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array:23 [ "pii" => "S2173572715000259" "issn" => "21735727" "doi" => "10.1016/j.medine.2014.11.002" "estado" => "S300" "fechaPublicacion" => "2015-05-01" "aid" => "748" "copyrightAnyo" => "2014" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Med Intensiva. 2015;39:244-50" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6298 "formatos" => array:3 [ "EPUB" => 209 "HTML" => 5012 "PDF" => 1077 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0210569114002599" "issn" => "02105691" "doi" => "10.1016/j.medin.2014.11.005" "estado" => "S300" "fechaPublicacion" => "2015-05-01" "aid" => "748" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Med Intensiva. 2015;39:244-50" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 23834 "formatos" => array:3 [ "EPUB" => 259 "HTML" => 20614 "PDF" => 2961 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">REVISIÓN</span>" "titulo" => "Doppler transcraneal en el diagnóstico de la muerte encefálica. ¿Es útil o retrasa el diagnóstico?" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "244" "paginaFinal" => "250" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Transcranial Doppler ultrasound in the diagnosis of brain death. Is it useful or does it delay the diagnosis?" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1321 "Ancho" => 1300 "Tamanyo" => 266433 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Arteria cerebral media que muestra un patrón muy sistolizado con mínimo flujo diastólico, compatible con una situación de preparada circulatoria cerebral. Índice de pulsatilidad de 2,90, que refleja una alta presión intracraneal.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Escudero, J. Otero, B. Quindós, L. 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"apellidos" => "Viña" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173572715000259" "doi" => "10.1016/j.medine.2014.11.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572715000259?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569114002599?idApp=WMIE" "url" => "/02105691/0000003900000004/v2_201504190201/S0210569114002599/v2_201504190201/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2173572715000260" "issn" => "21735727" "doi" => "10.1016/j.medine.2015.04.001" "estado" => "S300" "fechaPublicacion" => "2015-05-01" "aid" => "712" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Intensiva. 2015;39:256-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1555 "formatos" => array:3 [ "EPUB" => 148 "HTML" => 902 "PDF" => 505 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Shock following subcutaneous injections of polymethylmethacrylate" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "256" "paginaFinal" => "257" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Shock después de inyecciones subcutáneas de polimetilmetacrilato" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2597 "Ancho" => 1677 "Tamanyo" => 358555 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">1A. Chest X-ray showing bilateral lung infiltrates. 1B-E. Chest CT angiographyshowing bilateral consolidations with air-bronchograms and ground-glass-appearing opacities suggestive of alveolar damage.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Boattini, A.R. Francisco, R. Cavaco, J. Rodrigues, L. Bento" "autores" => array:5 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Boattini" ] 1 => array:2 [ "nombre" => "A.R." "apellidos" => "Francisco" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Cavaco" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Rodrigues" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Bento" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572715000260?idApp=WMIE" "url" => "/21735727/0000003900000004/v3_201509260116/S2173572715000260/v3_201509260116/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2173572715000247" "issn" => "21735727" "doi" => "10.1016/j.medine.2014.11.001" "estado" => "S300" "fechaPublicacion" => "2015-05-01" "aid" => "747" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Med Intensiva. 2015;39:234-43" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 8509 "formatos" => array:3 [ "EPUB" => 196 "HTML" => 6273 "PDF" => 2040 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Hyponatremia in the neurocritical care patient: An approach based on current evidence" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "234" "paginaFinal" => "243" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hiponatremias en el paciente neurocrítico: enfoque terapéutico basado en la evidencia actual" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2515 "Ancho" => 3267 "Tamanyo" => 486173 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Therapeutic algorithm for hyponatremia in the neurocritical patient.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "W. Manzanares, I. Aramendi, P.L. Langlois, A. Biestro" "autores" => array:4 [ 0 => array:2 [ "nombre" => "W." "apellidos" => "Manzanares" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Aramendi" ] 2 => array:2 [ "nombre" => "P.L." "apellidos" => "Langlois" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Biestro" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569114002587" "doi" => "10.1016/j.medin.2014.11.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569114002587?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572715000247?idApp=WMIE" "url" => "/21735727/0000003900000004/v3_201509260116/S2173572715000247/v3_201509260116/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Transcranial Doppler ultrasound in the diagnosis of brain death. Is it useful or does it delay the diagnosis?