Presentation
Underlying chronic renal failure due to nephrotic syndrome, with an eGFR of 15 ml/min/1.73m², the patient presented with two cardiac arrests. Despite negative brain function tests, there was evidence of residual vasomotor function.
Patient Data
Non-contrast CT reveals a diffuse pseudosubarachnoid hemorrhage in the bilateral cerebral hemispheres, causing complete effacement of all ventricles and sulci spaces. Large hematomas are evident in the left frontoparietal and right temporal lobes, accompanied by a diffuse lack of white-grey matter differentiation.
CT angiogram depicts progressive narrowing of the distal cervical, lacerum, and petrous segments of the bilateral internal carotid arteries, with complete occlusion of the distal segments (Bouthillier classification). Additionally, there is occlusion of the proximal foraminal segments (V2) of the bilateral vertebral arteries at the level of C5-C6.
Ring artifacts are observed in both the non-contrast CT and CT angiogram of the brain.
The overall impression suggests bilateral internal carotid and vertebral artery occlusion, likely stemming from severe brain swelling with raised intracranial pressure due to bilateral parenchymal hematoma and global hypoxic-ischemic encephalopathy.
Case Discussion
A four-vessel acute occlusion, resulting from a substantial increase in intracranial pressure, is an uncommon neuroimaging finding associated with a grim prognosis. The patient underwent two cardiac arrests, and subsequent negative brain function tests revealed residual vasomotor function. Clinically and radiologically, these findings are indicative of brain death.
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