Brain Death Scintigraphy: Do Not Blow the Flow.

Brain death denotes the loss of function in both the cerebrum and the brain stem, leading to coma, absence of spontaneous respiration in the setting of adequate stimulus, and the cessation of all brain stem reflexes. Although spinal reflexes such as deep tendon, plantar flexion, and withdrawal reflexes may persist, recovery is not possible. The cessation of brain function qualifies as death because of its central role in coordinating vital bodily functions. Although brain death is largely determined by a clinical and neurologic examination, confounding variables may necessitate ancillary testing such as cerebral brain perfusion imaging.

Computed Tomography Angiography as Ancillary Testing for Death Determination by Neurologic Criteria: A Technical Review.

The determination of death by neurological criteria (DNC) stands as a pivotal aspect of medical practice, involving a nuanced clinical diagnosis. Typically, it comes into play following a devastating brain injury, signalling the irreversible cessation of brain function, marked by the absence of consciousness, brainstem reflexes, and the ability to breathe autonomously. Accurate DNC diagnosis is paramount for adhering to the 'Dead donor rule', which permits organ donation solely from deceased individuals. However, complexities inherent in conducting a comprehensive DNC examination may impede reaching a definitive diagnosis. To address this challenge, ancillary testing such as computed tomography angiography (CTA) has emerged as a valuable tool. The aim of our study is to review the technique and interpretation of CTA for DNC diagnoses. CTA, a readily available imaging technique, enables visualization of the cerebral vasculature, offering insights into blood flow to the brain. While various criteria and scoring systems have been proposed, a universally accepted standard for demonstrating full brain circulatory arrest remains elusive. Nonetheless, leveraging CTA as an ancillary test in DNC assessments holds promise, facilitating organ donation and curbing healthcare costs. It is crucial to emphasize that DNC diagnosis should be exclusively entrusted to trained physicians with specialized DNC evaluation training, underscoring the importance of expertise in this intricate medical domain.

Criteria for brain death in Denmark.

In 1990, the Danish brain death legislation was adopted by the Danish Parliament. Each year, around 100 patients in Denmark fulfil criteria for brain death/death by neurological criteria (BD/DNC). In this review of current Danish criteria including the indication for ancillary investigation, which in Denmark is digital subtraction angiography (DSA), we conclude that the time has come to revise the national BD/DNC criteria. We propose that visible anoxic-ischaemic encephalopathy on brain CT after cardiac arrest does not require evaluation by ancillary testing, and that CT-angiography can be used instead of DSA.

The Role of Radionuclide Imaging in Brain Death Diagnosis.

Brain death is defined as the complete and irreversible cessation of the entire brain function, including the brainstem. For the most part, the diagnosis is clinical, and ancillary testing is only needed when clinical criteria are not satisfied. Differences exist in brain death diagnosis policy in the confirmation of brain death with ancillary testing and the particular test used. Demonstration of the absence of cerebral circulation is a reliable indicator of brain death. Currently, there are no agreed-on universal criteria for ancillary imaging investigation. However, several guidelines and meta-analyses have referred to radionuclide imaging as the most reliable, accurate, and validated ancillary imaging procedure in the confirmation of brain death. Whenever available, lipophilic agents should be preferred using tomographic imaging in all or as needed. False results may occur because of slight temporal delays in flow-function interaction, and such findings may carry prognostic information. Detectable cerebral circulation in the clinical presence of brain death most probably indicates that the process of dying is not yet complete. The results of radionuclide studies may also suggest that the loss of viability in a significant proportion of brain tissue is not compatible with life.

Orbital doppler ultrasound as an ancillary test for diagnosing brain death: A prospective, single blind comparative study.

OBJECTIVE: Transcranial Doppler ultrasound (TDUS), computed tomography angiography (CTA), and transcranial Doppler ultrasound to detect cerebral blood flow are among the adjunctive tests in diagnosing brain death. This study aimed to investigate the effectiveness of orbital doppler ultrasound (ODUS). METHODS: This prospective, single-blind study included 66 patients for whom brain death was to be diagnosed. Primary outcome measures were ODUS measurements, Ophthalmic artery peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive indices (RI) measurements recorded during the brain death determination process. Secondary outcome measures were computed tomography angio (CTA), transcranial Doppler ultrasound (TDUS), and demographic data. RESULTS: This study investigating the effectiveness of ODUS in diagnosing brain death provided diagnostic success with 100% sensitivity and 93% specificity compared to CT angiography. It was noted that anatomical variations may limit its use. CONCLUSION: ODUS was found to have high sensitivity and specificity in the diagnosis of clinical brain death. It may assist in early prognostic assessment and shorten patient follow-up and diagnostic processes.