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "244" "paginaFinal" => "250" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "D. Escudero, J. Otero, B. Quindós, L. Viña" "autores" => array:4 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Escudero" "email" => array:2 [ 0 => "dolores.escudero@sespa.princast.es" 1 => "lolaescudero@telefonica.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Otero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "B." "apellidos" => "Quindós" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Viña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Coordinación de Trasplantes y Medicina Regenerativa, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Doppler transcraneal en el diagnóstico de la muerte encefálica. ¿Es útil o retrasa el diagnóstico?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2199 "Ancho" => 2169 "Tamanyo" => 396725 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Middle cerebral artery showing a strongly systolic pattern with minimum diastolic flow, consistent with precerebral circulatory arrest. Pulsatility index 2.90, reflecting high intracranial pressure.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Brain death (BD) is defined as irreversible cessation of the brain and brainstem functions. Its diagnosis has great medical, ethical and legal implications, since it represents certification of the death of the patient and therefore allows withdrawal of all the artificial support measures, or organ harvesting for transplantation purposes. Cerebral circulatory arrest (CCA) that accompanies BD occurs when the intracranial pressure (ICP) exceeds the systolic blood pressure of the patient. The diagnosis of BD is based on an exhaustive neurological exploration that must abide with certain international standards.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,2</span></a> Instrumental tests may be obligate in some clinical cases, and vary according to the legal specifications in force in each individual country.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">3,4</span></a> If the patient is sedated, suffers serious craniofacial damage, or presents intolerance of the apnea test, techniques that study brain circulatory flow, such as angiography with multislice computed tomography (CT), brain scintigraphy with Tc<span class="elsevierStyleSup">99</span>-HMPAO, or transcranial Doppler (TCD) are advised.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">5–11</span></a> The diagnosis of BD is a key element in all national transplant programs. In Spain, almost 90% of all transplants are performed with organs obtained from donors that have died under conditions of BD.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Transcranial Doppler ultrasound is one of the most widely used methods for diagnosing BD, and is legally accepted in Spain.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">12</span></a> Knowing its advantages and limitations can help resolve frequent diagnostic problems in the intensive care unit (ICU), avoid unnecessary resource consumption, and optimize the obtainment of organs for transplantation.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Transcranial Doppler and the legal diagnosis of brain death</span><p id="par0015" class="elsevierStylePara elsevierViewall">Spanish Royal Decree (RD) 1723/2012, under Annex 1, <span class="elsevierStyleItalic">Protocols referred to the diagnosis and certification of death for the obtainment of dead donor organs</span>,<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">12</span></a> specifies the clinical circumstances in which instrumental tests are obligate. In its Section 4, and among the “tests evaluating cerebral blood flow”, TCD is described as one of the techniques that can be used, though the Decree does not specify which cerebral arteries are to be explored, or what type of ultrasound findings are needed to confirm CCA. As specified in Section 3 of the mentioned Decree, TCD allows abbreviation or even suppression (according to medical criterion) of the recommended 6-h observation period in destructive brain damage and 24<span class="elsevierStyleHsp" style=""></span>h of anoxia, thereby facilitating things in the event of organ donation.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Transcranial Doppler in cerebral circulatory arrest</span><p id="par0020" class="elsevierStylePara elsevierViewall">Patients with serious brain damage and refractory intracranial hypertension syndrome suffer a gradual decrease in brain perfusion pressure and cerebral blood flow, which finally causes CCA. The use of TCD for the diagnosis of CCA was first described in 1974,<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">13</span></a> and since then many publications have warranted its usefulness in this context.