A 15-YEAR-OLD African American girl was obtunded after being found in a pool of blood. No history was obtained. Discussion with her family revealed a history of hemoptysis. Evaluation of the hemoptysis included bronchoscopy and computed tomography (CT) of the thorax (Figure 1 and Figure 2). On this presentation she had respiratory distress and decerebrate posturing. Findings from a toxicology screening, coagulation panel, serum electrolyte levels, and complete blood cell count with differential were normal. A brain CT scan was obtained (Figure 3), and the patient was given mannitol, dexamethasone, and treated with hyperventilation. She was transported to a pediatric facility and admitted to the pediatric intensive care unit. She remained comatose with flexion posturing to deep pain. The pupils were initially equal and reactive to light, but she developed hypertension and fixed dilated pupils within 6 hours of arrival. Repeated CT scan of the brain showed multiple infarctions and uncal herniation. She met brain death examination criteria and mechanical ventilation was discontinued.