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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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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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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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Clinical Brain Death with False Positive Radionuclide Cerebral Perfusion Scans. Case Rep Crit Care 2015; 2015:630430. [PMID: 26167307 PMCID: PMC4475709 DOI: 10.1155/2015/630430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/19/2015] [Accepted: 05/25/2015] [Indexed: 11/17/2022] Open
Abstract
Practice guidelines from the American Academy of Neurology for the determination of brain death in adults define brain death as "the irreversible loss of function of the brain, including the brainstem." Neurological determination of brain death is primarily based on clinical examination; if clinical criteria are met, a definitive confirmatory test is indicated. The apnea test remains the gold standard for confirmation. In patients with factors that confound the clinical determination or when apnea tests cannot safely be performed, an ancillary test is required to confirm brain death. Confirmatory ancillary tests for brain death include (a) tests of electrical activity (electroencephalography (EEG) and somatosensory evoked potentials) and (b) radiologic examinations of blood flow (contrast angiography, transcranial Doppler ultrasound (TCD), and radionuclide methods). Of these, however, radionuclide studies are used most commonly. Here we present data from two patients with a false positive Radionuclide Cerebral Perfusion Scan (RCPS).
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George N, Gean EG, Nandi A, Frolov B, Zaidi E, Lee H, Brašić JR, Wong DF. Advances in CNS Imaging Agents: Focus on PET and SPECT Tracers in Experimental and Clinical Use. CNS Drugs 2015; 29:313-30. [PMID: 25948171 DOI: 10.1007/s40263-015-0237-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The physiological functioning of the brain is not well-known in current day medicine and the pathologies of many neuropsychiatric disorders are still not yet fully understood. With our aging population and better life expectancies, it has become imperative to find better biomarkers for disease progression as well as receptor target engagements. In the last decade, these major advances in the field of molecular CNS imaging have been made available with tools such as functional magnetic resonance imaging (fMRI), magnetic resonance spectroscopy (MRS), single photon emission computed tomography (SPECT), and neuroreceptor-targeted positron emission tomography (PET). These tools have given researchers, pharmaceutical companies, and clinical physicians a better method of understanding CNS dysfunctions, and the ability to employ improved therapeutic agents. This review is intended to provide an update on brain imaging agents that are currently used in clinical and translational research toward treatment of CNS disorders. The review begins with amyloid and tau imaging, the former of which has at least three [(18)F] agents that have been recently approved and will soon be available for clinical use for specific indications in the USA and elsewhere. Other prevalent PET and SPECT neurotransmitter system agents, including those newly US FDA-approved imaging agents related to the dopaminergic system, are included. A review of both mature and potentially growing PET imaging agents, including those targeting serotonin and opiate receptor systems, is also provided.
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Affiliation(s)
- Noble George
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins School of Medicine, Johns Hopkins Medical Institutions, 601 N. Caroline St., JHOC Room 3245, Baltimore, MD, 21287-0807, USA
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Computed tomographic angiography as a useful adjunct in the diagnosis of brain death. J Trauma Acute Care Surg 2013; 74:1279-85. [DOI: 10.1097/ta.0b013e31828c46ba] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The concept of brain death has gained importance in the past few decades to prevent futile attempts to sustain ventilation and blood circulation when the brain has lost all function and to procure beneficial tissues or life-saving organs for transplantation. However, differences remain among professional societies and various study group recommendations, as well as among individual legal statutes, in how brain death is defined and the methodology for which the diagnosis is attained. Furthermore, reports have appeared both in the medical literature and the lay press concerning quality assurance measures in brain death documentation. Scintigraphy is a commonly used technique in the evaluation of brain death and can be performed with the use of either nonspecific tracers, such as Tc99m diethylene triamine pentaacetic acid, or brain-specific tracers, such as Tc99m hexamethylpropyleneamineoxime (HMPAO). Planar imaging, with or without radionuclide angiography, continues to be the mainstay for the scintigraphic confirmation of brain death. Flow with multiprojection static planar imaging with the use of Tc99m HMPAO can be used to evaluate the cerebral hemispheres, basal ganglia, thalamus, and cerebellum. Single-photon emission computed tomography (SPECT) can provide cross-sectional information but can be difficult to perform in the context of brain death. The current use of SPECT primarily is supplemental to help differentiate overlying scalp from intracerebral activity. The reliability of SPECT to exclude flow and metabolism in the brainstem remains to be scientifically validated.
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Affiliation(s)
- Partha Sinha
- Department of Radiology, University of Kentucky, Lexington, KY 40536, USA.
