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Chin J, Vali R, Charron M, Shammas A. Update on Pediatric Nuclear Medicine in Acute Care. Semin Nucl Med 2023; 53:820-839. [PMID: 37211467 DOI: 10.1053/j.semnuclmed.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/24/2023] [Accepted: 04/29/2023] [Indexed: 05/23/2023]
Abstract
Various radiopharmaceuticals are available for imaging pediatric patients in the acute care setting. This article focuses on the common applications used on a pediatric patient in acute care. To confirm the clinical diagnosis of brain death, brain scintigraphy is considered accurate and has been favorably compared with other methods of detecting the presence or absence of cerebral blood flow. Ventilation-perfusion lung scans are easy and safe to perform with less radiation exposure than computed tomography pulmonary angiography and remain an appropriate procedure to perform on children with suspected pulmonary embolism as a first imaging test in a hemodynamically stable patient with no history of lung disease and normal chest radiograph. 99mTc-pertechnetate scintigraphy (Meckel's scan) is the best noninvasive procedure to establish the diagnosis of ectopic gastric mucosa in Meckel's diverticulum. 99mTcred blood cell scintigraphy generally is useful for assessing lower GI bleeding in patients from any cause. Hepatobiliary scintigraphy is the most accurate diagnostic imaging modality for acute cholecystitis. 99mTc-dimercaptosuccinic acid scintigraphy is the simplest, and the most reliable and sensitive method for the early diagnosis of focal or diffuse functional cortical damage. 99mTcmercaptoacetyltriglycine scintigraphy is used to evaluate for early and late complications of renal transplantation. Bone scintigraphy is a sensitive and noninvasive technique for diagnosis of bone disorders such as osteomyelitis and fracture. 18F-fluorodeoxyglucose-positron emission tomography could be valuable in the evaluation of fever of unknown origin in pediatric patients, with better sensitivity and significantly less radiation exposure than a gallium scan. Moving forward, further refinement of pediatric radiopharmaceutical administered activities, including dose reduction, greater radiopharmaceutical applications, and updated consensus guidelines is warranted, with the use of radionuclide imaging likely to increase.
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Affiliation(s)
- Joshua Chin
- Diagnostic Imaging, Nuclear Medicine Division, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Reza Vali
- Diagnostic Imaging, Nuclear Medicine Division, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Martin Charron
- Diagnostic Imaging, Nuclear Medicine Division, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Amer Shammas
- Diagnostic Imaging, Nuclear Medicine Division, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Gutgold A, Shorbaji N, Epstein D, Honen S, Diab T, Keidar Z, Miller A. The role of single positron emission computed tomography imaging in the diagnosis of brain death whenever Trans-cranial Doppler fails to support it: A retrospective cohort study. Clin Transplant 2023:e15003. [PMID: 37121778 DOI: 10.1111/ctr.15003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/09/2023] [Accepted: 04/17/2023] [Indexed: 05/02/2023]
Abstract
OBJECTIVE Although there is widespread acceptance of the concept of brain death/death by neurologic criteria (BD/DNC), there is marked variability in the use of ancillary tests worldwide. Transcranial Doppler (TCD) is a useful ancillary test for brain death confirmation because it is safe, noninvasive, and done at the bedside. However, it is considered less sensitive than Single Photon Emission Computed Tomography (SPECT) Tc-HMPAO (99 m). This study aims to test the yield of brain perfusion SPECT testing after a TCD has demonstrated some level of intracranial blood flow among patients fulfilling clinical criteria for BD/DNC. METHODS This was a single-center retrospective cohort study of all the patients fulfilling clinical criteria for BD/DNC who underwent brain perfusion SPECT after an intracerebral circulatory arrest was not confirmed by TCD between July 2016 and January 2022. RESULTS TCD was an initial ancillary test performed in 252 patients (99.6%) fulfilling clinical criteria for BD/DNC. A complete circulatory arrest was demonstrated in 228 (90.5%) patients. Brain perfusion SPECT was performed in the remaining 24 patients. The absence of cerebral perfusion consistent with BD/DNC was found in 21 cases (87.5%). BD/DN could not be confirmed in three patients (12.5%). CONCLUSIONS SPECT testing has a high diagnostic yield when TCD fails to confirm a suspected diagnosis of BD/DNC. Combining these two modalities may be an optimal strategy for BD/DNC diagnosis when this is required by local regulations or when confounding factors interfere with the performance of a complete clinical assessment.