Low frequency oscillations reflect neurovascular coupling and disappear after cerebral death.

Spectrum power analysis in the low frequency oscillations (LFO) region of functional near infrared spectroscopy (fNIRS) is a promising method to deliver information about brain activation and therefore might be used for prognostication in patients with disorders of consciousness in the neurocritical care unit alongside with established methods. In this study, we measure the cortical hemodynamic response measured by fNIRS in the LFO region following auditory and somatosensory stimulation in healthy subjects. The significant hemodynamic reaction in the contralateral hemisphere correlation with the physiologic electric response suggests neurovascular coupling. In addition, we investigate power spectrum changes in steady state measurements of cerebral death patients and healthy subjects in the LFO region, the frequency of the heartbeat and respiration. The spectral power within the LFO region was lower in the patients with cerebral death compared to the healthy subjects, whereas there were no differences in spectral power for physiological activities such as heartbeat and respiration rate. This finding indicates the cerebral origin of our low frequency measurements. Therefore, LFO measurements are a potential method to detect brain activation in patients with disorders of consciousness and cerebral death. However, further studies in patients are needed to investigate its potential clinical use.

Pulmonary strain and end-expiratory lung volume during apnea test: a comparative analysis using electrical impedance tomography.

The apnea test, employed for brain death assessment, aims to demonstrate the absence of respiratory drive due to hypercapnia. The tracheal oxygen insufflation apnea test mode (I-AT) involves disconnecting the patient from invasive mechanical ventilation (iMV) for approximately 8 minutes while maintaining oxygenation. This test supports the diagnosis of brain death based on a specified increase in PaCO2. Common complications include hypoxemia and hemodynamic instability, and lung collapse-induced reduction in end-expiratory lung volume (EELV). In our case series utilizing electrical impedance tomography (EIT), we observed that continuous positive airway pressure during the apnea test (CPAP-AT) effectively mitigated lung collapse. This resulted in improved pulmonary strain compared to the disconnection of iMV. These findings suggest the potential benefits of routine CPAP-AT, particularly for potential lung donors, emphasizing the relevance of our study in providing quantitative insights into EELV loss and its association with pulmonary strain and potential lung injury.

La prueba de apnea es una técnica diagnóstica ampliamente utilizada para la evaluación de la muerte cerebral, con el objetivo de demostrar la ausencia de impulso respiratorio debido a la hipercapnia. La variante de la prueba de apnea con insuflación de oxígeno traqueal (I-AT) implica desconectar al paciente de la ventilación mecánica invasiva (iVM) durante aproximadamente 8 minutos, manteniendo la oxigenación mediante un catéter de insuflación. Esta prueba respalda el diagnóstico de muerte cerebral cuando se determina un aumento de la PaCO 2 superior a 20 mmHg en comparación con el valor inicial o un nivel de PaCO 2 superior a 60 mmHg al final de la prueba. En nuestra serie de casos, la implementación de la tomografía de impedancia eléctrica (EIT) reveló que la prueba de apnea con presión positiva continua (CPAPAT) mitiga eficazmente el colapso pulmonar. Este enfoque resulta en una mejora en la tensión pulmonar en comparación con la desconexión de iMV, demostrando su relevancia en el contexto de potenciales donantes de pulmones.

Aneurysmal 99m Tc-HMPAO Uptake in Brain Death.

ABSTRACT: A 41-year-old man was admitted to hospital due to sudden loss of consciousness. A regional brain perfusion SPECT/low-dose CT showed abnormal 99m Tc-HMPAO uptake in the right hemisphere frontotemporally without any other supratentorial or infratentorial radiotracer uptake. A neuropathological examination disclosed a middle cerebral artery aneurysm. Presumably, vessel wall fibrosis prevented collapse. Multiple transmural dissections of the fibrotic aneurysmal wall were the source of the subarachnoid hemorrhage. This interesting image shows that radiotracer accumulation in cerebral artery aneurysms can be a diagnostic pitfall in brain death scintigraphy assessment.

Self-harm, suicide and brain death: the role of the radiologist.