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,14,15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The study of cerebral blood flow velocity with TCD during the development of CCA distinguishes four evolutive stages,<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">5</span></a> each with its own characteristic flow pattern:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0030" class="elsevierStylePara elsevierViewall">When the ICP exceeds the diastolic blood pressure, the cerebral blood flow velocity at the end of diastole is zero, and flow persists only during systole. The mean velocity is >10<span class="elsevierStyleHsp" style=""></span>cm/s, and there is still some net flow, with a very high pulsatility index. These findings are recorded in situations of severe intracranial hypertension and may be taken to represent a pre-CCA pattern (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0035" class="elsevierStylePara elsevierViewall">When the ICP is equal to or greater than the systolic blood pressure of the patient, brain perfusion ceases. This phase is characterized by the appearance of a pattern known as <span class="elsevierStyleItalic">reverberant flow</span>, <span class="elsevierStyleItalic">biphasic oscillating flow</span> or <span class="elsevierStyleItalic">inverted diastolic flow</span> (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>), produced by the elasticity of the arterial wall. It involves anterograde flow in systole, and retrograde or inverted flow in diastole–both being approximately equal in the same cardiac cycle, and the net brain flow is zero. This pattern has a brief systolic phase. All these observations are correlated to CCA in the arteriographic study.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0040" class="elsevierStylePara elsevierViewall">When the ICP exceeds the systolic blood pressure of the patient we only record <span class="elsevierStyleItalic">systolic spikes</span> or <span class="elsevierStyleItalic">systolic spicules</span>, which are small, anterograde sharp systolic waves with a duration of <200<span class="elsevierStyleHsp" style=""></span>ms and with a systolic peak velocity of <50<span class="elsevierStyleHsp" style=""></span>cm/s. Flow is likewise lacking during the rest of systole and in diastole of the cardiac cycle (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0045" class="elsevierStylePara elsevierViewall">In very advanced cases, with great ICP elevations, we observe flow obstruction in the more proximal segments of the arteries of the skull base, causing a <span class="elsevierStyleItalic">total absence of flow signals</span>. In these cases the doubt may arise as to whether the absence of signals is due to CCA or to the lack of an acoustic window. In order to accept the absence of a signal as criterion of CCA, the TCD exploration must be performed under the same clinical conditions and by the same expert explorer as in the previous studies in which flow was still observed.</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">The presence of effective flow in any intracranial artery completely discards CCA (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Doppler study in the extracranial arteries</span><p id="par0055" class="elsevierStylePara elsevierViewall">One of the main limitations of TCD is the absence of an acoustic window, which prevents us from obtaining intracranial signals–a situation that is found in about 10–20% of the population<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">17,18</span></a> and which is more common in elderly females. In these cases we can study the internal carotid artery (ICA) and the vertebral arteries (VAs) at extracranial level. When access through the temporal window is not possible, some authors use the ophthalmic window to study the internal carotid artery at carotid siphon level.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">19,20</span></a> In this way, Lampl et al.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a> were able to improve the diagnostic performance of the technique by 9%. The use of echo-enhancers also improves exploration in cases of a poor acoustic window. The presence of flow in the carotid siphon is explained by the shunting of blood from the external carotid artery or by CCA occurring distal to it.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The presence of flow in the internal carotid artery and extracranial vertebral arteries does not discard CCA. Consequently, only the transcranial study and the presence of systolic spikes or inverted diastolic flow in the arteries of the skull base are of diagnostic usefulness in relation to BD.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conditions for establishing a diagnosis of cerebral circulatory arrest using transcranial Doppler ultrasound</span><p id="par0065" class="elsevierStylePara elsevierViewall">An adequate system is required, equipped with a 2<span class="elsevierStyleHsp" style=""></span>MHz pulsed-Doppler probe and involving a study sample volume of under 10<span class="elsevierStyleHsp" style=""></span>mm, with the capacity to reach a transmission power of 100<span class="elsevierStyleHsp" style=""></span>mW/cm<span class="elsevierStyleSup">2</span>. The explorer must be an expert, and some guides recommend performing two explorations spaced 30<span class="elsevierStyleHsp" style=""></span>min apart in order to guarantee the irreversibility of CCA.