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Affiliation(s)
- Amichai Gutgold
- Medical Intensive Care Unit, Rambam Health Care Campus, Haifa, Israel
| | - Nadeem Shorbaji
- Medical Imaging Division, Rambam Health Care Campus, Haifa, Israel
| | - Danny Epstein
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | | | - Tarek Diab
- Neurosurgical Intensive Care Unit, Rambam Health Care Campus, Haifa, Israel
| | - Zohar Keidar
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Asaf Miller
- Medical Intensive Care Unit, Rambam Health Care Campus, Haifa, Israel
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Cerebral blood vessels and perfusion in the pediatric brain death: five cases studied by neuroimaging. Neuroradiology 2022; 64:1661-1669. [PMID: 35511244 DOI: 10.1007/s00234-022-02955-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/11/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE To detect the cerebral blood vessels and perfusion using neuroimaging modalities including computed tomography angiography (CTA), computed tomography perfusion (CTP), and arterial spin labeling (ASL) in children with brain death (BD). METHODS According to the current children's BD criteria, 5 children (3 males, 2 females, mean age of 5.65 years) with BD were enrolled from January 2019 to December 2020. The imaging features of CTA, CTP, and ASL were evaluated to analyze the visualization of important intracranial blood vessels and the states of the cerebral blood flow (CBF) and cerebral blood volume (CBV) related to the region of interest (ROI) brain tissue during the two clinical assessments for BD. RESULTS The "4-point scale" scoring system of CTA was applied to evaluate BD and no negative results were detected. The CTP results of the 5 children suggested the cessation of cerebral circulation with 100% positive results. The ranges of CBF and CBV were 0.00-9.52 ml/100 g/min (mean value 4.95 ± 1.69 ml/100 g/min) and 0.00-1.34 ml/100 g (mean value 0.36 ± 0.20 ml/100 g), respectively. One patient also underwent ASL examination, which demonstrated a significant reduction in whole brain perfusion, indicating the absence of cerebral circulation. The CBF values of the brainstem, basal ganglia, and prefrontal lobe were 11.61 ± 1.49 ml/100 g/min, 7.81 ± 2.42 ml/100 g/min, and 9.94 ± 2.01 ml/100 g/min, respectively. CONCLUSION Neuroimaging examinations particularly CTA and CTP reveal well the hemodynamic and cerebral blood vessels changes of BD, which can be used as supplementary supportive evidence for the declaration of brain death in children.
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Yoshikawa MH, Rabelo NN, Welling LC, Telles JPM, Figueiredo EG. Brain death and management of the potential donor. Neurol Sci 2021; 42:3541-3552. [PMID: 34138388 PMCID: PMC8210518 DOI: 10.1007/s10072-021-05360-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/28/2021] [Indexed: 11/22/2022]
Abstract
One of the first attempts to define brain death (BD) dates from 1963, and since then, the diagnosis criteria of that entity have evolved. In spite of the publication of practice parameters and evidence-based guidelines, BD is still causing concern and controversies in the society. The difficulties in determining brain death and making it understood by family members not only endorse futile therapies and increase health care costs, but also hinder the organ transplantation process. This review aims to give an overview about the definition of BD, causes, physiopathology, diagnosis criteria, and management of the potential brain-dead donor. It is important to note that the BD determination criteria detailed here follow the AAN’s recommendations, but the standard practice for BD diagnosis varies from one country to another.
