{
  "abstract": "Introduction We sought catheter-guided and CT-angiograms (DSA and CTA) standard criteria in establishing cerebral circulatory arrest (CCA) in scenarios of death by neurologic criteria (DNC) but incomplete clinical exam. We found in Europe the Toulouse and Rennes scoring systems highlighting that if supratentorial data is relevant, only cortical branches matter, and that in cases with omitted apnea test, pediatric or skull base fractures, it seems logical to focus on brainstem perfusion.Methods We critically appraised the current American Academy of Neurology (AAN) guidelines advocating for specific brain death ancillary testing (BDAT). We complemented our search with the World Brain Death Project (WBDP) Lewis A et al. JAMA 2020 and Srairi M et al. report in Eur J Radiol. 2020. Experts have established that a focus on arteries perfusing and veins draining the brainstem on CTA or DSA can yield accuracy with CCA gold standard. We then substantiated this stance with illustrations from clinical experience at a level 1 trauma center with clinical pearls and pitfalls in open skull cases, with pediatric and trauma challenges.Results The 2023 AAN DNC guidelines posit that trauma and pediatric cases with open skull may resort to DSA as first accepted modality, with CTA deemed unacceptable. However, literature and clinical experiences support that preservation of cortical branches on CTA/DSA may not be rare in open skull cases even with exam compelling for DNC. Similarly, reports of SPECT islands of viable tissue under craniectomy sites, and transcranial doppler (TCD) being not recommended by the AAN in open skull situations, all make angiographic, nuclear and sonographic tests illogical choices in many cases. Skull base fractures and unsafe apnea tests represent the vast majority of scenarios requiring BDAT. In these cases, some use TCD of the vertebrobasilar system, or if using CTA-CTV, some advocate to focus on the absence of brainstem venous drainage using the French scoring system. Standards can now be established in the USA for DSA and CTA performed as formal BDAT.Conclusions Our systematic review asserts a new paradigm with topography-based selection of the BDAT. Given the challenges seen in primary brainstem lesions leading to DNC, or in pediatric and trauma cases with open skulls, we recommend SNIS establishes with the American Society of Neuroimaging (ASN) clear criteria to confirm DNC: 1) only cortical branches matter supratentorially; 2) when to exclude supratentorial assessment completely and focus solely on the brainstem; and 3) brainstem assessment shall consist of distal vertebral, posterior inferior cerebellar and basilar arteries, as well as internal cerebral and superior petrosal veins, all with no opacification. Additionally, some may argue for ruling out any retrograde perfusion of the low medulla from high the anterior or posterior spinal arteries. Lastly, in this redefined framework, we call for a revalidation of CTA and comparison to DSA yield, with focus on brainstem arterial and venous flow, to subsequently prove that DSA may not be needed, as it is more resource-intense.Disclosures G. Kapinos: None. L. Salgado-Lopez: None. B.D. Philbrick: None. J. Zhang: None. Z. Hickman: None.",
  "authors": [
    {
      "affiliations": [
        "Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY"
      ],
      "name": "G Kapinos"
    },
    {
      "affiliations": [
        "Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY"
      ],
      "name": "L Salgado-Lopez"
    },
    {
      "affiliations": [
        "Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY"
      ],
      "name": "BD Philbrick"
    },
    {
      "affiliations": [
        "Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY"
      ],
      "name": "J Zhang"
    },
    {
      "affiliations": [
        "Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY"
      ],
      "name": "Z Hickman"
    }
  ],
  "title": "E-045 Conventional and CT angiograms in brain death ancillary testing shall focus on brainstem arteries and veins when surrogate for apnea test",
  "uid": "2bd93c7e-dbf9-555e-bfe8-d3061536bc73"
}