The Reversal Sign: An Ominous Imaging Finding.

Abstract

A 60-year-old man was admitted with anoxic brain injury after surviving a cardiopulmonary arrest in an apartment fire. The patient’s initial rhythm was pulseless electrical activity and an estimated 45 minutes elapsed until return of spontaneous circulation. The patient had also suffered carbon monoxide poisoning, (carboxyhemoglobin of 35% on 100% supplemental oxygen), severe inhalation injury, and multiple first- and second-degree burns to face and extremities. A noncontrast head computed tomography (NCCT) on admission (Figure 1A and ​andB)B) showed inversion of the normal relative densities of gray and white matter with gray matter exhibiting lower attenuation than the white matter, a pattern known as the “reversal sign.”1-3 Care was withdrawn on the third day of admission when patient met brain death criteria. Figure 1. The reversal sign represents severe anoxic–ischemic brain injury and can include diffuse, symmetric bilateral reversal of the gray and white matter density relationship on noncontrast head computed tomography (NCCT; A) and relative preservation ...