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Affiliation(s)
- Marcia Harumy Yoshikawa
- Department of Neurological Surgery, University of Sao Paulo, Rua Eneas Aguiar, 255, São Paulo, 05403-010, Brazil.
| | - Nícollas Nunes Rabelo
- Department of Neurological Surgery, University of Sao Paulo, Rua Eneas Aguiar, 255, São Paulo, 05403-010, Brazil
| | | | - João Paulo Mota Telles
- Department of Neurological Surgery, University of Sao Paulo, Rua Eneas Aguiar, 255, São Paulo, 05403-010, Brazil
| | - Eberval Gadelha Figueiredo
- Department of Neurological Surgery, University of Sao Paulo, Rua Eneas Aguiar, 255, São Paulo, 05403-010, Brazil
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Chaudhari AJ, Badawi RD. Application-specific nuclear medical in vivoimaging devices. Phys Med Biol 2021; 66. [PMID: 33770765 DOI: 10.1088/1361-6560/abf275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/26/2021] [Indexed: 11/11/2022]
Abstract
Nuclear medical imaging devices, such as those enabling photon emission imaging (gamma camera, single photon emission computed tomography, or positron emission imaging), that are typically used in today's clinics are optimized for assessing large portions of the human body, and are classified as whole-body imaging systems. These systems have known limitations for organ imaging, therefore application-specific devices have been designed, constructed and evaluated. These devices, given their compact nature and superior technical characteristics, such as their higher detection sensitivity and spatial resolution for organ imaging compared to whole-body imaging systems, have shown promise for niche applications. Several of these devices have further been integrated with complementary anatomical imaging devices. The objectives of this review article are to (1) provide an overview of such application-specific nuclear imaging devices that were developed over the past two decades (in the twenty-first century), with emphasis on brain, cardiac, breast, and prostate imaging; and (2) discuss the rationale, advantages and challenges associated with the translation of these devices for routine clinical imaging. Finally, a perspective on the future prospects for application-specific devices is provided, which is that sustained effort is required both to overcome design limitations which impact their utility (where these exist) and to collect the data required to define their clinical value.
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Affiliation(s)
- Abhijit J Chaudhari
- Department of Radiology, University of California Davis, Sacramento, CA 95817, United States of America.,Center for Molecular and Genomic Imaging, University of California Davis, Davis, CA 95616, United States of America
| | - Ramsey D Badawi
- Department of Radiology, University of California Davis, Sacramento, CA 95817, United States of America.,Department of Biomedical Engineering, University of California Davis, Davis, CA 95616, United States of America
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Radionuclide Imaging of Children. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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7
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Ozdemir S, Tan YZ, Ozturk FK, Battal F. Confirmation of Brain Death with Positron Emission Tomography. J Pediatr Intensive Care 2019; 9:51-53. [PMID: 31984158 DOI: 10.1055/s-0039-1696652] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 07/25/2019] [Indexed: 10/26/2022] Open
Abstract
After recent advances regarding organ transplantation, accurate and timely diagnosis of brain death has gained importance. In the diagnosis of brain death, in addition to clinical findings, various ancillary tests are very crucial. In this study, the scintigraphic imaging of the brain death of an 8-year-old girl with both Tc-99m diethylenetriaminepentaacetic and 18F-fluorodeoxyglucose (FDG) has been presented. This case study shows that 18F-FDG positron emission tomography-computed tomography imaging can be a useful technique in evaluating brain death in patients.
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Affiliation(s)
- Semra Ozdemir
- Department of Nuclear Medicine, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Yusuf Ziya Tan
- Department of Nuclear Medicine, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Fulya Koc Ozturk
- Department of Nuclear Medicine, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Fatih Battal
- Department of Pediatrics, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey
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Peckham ME, Anderson JS, Rassner UA, Shah LM, Hinckley PJ, de Havenon A, Kim SE, McNally JS. Low b-value diffusion weighted imaging is promising in the diagnosis of brain death and hypoxic-ischemic injury secondary to cardiopulmonary arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:165. [PMID: 29925413 PMCID: PMC6011248 DOI: 10.1186/s13054-018-2087-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/30/2018] [Indexed: 12/20/2022]
Abstract
Background Cardiorespiratory arrest can result in a spectrum of hypoxic ischemic brain injury leading to global hypoperfusion and brain death (BD). Because up to 40% of patients with BD are viable organ donors, avoiding delayed diagnosis of this condition is critical. High b-value diffusion weighted imaging (DWI) measures primarily molecular self-diffusion; however, low b-values are sensitive to perfusion. We investigated the feasibility of low b-value DWI in discriminating the global hypoperfusion of BD and hypoxic ischemic encephalopathy (HIE). Methods We retrospectively reviewed cardiorespiratory arrest subjects with a diagnosis of HIE or BD. Inclusion criteria included brain DWI acquired at both low (50 s/mm2) and high (1000–2000 s/mm2) b-values. Automated segmentation was used to determine mean b50 apparent diffusion coefficient (ADC) values in gray and white matter regions. Normal subjects with DWI at both values were used as age- and sex-matched controls. Results We evaluated 64 patients (45 with cardiorespiratory arrest and 19 normal). Cardiorespiratory arrest patients with BD had markedly lower mean b50 ADC in gray matter regions compared with HIE (0.70 ± 0.18 vs. 1.95 ± 0.25 × 10−3 mm2/s, p < 0.001) and normal subjects (vs. 1.79 ± 0.12 × 10−3 mm2/s, p < 0.001). HIE had higher mean b50 ADC compared with normal (1.95 ± 0.25 vs. 1.79 ± 0.12 × 10−3 mm2/s, p = 0.016). There was wide separation of gray matter ADC values in BD subjects compared with age matched normal and HIE subjects. White matter values were also markedly decreased in the BD population, although they were less predictive than gray matter. Conclusion Low b-value DWI is promising for the discrimination of HIE with maintained perfusion and brain death in cardiorespiratory arrest.