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">6,8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The consensus conference on the diagnosis of CCA, held by a task force of the Neurosonology group dependent upon the World Federation of Neurology,<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">5</span></a> together with the recommendations of the Spanish Society of Neurology,<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">7</span></a> require the patient to be hemodynamically stable with a mean blood pressure (MBP)<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>70<span class="elsevierStyleHsp" style=""></span>mmHg (blood pressure no lower than 90/50<span class="elsevierStyleHsp" style=""></span>mmHg), and PaCO<span class="elsevierStyleInf">2</span> 35–45<span class="elsevierStyleHsp" style=""></span>mmHg. Other prerequisites are knowledge of the cause of coma, and the exclusion of hypothermia, metabolic alterations, intoxications and other factors that may alter the neurological findings. Furthermore, two expert physicians are required to determine the absence of brain functions. These conditions seem very restrictive, since one of the main advantages of TCD is its capacity to diagnose CCA in sedated patients or in cases posing clinical diagnostic problems. What advantage could TCD offer if the patient diagnosis has already been confirmed? In our opinion, the requirements of the task force<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">5</span></a> and the recommendations of the Spanish Society of Neurology<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">7</span></a> regarding a complete clinical diagnosis before accepting Doppler ultrasound as a criterion for diagnosing CCA represent unjustified diagnostic demands that deserve to be reconsidered.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In diagnosing CCA, use is made of both TCD, which is a blind technique, and transcranial color-coded duplex sonography,<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">21–23</span></a> which offers more advantages, but which is less widely used in ICUs. Transcranial color-coded duplex sonography allows simultaneous two-dimensional study of the brain (with visualization in color of the arteries and veins of the skull base) and analysis of the vascular Doppler spectra. The transcranial color-coded angioduplex mode, together with the use of echo-enhancers, allows greater percentage vascular identification than conventional TCD. Because of its advantages, it probably will become the most widely used technique in the future.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Transcranial Doppler ultrasound and the diagnosis of brain death</span><p id="par0080" class="elsevierStylePara elsevierViewall">In order to diagnose BD using TCD, we must confirm CCA based on the bilateral recording of reverberant or inverted diastolic flow and systolic spikes in the anterior and posterior circulation.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,14</span></a> These findings must be demonstrated by exploring through the temporal window (both middle cerebral arteries; anterior circulation) and through the suboccipital window (vertebral arteries and basilar artery; posterior circulation)–though some authors consider exploration of the basilar artery to be sufficient.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a> The advantages and limitations of TCD in diagnosing CCA associated to BD are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">A metaanalysis published in 2006<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">6</span></a> evaluated a total of 684 patients included in 10 studies covering the period 1980–2004. Only two of the studies were considered to be of high quality, and these two articles reported a sensitivity of 95% and a specificity of 99%. On including the other 8 studies of lesser quality in the analysis, the sensitivity was seen to decrease to 88%, while specificity remained the same (99%). Of note in this review is the many studies that did not explore the posterior fossa. This must be criticized, since a diagnosis of BD requires the confirmation of CCA by exploring both the anterior and the posterior circulation. Ultrasound exploration of the posterior circulation in an intubated patient involves some technical difficulty, and therefore the high sensitivity obtained in the mentioned metaanalysis can be explained by the many studies that failed to explore the posterior fossa. The specificity of TCD as a test for confirming BD in the literature varies between 97 and 100%.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">6,11,14</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Limitations of transcranial Doppler in diagnosing brain death</span><p id="par0090" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Absence of an acoustic window.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Explorer dependency.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Difficulty exploring the posterior circulation.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">False-positive readings in diagnosing BD (patients who do not meet the clinical criteria of BD but present CCA at Doppler exploration): ultrasound patterns consistent with CCA have been described in the early stage of subarachnoid hemorrhage secondary to aneurysmal rupture with large ICP elevations, and in cardiac arrest. These situations are transient and reversible; some guides therefore recommend repeating the exploration after 30<span class="elsevierStyleHsp" style=""></span>min.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">5,7</span></a> However, this general norm does not appear to be very justified in patients with refractory and progressive intracranial hypertension syndrome, in which daily TCD monitoring is performed, and gradual worsening until reaching criteria of CCA is confirmed. In addition to these transient situations, there have been some exceptional reports of false-positive readings in both open-skull patients and in patients without cranial defects. In all of these cases TCD exploration was complete, comprising both the anterior and the posterior circulation.