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Dynamic computed tomography in brain death
Dynamic Computed Tomo phy in Brain Death jyoli Hand,t, MA),, M. Mar.~uda. M,D,. I, .Ma~.~uda~M, I'L and S. Nakasu, M.D,
Rapid-sequence computed mmogra~ic scanning with timeMensity analysis |"or selected regions of interest ~:~ms to ~ a umful, noninvasive test to c o n f i ~ a total arrest of cerebol circulation in the dia~osls of brain death, H;w,Ja J~ M;~tmdaM, M/mazdaL Naka~a~S~ [M~am~cc~va~ltq *ohm;rat,by in brain dmch. Su~*:.~-Zemd17417~-42L 1~82 ~ e ~2cent tc,chno|ogicat advance in tapid-.veqt~nce cornpuled tomographic (C~) ~anning has made it ix~.~sihleto assex~ ~rfusion through the brain lk)llowing an intraveni~s inj~tion d iodinated contrast medium. This tcxzhnique of dynamic (,5~ ~atmin~ seems to be usefial a:~ an essentially noninvasive test to confirm a ~otal a~est of cerebral circulation in patients with susD:cted brain death. Technique ~ e General El~tnc CTTI" 88~0 ~anner equipred with a special mftware progra~ was used. Initially, conventional noncontrast axial ~:ans were F~rformed and the optimal plane of ~ction was ~elected fiorfu~her d~q'lamic studies, ~ e fit.~t~an of a dynamic study was started simultaneously with the start of an intravenous inj~tion M 50 ml of covitrast medium. ~ntr~st medium, 65% amidotrizoate me#umine (Angiog~fin)~ ~x,as injected through art 18. gauge c~theter introduc¢~2 into the antecubital vein, 25 mI delivered on each side, and this was foflowed b~' a rapid intraveno~ infusion of saline solution in an attempt to wafl~ out the contest medium. Injection of contrast medium w ~ done b.f hand in approximately a 2*~cond r*.~riM. The ~an sequence was composed of a 4.8.~cc, nd, 3&3degree, fi.~lLmtating, clockwi~ ~an followed by an intet~ n delay time of I~2 seconds, then a 4.8-g_~ond coun* rercl~kwi~ scan. ~ i s sequence was re~2ato3 for a total of six ~atxs covering a period M 34.8 ~x:cmda. The data from each hail 3&~d~ree ~an were ~gmented into tyro con.
secutive but partially twerlapping Zl2-degree ~an.,. and a ~eries of twdve mpid..~equence Cq~ images was generated. in addition, muhiple rc~ums of imeresr were :elected t,} the use of a cur>a:,r, and a graph tg the change m demtw over time l~ime.densitv curve) wa~ obtained fi~reach regioi1 of ~ntere.~L C a ~ Re~x~rts l'a.e.t l
A 17-~;ea~mldwoman had genendi:ed convul~ion~ at 5 ^.~. on May 23, 1981. On admi.'¢dtm 3 hou~ ialcr, .~hewas clmv ato.,e+ her tight pupil was dilated, and the ~ul,:,,:ephalic reilcx was absent+ C~ scanning and carotid angioi~,vaphv ~howo_'l a .~mall arrerwtvenous maltbrmation in the ri~;ht boreal parasa~2itral re, iota ~-ociated with a large in. t~acerebral hemat~xma and a mas.~ive ventncular hereof rha~,~, ~ e intracerebr;d hermmm~a wa~ evacuated and the arteriovenous malfo~ation was removed. A lar~:e fron~ totemr~rolxmetal i~me flap was not ~eplaced. PostoF~rativel£ at 2:30 p~l., ~ e showed .v~me with~ drawal movemem~ of the arms on p~inful stimulation, and the ~ule, cephatic reflex was prewar. Her pupils, however, were dilatM on ~oth sides~ At 9:30 p . . , . ~he lap~d into a deep coma again. ~)th pupils were dilated and fixed and all cephalic reflexes were lost. ~a~on after this+ spamaneom respiratior~+ ceased and the blc¢.x:ipressure tended to £ML ~ereafter. she required hall respiratov¢ suppo~ and a continuous intravenous infusion of vamactive agent~ for a ~tic~J of 38 hot;: until 11: lO a..~), on May 25~ when the dynamic (~" ~anning was l~2rfiarme& [>afing this F.etiM, her clinical condition did not improve, and el~troencephalngtams tep~.att~dly confint~ed abso|ute electr~erebral silence. ~ e dynamic study showed a total a~est of circulation through the brain {Fire I). At the time d the srudv~ her bl~ad pre~ute was 110170 mm Hg with the u ~ of va:.opr~-~rs, and her ~,dy remF~raoare was 34%L She dim at 12:18 ^ . ~ on May 25, Postmortem examination confirmed a clinical diagnosis of brain death.