Suicide is a leading cause of death worldwide and takes many forms, which include hanging, jumping from a height, sharp force trauma, ingestion/poisoning, drowning, and firearm injuries. Self-harm and suicide are associated with particular injuries and patterns of injury. Many of these patterns are apparent on imaging. Self-harm or suicidal intent may be overlooked initially in such cases, particularly when the patient is unconscious or uncooperative. Correct identification of these findings by the radiologist will allow a patient's management to be tailored accordingly and may prevent future suicide attempts. The initial role of the radiologists in these cases is to identify life-threatening injuries that require urgent medical attention. The radiologist can add value by drawing attention to associated injuries, which may have been missed on initial clinical assessment. In many cases of self-harm and suicide, imaging is more reliable than clinical assessment. The radiologist may be able to provide important prognostic information that allows clinicians to manage expectations and plan appropriately. Furthermore, some imaging studies will provide essential forensic information. Unfortunately, many cases of attempted suicide will end in brain death. The radiologist may have a role in these cases in identifying evidence of hypoxic-ischaemic brain injury, confirming a diagnosis of brain death through judicious use of ancillary tests and, finally, in donor screening for organ transplantation. A review is presented to illustrate the imaging features of self-harm, suicide, and brain death, and to highlight the important role of the radiologist in these cases.

Transcranial Doppler and Color-Coded Doppler Use for Brain Death Determination in Adult Patients: A Pictorial Essay.

Transcranial Doppler (TCD) is a repeatable, at-the-bedside, helpful tool for confirming cerebral circulatory arrest (CCA). Despite its variable accuracy, TCD is increasingly used during brain death determination, and it is considered among the optional ancillary tests in several countries. Among its limitations, the need for skilled operators with appropriate knowledge of typical CCA patterns and the lack of adequate acoustic bone windows for intracranial arteries assessment are critical. The purpose of this review is to describe how to evaluate cerebral circulatory arrest in the intensive care unit with TCD and transcranial duplex color-coded doppler (TCCD).

Computed Tomography Perfusion for the Diagnosis of Brain Death: A Technical Review.

Timely diagnosis of brain death (BD) is critical as it prevents unethical and futile continuation of support of vital organ functions when the patient has passed. Furthermore, it helps with avoiding the unnecessary use of resources and provides early opportunity for precious organ donation. The diagnosis of BD is mainly based on careful neurological assessment of patients with an established underlying diagnosis of neurological catastrophe capable of causing BD.Ancillary testing, however, is tremendously helpful in situations when the presence of confounders prevents or delays comprehensive neurological assessment. Traditionally, four-vessel digital subtraction angiography and computed tomography angiography have been used for blood flow (BF) examinations of the brain. The lack of BF in the intracranial arteries constitutes conclusive evidence that the brain is dead. However, there is an apparent discrepancy between the BF and sufficient cerebral perfusion; several studies have shown that in 15% of patients with confirmed clinical diagnosis of BD, BF is still preserved. In these patients, cerebral perfusion is significantly impaired. Hence, measurement of cerebral perfusion rather than BF will provide a more precise assessment of the brain function.In this review article, we discuss a brief history of BD, our understanding of its complex pathophysiology, current Canadian guidelines for the clinical diagnosis of BD, and the ancillary tests-specifically CT perfusion of the brain that help us with the prompt and timely diagnosis of BD.

Brain Death Confirmation by 18F-FDG PET/CT: A Case Series.

OBJECTIVES: Brain death is a state of irreversible loss of brain function in the cortex and brainstem. Diagnosis of brain death is established by clinical assessments of cranial nerves and apnea tests. Different conditions can mimic brain death. In addition, confirmatory tests may be falsely positive in some cases. In this study, we aimed to evaluate the role of positron emission tomography-computed tomography scan with 2-deoxy-2[18F]fluoro-D-glucose (18F-FDG-PET/CT) as an ancillary test in diagnosing brain death. MATERIALS AND METHODS: We analyzed 6 potential brain death donors for the confirmatory diagnosis of brain death using FDG-PET/CT. All 6 donors were brain dead by clinical criteria. All patients had electroencephalogram and brain computed tomography. Other than FDG-PET/CT, transcranial Doppler was performed in 1 patient, with other patients having no confirmatory ancillary imaging tests. Patients had nothing by mouth for 6 hours before imaging. Patients were supine in a semi-dark, noiseless, and odorless room with closed eyes. After 60 minutes of uptake,the brain PET/CT scan was performed with sequential time-of-flight-PET/CT (Discovery 690 PET/CT with 64 slices, GE Healthcare). The PET scan consisted of LYSO (Lu1.8Y0.2 SiO5) crystals with dimensions of 4.2 × 6.3 × 25 mm3. Three-dimension images were with scan duration of 10 minutes. RESULTS: The PET scan confirmed brain death in 5 of the 6 cases. However, we ruled out brain death using PET/CT in a 3-year-old child, although all clinical tests confirmed brain death. CONCLUSIONS: A PET scan illustrates a hollow skull phenomenon suggestive of brain death. It can be a powerful diagnostic tool to assess brain death.