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International perspectives in the diagnosis of brain death in adults. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2011.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Joffe AR, Lequier L, Cave D. Specificity of Radionuclide Brain Blood Flow Testing in Brain Death: Case Report and Review. J Intensive Care Med 2010; 25:53-64. [DOI: 10.1177/0885066609355388] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Brain blood flow tests with diffusible radiopharmaceuticals are often done as an ancillary test in brain death (BD). We report a case of an infant with absent brain blood flow on an anterior planar image despite persistent breathing and extensor posturing. We reviewed the literature from 1980 to 2008 using MEDLINE and PubMed to determine the sensitivity and specificity of these tests in the diagnosis of BD. Search terms were any combination of: brain death; and single photon emission computed tomography (SPECT), radiopharmaceuticals, technetium Tc 99m exametazime, or organotechnetium compounds. The sensitivity of absent brain blood flow on planar imaging for clinically confirmed BD is 119/153 = 77.8% [95% CI 70.5%—83.7%]; and the specificity is 41/41 (100%) [95% CI 92.6%—100%]. For clinically confirmed BD, the sensitivity of SPECT is 107/121 (88.4%) [95% CI 81.4%—93.1%], and specificity is 12/12 (100%) [95% CI 78.4%—100%]. For contrast angiography confirmed BD, the sensitivity of SPECT is 34/34 (100%) [95% CI 91.2%—100%]; the specificity could not be estimated as there were no patients without clinical BD having both tests. Case reports emphasized the possibility of isolated posterior-fossa blood flow, which would not be detectable using non-diffusible radiopharmaceuticals, or without a lateral view using diffusible agents. We conclude that patients having an ancillary radiopharmaceutical brain blood flow test for BD should have anterior and lateral views without exception. Larger numbers of patients both with and without BD (but with severe brain injury) must be studied to determine the sensitivity and specificity of these tests.
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Affiliation(s)
- Ari R. Joffe
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada,
| | - Laurance Lequier
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Dominic Cave
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
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Zuckier LS, Kolano J. Radionuclide Studies in the Determination of Brain Death: Criteria, Concepts, and Controversies. Semin Nucl Med 2008; 38:262-73. [DOI: 10.1053/j.semnuclmed.2008.03.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Van Heertum RL, Ichise M. Brain. Clin Nucl Med 2007. [DOI: 10.1007/978-3-540-28026-2_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Young GB, Shemie SD, Doig CJ, Teitelbaum J. Brief review: the role of ancillary tests in the neurological determination of death. Can J Anaesth 2006; 53:620-7. [PMID: 16738299 DOI: 10.1007/bf03021855] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE The acceptance of brain death by society has allowed for the discontinuation of "life support" and the transplantation of organs. In Canada we accept the clinical criteria for brain death (essentially brain stem death) when they can be legitimately applied. Ancillary tests are needed when these clinical criteria cannot be applied or when there are confounders. Ancillary tests include tests of intracranial blood circulation, electrophysiological tests, metabolic studies and tests for residual vagus nerve function. The ideal confirmatory test is one which, when positive, would be incompatible with recoverable brain function (i.e., has no false positives), is not influenced by drugs or metabolic disturbances and which can be readily applied. A critical review of the various ancillary tests used to support the neurological determination of death (brain death) was undertaken. METHODS A literature review based on a MEDLINE search of relevant articles published between January 1966 to January 2005 was undertaken. RESULTS Tests of whole brain perfusion/intracranial blood circulation are the only ones that meet stated criteria. CONCLUSIONS At present only cerebral angiography and nuclear medicine tests of perfusion are accepted by Canadian standards, but computed tomography and magnetic resonance angiography should prove to be suitable. Transcranial Doppler studies may be suitable for specific cases once appropriate guidelines are established.
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Affiliation(s)
- G Bryan Young
- Department of Clinical Neurological Sciences, London Health Sciences Centre, 339 Windermere Road, London, Ontario N6A 5A5, Canada.
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Shemie SD, Doig C, Dickens B, Byrne P, Wheelock B, Rocker G, Baker A, Seland TP, Guest C, Cass D, Jefferson R, Young K, Teitelbaum J. Severe brain injury to neurological determination of death: Canadian forum recommendations. CMAJ 2006; 174:S1-13. [PMID: 16534069 PMCID: PMC1402399 DOI: 10.1503/cmaj.045142] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Sam D Shemie
- Division of Pediatric Critical Care, Montreal Children's Hospital, McGill University Health Centre, Montréal, Que.
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Abstract
Until 1968, when an ad hoc Harvard Medical School Committee published a landmark paper calling for determination of death using neurological rather than cardiovascular criteria, death was considered to have occurred when the heart irreversibly ceased beating. Since that time, every jurisdiction in the country has come to accept through law or court decision neurological criteria to define death. The authors review the issue of death by neurological criteria in light of current guidelines and recent advances.