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">8,24,25</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall">False-negative readings in diagnosing BD (patients with clinical criteria of BD and the presence of flow at Doppler exploration): open-skull patients may have clinical criteria of BD in the presence of cerebral blood flow. This situation can be seen in patients with a ventricular drain, decompressive craniectomy, skull dome rupture, fractures of the base of the skull, and in infants under 1 year of age with still open fontanelles. In all of these cases the open skull condition allows a certain intracranial decompression that explains the persistence of flow in some of the intracranial arteries, despite clinically confirmed BD.<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">26–28</span></a> It is therefore very important to remember that CCA is not always in synchrony with the clinical exploration of BD, i.e., CCA is accompanied by clinical data of BD, though the opposite is not always true, since some patients present cerebral blood flow despite a clinically confirmed diagnosis of BD (these being cases of “flow without function”). This same phenomenon has been described in patients with post-cardiac arrest anoxic encephalopathy.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">28–30</span></a> In such cases, during the interval of cardiac arrest, the neurons suffer irreversible damage, though the recovery of heart beat with cardiopulmonary resuscitation maneuvering produces cerebral reperfusion that explains the ultrasound confirmation of flow despite the existence of neuron death. This mechanism explains the “flow without function” phenomenon in anoxia.</p></li></ul></p><p id="par0120" class="elsevierStylePara elsevierViewall">In these cases, the use of TCD not only fails to help in diagnosing BD but also may even complicate things by causing a delay in confirming CCA. For this reason the Spanish Neurosonology Society recommends that TCD should not be used as a complementary technique for diagnosing BD in open-skull patients.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">7</span></a> However, and since this persistent flow phenomenon does not always occur, we consider that the use of TCD can be defended, bearing in mind these limitations, with a view to avoiding delays in the diagnosis of BD and the certification of patient death. If there are no problems or interferences in establishing a clinical diagnosis of BD, then the clinical exploration should prevail over the TCD findings. The presence of “flow without function” in open-skull patients and a clinical diagnosis of BD has also been demonstrated in other flow studies such as cerebral angiography with multislice computed tomography.<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">30–32</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The diagnosis of CCA is time-dependent: some authors have found that CCA documented by TCD (even in closed-skull patients) is not simultaneous to the clinical diagnosis of BD; its diagnostic performance is therefore regarded as being time-dependent. Dosemeci et al.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">33</span></a> reported a sensitivity of 70.5% in a study of 61 patients with a clinical diagnosis of BD. In the first TCD exploration performed 0.5–4<span class="elsevierStyleHsp" style=""></span>h after confirmation of the clinical diagnosis, the authors recorded persistent flow in 18 patients (29%). Subsequent follow-up of these patients confirmed CCA in 12 cases at second TCD exploration 12.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8.3<span class="elsevierStyleHsp" style=""></span>h after the clinical diagnosis. Two patients required a third exploration, and another required four TCD explorations to confirm BD 96<span class="elsevierStyleHsp" style=""></span>h after the clinical diagnosis. Based on these results, Dosemeci et al. concluded that the need to demonstrate CCA in patients with a clinical diagnosis of BD should be debated, since it can delay the certification of patient death. Kuo et al.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">34</span></a> reported a sensitivity of 77.2% in 44 patients diagnosed with BD, and likewise found the diagnostic sensitivity to increase over time. Specifically, up until 6<span class="elsevierStyleHsp" style=""></span>h after the clinical diagnosis, TCD only confirmed CCA in 58.3% of the patients, while after 6–12<span class="elsevierStyleHsp" style=""></span>h, 12–24<span class="elsevierStyleHsp" style=""></span>h and 24–36<span class="elsevierStyleHsp" style=""></span>h the percentage was seen to increase to 76.9, 83.3 and 100%, respectively.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">Exploration with TCD is noninvasive, repeatable and readily available, and allows the demonstration of CCA accompanying BD. Thanks to its specificity of close to 100%, the technique is particularly useful in sedated patients or in individuals in which a complete neurological exploration proves difficult. Its limitations comprise the absence of an acoustic window, explorer dependency, and the existence of false-negative readings (patients with blood flow at TCD exploration but with a clinical diagnosis of BD) in the presence of an open skull and anoxia. On the other hand, CCA is not always synchronic to the clinical diagnosis of BD; as a result, its diagnostic performance is time-dependent–a fact that must be taken into account in order to avoid delays in certifying patient death. Despite its limitations, TCD is an excellent tool for diagnosing BD and can optimize the obtainment of organs for transplantation purposes. An update on the diagnostic criteria of CCA, based on a multidisciplinary consensus conference, would be desirable.