The role of optic nerve sheath diameter measurement in the diagnosis of brain death.

OBJECTIVE: The aim of this study is to evaluate the correlation between optic nerve sheath diameter (ONSD) measured using computed tomography (CT), and ONSD measured using bedside ultrasonography (USG) in the diagnosis of brain death. PATIENTS AND METHODS: A total of 21 brain-dead patients were included in the study. The ONSD values of these patients were measured using both USG and CT before and after brain death, and the relationship between these measurements was evaluated. RESULTS: There was a high level of correlation between the right-left eye ONSD measurements conducted before brain death using USG and CT, respectively (p=0.000, p=0.001). There was a high level of correlation between the right-left eye ONSD measurements conducted after brain death using USG and CT, respectively (p=0.000, p=0.00). Pre-brain death ONSD mean values of both left and right eyes, measured using USG and CT, were found to be statistically significantly lower than the mean values of post-brain death measurements. CONCLUSIONS: In conclusion, a statistically significant difference was found between the optic nerve sheath diameter values measured before and after brain death using USG and CT. At the same time, it was determined that the values of the optic nerve sheath diameter measured using both CT and USG were correlated.

Ancillary radionuclide perfusion studies in the determination of death by neurologic criteria: methods, interpretation, and lexicon-a user guide for the clinician.

Radionuclide perfusion studies have an established ancillary role in determination of death by neurologic criteria (DNC). While critically important, these examinations are not well understood by individuals outside of the imaging specialties. The purpose of this review is to clarify relevant concepts and nomenclature and provide a lexicon of relevant terminology of value to non-nuclear medicine practitioners who wish to better understand these examinations. Radionuclides were first employed to evaluate cerebral blood flow in 1969. Radionuclide DNC examinations that use lipophobic radiopharmaceuticals (RPs) entail a flow phase followed immediately by blood pool images. On flow imaging, presence of intracranial activity within the arterial vasculature is scrutinized following arrival of the RP bolus into the neck. Lipophilic RPs designed for functional brain imaging were introduced to nuclear medicine in the 1980s and were engineered to cross the blood-brain-barrier and be retained in the parenchyma. The lipophilic RP 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO) was first used as an ancillary investigation in DNC in 1986. Examinations using lipophilic RPs entail both flow and parenchymal phase images. According to some guidelines, parenchymal phase uptake should be assessed by tomographic imaging, while other investigators consider simple planar imaging sufficient. Findings of perfusion on either the flow or parenchymal phase of the examination effectively precludes DNC. If the flow phase is omitted or somehow compromised, the parenchymal phase remains sufficient for DNC. A priori, parenchymal phase imaging is superior to flow phase imaging for several reasons and lipophilic RPs are favoured over lipophobic RPs in that both flow and parenchymal phase imaging are performed. Disadvantages of lipophilic RPs are increased cost and the need to procure them from a central laboratory, which can prove difficult, especially outside usual working hours. According to most current guidelines, both lipophilic and lipophobic RP categories are acceptable for use in ancillary investigations in DNC, with a growing overt preference for studies using the lipophilic RPs based on their ability to capture the parenchymal phase. The new adult and pediatric Canadian recommendations favour use of lipophilic RPs to variable degrees, specifically 99mTc-HMPAO, the lipophilic moiety which has undergone the greatest validation. Although ancillary use of radiopharmaceuticals is quite settled in multiple DNC guidelines and best practices, several areas of further research remain open to investigation. Examens auxiliaires de perfusion nucléaire pour la détermination du décès selon des critères neurologiques : méthodes, interprétation et lexique-un guide de l'utilisateur à l'intention du clinicien.

