.
Radiologie Pôle 3 et CHPOT - Hôpital Louis Pasteur (HCC) - COLMAR - France

2. Introduction : CT angiography in brain death MM
I thought that it was suitable to start considering the concept of brain death.
For the first time in history we have the possibility of interfering in the process of dying with manoeuvres which are of no utility for the patient but which
can greatly help others. This ambiguous situation have revive old debates about the significance of life and death, in many fields: theology, ethics, philosophy, anthropology and of course, medicine.
Neuroradiology - Louis Pasteur Hospital (HCC) - COLMAR - France MM

3. all functions of the brain, including the brain stem
CT angiography in brain death
Introduction :
Brain death concept:
Irreversible loss of
all functions of the brain,
including the brain stem

4. Introduction - Brain death Legislation in France
CT angiography in brain death
Introduction - Brain death Legislation in France
Decree n° (December 2nd 1996)
Non reactive coma
Abolition of brain stem reflexes
Abolition of spontaneous respiration (hypercapnia test)
Photomotor
Corneal
Oculo-vestibular
Oculo-cardiac
Clinical
Criteria
Suspicion +
In France, the clinical diagnosis of brain death must be confirmed by 2 non reactive, flat EEG or by a 4 vessel cerebral angiography.
This last option can be performed using an arterial or venous approach, by selective catheterism or not.
The angio CT scan is one of the methods that could be employed in this prospect.
Paraclinical
Criteria
2 non reactive, flat, 30 min long EEG with a 4 h interval or
4-vessel cerebral angiography showing no cerebral circulation
Confirmation
Neuroradiology - Louis Pasteur Hospital (HCC) - COLMAR - France MM

5. To evaluate clinical usefulness of CT cerebral angiography
CT angiography in brain death
Objectives:
To evaluate clinical usefulness of CT cerebral angiography
in confirmation of
brain death diagnosis
The history of the concept of brain death is closely linked to developments in organ transplantation.
In 1959, Mollaret and Goullon used the term coma dépassé, "a state beyond coma", to describe a condition from which they believed recovery was not possible.
The term “brain death” was introduced in 1965 following a report of renal transplantation from a heart-beating but “brain-dead” donor, and was defined formally in 1968 in the report of the Ad Hoc Committee of the Harvard Medical School.
The clinical diagnostic criteria that were retained at that moment were mostly based on the lost of brain stem functions.

6. CT angiography in brain death
Material and Methods :
Population
From July 2003 to December 2009
196 patients
97 women / 95 men
17 to 86 years
Mean = 52 years

7. CT angiography in brain death
Etiology
n = 196 patients
Vascular
Trauma
Brain tumor (glial)
Brain Infection (abscess)

8. Multi-row CT scanner Material and Methods : Imaging modality
CT angiography in brain death
Material and Methods :
Imaging modality
Multi-row CT scanner
However, things proved to be complex in clinical practice. The interpretation is sometimes difficult…
Accessibility (24h/24)
Simplicity (installation, acquisition, post-treatment)
Diagnostic performance

9. CT angiography in brain death
Multi-row CT Scanner
BD 
Only 1 passage
The history of the concept of brain death is closely linked to developments in organ transplantation.
In 1959, Mollaret and Goullon used the term coma dépassé, "a state beyond coma", to describe a condition from which they believed recovery was not possible.
The term “brain death” was introduced in 1965 following a report of renal transplantation from a heart-beating but “brain-dead” donor, and was defined formally in 1968 in the report of the Ad Hoc Committee of the Harvard Medical School.
The clinical diagnostic criteria that were retained at that moment were mostly based on the lost of brain stem functions.
No unnecessary displacements!
Organs 

10. CT angiography in brain death
BRAIN DEATH DIAGNOSIS!
Cerebral acquisition at 60 sec
Keystone !
Visceral arterial phase
Visceral venous phase
However, things proved to be complex in clinical practice. The interpretation is sometimes difficult…
Injection !
Timing!

11. CT angiography in brain death
Multi-row CT Scanner
“Whole body” CT scan (Colmar)
1 – AP scout (1200 mm)
2 – Non-enhanced cerebral volumetric acquisition (2 mm/1 mm)
3 – Non-enhanced abdominal volumetric acquisition
from upper liver to inferior pole of kidneys (5 mm/5 mm)
4 – Locator + Tracker (ROI on thoracic aorta)

12. CT angiography in brain death
Multi-row CT Scanner
“Whole-body” CT scan (Colmar)
Contrast injection (400mg/ml) : Volume 2 ml/kg (≤ 120 ml); Rate 3 ml/sec
5 – Enhanced thoracic abdominal volumetric acquisition
from aortic arc to inferior pole of kidneys (2 mm/1 mm)
6 – Enhanced cerebral volumetric acquisition
60 sec after IV injection (1,5 mm/0,8 mm)
7 – Enhanced abdomino-pelvic volumetric acquisition
90 sec after IV injection (3 mm/3 mm)
8 – Lung window thoracic reconstruction

13. CT angiography in brain death
Material and Methods :
SFAR, 1998
Patient conditioning
Optimal conditions !
Clinical confirmation of brain death
> 6 hours
However, things proved to be complex in clinical practice. The interpretation is sometimes difficult…
Hemodynamic stability
MAP ≥ 65 mmHg
Suspicion of cerebral circulatory arrest
TC Doppler