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Affiliation(s)
- Miriam E Peckham
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA. .,Department of Radiology and Imaging Sciences, University of Utah Health Sciences Center, 30 North, 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA.
| | - Jeffrey S Anderson
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Ulrich A Rassner
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Lubdha M Shah
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Peter J Hinckley
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Seong-Eun Kim
- Utah Center for Advanced Imaging Research, Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - J Scott McNally
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
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Tatli O, Bekar O, Imamoglu M, Gonenc Cekic O, Aygun A, Eryigit U, Karaca Y, Sahin A, Turkmen S, Turedi S. Cerebral Oximetry as an Auxiliary Diagnostic Tool in the Diagnosis of Brain Death. Transplant Proc 2017; 49:1702-1707. [DOI: 10.1016/j.transproceed.2017.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/16/2017] [Indexed: 10/18/2022]
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Zuckier LS. Radionuclide Evaluation of Brain Death in the Post-McMath Era. J Nucl Med 2016; 57:1560-1568. [PMID: 27516449 DOI: 10.2967/jnumed.116.174037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 08/08/2016] [Indexed: 12/19/2022] Open
Abstract
The pronouncement of death is a determination of paramount social, legal, and ethical import. The novel construct of "brain death" was introduced 50 years ago, yet there persist gaps in understanding regarding this diagnosis on the part of medical caregivers and families. The tragic, much-publicized case of Jahi McMath typifies potential problems that can be encountered with this diagnosis and serves as an effective point of departure for discussion. This article recapitulates the historical development of brain death and the evolution of scintigraphic examinations as ancillary or confirmatory studies, emphasizing updated clinical and imaging practice guidelines and the current role of scintigraphy. The limitations of clinical and radionuclide studies are then reviewed. Finally, the article examines whether radionuclide examinations might be able to play an expanded role in the determination of brain death by improving accuracy and facilitating effective communication with family members.
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Affiliation(s)
- Lionel S Zuckier
- The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
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11
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Kang KM, Yun TJ, Yoon BW, Jeon BS, Choi SH, Kim JH, Kim JE, Sohn CH, Han MH. Clinical utility of arterial spin-labeling as a confirmatory test for suspected brain death. AJNR Am J Neuroradiol 2015; 36:909-14. [PMID: 25572951 DOI: 10.3174/ajnr.a4209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 11/11/2014] [Indexed: 01/03/2023]
Abstract
Diagnosis of brain death is made on the basis of 3 essential findings: coma, absence of brain stem reflexes, and apnea. Although confirmatory tests are not mandatory in most situations, additional testing may be necessary to declare brain death in patients in whom results of specific components of clinical testing cannot be reliably evaluated. Recently, arterial spin-labeling has been incorporated as part of MR imaging to evaluate cerebral perfusion. Advantages of arterial spin-labeling include being completely noninvasive and providing information about absolute CBF. We retrospectively reviewed arterial spin-labeling findings according to the following modified criteria based on previously established confirmatory tests to determine brain death: 1) extremely decreased perfusion in the whole brain, 2) bright vessel signal intensity around the entry of the carotid artery to the skull, 3) patent external carotid circulation, and 4) "hollow skull sign" in a series of 5 patients. Arterial spin-labeling findings satisfied the criteria for brain death in all patients. Arterial spin-labeling imaging has the potential to be a completely noninvasive confirmatory test to provide additional information to assist in the diagnosis of brain death.
