Diagnostic Sensitivity of the Revised Venous System in Brain Death in Children

Abstract

Background/objectives: While ancillary tests for brain death diagnosis are not routinely recommended in guidelines, they may be necessary in specific clinical scenarios. Computed tomography angiography (CTA) is particularly advantageous in pediatric patients due to its noninvasive nature, accessibility, and rapid provision of anatomical information. This study aims to assess the diagnostic sensitivity of a revised venous system (ICV-SPV) utilizing a 4-point scoring system in children clinically diagnosed with brain death.

Materials and methods: A total of 43 pediatric patients clinically diagnosed with brain death who underwent CTA were retrospectively analyzed. Imaging was performed using a standardized brain death protocol. Three distinct 4-point scoring systems (A20-V60, A60-V60, ICV-SPV) were utilized to assess vessel opacification in different imaging phases. To evaluate age-dependent sensitivity, patients were categorized into three age groups: 26 days-1 year, 2-6 years, and 6-18 years. The sensitivity of each 4-point scoring system in diagnosing brain death was calculated for all age groups.

Results: The revised venous scoring system (ICV-SPV) demonstrated the highest overall sensitivity in confirming brain death across all age groups, significantly outperforming the reference 4-point scoring systems. Furthermore, the ICV-SPV system exhibited the greatest sensitivity in patients with cranial defects.

Conclusions: The revised 4-point venous CTA scoring system, which relies on the absence of ICV and SPV opacification, is a reliable tool for confirming cerebral circulatory arrest in pediatric patients with clinical brain death.

Keywords: angiography; brain death; children; computed tomography.

Figure 1

Axial CTA image of a control patient without brain death shows SPVs (red arrows) draining into the petrosal sinus at the level of the middle and superior cerebral peduncle of the mesencephalon. CTA: CT angiography, SPV: Superior petrosal vein.

Figure 2

CTA images were taken with the brain death protocol of a 13-year-old boy who was brain dead. (A), Axial pre-contrast CT image shows cerebral edema with the disappearance of the ventricles and flattening of the subarachnoid sulci. (B), Axial post-contrast arterial-phase (20th second) image shows opacification of superficial temporal artery (red arrow), which indicates adequate technique. (C), Axial post-contrast venous-phase image (60th second). The arterial phase and venous phase show an absence of opacification of the bilateral MCA and branches. (D), The venous phase shows the absence of opacification of the ICV and SPV. CTA: CT angiography, MCA: Middle cerebral artery, ICV: Internal cerebral vein, SPV: Superior petrosal vein.

Figure 3

CTA in a 13-year-old boy with clinically confirmed brain death. (A), Craniectomy defect is visualized in VR images. (B), A lack of opacification is observed in the SPV and ICV during the venous phase. (C), However, persistent opacification of the right MCA-M4 segment is noted (white arrow). (D), Brain perfusion was absent on scintigraphy, further supporting the diagnosis of brain death. CTA: CT angiography, MCA: Middle cerebral artery, ICV: Internal cerebral vein, SPV: Superior petrosal vein, VR: 3D volume-rendered.

Figure 4

CTA in a 2-year-old boy with clinically confirmed brain death. (A), A cranial fracture is visualized in VR images. (B), A lack of opacification is observed in the SPV and ICV during the venous phase. (C), However, persistent opacification of the right MCA-M4 segment is noted (white arrow). (D), Brain perfusion was absent on scintigraphy, further supporting the diagnosis of brain death. CTA: CT angiography, MCA: Middle cerebral artery, ICV: Internal cerebral vein, SPV: Superior petrosal vein, VR: 3D volume-rendered.

Figure 5

CTA was performed in a 1-year-old boy with clinically confirmed brain death who did not meet the criteria for brain death. (A), Arterial-phase image and (B,C), Venous-phase images reveal an absence of opacification in the branches of the MCAs. Conversely, opacification of the SPV is seen (red arrow). CTA: CT angiography, MCA: Middle cerebral artery, ICV: Internal cerebral vein, SPV: Superior petrosal vein.