Diagnose des Hirntodes: Grenzen der Angiographie nach osteoklastischer Trepanation

Abstract

A 50-year-old man sustained severe skull-brain trauma with intracerebral bleeding, cortical contusion foci and fracture of the petrosal bone. He went into coma a few hours after the accident. Three days after surgical removal of an intracerebral bleeding via a frontoparietal osteoclastic trepanation (removal of a 4 x 5 cm piece of bone) there occurred complete brainstem areflexia, respiratory arrest and drop in temperature; the encephalogram was isoelectric. There was thus no clinical-neurological doubt of brain death. But cranial digital subtraction angiography, generally considered to give the most reliable evidence of irreversible loss of cerebral functions, showed contrast medium in the branches of the left cerebral artery. The diagnostic criteria of brain death, as proposed by the Federal German Chamber of Physicians (Bundesärztekammer), were thus not exactly met, and despite the clinically obvious brain death a contemplated removal of organs for transplantation was therefore not undertaken. The patient died 6 hours after the angiography. This case shows that the value of angiography for the diagnosis of brain death may sometimes be limited, at least in those cases in which osteoclastic trepanation has been performed or there are other causes for a skull defect, because they can prevent the rise of intracranial pressure which brings about the cerebral circulatory arrest.