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Affiliation(s)
- K M Kang
- From the Institute of Radiation Medicine (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.), Seoul National University Medical Research Center, Seoul, Republic of Korea Departments of Radiology (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.)
| | - T J Yun
- From the Institute of Radiation Medicine (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.), Seoul National University Medical Research Center, Seoul, Republic of Korea Departments of Radiology (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.)
| | - B-W Yoon
- Neurology (B.-W.Y., B.S.J.) Clinical Research Center for Stroke (B.-W.Y., B.S.J.), Clinical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - B S Jeon
- Neurology (B.-W.Y., B.S.J.) Clinical Research Center for Stroke (B.-W.Y., B.S.J.), Clinical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - S H Choi
- From the Institute of Radiation Medicine (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.), Seoul National University Medical Research Center, Seoul, Republic of Korea Departments of Radiology (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.)
| | - J-H Kim
- From the Institute of Radiation Medicine (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.), Seoul National University Medical Research Center, Seoul, Republic of Korea Departments of Radiology (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.)
| | | | - C-H Sohn
- From the Institute of Radiation Medicine (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.), Seoul National University Medical Research Center, Seoul, Republic of Korea Departments of Radiology (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.)
| | - M H Han
- From the Institute of Radiation Medicine (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.), Seoul National University Medical Research Center, Seoul, Republic of Korea Departments of Radiology (K.M.K., T.J.Y., S.H.C., J.-h.K., C.-H.S., M.H.H.)
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Ergun O, Birgi E, Tatar IG, Oztekin MF, Hekimoglu B. Can arteriovenous malformation prevent the diagnosis of brain death? Emerg Radiol 2014; 22:199-201. [PMID: 25142907 DOI: 10.1007/s10140-014-1264-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 08/15/2014] [Indexed: 10/24/2022]
Abstract
We present a case of a 14-year-old boy with spontaneous intracranial hemorrhage that was referred to us to confirm the diagnosis of brain death with cerebral angiography. In the left carotid angiogram, there was no arterial flow above the craniovertebral junction. But in the right carotid angiogram, there was arterial flow up to the level of posterior communicating artery. Right posterior cerebral artery was filled with contrast medium via patent posterior communicating artery and later, an opacifying arteriovenous malformation (AVM) was detected which was also seen in the vertebral angiogram. Although the angiographic findings of the patient did not confirm the angiographic criteria for the diagnosis of brain death, it could not be also excluded because the only cerebral flow was the filling of the AVM and no other cerebral perfusion was detected.
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Affiliation(s)
- Onur Ergun
- Department of Radiology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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Abstract
When brain injury is refractory to aggressive management and is considered nonsurvivable, with loss of consciousness and brain stem reflexes, a brain death protocol may be initiated to determine death according to neurological criteria. Clinical evaluation typically entails 2 consecutive formal neurological examinations to document total loss of consciousness and absence of brain stem reflexes and then apnea testing to evaluate carbon dioxide unresponsiveness within the brain stem. Confounding factors such as use of therapeutic hypothermia, high-dose metabolic suppression, and movements associated with complex spinal reflexes, fasciculations, or cardiogenic ventilator autotriggering may delay initiation or completion of brain death protocols. Neurodiagnostic studies such as 4-vessel cerebral angiography can rapidly document absence of blood flow to the brain and decrease intervals between onset of terminal brain stem herniation and formal declaration of death by neurological criteria. Intracranial pathophysiology leading to brain death must be considered along with clinical assessment, patterns of vital signs, and relevant diagnostic studies.
