Brain death

Last revised by Dr Ian Bickle on 28 Dec 2021

Brain death refers to the irreversible end of all brain activity and is usually assessed clinically. Radiographic testing may be used as additional support for a clinical diagnosis of brain death, such as when clinical tests are impossible to perform, e.g. ocular trauma, precluding brainstem function assessment. 

As the diagnosis of brain death is considered equivalent with cardiac death in many jurisdictions 4 and it allows organ donation for transplantation or withdrawal of life support, most countries have specific and varied related legal standards and practice guidelines 2,10

Radiographic features

Most imaging tests for brain death rely on the absence of cerebral blood flow as a surrogate for brain death. This can be assessed by a number of modalities including CT, MRI, ultrasound, nuclear medicine examinations, and catheter angiography. 

It is important to note that not all modalities and examinations are approved for the legal determination of brain death and that this will vary from country to country. 


While brain death is ultimately a clinical diagnosis, transcranial Doppler sonography (TCD) may be used as an ancillary modality to provide further clinical support by detecting the presence of cerebral circulatory arrest, features of which include:

  • reverberant or oscillating flow in the MCA vessels has been reported 8
  • loss or reversal of diastolic flow in the MCA/ICA
  • low acceleration time in the MCA
  • diffuse cerebral edema with effacement of the grey-white matter borders
    • reversal sign (density of cerebellum is greater than cerebral hemispheres)
    • pseudosubarachnoid hemorrhage due to venous congestion in effaced sulci
    • swollen gyri, effaced/narrowed sulci, compressed ventricles/cisterns
  • CT angiography: non-opacification of the cortical middle cerebral arteries and internal cerebral veins are the most sensitive and specific markers on CTA 3
Angiography (DSA)
  • T1: hypointense, with lost grey-white matter differentiation
  • T2
    • swollen gyri with hyperintense cortex
    • expected flow void may be absent in vessels
  • DWI: hemispheric high signal, severe ADC drop
  • MR angiography: may be interpreted similarly to CT angiography, with non-visualization of the intracranial vessels 5,6
  • BOLD: absence of long-range functional connectivity 11
Nuclear medicine
  • cerebral perfusion 4,7
    • flow images are obtained in the anterior projection; delayed images follow 5 to 10 minutes after the injection
    • empty light bulb sign: absent intracranial uptake
    • hot nose sign: increased external carotid artery perfusion to the nasal region (an interesting sign, but of no real diagnostic value) 1

ADVERTISEMENT: Supporters see fewer/no ads

Cases and figures

  • Case 1
    Drag here to reorder.
  • Case 2
    Drag here to reorder.
  •  Case 3: with hot nose sign
    Drag here to reorder.
  • Case 4
    Drag here to reorder.
  • Case 5: CTA
    Drag here to reorder.
  • Case 6
    Drag here to reorder.
  • Case 7
    Drag here to reorder.
  • Case 8: fused images on SPECT 99mTC
    Drag here to reorder.
  • Case 9
    Drag here to reorder.
  • Case 10
    Drag here to reorder.
  • Case 11
    Drag here to reorder.
  • Case 12
    Drag here to reorder.
  • Updating… Please wait.

     Unable to process the form. Check for errors and try again.

     Thank you for updating your details.