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Financial support</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have received no financial support of any kind in relation to this study.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres559368" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec575066" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres559369" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec575067" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Transcranial Doppler and the legal diagnosis of brain death" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Transcranial Doppler in cerebral circulatory arrest" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Doppler study in the extracranial arteries" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conditions for establishing a diagnosis of cerebral circulatory arrest using transcranial Doppler ultrasound" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Transcranial Doppler ultrasound and the diagnosis of brain death" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Limitations of transcranial Doppler in diagnosing brain death" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Financial support" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-10-15" "fechaAceptado" => "2014-11-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec575066" "palabras" => array:4 [ 0 => "Brain death" 1 => "Transcranial Doppler" 2 => "Diagnosis" 3 => "Organ donor" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec575067" "palabras" => array:4 [ 0 => "Muerte encefálica" 1 => "Doppler transcraneal" 2 => "Diagnóstico" 3 => "Donante de órganos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transcranial Doppler ultrasound is able to demonstrate cerebral circulatory arrest associated to brain death, being especially useful in sedated patients, or in those in which complete neurological exploration is not possible.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Transcranial Doppler ultrasound is a portable, noninvasive and high-availability technique. Among its limitations, mention must be made of the absence of acoustic windows and false-negative cases. In patients clinically diagnosed with brain death, with open skulls or with anoxia as the cause of death, cerebral blood flow can be observed by ultrasound, since cerebral circulatory arrest is not always synchronized to the clinical diagnosis. The diagnostic rate is therefore time-dependent, and this fact must be recognized in order to avoid delays in death certification.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Despite its limitations, transcranial Doppler ultrasound helps solve common diagnostic problems, avoids the unnecessary consumption of resources, and can optimize organ harvesting for transplantation.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El Doppler transcraneal permite demostrar la parada circulatoria cerebral que acompaña a la muerte encefálica, siendo especialmente útil en pacientes sedados, o en los que no puede realizarse la exploración neurológica completa.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El Doppler transcraneal es una técnica portátil, no invasiva y de alta disponibilidad. Entre sus limitaciones está la ausencia de ventana sónica y los casos falsos negativos. En pacientes con diagnóstico clínico de muerte encefálica, que tienen cráneos abiertos o anoxia como causa de la muerte, puede sonorizarse flujo sanguíneo cerebral, ya que la parada circulatoria cerebral no siempre es sincrónica con el diagnóstico clínico. Su rentabilidad diagnóstica es, por tanto, dependiente del tiempo, hecho que debe ser reconocido para no retrasar la declaración de muerte.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A pesar de sus limitaciones, el Doppler transcraneal ayuda a resolver frecuentes problemas diagnósticos, evita un consumo innecesario de recursos y puede optimizar la obtención de órganos para trasplante.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Escudero D, Otero J, Quindós B, Viña L. Doppler transcraneal en el diagnóstico de la muerte encefálica. ¿Es útil o retrasa el diagnóstico? Med Intensiva. 2015;39:244–250.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2199 "Ancho" => 2169 "Tamanyo" => 396725 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Middle cerebral artery showing a strongly systolic pattern with minimum diastolic flow, consistent with precerebral circulatory arrest. Pulsatility index 2.90, reflecting high intracranial pressure.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1745 "Ancho" => 3251 "Tamanyo" => 417406 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Middle cerebral artery explored through the temporal window with an inverted diastolic flow pattern (A) and systolic spikes (B), exhibiting a systolic peak of under 50<span class="elsevierStyleHsp" style=""></span>cm/s, characteristic of cerebral circulatory arrest.