Computed tomography angiography scoring systems and the role of skull defects in the confirmation of brain death

To assess and compare all current computed tomography angiography (CTA) scoring systems for the diagnostic workup of brain death (BD) to digital subtraction angiography (DSA) and clinical tests. Fifty-two patients with a clinical suspicion of BD underwent CTA and subsequently DSA. The diagnostic performance of all current CTA scoring systems was compared to that of DSA, in all patients with a suspicion of BD. A comparison to clinical tests was made only in DSA-positive for BD patients (n = 49), since in DSA-negative BD patients (n = 3) clinical tests were not performed. Further subgroup analysis was performed in relation to skull defects (SDs) stratification. Statistical analysis was conducted by applying statistics-contingency tables, Cochran’s-Q test and McNemar’s test. The CTA -10, and -7- and all 4-point scoring systems, showed overall sensitivities of 81,6%, 87.8% and 95.9% respectively and 100% specificity, when compared to DSA. In patients with a clinical verification of BD, the CTA -10 and -7-point scoring systems were significantly inferior to clinical tests (p = 0.004 and p = 0.031), while the 4-point scoring systems showed no such difference (p = 0.5). All 4-point scoring systems showed 100% sensitivity in patients with a minor SD or no SD. In patients with a major SD, all CTA scoring systems (− 10, − 7- and all 4-point) were less sensitive (62.5%, 62.5% and 75% respectively). The presence of a major SD was associated with an 8 × relative risk for false negative results in all 4-point scoring systems. CTA showed excellent diagnostic performance in patients with a suspicion of BD. The 4-point CTA scoring systems are the most sensitive for the diagnosis of BD, although in patients with a major SD patient, the role of CTA is ambiguous.