Fv~ the l ~ W ~ n t of Nc~s~c~rv, Sh~ L~.ivtmw(~ M ~ I Scierie. ~ta. Ohio. ~i~&en 52~21, J~T.,~r~ PaPa 2 Add~ r~pl'illrr e q ~ to ~. J~/oji}'tar,all, t ~ Neu~.~.a~F, A 5byear~old woman with a p r o w anterior communicav ing arte~" aneu~'sm had bad two previo~ epL,~xt~ of sub. a m & ~ i d hemoffhag~. At 6:30 ^.~. on M~rch IG I981, she had ~ e r e generMi:ed convulsio~s and I ~ - d into a C~'-~-301
17-06501.25 © 1981 D; Litde. Bm~-n ar~ Oamlxmv (Inc.~ 417
418
>q++:.:+,+++Nc~.,&++~ Via ! : >g. ( J~+~w I+>2
|¢vels Ne~++ok++:+ea+ ¢+md+t+~+~- +m++a++~+du~chat+~.+d ut~t~| 5 i++++++when dynamic C 7 <+mnit+~ was pvffomv:d+ At that tit+++ he+ ~<~J pet+me wa, 90 to I{"3 mm I {~ -V>to+i¢m~d 70 to 80 +ran I+~ d~a+++hc wtd+ vampre+,>~+r+-~her |~+Jr +era+ ~mt~++c w.+~ 35+C a++d ek~t++~¢rebraI >ii¢++ce w+> a~:am ¢o++finm:d+ g+apld..eq~m++¢e C ~ image++ and +h~: t+nm+ dc++~-itg data+ at muhiple +ire+ +.h{+wc.J a+~ ab.+.cnce +f ~ff~+later+
A
P,~ticm 3 At .o~m on May Z 198t+ a % v¢o>~ld ma~ ,,~Jdde~iv~om+ plamed of ~cvct~" headache~ and yam+ted ficquendy+ C ~ ~
a+~{ re~+.a~ CW ~ ; m n i , ~ diy
a~z anJ a |rage tL~h| f~o:r++~¢mp.~rop+rietal exte~na| Je. ¢ompre:+ioa were perforated, hit his co~diti~m failed to improve+
C~m~to||cd mc
B F< ++ Va,++c++tL {At +'ifme +¢ +2 .++a,~+.+~+/~,+++q~+:bu+q+u:++cvC+T -. ++m.hi++m+ +++2,++~,~+~.'+k++mv+b@m i++;~++Vrc++++++g+sm~+t +++++++++t+++ +~++c+.P.+++++a~+>,+++++.m+++,iv+m,++m~++++++++4 ++~++,++<++w,>s~++++,+++~++++~+q m~+a4++A+,+++++~++.+ .+ml++m,++ +~+d+++++++,~¢++¢+m~++m+~+Gait++ +~~++ +++++~.+.++{|NC (~r# } me u+&+++K.++~¢ +$+v~+
paduund coma+ Her tcsp~mtkm+ m~m cca~+& t~:+ite immcdiat+ +c>usdta+it+g +florist +~p.mtan~ms m.spieation+ faik-j to temme, and ~te was maintam+-J on controlled me+ ¢imnical vemi|ation° At l0 ^+m+ +he w + it+ a d¢~+p c o m a + k++lh+p+api+s++m dilat+J and time,J+ and 110 c+ania| nerve +eflex+ C+ald elicited. E l ~ . ~ n e e p h a l o g ~ a p l w confimled el rebra|
fix~d. ;rod t ~ ctaniM n e t ~ re~lexe~, were ptc~e+~L Sy~tdic bk'~J p~s+ute ~ maintained at ~0 m 80 mm Hg ~i+h a ¢onti,mous infu~m+~ of va~:~pres.,~m~ Elecm~±neephaicvg~ p h y at d~at time s,maradicMly sho~,.J mi+~imaI ek~tricaI activity in a few l e a n or~ tl~. left side. O+~ the tight s/de. recording, were i~'fecmc+ t]h'namic GW scanning at that time showed an increa+¢ in at~enuatio~ only in the region of +~¢ large h k ~ l vc~:is at the ba~e ~ff ~he brain. %r~ cnehyma| pcdu~hm was ab~-nt m the tcrtltory ~f either the internal carotid or the vc~tebmbasilat ancdal sy,tcm