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Affiliation(s)
- Richard B. Arbour
- Richard B. Arbour is a liver transplant coordinator at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania
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Güzel Y, Koç ZP, Mitil HA, Köm M, Özer AB, Özercan Hİ, Balcı TA. Brain death scintigraphy and pathology results in a rat model. EXP CLIN TRANSPLANT 2013; 12:143-7. [PMID: 24188426 DOI: 10.6002/ect.2013.0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Brain scintigraphy with Tc-99m-labeled diethylenetriaminopenta-acetic acid is a sensitive diagnostic method showing loss of cerebral blood flow that occurs after brain death. Cerebral blood flow can be quantitatively estimated by this method. The aim of this study was to compare histopathologic changes occurring with the decrease of cerebral blood flow (as shown by Tc-99m-labeled diethylenetriaminopenta-acetic acid brain death scintigraphy) after brain death in an experimental model. MATERIALS AND METHODS The study included examination of cerebral blood flow by Tc-99m-labeled diethylenetriaminopenta-acetic acid brain scintigraphy in the 20 rats, 1 day before brain death, after producing brain death in 11 surviving rats. Tc-99m-labeled diethylenetriaminopenta-acetic acid brain scintigraphy was performed under intubation and monitored. The Mann-Whitney U test was performed to compare groups (scintigraphic quantification results before and after brain death). RESULTS In the time activity curves generated from the analysis of the scintigraphies, decreases in counts in the brain death group were obtained in the arterial phase (P < .01). Decreases of the cerebral blood flow between the first and the sixth minutes were statistically significant (P < .05). Common principal histopathologic changes of the brain death (ie, autolysis and color loss in the nerve cells, diffuse edema, petechial hemorrhage in the brain tissues) were observed in all subjects. CONCLUSIONS Quantitative findings of the brain scintigraphy by Tc-99m-labeled diethylenetriaminopenta-acetic acid was related with the histopathologic findings seen during the early brain death, with significant decreases of the cerebral blood flow. Quantification of Tc-99m-labeled diethylenetriaminopenta-acetic acid brain death scintigraphy as an easier and less-expensive scintigraphic method of cerebral blood flow might indicate a definite diagnosis of brain death and thus, potential donors can be determined earlier, leaving to increased transplant rates.
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Affiliation(s)
- Yunus Güzel
- Department of Nuclear Medicine, Firat University Medical Faculty, Elazig, Turkey
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Zuckier LS, Sogbein OO. Brain perfusion studies in the evaluation of acute neurologic abnormalities. Semin Nucl Med 2013; 43:129-38. [PMID: 23414828 DOI: 10.1053/j.semnuclmed.2012.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Two categories of single-photon radiopharmaceuticals for brain perfusion exist, nonlipophilic and lipophilic compounds. The former are useful in performing simple flow examinations which today have application primarily in the determination of brain death. The latter also exhibit a parenchymal uptake phase that allows for evaluation of the distribution of blood flow within the brain. The lipophilic radiopharmaceuticals, therefore, have application in the evaluation of patients following catastrophic brain injury and traumatic brain injury (TBI) and in prognosticating the outcome following cerebral vascular accidents. Use of these agents to monitor therapy with thrombolytic agents, although theoretically helpful, is technically difficult due to the need to institute treatment rapidly, without undue delay.
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Affiliation(s)
- Lionel S Zuckier
- Division of Nuclear Medicine, Department of Medicine, The Ottawa Hospital, University of Ottawa, General Campus, Ottawa, Ontario, Canada.
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Banzo J, Razola P, Araíz JJ, Larraga J, Tardín L, Andrés A, Santapau A, Parra A, Rambalde E, Ayala S, Prats E. Cerebral perfusion scintigraphy study as confirmation test of brain death in the process of organ donation for transplant. Rev Esp Med Nucl Imagen Mol 2012; 31:278-85. [PMID: 23067532 DOI: 10.1016/j.remn.2012.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 03/15/2012] [Indexed: 10/28/2022]
Affiliation(s)
- J Banzo
- Servicio de Medicina Nuclear, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.
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Cerebral perfusion scintigraphy study as confirmation test of brain death in the process of organ donation for transplant. Rev Esp Med Nucl Imagen Mol 2012. [DOI: 10.1016/j.remnie.2012.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Affiliation(s)
- Partha Sinha
- Department of Radiology, Division of Nuclear Medicine, 800 Rose Street, HX-313D, University of Kentucky, USA. E-mail:
| | - Gary R Conrad
- Department of Radiology, Division of Nuclear Medicine, 800 Rose Street, HX-313D, University of Kentucky, USA. E-mail:
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