14. CT angiography in brain death
Material and Methods :
Diagnostic algorithm
EEG
Brain death
Suspicion
Cerebral angiography
Cerebral CT angioscan
TC Doppler +
Cerebral CT angioscan
Visceral exploration +
> 6 hours
> 4 hours
Non
Non
However, things proved to be complex in clinical practice. The interpretation is sometimes difficult…
Visceral exploration ?
Circulatory arrest ?
Yes
Cerebral CT angioscan
Yes
Brain death
Confirmation

15. CT angiography in brain death
Material and Methods :
How to interpret?
Visceral exploration
Exclude contraindications
for organ transplantation
However, things proved to be complex in clinical practice. The interpretation is sometimes difficult…
Identify anatomic features of surgical interest

16. cerebral circulatory arrest ?
CT angiography in brain death
Material and Methods :
How to interpret?
Cerebral exploration
How
to prove
cerebral circulatory arrest ?
However, things proved to be complex in clinical practice. The interpretation is sometimes difficult…

17. CT angiography in brain death
AngioCT
Interpretation
Almost simultaneous enhancement of arteries and veins
Less than 20 seconds after injection (in normal physiological conditions)
In normal circumstances, enhancement of cerebral arteries and veins occur almost simultaneously, less than 20 seconds after antecubital injection of contrast product. Many physiological or pathological conditions may modified this delay, but if cerebral blood flow remains above the critical threshold, cerebral vessels will be injected in brief delay.
Arteries
Veins
Neuroradiology - Louis Pasteur Hospital (HCC) - COLMAR - France MM

18. Diagnostic criteria Dupas et all. (1998) CT angiography in brain death
Absence of enhancement 1 minute after injection
Anterior
cerebral
arteries
Distal
cortical
vessels (M4)
Internal
cerebral
veins
Vein of
Galen

19. CT angiography in brain death
New recommendations…
SFNR, 2007
But how to perform an angio ct for the diagnosis of brain death? This year, the French Society of Neuroradiology had published clear guidelines and recommendations concerning the way the exploration must be done for this purpose.

20. CT angiography in brain death
New diagnostic criteria
SFNR, 2007
So, as we saw previously, because proximal branches of the circle of Willis and dural sinuses might enhance after injection in a brain-dead patient, only the analysis of distal cortical branches and deep veins could help us to asses the status of cerebral blood circulation.
Absence of enhancement
Distal cortical vessels (M4), unilateral or bilateral
Deep cerebral veins
(venae internae cerebri et vena magna cerebri)

21. CT angiography in brain death
But how to perform an angio ct for the diagnosis of brain death? This year, the French Society of Neuroradiology had published clear guidelines and recommendations concerning the way the exploration must be done for this purpose.

22. CT angiography in brain death
Results:
Diagnosis of brain death
n = 196 patients
DSA
TCD
79.3%
7.1% 6% 6%
ANGIOSCANNER
EEG
NON
Explored

23. CT angiography in brain death
Results:
Diagnosis of brain death
Cerebral CT angioscan 14 18
132 4

24. CT angiography in brain death
Dupas
SFNR
Angioscaner
85%
99%
79 pts
117 pts
Angiosc + EEG / DSA

25. CT angiography in brain death
Case 1
60sec after injection
One example. A 27 year old male, with severe brain injuries due to self-inflected gun shot. 24 hours after admission, he presented clinical signs of brain death. The angioCT scan demonstrated enhancement of all proximal branches of the circle of Willis.
MCAs
BA & PCAs
ACAs & PICAs
Cerebral oedema
Cerebral haemorrhage
Bone fracture due to gunshot

26. Absence of venous enhancement ! X X
CT angiography in brain death
EEG = flat, not reactive
Case 1
Non-enhanced
Enhanced (60 sec)
Absence of venous enhancement ! X X
Absence of M4
Non-enhanced
Enhanced (60 sec)
However, at the 60 second acquisition there was no enhancement of distal branches of the MCAs (only the insular and opercular segments were injected) and particularly, no enhancement of deep cerebral veins. We hesitated about the diagnosis, and even if we didn’t have any prove of blood circulation at angioCT scan, an EEG was performed, that clearly showed no electrical brain activity, compatible with the diagnosis of brain death. X X X X
Absence of ICV
Absence of VG

27. CT angiography in brain death
Results:
Visceral exploration
n = 196 patients
ECHO
NON EXPLORED
42.4%
16.3%
11.4%
17.4%
SCANNER
MULTIPLE MODALITIES

28. 2003 2004 2005 2006 2007 2008 34 TAP 28 AP Echo Multiple modalities 21

29. CT angiography in brain death
Results:
Visceral exploration 47
134
n = 196 patients 35
7 tumours diagnosed
after whole-body scan

30. CT angiography in brain death
Results:
Contraindication
Lung tumours 2
Suprarenal tumours 2
Hepatic tumours 2
Bilateral renal tumours 1

31. CT angiography in brain death
Results:
Anatomic variants
Celiac artery absent 1
Common hepatic artery duplic. 1
Renal artery duplication 2
Pyelo-ureteral duplication 1

32. CT angiography in brain death
Conclusion:
CT angiography allows confirmation of brain death.
Non enhancement of distal cortical vessels and
internal cerebral veins/vein of Galen
Method demands strict respect of the acquisition protocol and a careful analysis of the results
Multi-row CT technology permits simultaneous analysis of all internal organs in a single exploration.

33. Bis Boll! Vielmols Merci… Château de Haut-Koeningsbourg
And for you, thank you for your attention. Bis ball.
Château de Haut-Koeningsbourg
Bis Boll!