(Fro. 3)+ At n ~ , the el~m~e~c~:phak, gmm was Mt~MteIy ig~ie~tr~c E | ~ t t ~ e t e b m | ~ilence continuc~3 Imti| his d~ath at 4:}8 P.~++ I4 hou+~ ariel s ~ n t ~ e o . a s re~pi~atim~ cea>ed+ A u t o ~ y di~losed ma~dve cerebral s~a:tlin~, bilat+ era| mmstentodM hemia6ol~s+ and ~ o n d a ~ ' brain stem he Patiem + R e ¢a~ of a 19+year-old man with | ytic met+in. ~mcephaIRi+ t r e a ~ wi~h barb~tu~te coma is bristly re+ ~ t e d ~ ¢ompad~n+ The patient g~+ ~m to o~r clinic on Ju~e I3+
A
C
hyde" temperature was 37~7~¢L He did no* ¢~F~md ~o n~,xit~.~S~Iimu|i and the ~a,g reflex w~, akwlm |tmvcver, ~pl|~ wea i~¢orlc aM Iml dilated (2 m~n} and the lighl re~k.x wa~ d u ~ i d l bul pte~'m:,£ ~ e elf~tt~eeeNud~Nmm wa~ the ' N t i ~ ~g elec¢~etebml ~dm~ce and i~ ~h~x.d presto v;~ion ~ff circulation tht~u~hou~ the }-4am (Fig 41, "ll~e pat|era recto,cecal comNetely and he ~ , di.,char~ed ~m July 2L
Discussion
1981, with a one-day history d , t a t ~ epileptkm. ~ g e dens of phe and dia:epam we~ ineffective, and the baeNtumte-i~ueed coma had to ~ ¢onJiauc-] for a lOd;w Nrie,j. l)om Juae I 5 t June 24. C~ the afiemt~n of June 22. he ~came d~l~" c o m a ~ and his s~ntaneous respiraao~ c ~ d , ap~ent|r' due ~6 an d intraveno~ E~rbi~u~te. His bl~,d pte'~ure w ~ I mm Hg, epldu~| inrmcranial pr~ure w ~ 20 mm Hg~ and his
~ e concept ofb~am death ha~ now |~cn accep~xl b~~mare~ phy~iciap~ hut the criteria ft. it~ dk~gn,~is are not entirely agreed ur~m N all a u t h ~ . A dctaRcd discus, kin d the criteria f0t determining badn death is |,¢~ond the ~ o N of this pant. Hm,~'et, it ~eems to have F~cenget,emily agreed that unre,~g~m~vene.,s, apnem ab~znce ~ff crm~ial nerve ~|Texes, and ek~m~etebral siNnee N~v~de d~e basic requi~emeats for a N is d b~aln death~ |t~ additmn, it is apparent that a h~tory ~r finding d an mat~ea~able ~;~r',~c~ m ~ | brain |¢~itm must ~ pre:.e+~+ and a*diag+~Ns ~ff beam d ~ t h ~hou|d not be ¢or~side~ed for at |e;~t ~zve~M h ~ . ~ after the onset of artificial ~uplx~ts ~ff vitM Nnctiov~. Furdaermo~e, a d s of b~ain death ~h~Md ~t~t be made ff ~here i~ any ~ p i c i o n d remediable end~eao~s ~r ex~Nee . ~ in~o×k~tion or if~b~ patient is h ~ o ~ h e ~ i c ~r i~ pro~ f ~ t ~ cardiova~zu|ar ~h¢~:k~ ~ rn~icuh~ t ~ e is the eff~t d varic~ central ne~'ou~, s~tem depte~ms. The patients w|~o have te~ep¢,~.tan o v e ¢ ~ e of d~te~;mts ma~
A
B l/g. 3. Pam~u 3, ~A~ E,da~ed r@d.~:O~e,+.',, C~" ~++~es+h,ya, m~
&+~si~ya~ad)+~i~lm,nxs prca++nz'Jo~ad.tgi+m in ~b~+a + ~ n p+tra:i~m+¢
C
Ha.da c~ a}: l~a'+~m~c (7I" +++~k+++m[k++sh '+2I
w~d~ ~vet¢ ~tn~+r,~| braw+ ++|am~c v:ho were pre:+umed m
be "|,ram dea& ~ Brada¢ ~md Sims.+ HL ~+:quL-t a~d B+:t~,,~r6m 12L a+~d .,,ever,+}others- |x,~rmcd ceu;bral ar~+
A