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Affiliation(s)
- John D Morenski
- Division of Neurological Surgery, University of Missouri-Columbia 65212, USA.
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Abstract
The concept of "brain death" was introduced to medicine in the second half of the 20th century, when technological advancements began to allow sustaining cardiorespiratory functioning of the body in the absence of brain function. Although physicians generally agree that a patient can be declared brain dead when the loss of brain function is total and irreversible, different approaches have been taken to define what constitutes brain death. A thorough clinical examination is essential to the diagnosis. The role of confirmatory tests differ among countries in the world but generally are indicated when a specific part of the clinical examination cannot be performed or is deemed unreliable. Under certain circumstances, confirmatory tests can be used to shorten the clinical observation. Of the confirmatory tests recommended by the American Academy of Neurology and the American Academy of Pediatrics, cerebral scintigraphy is a safe, reliable, and widely available alternative. Once the radiopharmaceutical is properly compounded, cerebral scintigraphy can be performed rapidly and can be interpreted in a straightforward manner. It is tolerant of metabolic aberrations and pharmacologic intoxicants. It is not affected by electrical interference, and the presence of skull defects or scalp trauma do not preclude its performance. The radiopharmaceuticals used in scintigraphy have no deleterious effects on potential donor organs. Cerebral radionuclide angiography has been highly sensitive. Either cerebral planar scintigraphy or cerebral scintitomography with Tc-99m hexamethylpropyleneamineoxime also are highly sensitive, but, in addition, appear to be 100% specific.
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Affiliation(s)
- Gary R Conrad
- Nuclear Medicine Section, Department of Radiology, The University of Kentucky Chandler Medical Center, Lexington, KY, USA
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Kurtek RW, Lai KK, Tauxe WN, Eidelman BH, Fung JJ. Tc-99m hexamethylpropylene amine oxime scintigraphy in the diagnosis of brain death and its implications for the harvesting of organs used for transplantation. Clin Nucl Med 2000; 25:7-10. [PMID: 10634522 DOI: 10.1097/00003072-200001000-00002] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Diagnosing brain death is important in managing the comatose patient for whom the continuation of life support is being questioned and when organ harvesting is being considered. The virtual immediate localization of Tc-99m HMPAO to cerebral and cerebellar tissue provides an index of blood perfusion, and its absence denotes brain death. Other methods for assessing brain death include cerebral angiography, MRI, CT imaging after inhalation of stable xenon, electroencephalography, and clinical examination. The contrast material used for angiography may damage harvested organs, and the other studies have significant errors. MRI, CT imaging, and angiography are unsuitable for bedside use. METHODS Twenty-three patients, who presented with head trauma, prolonged anoxia or intrinsic brain disease (e.g., glioblastoma multiforme) and who were brain-dead by clinical examination criteria, were referred to the nuclear medicine division for verification of brain death. For adults, approximately 25 mCi Tc-99m hexamethylpropylene amineoxime (HMPAO) was administered intravenously. All patients but one were imaged using a mobile scintillation camera at the bedside. RESULTS We demonstrated (1) both cerebral and cerebellar perfusion, (2) neither cerebral nor cerebellar perfusion, (3) cerebral without cerebellar perfusion, and (4) cerebellar without cerebral perfusion. Patients without cerebral perfusion were diagnosed as brain-dead. The significance of a viable cerebellum in the absence of cerebral viability was not fully appreciated, although organs were harvested from such patients. We determined how well the clinical examination criteria held up in the diagnosis of brain death against the new gold standard of Tc-99m HMPAO scintigraphy: Clinical examination criteria correctly predicted brain death only 83% of the time compared with HMPAO scintigraphy. CONCLUSIONS Brain death assessment by Tc-99m HM-PAO scintigraphy has proved to be a reliable, safe, and cost-effective bedside method and may have practical application in the assessment of brain death in potential cadaveric donors.
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Affiliation(s)
- R W Kurtek
- Department of Radiology, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pennsylvania 15213, USA
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Medicina nuclear y diagnóstico de muerte encefálica: angiogammagrafía cerebral con Tc99m-HMPAO. Sensibilidad y especificidad diagnóstica. Med Intensiva 2000. [DOI: 10.1016/s0210-5691(00)79574-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Keske U. Tc-99m-HMPAO single photon emission computed tomography (SPECT) as an ancillary test in the diagnosis of brain death. Intensive Care Med 1998; 24:895-7. [PMID: 9803324 DOI: 10.1007/s001340050687] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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