NEU1 Pseudosubarachnoid hemorrhage in a patient with brain death. (Neurosurgery).

NEU1 PSEUDOSUBARACHNOID HEMORRHAGE IN A PATIENT WITH BRAIN DEATH. W. Mel. Flowers, Jr., MD, George Benashvili, MD, Ayman Asfour, MD, and Jonathan D. Fratkin, MD. University of Mississippi Medical Center, Jackson.

We report an unusual case of noncontrasted computed tomography in a patient with brain death that closely simulates the findings in subarachnoid hemorrhage. A 35-year-old white woman was admitted to UMC with a staghorn kidney stone and left perinephric hematoma and had left percutaneous nephrolithotomy 1 day after admission. Significant medical history included hypertension, myocardial infarct 1 year earlier, and crack cocaine abuse. The following day, she became confused and felt unwell after self-administered doses of meperidine via a PCA pump. The pump was discontinued. Two and one half hours later, she was unresponsive with pupils fixed and dilated. Blood pressure and heart rate were reestablished, she was intubated and admitted to the SICU. A CT scan of the head was thought to show massive subarachnoid hemorrhage, diffuse cerebral edema, and cerebellar herniation. Neurosurgical evaluation showed the following: pupils fixed and dilated, bilaterally (6 mm); retinal hemorrhage, OD; no response to doll's eye maneuver or cold water calorics. Corneal reflex was absent, bilaterally; gag and cough reflexes were absent as well. EEG documented a flat line, with brain death voltage (2 microvolts). The patient remained unresponsive, and life support was withdrawn 22 hours later. At autopsy, there was no subarachnoid hemorrhage in the leptomeninges of the hemisphere convexities or around the brainstem. No hemosiderin staining of the brain was evident. The findings of massive cerebral edema included flattened gyri, narrowed sulci, obliteration of the lateral and fourth ventricles, and herniation of the cerebellar tonsils. We conclude that brain death can mimic subarachnoid hemorrhage on CT examination. Neurosurgeons, neurologists, and neuroradiologists should be aware of this pitfall.