B F++¢4+ P,,++mmt4+ CA} R+q+,d+++c~,+e+~++ ~CF i.~+g~+~,>++m++NF~++++++:+:J
cereS3 p~qus#m O+J
+N++,t+++~ ,&¢~<+'+tc+++,+&m
~:~¢,~ted de++ +l~m+:nt t,+,+,:~+
i++a +leo +~n+++u~l+gm++~+++#u+hi+ ¢|¢c+++~+++++~b*+a+++
++,+:+as+~++e++
exhibit ptof~mnd ~nree~msiveness and +pne~+ and have an +mmk~:uic ekxtt~+~o~alc+am, but the+++re pt~entia|ly c~rable+ as wiines~d in h t i e n t 4+ Even in ~ t i e n t s m+ho meet the ¢|iniea| criten+ of ~ i n dead~+ confinn~tor~+studies to establish the d ~ i s are still requested by m ~ t ph.>~ieians+ Since death of the brain is inevitable ff cerebral ¢i~uhtiota is total|~+ a for a
bLil v¢:~e~|* A+~i~ra#~c non~lhn~+ hmvevc~ m;w bc due tO a techI+d+cd++aih+te+ ~+ +;+re+++it r+r+V~+¢++ {br ~++l~+mwn r~+ammsm ram+net, with n+#+++a!~+eua+h++:icald+m,+&'> tg)+ In add++ion+ mjecl~m imo +he ,tome +r+h or +c+++c++b e+,:<~ cat,mid and venebral in+eeti+m. ~m b.+th ~.id+ are ++cce>.+-+++ to c+mfim+ totM arre:.t of F+'rt+i+im+through the inmL ~+v+nd autho+> h+vc u+d radio+met+de an~hmtaph+ li+r the purr+am+ ~4 evah+atmg patient+ with +,t~+W~:ctedhain death )7+ 81+ Althou~th th+~.tc.~t ++nommam+e +rod pemms + on+de e+rimathm~~4 cerebral citeuL+ti+m++r<+¢iattcmaution is rather r++~+rand ~ ditlk+tcNia+h m d it~tema| tm+n extcmat c;mn id ¢~rcu|ation a.d at~ evalt+ati~m o|'+++¢+|ation through the vertebroba>i|++ a+terial +;;>tern +ire difl+¢~dt w+th tidies med-a-d~ Xenon 13) eh:+mmce tedmiq~le~+ t~ mea~ir¢~ re¢itma~ ce+eb++ l.k~+ flow have a++o|+.en u.ed m +tudyinmp.mer,t+~ in profotmd corn+ [ | , L 5]+ M++t +uthor> have umvJ ;m m+ traearutid iN~-altm d xenon I ~3 an,I extema| ~omnin~f~r t}li~ puI~me+ thus the ~*~h~M m.df is mva++,ivc+Rcccmiy deve|o~d Mlem~tive method- +S~tN;m imraveu~m~ injt~::+ tion o+ inhah|hm ~+fxeno~ 13 ~ are nomm+asive; how+++ver~ dm ~+ib+e omtaminatio++ tff tl+ d.+++obt+med }W the d; f a t s +l+¢xtracmniM Fire+ flow+ which w+|i probable in + erea+ wile+++the inttmctmiia| ¢i+¢+i:+tim+ i+ +nc+~cd+ |me to +erkm+l+ considered with the+: meth~-+ brahe+more+ with the ptemm +-tmu+of t~,chnolo+,¢, external mo+litorin~ f01|owing either h~tn+carotid injection+ intravelums inj+~:+ lion+ or inhM~tion ofdii~asable r,~dioactivc +tacet~&,e~ no+ pt:m~it estim:ation of I:,h~d flow through ~he hmin stem+ which is imp+arrant in patterers wkh eaaspvcted brain death 161, Various indirect metlu~Js of determh~ing cerebral bkx~3 flow+ such as rheoencepl~alola~a0v¢~edu~neephMo+~r/hv+ measurements d ophtha|mi¢ ~rteW b f o ~ Ik~w+ and dec+ trt)retiflok++ph}++ h~V¢ b+e~ +~|M~++tf+ldi~+~+J+}~om?e+]e++ me+lit+ are inconsistent+ with falm Ix+sitive++ raise ned+at+yes+ t+r ¢~u>ingpg~i~[ ¢or,tehatioe+++a++dthese t~i+~el~+d*+ate