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A 37-Year-Old Man With Severe Head Trauma, and a “Hot Nose” Sign on Brain Flow Study* FREE TO VIEW

Michael Baron, MD, FCCP; James Brasfield, MD
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*From the James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

Correspondence to: Michael Baron, MD, FCCP, Midway Medical Group, P.C., 28 Midway St, Bristol, TN 37620

Chest. 1999;116(5):1468-1470. doi:10.1378/chest.116.5.1468
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A 37 -year-old man was found at home in a comatose condition after having been in a fight the evening before. He was brought to a local emergency department and was transferred to our tertiary care hospital for possible neurosurgical intervention.

Physical examination:The patient’s temperature was 35.8°C; heart rate, 44 beats/min; respirations, 12 breaths/min; and BP, 140/73 mm Hg. A neurologic examination revealed that the patient was in a coma. The pupils were fixed and dilated, and the eyes did not move in their sockets when the head was turned. Corneal reflex was absent. There was no withdrawal to deep pain, and the extremities were flaccid. There was a large hematoma over the right parietal/occipital area. Frank blood was draining from the right ear. There were no signs of any other trauma, and findings of the heart, lung, and abdominal examinations were all within normal limits. The head trauma that was present was not thought to be due to a fall.

A CT scan showed a large right parietal epidural hematoma, with marked compression and right to left shift. He had been started on mannitol, dexamethasone, and diazepam, and he went immediately to the surgical suite for craniotomy with removal of a massive epidural clot. The brain was not pulsatile.

A postoperative CT scan of the head showed extensive infarction with subfalcine herniation and 2-cm midline shift. Shown here is the nuclear brain flow study with technetium 99M pertechnetate. This was performed about 15 h after admission.

Diagnosis: The nuclear brain flow study shows a “hot nose” sign indicative of brain death

The diagnosis of brain death is misunderstood by many physicians. This diagnosis is made on clinical grounds with history and physical examination. Although they are not required to make this diagnosis, confirmatory studies may be done to support it. This becomes particularly important if there are any legal issues surrounding the case. Confirmatory tests may include the brain flow study, EEG, cerebral angiography, MRI, Doppler ultrasound, brainstem-evoked response, or CT. Our test of choice is the radionuclide brain flow study. It is specific and readily available.

The patient must be in deep coma with no spontaneous movements, with the possible exception of spinal reflexes. The cause of the coma must be established and should be sufficient to account for the loss of brain function, as is seen with, for example, massive intracranial hemorrhage or cranial trauma. The corneal, gag, cough, oculocephalic (commonly called “doll’s eyes”) and oculovestibular reflexes need to be absent. In order to test the oculocephalic reflex, the head must be rotated to one side; in brain death, the eyes stay fixed in their sockets. In deep coma with an intact reflex, the eyes do not turn to the opposite side when the head is turned; instead, they stay where they were and slowly “right” themselves to the midline. This may be thought of as a “righting” reflex.

The oculovestibular reflex is also absent in brain death. The test is performed at a 30° angle of the head to the horizontal plane; after checking the tympanic membranes for intactness, ice water (a noxious stimulus) is flushed into the ear canal. It is mistakenly thought that nystagmus should be looked for; but, in fact, in coma, an intact reflex means that both eyes turn toward the side of the painful ice water. This should be thought of as the brain forcing the eyes to look toward the threat to the body. In brain death, there is no movement of either eye.

The patient cannot be hypothermic (temperature < 32.2°C). Also, drug overdoses with barbiturates, sedatives, and hypnotics must be ruled out with drug screens at times.

The absence of spontaneous breathing must be confirmed by an apnea test to diagnose brain death. The patient is disconnected from the ventilator. Oxygen is flushed into the tracheal tube, while oximetry confirms the adequacy of oxygenation. This is essential so that in the event that the patient is not brain dead, no further damage will occur to the brain. The Pco2 must increase to a level > 60 mm Hg without stimulating any spontaneous respirations. The patient can now be pronounced dead if all these criteria are met.

During this process, the family should be kept informed about the severity of the injury, so that the diagnosis of brain death is not a surprise to them. As soon as a diagnosis of brain death is even considered or expected, the transplant coordinators should be called so that they can start talking with the family about the possibility of organ donation. HIV and hepatitis testing are done along with the other tests.

It is essential to notify the police of any suspected foul play. Coordination needs to be made with the authorities before the ventilator is disconnected officially. The physician and transplant coordinator need to contact the coroner and then the forensic pathologist to see if the organs can be harvested and if there are any restrictions when there is any question of foul play. There must be unanimous agreement by the closest relatives before the transplant team can proceed with their workup and protocols.

Once brain death is determined and the organ procurement organization accepts the case, they assume all hospital and physician bills. It has been suggested that a brain flow study be performed as early in the hospital course as possible after the clinical diagnosis of brain death is made, with markedly reduced charges to the institution.

The present patient’s nuclear brain flow study demonstrated an absence of blood flow into the brain and sagittal sinus. The blood that would have gone to the internal carotids is shunted to the external carotids and the multitude of blood vessels in and around the nose and sinuses. This test finding, when combined with an abnormal physical examination consistent with brain death, confirms brain death as was present in this patient.

Early in this patient’s course, an apnea test was performed following craniotomy. He demonstrated spontaneous breathing and was placed back on the ventilator. On retesting hours later, he no longer had spontaneous respirations (after the Pco2 was confirmed to be > 60 mm Hg) and was declared brain dead. For absolute confirmation however, since this was a suspected murder, the brain flow study was ordered.

Unfortunately, in this case, after spending most of the evening with the family, the transplant coordinator found that the patient was positive for hepatitis B surface and core antibody as well as hepatitis C. Therefore his organs could not be harvested.

  1. The diagnosis of brain death is a clinical one. After ruling out hypothermia and drug overdose (especially phenobarbital, sedatives, and hypnotics), brainstem reflexes (pupillary, corneal, oculocephalic, and oculovestibular) and respirations must be absent.

  2. When brain death appears imminent, physicians should inform the family of the gravity and poor prognosis of the situation. The transplant coordinator should be contacted as soon as possible so that the family can be counseled. The patient may be a transplant donor.

  3. Physicians must contact the police immediately whenever foul play is suspected to underlie a patient’s injuries. Harvesting of organs cannot occur until they have released the body along with the coroner.

  4. Once the local organ procurement organization accepts the case, it assumes all charges.

Jenkins DH, Reilly PM, McMahon DJ, et al Minimizing charges associated with the determination of brain death. Crit Care 1997; 1:65–70

Takehara Y, Takahashi M, Isoda H, et al. Scintigraphic evaluation of brain death with 99mTc-d, l-Hexamethyl-propyleneamine Oxime (HMPAO). Radioisotopes 1989; 38:335–338

Tien RD, Lin DS, Kutka N. The “Hot Nose” sign in the cerebral radionuclide angiogram. Semin Nucl Med 1992; 22:295–296

Wilkins RH, Rengachary SS. Neurosurgery. 2nd ed. New York, NY: McGraw-Hill, 1996; 4242

Figure Jump LinkFigure 1. What does the blood flow study show, what in the physical examination confirmed this finding at this time, and what steps need to be taken now?Grahic Jump Location


Figure Jump LinkFigure 1. What does the blood flow study show, what in the physical examination confirmed this finding at this time, and what steps need to be taken now?Grahic Jump Location



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