RéSUMé: Les examens de la perfusion nucléaire jouent un rôle auxiliaire bien établi dans la détermination du décès selon des critères neurologiques (DCN). Bien qu'ils soient d'une importance cruciale, ces examens ne sont pas bien compris par les personnes en dehors des spécialités d'imagerie. Le but de cette revue est de clarifier les concepts et la nomenclature pertinents et de fournir un lexique de terminologie pertinente utile aux praticiens non spécialisés en médecine nucléaire qui souhaitent mieux comprendre ces examens. Les radionucléides ont été utilisés pour la première fois pour évaluer la circulation sanguine cérébrale en 1969. Les examens de DCN par radionucléides qui utilisent des produits radiopharmaceutiques (RP) lipophobes impliquent une phase de circulation suivie immédiatement d'images de pool sanguin. Sur l'imagerie en circulation, la présence d'une activité intracrânienne dans le système vasculaire artériel est examinée après l'arrivée du bolus de RP dans le cou. Les RP lipophiles conçus pour l'imagerie cérébrale fonctionnelle ont été introduits en médecine nucléaire dans les années 1980 et ont été conçus pour franchir la barrière hémato-encéphalique et être retenus dans le parenchyme. Le RP lipophile 99mTc-hexaméthylpropylèneamine-oxime (99mTc-HMPAO) a été utilisé pour la première fois comme examen auxiliaire pour le DCN en 1986. Les examens utilisant des RP lipophiles impliquent à la fois des images de circulation et de phase parenchymateuse. Selon certaines lignes directrices, l'absorption durant la phase parenchymateuse devrait être évaluée par imagerie tomographique, tandis que d'autres chercheurs considèrent qu'une imagerie planaire simple suffit. Les résultats de perfusion sur la phase de circulation ou la phase parenchymateuse de l'examen excluent effectivement un DCN. Si la phase de circulation est omise ou compromise d'une manière ou d'une autre, la phase parenchymateuse reste suffisante pour établir un DCN. A priori, l'imagerie en phase parenchymateuse est supérieure à l'imagerie en phase de circulation pour plusieurs raisons et les RP lipophiles sont privilégiés par rapport aux RP lipophobes parce que l'imagerie en circulation et en phase parenchymateuse sont toutes deux réalisées. Les inconvénients des RP lipophiles sont l'augmentation des coûts et la nécessité de les obtenir auprès d'un laboratoire central, ce qui peut s'avérer difficile, surtout en dehors des heures de travail habituelles. Selon la plupart des lignes directrices actuelles, les catégories de RP lipophiles et lipophobes sont toutes deux acceptables pour une utilisation dans les examens auxiliaires pour un DCN, avec une préférence manifeste croissante pour les études utilisant les RP lipophiles en fonction de leur capacité à capturer la phase parenchymateuse. Les nouvelles recommandations canadiennes pour adultes et enfants privilégient l'utilisation de RP lipophiles à des degrés variables, en particulier le 99mTc-HMPAO, le fragment lipophile qui a subi la plus grande validation. Bien que l'utilisation auxiliaire des produits radiopharmaceutiques soit tout à fait établie dans de multiples lignes directrices et meilleures pratiques de DCN, plusieurs domaines de recherche supplémentaires restent ouverts à l'étude.

Ultrasound Scanning in Lung Procurement. Protocol for Decision-Making With the Purpose of Increasing Transplant Eligible Lungs.

BACKGROUND: The main obstacle to obtaining lungs for transplantation is the shortage of donors. Once potential donors have been offered to transplant programs, the acceptance rate is highly variable, ranging from 5% to 20%. Minimizing donor leakage by converting potential lung donors into real donors is one of the key elements to improve results, and it is essential to have tools that facilitate decision-making in this scenario. The selection and rejection of transplantation-eligible lungs are usually made with chest x-rays; however, lung ultrasound scanning has shown better sensitivity and specificity for diagnosing pulmonary pathologies. Lung ultrasound scanning allows us to identify the reversible causes of low PaO2/fraction of inspired oxygen (FIO2) ratio, thus enabling the establishment of specific interventions, which, if proved successful, could turn lungs into transplant-eligible lungs. The available literature on its use in managing brain death donors and lung procurement is extremely scarce. METHODS: A simple protocol aimed at identifying and treating the main reversible causes of low PaO2/FIO2 ratio to aid in decision-making is presented in this paper. CONCLUSION: Lung ultrasound is a powerful, useful, and cheap technique available at the donor's bedside. It is conspicuously underused, despite being potentially helpful in decision-making by minimizing the discarding of donors, thus probably increasing the number of lungs sui for transplantation.