hardh+ ~commendM ~ ~ reliable method to demotes+ate bndn d~th+ Wi~h the ~eent po~lari:ation d C W vcannin~+ it~ value in diagnosin~ b~ain death ~++n+ m Fm wtmh t¢+6n+:+ \g+ith the s~ati¢ ~ im~g~ t~ken w i t h ~ l enntra,'a er~a~cement+ prima+ imr+:nm++I rat change+, +t~dh a+ hen+of ~+g~+ infant+on+ and ¢onmskm+ are easit+' clemens+rated+ R,adbeN and lun& ||01 {ai|+d m find an+ definite c h a n ~ in tb+ attenuation vMms t i t h e brain in their corn + atem patients with anN¢~m+phica||++do
422
5~++~+c++iNvm,+k+~v V,++ ~7 N++ ~+kin,, ~'+'2
p¢i~t +v a jy~+ami~ ~(~J,~ p~oviJcs miom~a{u~+} o~ ~he r~b m a ~ ~ ,rod ~++'~mda~y ~,r~amc cha~m,o o| ~hc mua¢~af~a~
RaJherg ;rod S~¢~hmJh .h~,we3 ~emamm~ pim~ ~ff a
¢~t¢dali~m i ea+-vw.mg dyi~amvc >~d~¢~ A {~=hcr advantage ~g {hi ~+~.hmqu¢ is ~)mt +he ¢ir+,°ulali~m ~hmugh <:he
\~%e+~ +by ,4i¢e )eve) +~ adeq~ateiv ~:k aI ~b¢ )v+-e~ff+he b+ah~ a~e rot+freely ~+>~aIi:ed R+ft.~n¢~:s
m~+ +~t++++t ++}+~++~¢~I + i++c+t+;++ i+ att+¢Flt~a~+m~ yah+e>i+~e~;¢+.:-~ff+/o+~a:h++vek |++o~e p.lti¢llt {Pallen+ 3}. ;1 few )a~ge v+x~I+ wePce+~ha+~cedm J ~he ~ime~de+~+ity¢utv+s Je+i~x+d t}om the +i+e+ of ~hc-+: v~,,,-.~+is+h++w~dek~+d b~+t I.+t+m~ccedentw # ¢~mml+-~+)l~Jia Pat~x,ch~ma) ~t/u~i~.++ bray+vet+ was ei+li+iy M+.en+: i+l the +mlh+ple +'egi+~s of mte+m mlectd+ i~¢ludi+~g +he I,~++~ mere a ~ c\++e~ltum+ IN++amic CW ++atoning +s e+v+¢+~tialivn~mhwas~ve and ;d| I L ~he patien~s .~ t+a~~di+M {ole+at~J (he pavc-dum wifl~ou+ Y~nk;$~m~t, |98I+ pp I%-25| am +c~m~phcaion~ ~mventional CW ~anning ~r~ormed
Rapid-sequence computed mmogra~ic scanning with timeMensity analysis |"or selected regions of interest ~:~ms to ~ a umful, noninvasive test to c o n f i ~ a total arrest of cerebol circulation in the dia~osls of brain death, H;w,Ja J~ M;~tmdaM, M/mazdaL Naka~a~S~ [M~am~cc~va~ltq *ohm;rat,by in brain dmch. Su~*:.~-Zemd17417~-42L 1~82 ~ e ~2cent tc,chno|ogicat advance in tapid-.veqt~nce cornpuled tomographic (C~) ~anning has made it ix~.~sihleto assex~ ~rfusion through the brain lk)llowing an intraveni~s inj~tion d iodinated contrast medium. This tcxzhnique of dynamic (,5~ ~atmin~ seems to be usefial a:~ an essentially noninvasive test to confirm a ~otal a~est of cerebral circulation in patients with susD:cted brain death. Technique ~ e General El~tnc CTTI" 88~0 ~anner equipred with a special mftware progra~ was used. Initially, conventional noncontrast axial ~:ans were F~rformed and the optimal plane of ~ction was ~elected fiorfu~her d~q'lamic studies, ~ e fit.