Korean J Radiol.  2012 Oct;13(5):541-549. 10.3348/kjr.2012.13.5.541.

Imaging Findings of Brain Death on 3-Tesla MRI

• Sohn CH
• Lee HP
• Park JB
• Chang HW
• Kim E
• Kim E
• Park UJ
• Kim HT
• Ku J

• KMID: 1392931
• DOI: http://doi.org/10.3348/kjr.2012.13.5.541

Abstract

OBJECTIVE
To demonstrate the usefulness of 3-tesla (3T) magnetic resonance imaging (MRI) including T2-weighted imaging (T2WI), diffusion weighted imaging (DWI), time-of-flight (TOF) magnetic resonance angiography (MRA), T2*-weighted gradient recalled echo (GRE), and susceptibility weighted imaging (SWI) in diagnosing brain death.
MATERIALS AND METHODS
Magnetic resonance imaging findings for 10 patients with clinically verified brain death (group I) and seven patients with comatose or stuporous mentality who did not meet the clinical criteria of brain death (group II) were retrospectively reviewed.
RESULTS
Tonsilar herniation and loss of intraarterial flow signal voids (LIFSV) on T2WI were highly sensitive and specific findings for the diagnosis of brain death (p < 0.001 and < 0.001, respectively). DWI, TOF-MRA, and GRE findings were statistically different between the two groups (p = 0.015, 0.029, and 0.003, respectively). However, cortical high signal intensities in T2WI and SWI findings were not statistically different between the two group (p = 0.412 and 1.0, respectively).
CONCLUSION
T2-weighted imaging, DWI, and MRA using 3T MRI may be useful for diagnosing brain death. However, SWI findings are not specific due to high false positive findings.

Keyword

CNS; MR imaging; Brain; Adult; Brain death

MeSH Terms

Adolescent
Adult
Aged
Brain Death/*pathology
Diffusion Magnetic Resonance Imaging
False Positive Reactions
Female
Humans
Image Interpretation, Computer-Assisted
Magnetic Resonance Angiography
Magnetic Resonance Imaging/*methods
Male
Middle Aged
Retrospective Studies
Sensitivity and Specificity

Figure

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  Fig. 1 Bilateral transcerebral and cortical vein signs on T2*-weighted gradient recalled echo (GRE) and susceptibility weighted image (SWI) in patient 1. A. GRE image shows multiple and branching low signal intensities extending through cerebral hemisphere parallel or perpendicular to outer wall of both lateral ventricles (arrows, bilateral transcerebral vein sign) and abnormal low signal intensities in both cerebral hemisphere cortical areas (arrow heads, bilateral cortical vein sign). B. Similar, but more prominent low signal intensities are visualized on SWI.

• 

  Fig. 2 Group I (patient 9). 66-year-old male with massive intracerebral hemorrhage (ICH). A. T2-weighted image (T2WI) sagittal scan shows intraventricular hemorrhage (IVH) in 3rd and 4th ventricles (arrows) and tonsillar herniation (arrowhead). Diffuse swelling with effacement of cortical gyri is noted. B. T2WI axial image reveals loss of intraarterial flow signal voids in both cavernous and paraclinoid internal carotid arteries (arrows). There is hydrocephalus in both lateral ventricles due to IVH (arrowheads). C. Diffusion weighted image (b value = 1000) shows diffuse increased signal intensities in both periventricular white matters. D. Maximum intensity projection reconstruction of time-of-flight magnetic resonance angiography shows loss of intracranial arterial flow signal intensities. There is visualization of both superficial temporal arteries (arrows) and occipital arteries (arrowhead). E, F. T2*-weighted gradient recalled echo and susceptibility weighted imaging show visualization of transcerebral vein sign in right cerebral hemisphere (arrow) and bilateral cortical vein sign (arrowhead). Transcerebral vein sign in left cerebral hemisphere is not visualized due to massive ICH (asterisk).

• 

  Fig. 3 Group II (patient 12). 42-year-old female with ruptured left middle coronary artery bifurcation aneurysm and subarachnoid hemorrhage (SAH). A, B. T2 weighted image sagittal and axial scans reveal diffuse swelling of both cerebral hemisphere and cerebellum (arrows) and intraventricular hemorrhage in 4th ventricle (arrowhead), but there is no evidence of definite tonsillar herniation or loss of intraarterial flow signal voids (asterisk). C. Diffusion weighted imaging (b value = 1000) shows increased signal intensity in cerebral sulci, possibly due to SAH (arrows), but there was no evidence of definite increased signal intensity in brain parenchyma. D, E. T2*-weighted gradient recalled echo (GRE) reveals transcerebral (arrows) and cortical vein (arrowheads) signs in both cerebral hemispheres. F. Susceptibility weighted image reveals bilateral bilateral transcerebral and cortical vein sign (BTCVS) (arrows and arrowheads). In this case, we could not discriminate SAH from BTCVS on GRE and SWI due to an increased oxygen extraction fraction and increase in deoxyhemoglobin in capillaries and veins in setting of SAH and subsequent vascular spasm or increased intracranial pressure.

• 

  Fig. 4 Group II (patient 14). 50-year-old male admitted due to injuries sustained in traffic accident. A. T2 weighted imaging sagittal scan reveals focal intracerebral hemorrhage (ICH) in frontal lobe (arrow) and subarachnoid hemorrhage (SAH) in frontal and parietal lobe sulci (arrowhead), fracture in parietal bone and massive hematoma in scalp (asterisk). However, there is no evidence of definite tonsillar herniation. B. T2WI axial image reveals normal intravascular flow void signal in both cavernous ICAs (arrow). Minimal IVH in 4th ventricle (arrowhead). C. Diffusion weighted image (b value = 1000) shows multifocal high signal intensities in right corona radiata, right parieto-occipital lobe, and left frontoparietal lobe sulci, possibly due to shearing injury (arrows). D. Minimum-intensity projection reconstruction of TOF-MRA visualizes intracranial vasculature. E. T2*-weighted gradient recalled echo image reveals petechial hemorrhage in right periventricular white matter (arrow), minimal SAH in right parietal lobe sulci, and subdural hemorrhage in left frontoparietal convexity. There is no evidence of bilateral transcerebral and cortical vein signs (BTCVS). F. Susceptibility weighted imaging (SWI) shows bilateral transcerebral (arrows) and cortical vein (arrowheads) signs. In this case, we could not discriminate traumatic SAH and petechial hemorrhage from BTCVS on SWI.

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