 Objective: We present a case of coma with uncertain inception and brain death (BD) diagnosis misconducting. The definite diagnosis was Bickerstaff syndrome (brainstem encephalitis), with good recovery posterior to immunoglobulin therapy. Situations with potential to challenge coma evaluation are presented and the beneficial role of blood flow ancillary testing is discussed.  Methods: Hospitalization report and online literature review.  Discussion: Not only acceptance and understanding of death are fraught with variation worldwide, but even medical knowledge and training to perform BD assessment, especially when situations are not ordinary.  Conclusion: Performing a blood flow examination prior to initiating BD clinical assessment in uncommon cases may be the best practice.

Keywords : BD: Brain Death, CTA: Computed Tomography Angiography, DSA: Digital Subtraction Angiography, TCD: Transcranial Doppler.