~t~an of a dynamic study was started simultaneously with the start of an intravenous inj~tion M 50 ml of covitrast medium. ~ntr~st medium, 65% amidotrizoate me#umine (Angiog~fin)~ ~x,as injected through art 18. gauge c~theter introduc¢~2 into the antecubital vein, 25 mI delivered on each side, and this was foflowed b~' a rapid intraveno~ infusion of saline solution in an attempt to wafl~ out the contest medium. Injection of contrast medium w ~ done b.f hand in approximately a 2*~cond r*.~riM. The ~an sequence was composed of a 4.8.~cc, nd, 3&3degree, fi.~lLmtating, clockwi~ ~an followed by an intet~ n delay time of I~2 seconds, then a 4.8-g_~ond coun* rercl~kwi~ scan. ~ i s sequence was re~2ato3 for a total of six ~atxs covering a period M 34.8 ~x:cmda. The data from each hail 3&~d~ree ~an were ~gmented into tyro con.
secutive but partially twerlapping Zl2-degree ~an.,. and a ~eries of twdve mpid..~equence Cq~ images was generated. in addition, muhiple rc~ums of imeresr were :elected t,} the use of a cur>a:,r, and a graph tg the change m demtw over time l~ime.densitv curve) wa~ obtained fi~reach regioi1 of ~ntere.~L C a ~ Re~x~rts l'a.e.t l
A 17-~;ea~mldwoman had genendi:ed convul~ion~ at 5 ^.~. on May 23, 1981. On admi.'¢dtm 3 hou~ ialcr, .~hewas clmv ato.,e+ her tight pupil was dilated, and the ~ul,:,,:ephalic reilcx was absent+ C~ scanning and carotid angioi~,vaphv ~howo_'l a .~mall arrerwtvenous maltbrmation in the ri~;ht boreal parasa~2itral re, iota ~-ociated with a large in. t~acerebral hemat~xma and a mas.~ive ventncular hereof rha~,~, ~ e intracerebr;d hermmm~a wa~ evacuated and the arteriovenous malfo~ation was removed. A lar~:e fron~ totemr~rolxmetal i~me flap was not ~eplaced. PostoF~rativel£ at 2:30 p~l., ~ e showed .v~me with~ drawal movemem~ of the arms on p~inful stimulation, and the ~ule, cephatic reflex was prewar. Her pupils, however, were dilatM on ~oth sides~ At 9:30 p . . , . ~he lap~d into a deep coma again. ~)th pupils were dilated and fixed and all cephalic reflexes were lost. ~a~on after this+ spamaneom respiratior~+ ceased and the blc¢.x:ipressure tended to £ML ~ereafter. she required hall respiratov¢ suppo~ and a continuous intravenous infusion of vamactive agent~ for a ~tic~J of 38 hot;: until 11: lO a..~), on May 25~ when the dynamic (~" ~anning was l~2rfiarme& [>afing this F.etiM, her clinical condition did not improve, and el~troencephalngtams tep~.att~dly confint~ed abso|ute electr~erebral silence. ~ e dynamic study showed a total a~est of circulation through the brain {Fire I). At the time d the srudv~ her bl~ad pre~ute was 110170 mm Hg with the u ~ of va:.opr~-~rs, and her ~,dy remF~raoare was 34%L She dim at 12:18 ^ . ~ on May 25, Postmortem examination confirmed a clinical diagnosis of brain death.
