Silence of the Brain (Brain Death)

Background: Brain death encompasses a clinical scenario characterized by irreversible nonfunctionality of central neurological function.Differentiating brain death from other types of severe brain damage is essential.Official certification criteria for brain death may differ across geographies, age-groups, and legal standards.Case description: A 52-year-old woman was admitted with a sudden decrease in sensorium, evaluation of which established a right middle cerebral artery (MCA) aneurysmal bleed.Following a right fronto-temporo-parietal decompressive hemicraniectomy, the Glasgow coma scale (GCS) remained poor, and brainstem reflexes were absent.After the elimination of all confounding parameters, brain death evaluation was initiated.This case presented a challenge in the certification of brain death, where the initial apnea test could not be completed due to pulmonary dysfunction.Hence, the need for advanced neurovascular imaging came into purview to move forward with the brain death certification process.Establishing a diagnosis of brain death is a multistep process that requires strict adherence to locally established protocols, which could be complicated by non-neurological morbid factors.In the event that clinical tests become infeasible, ancillary modalities become crucial.