Background:

Brain death accounts for about 2% of deaths in the United States and is often caused by traumatic brain injury. It is also commonly referred to as death in terms of neurologic language and is used as a legal definition of death. It is regarded as irreversible termination of the entire brain functionality and loss of brainstem reflexes such as loss of pupillary responsiveness, loss of corneal, gag, and cough reflexes. There is no regularity to confirm brain death. Therefore, different standards are in effect to assess a brain death examination and document the patient as brain dead.

Introduction:

We present a case of an 18-year-old female who suffered a devastating gunshot wound to the head under unknown circumstances. On initial presentation, the patient had a Glasgow Coma Scale score below 8, with loss of consciousness and inability to communicate. The brain injury was felt to be nonsurvivable by the neurosurgeon on call and was reportedly verified by a second neurosurgeon. Neurology was consulted and recommended palliative care when patient had no seeming improvement in neurological function along with negligible intracranial blood flow throughout the sagittal sinus on nuclear medicine study. The patient had retained a cough and gag reflex, which led to a transfer to another hospital at the request of the family for a second opinion. A repeat nuclear medicine study and CT Venogram to evaluate for sinus injury was completed for recommended craniectomy with washout and closure of the wound. To our surprise, these new studies showed normal patent blood perfusion of the intracranial system, despite the initial image findings. After gunshot cranial wound excision and craniectomy of the bone fragment, the patient’s neurological status showed improvement. Management/ Outcome/and Conclusion:

Patient was managed with standard hospitalization procedures including an inferior vena cava filter, tracheostomy, and peg tube placement. She has been monitored for intracranial pressures and potential hydrocephalus development. With all measures in place, the patient is improving in function and neurological status. Despite the initial presentation and declaration of brain death, it was confirmed that the patient has complete brain function with present brainstem reflexes and positive imaging studies showing perfusion and blood flow to the brain. Although prognosis cannot be determined, it cannot be confirmed that the patient has suffered a brain death injury.

References

Starr R, Tadi P, Pfleghaar N. Brain Death. [Updated 2021 Oct 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538159/

Starr R, Tadi P, Pfleghaar N. Brain Death. 2021 Oct 14. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30844186.

Russell JA, Epstein LG, Greer DM, Kirschen M, Rubin MA, Lewis A., Brain Death Working Group. Brain death, the determination of brain death, and member guidance for brain death accommodation requests: AAN position statement. Neurology. 2019 Jan 02; [PubMed]