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1707 "Ancho" => 3250 "Tamanyo" => 407392 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Basilar artery explored through the suboccipital window at a depth of 81<span class="elsevierStyleHsp" style=""></span>mm (A) and vertebral artery at 65<span class="elsevierStyleHsp" style=""></span>mm, with inverted diastolic flow (B), typical of cerebral circulatory arrest.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Advantages</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Portable technique allowing patient bedside explorations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Noninvasive method measuring intracranial arterial flow velocity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Allows monitoring of patient evolution \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Relatively inexpensive \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Widely available \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Very specific \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Results not interfered with by central nervous system depressor drugs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Limitations</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Explorer dependent technique \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Absence of acoustic window, which prevents ultrasound transmission (10–20%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Difficulty exploring posterior circulation in critical patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>False-negative results in patients with anoxia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span> False-negative results in patients with open skull (decompressive craniectomy, fractures with skull dome rupture, ventricular drainage, and infants with open fontanelles) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Time-dependent diagnostic performance (diagnostic sensitivity increases over time) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab902826.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Advantages and limitations of transcranial Doppler in diagnosing brain death.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0175" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evidence-based guideline update: determining brain death in adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E.F. 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Year/Month | Html | Total | |
---|---|---|---|
2024 November | 45 | 24 | 69 |
2024 October | 174 | 76 | 250 |
2024 September | 227 | 75 | 302 |
2024 August | 303 | 93 | 396 |
2024 July | 286 | 78 | 364 |
2024 June | 250 | 80 | 330 |
2024 May | 197 | 65 | 262 |
2024 April | 160 | 63 | 223 |
2024 March | 189 | 58 | 247 |
2024 February | 194 | 68 | 262 |
2024 January | 270 | 49 | 319 |
2023 December | 223 | 68 | 291 |
2023 November | 283 | 70 | 353 |
2023 October | 261 | 86 | 347 |
2023 September | 195 | 58 | 253 |
2023 August | 151 | 15 | 166 |
2023 July | 161 | 24 | 185 |
2023 June | 142 | 34 | 176 |
2023 May | 194 | 42 | 236 |
2023 April | 138 | 49 | 187 |
2023 March | 169 | 41 | 210 |
2023 February | 160 | 42 | 202 |
2023 January | 187 | 52 | 239 |
2022 December | 168 | 43 | 211 |
2022 November | 170 | 49 | 219 |
2022 October | 198 | 37 | 235 |
2022 September | 146 | 57 | 203 |
2022 August | 127 | 44 | 171 |
2022 July | 121 | 45 | 166 |
2022 June | 172 | 50 | 222 |
2022 May | 135 | 84 | 219 |
2022 April | 151 | 51 | 202 |
2022 March | 164 | 64 | 228 |
2022 February | 164 | 40 | 204 |
2022 January | 202 | 42 | 244 |
2021 December | 167 | 66 | 233 |
2021 November | 172 | 67 | 239 |
2021 October | 190 | 109 | 299 |
2021 September | 154 | 58 | 212 |
2021 August | 155 | 53 | 208 |
2021 July | 147 | 69 | 216 |
2021 June | 145 | 57 | 202 |
2021 May | 219 | 80 | 299 |
2021 April | 585 | 135 | 720 |
2021 March | 425 | 44 | 469 |
2021 February | 328 | 55 | 383 |
2021 January | 253 | 52 | 305 |
2020 December | 215 | 59 | 274 |
2020 November | 199 | 50 | 249 |
2020 October | 213 | 59 | 272 |
2020 September | 179 | 33 | 212 |
2020 August | 190 | 33 | 223 |
2020 July | 219 | 33 | 252 |
2020 June | 170 | 20 | 190 |
2020 May | 180 | 39 | 219 |
2020 April | 197 | 28 | 225 |
2020 March | 158 | 26 | 184 |
2020 February | 365 | 71 | 436 |
2020 January | 164 | 45 | 209 |
2019 December | 189 | 37 | 226 |
2019 November | 458 | 78 | 536 |
2019 October | 220 | 42 | 262 |
2019 September | 133 | 44 | 177 |
2019 August | 125 | 33 | 158 |
2019 July | 159 | 43 | 202 |
2019 June | 120 | 21 | 141 |
2019 May | 157 | 52 | 209 |
2019 April | 136 | 46 | 182 |
2019 March | 134 | 48 | 182 |
2019 February | 95 | 34 | 129 |
2019 January | 141 | 45 | 186 |
2018 December | 195 | 45 | 240 |
2018 November | 267 | 47 | 314 |
2018 October | 231 | 31 | 262 |
2018 September | 104 | 7 | 111 |
2018 August | 88 | 6 | 94 |
2018 July | 74 | 11 | 85 |
2018 June | 79 | 9 | 88 |
2018 May | 34 | 3 | 37 |
2018 April | 76 | 13 | 89 |
2018 March | 73 | 11 | 84 |
2018 February | 78 | 7 | 85 |
2018 January | 98 | 12 | 110 |
2017 December | 63 | 7 | 70 |
2017 November | 77 | 10 | 87 |
2017 October | 102 | 10 | 112 |
2017 September | 51 | 9 | 60 |
2017 August | 44 | 9 | 53 |
2017 July | 66 | 6 | 72 |
2017 June | 68 | 20 | 88 |
2017 May | 88 | 6 | 94 |
2017 April | 64 | 18 | 82 |
2017 March | 45 | 7 | 52 |
2017 February | 111 | 18 | 129 |
2017 January | 28 | 12 | 40 |
2016 December | 38 | 8 | 46 |
2016 November | 53 | 32 | 85 |
2016 October | 63 | 25 | 88 |
2016 September | 88 | 24 | 112 |
2016 August | 43 | 12 | 55 |
2016 July | 42 | 17 | 59 |
2016 May | 1 | 0 | 1 |
2016 February | 1 | 0 | 1 |
2015 December | 2 | 0 | 2 |