496 When the result of ancillary test does not support neurological criteria of brain death – a case of a 3-year old girl with head trauma

• Published in: Archives of disease in childhood 2021-10, Vol.106 (Suppl 2), p.A208-A209
• Main Authors: Hamidović, Nikolina, Čondor, Anamarija, Berecki, Igor
• Format: Article
• Language: English
• Subjects: Abstracts; Anesthesia; Angiography; Apnea; Blood flow; Brain; Brain death; Brain stem; Clinical Diagnosis; Coma; Computed tomography; Death; Decompression; Diagnosis; Dura mater; Edema; EEG; Emergency medical care; Emergency medical services; Hematoma; Meninges; Mortality; Neurosurgery; Pediatrics; Perfusion; Scintigraphy; Somatosensory evoked potentials; Spine; Spine (cervical); Subarachnoid hemorrhage; Trauma; Traumatic brain injury; Ultrasound
• ISSN: 0003-9888; 1468-2044
• DOI: 10.1136/archdischild-2021-europaediatrics.496

Brain death occurs when a person has an irreversible brain injury causing total cessation of cerebral and brainstem function, different from coma or persistent vegetative state. The diagnosis of brain death is made clinically with different practises for need of confirmation with ancillary test in different countries.Here we present a case of a 3-year old girl that was admitted to the emergency room after a fall with a Glasgow coma scale score 3 but still breathing spontaneously. She underwent head and cervical spine computed tomography (CT) that showed smaller bilateral frontotemporoparietal subdural hematoma and subarachnoid haemorrhage. After a neurosurgical consultation she was initially treated conservatively. About three hours later her condition profusely deteriorated with apnoea, hemodynamic instability and profound anaemia. Second CT scan showed oedema and decompression craniotomy was indicated. 72 hours after the trauma the patient was hemodynamically stabile and it was decided to discontinue sedation in order to evaluate brain function. 24 hours after the complete cessation of sedation there was no neurological improvement indicating she was probably brain dead. Two neurological examinations were done with observation period of 12 hours, including apnoea test, demonstrating absent cerebral and brainstem function and confirming the diagnosis of brain death. Croatian legal regulations mandate the use of confirmatory tests to supplement the clinical examination so we decided to do scintigraphic blood flow study, ancillary test of choice in our institution. First test failed to show ‘hollow skull phenomenon’, as the second one done 24 hours later. Because of craniotomy, it was impossible to consider the use of electroencephalography and there was not enough experience and expertise with somatosensory evoked potentials, leaving as with only blood flow studies. Since experts in their field did not expect different results with cerebral angiography or Transcranial Doppler, we repeated cerebral perfusion scintigraphy four more times in the next forty days without confirming the clinical diagnosis of brain death.During that time there was no change in neurological status. We were able to maintain vital functions for two months in total after which the child died.Our experience shows that even though neurological examinations demonstrated absent cerebral and brainstem function blood flow study failed to confirm the diagnosis of brain death, probably becau