Case Author(s): J. Philip Moyers, M.D., Tom R. Miller, M.D., Ph.D. , 7/28/95 . Rating: #D2, #Q4

Diagnosis: Normal brain perfusion study

Brief history:

Evaluate for brain death.


Anterior perfusion images of the head

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Full history/Diagnosis is available below

Diagnosis: Normal brain perfusion study

Full history:

This is a 76-year old man who underwent surgery yesterday for repair of a thoracoabdominal aneurysm. He now has nonreactive pupils, and brain scintigraphy is requested to evaluate for brain death.


Tc-99m DTPA


This is a normal study with prompt, symmetric perfusion of both cerebral hemispheres. These two-second anterior images obtained after bolus injection in an antecubital fossa show perfusion of both common carotid arteries followed by passage of the bolus through the circle of Willis. On the third image, activity is seen in the anterior and middle cerebral arteries, followed by a capillary phase and, beginning in the fifth image, the venous sinuses.


A prolonged bolus injection may lead to no-diagnostic perfusion images where clear separation of the phases of perfusion through the carotid arteries and intracranial vascular system is not seen. A similar appearance can be seen in patients with congestive heart failure who have a prolonged central circulation time. Localized reduced perfusion can be caused by occlusive disease, neoplasm, hematoma, a cystic lesion, or edema. Localized increased perfusion can be caused by arterial venous malformation, tumor, vascular metastases, meningioma, or inflammatory lesion. A dose of 15-25 mCi Tc-99m DTPA is usually used for this study. A diagnosis of "no effective cerebral perfusion" is made when there is a good bolus, assessed by evaluation of the common carotid arteries, with no flow through the circle of Willis, anterior and middle cerebral arteries, and no capillary phase. Faint venous sinus activity does not preclude this interpretation. This study is useful in making the diagnosis of brain death when supporting clinical data are present.

References: 1) Mettler FA. Essentials of Nuclear Medicine Imaging. 1991, 3rd edition. 2) Datz FL. Handbook of Nuclear Medicine, Mosby Yearbook Publishers, 1993, 2nd edition.

Major teaching point(s):

Appreciation of the scintigraphic appearance of normal brain perfusion is useful in accurate evaluation of brain death.

ACR Codes and Keywords:

References and General Discussion of Brain Scintigraphy (Anatomic field:Skull and Contents, Category:Normal, Technique, Congenital Anomaly)

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Case number: br001

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