Fv~ the l ~ W ~ n t of Nc~s~c~rv, Sh~ L~.ivtmw(~ M ~ I Scierie. ~ta. Ohio. ~i~&en 52~21, J~T.,~r~ PaPa 2 Add~ r~pl'illrr e q ~ to ~. J~/oji}'tar,all, t ~ Neu~.~.a~F, A 5byear~old woman with a p r o w anterior communicav ing arte~" aneu~'sm had bad two previo~ epL,~xt~ of sub. a m & ~ i d hemoffhag~. At 6:30 ^.~. on M~rch IG I981, she had ~ e r e generMi:ed convulsio~s and I ~ - d into a C~'-~-301
17-06501.25 © 1981 D; Litde. Bm~-n ar~ Oamlxmv (Inc.~ 417
418
>q++:.:+,+++Nc~.,&++~ Via ! : >g. ( J~+~w I+>2
|¢vels Ne~++ok++:+ea+ ¢+md+t+~+~- +m++a++~+du~chat+~.+d ut~t~| 5 i++++++when dynamic C 7 <+mnit+~ was pvffomv:d+ At that tit+++ he+ ~<~J pet+me wa, 90 to I{"3 mm I {~ -V>to+i¢m~d 70 to 80 +ran I+~ d~a+++hc wtd+ vampre+,>~+r+-~her |~+Jr +era+ ~mt~++c w.+~ 35+C a++d ek~t++~¢rebraI >ii¢++ce w+> a~:am ¢o++finm:d+ g+apld..eq~m++¢e C ~ image++ and +h~: t+nm+ dc++~-itg data+ at muhiple +ire+ +.h{+wc.J a+~ ab.+.cnce +f ~ff~+later+
A
P,~ticm 3 At .o~m on May Z 198t+ a % v¢o>~ld ma~ ,,~Jdde~iv~om+ plamed of ~cvct~" headache~ and yam+ted ficquendy+ C ~ ~
a+~{ re~+.a~ CW ~ ; m n i , ~ diy
a~z anJ a |rage tL~h| f~o:r++~¢mp.~rop+rietal exte~na| Je. ¢ompre:+ioa were perforated, hit his co~diti~m failed to improve+
C~m~to||cd mc
B F< ++ Va,++c++tL {At +'ifme +¢ +2 .++a,~+.+~+/~,+++q~+:bu+q+u:++cvC+T -. ++m.hi++m+ +++2,++~,~+~.'+k++mv+b@m i++;~++Vrc++++++g+sm~+t +++++++++t+++ +~++c+.P.+++++a~+>,+++++.m+++,iv+m,++m~++++++++4 ++~++,++<++w,>s~++++,+++~++++~+q m~+a4++A+,+++++~++.+ .+ml++m,++ +~+d+++++++,~¢++¢+m~++m+~+Gait++ +~~++ +++++~.+.++{|NC (~r# } me u+&+++K.++~¢ +$+v~+
paduund coma+ Her tcsp~mtkm+ m~m cca~+& t~:+ite immcdiat+ +c>usdta+it+g +florist +~p.mtan~ms m.spieation+ faik-j to temme, and ~te was maintam+-J on controlled me+ ¢imnical vemi|ation° At l0 ^+m+ +he w + it+ a d¢~+p c o m a + k++lh+p+api+s++m dilat+J and time,J+ and 110 c+ania| nerve +eflex+ C+ald elicited. E l ~ . ~ n e e p h a l o g ~ a p l w confimled el rebra|
fix~d. ;rod t ~ ctaniM n e t ~ re~lexe~, were ptc~e+~L Sy~tdic bk'~J p~s+ute ~ maintained at ~0 m 80 mm Hg ~i+h a ¢onti,mous infu~m+~ of va~:~pres.,~m~ Elecm~±neephaicvg~ p h y at d~at time s,maradicMly sho~,.J mi+~imaI ek~tricaI activity in a few l e a n or~ tl~. left side. O+~ the tight s/de. recording, were i~'fecmc+ t]h'namic GW scanning at that time showed an increa+¢ in at~enuatio~ only in the region of +~¢ large h k ~ l vc~:is at the ba~e ~ff ~he brain. %r~ cnehyma| pcdu~hm was ab~-nt m the tcrtltory ~f either the internal carotid or the vc~tebmbasilat ancdal sy,tcm