The use of cerebral computed tomographic angiography as an ancillary investigation to support a clinical diagnosis of death using neurological criteria: a consensus guideline.

This multidisciplinary consensus statement was produced following a recommendation by the Faculty of Intensive Care Medicine to develop a UK guideline for ancillary investigation, when one is required, to support the diagnosis of death using neurological criteria. A multidisciplinary panel reviewed the literature and UK practice in the diagnosis of death using neurological criteria and recommended cerebral CT angiography as the ancillary investigation of choice when death cannot be confirmed by clinical criteria alone. Cerebral CT angiography has been shown to have 100% specificity in supporting a diagnosis of death using neurological criteria and is an investigation available in all acute hospitals in the UK. A standardised technique for performing the investigation is described alongside a reporting template. The panel were unable to make recommendations for ancillary testing in children or patients receiving extracorporeal membrane oxygenation.

Brain death in children: is computed tomography angiography reliable as an ancillary test?

BACKGROUND: The diagnosis of brain death is primarily clinical. Sometimes ancillary tests are needed. OBJECTIVE: This study compared sensitivity and interobserver agreement of the 10-, 7- and 4-point CT angiography scoring systems for the diagnosis of brain death in children. MATERIALS AND METHODS: CT angiography examinations of 50 pediatric patients with a clinical diagnosis of brain death were evaluated according to 10-, 7- and 4-point scoring systems. Images were evaluated by two radiologists who considered the vessel opacification first in the arterial phase (A0-V50) and then in the venous phase (A0-V50). We evaluated interobserver agreement for the assessment of vessel opacification and diagnosis of brain death. We compared the differences among brain death diagnoses between children with craniotomy-craniectomy defects, open fontanelles and preserved bone integrity. We subdivided children into two groups according to age: ≤ 2 years and > 2 years. We calculated sensitivities according to age groups. RESULTS: Using the clinical exam as the reference standard, we found sensitivities for 10-, 7- and 4-point scoring systems to be 70%, 88% and 92% in the A0-V50 method and 40%, 82% and 82% in the A50-V50 method, respectively. Percentage agreement between readers was 78% for the 7-point scale using the A0-V50 method and more than 90% for other scoring systems for both the A0-V50 method and the A50-V50 method. The sensitivity was much lower in children with open anterior fontanelles compared to the groups with preserved bone integrity and with a craniotomy-craniectomy defect. CONCLUSION: Just as in adult age groups, in children the 4-point scale appears to be more sensitive than the 10- and 7-point scales for CT angiography-based assessment of brain death. Because the scoring systems have similar sensitivities, they could be used as ancillary tests in pediatric cases.

Cerebral circulatory arrest diagnosed with transoral Doppler ultrasonography.

We describe the case of a patient with malignant stroke in whom brain death was diagnosed by evaluating the neck vessels by transoral ultrasonography.

Use of duplex echoencephalography to evaluate brain death in children: A novel approach to the diagnosis.

BACKGROUND AND PURPOSE: Brain death is defined as the irreversible cessation of brain function with a known etiology. This study aims to establish the value of duplex echoencephalography (DEG) in children fulfilling clinical brain death diagnostic criteria. METHODS: DEG must show intracranial brain structures. Power Doppler is used to assess venous flow when feasible. Color Doppler patterns in all major arteries are assessed. Spectral analysis of arterial flow is divided into four grades: grade 1: inverted flow during entire diastole with time average peak velocity (TAPV) less or equal to zero; grade 2: disappearance of the inverted diastolic flow at the end of diastole; grade 3: oscillating pattern in early diastole; and grade 4: no diastolic flow with systolic blip. To fulfill diagnosis of brain death, brain perfusion must be lost for 30 minutes. RESULTS: DEG is performed in 41 pediatric patients. In infants, loss of venous flow occurs regardless of the etiology. Grade 1 is the most common arterial color flow pattern and TAPV is always below zero. A pulsatile color flow is associated with three other types of flow patterns (grades 2-4). TAPV is not calculated, when there is loss of diastolic flow. Diagnosis of brain death is validated using nuclear brain scan in 4 patients. Two have a grade 1 flow pattern, while the other two have a grade 4 flow pattern. CONCLUSIONS: In children, DEG following a strict protocol can be used to confirm diagnosis of brain death in the appropriate clinical setting.