(Fro. 3)+ At n ~ , the el~m~e~c~:phak, gmm was Mt~MteIy ig~ie~tr~c E | ~ t t ~ e t e b m | ~ilence continuc~3 Imti| his d~ath at 4:}8 P.~++ I4 hou+~ ariel s ~ n t ~ e o . a s re~pi~atim~ cea>ed+ A u t o ~ y di~losed ma~dve cerebral s~a:tlin~, bilat+ era| mmstentodM hemia6ol~s+ and ~ o n d a ~ ' brain stem he Patiem + R e ¢a~ of a 19+year-old man with | ytic met+in. ~mcephaIRi+ t r e a ~ wi~h barb~tu~te coma is bristly re+ ~ t e d ~ ¢ompad~n+ The patient g~+ ~m to o~r clinic on Ju~e I3+
A
C
hyde" temperature was 37~7~¢L He did no* ¢~F~md ~o n~,xit~.~S~Iimu|i and the ~a,g reflex w~, akwlm |tmvcver, ~pl|~ wea i~¢orlc aM Iml dilated (2 m~n} and the lighl re~k.x wa~ d u ~ i d l bul pte~'m:,£ ~ e elf~tt~eeeNud~Nmm wa~ the ' N t i ~ ~g elec¢~etebml ~dm~ce and i~ ~h~x.d presto v;~ion ~ff circulation tht~u~hou~ the }-4am (Fig 41, "ll~e pat|era recto,cecal comNetely and he ~ , di.,char~ed ~m July 2L
Discussion
1981, with a one-day history d , t a t ~ epileptkm. ~ g e dens of phe and dia:epam we~ ineffective, and the baeNtumte-i~ueed coma had to ~ ¢onJiauc-] for a lOd;w Nrie,j. l)om Juae I 5 t June 24. C~ the afiemt~n of June 22. he ~came d~l~" c o m a ~ and his s~ntaneous respiraao~ c ~ d , ap~ent|r' due ~6 an d intraveno~ E~rbi~u~te. His bl~,d pte'~ure w ~ I mm Hg, epldu~| inrmcranial pr~ure w ~ 20 mm Hg~ and his
~ e concept ofb~am death ha~ now |~cn accep~xl b~~mare~ phy~iciap~ hut the criteria ft. it~ dk~gn,~is are not entirely agreed ur~m N all a u t h ~ . A dctaRcd discus, kin d the criteria f0t determining badn death is |,¢~ond the ~ o N of this pant. Hm,~'et, it ~eems to have F~cenget,emily agreed that unre,~g~m~vene.,s, apnem ab~znce ~ff crm~ial nerve ~|Texes, and ek~m~etebral siNnee N~v~de d~e basic requi~emeats for a N is d b~aln death~ |t~ additmn, it is apparent that a h~tory ~r finding d an mat~ea~able ~;~r',~c~ m ~ | brain |¢~itm must ~ pre:.e+~+ and a*diag+~Ns ~ff beam d ~ t h ~hou|d not be ¢or~side~ed for at |e;~t ~zve~M h ~ . ~ after the onset of artificial ~uplx~ts ~ff vitM Nnctiov~. Furdaermo~e, a d s of b~ain death ~h~Md ~t~t be made ff ~here i~ any ~ p i c i o n d remediable end~eao~s ~r ex~Nee . ~ in~o×k~tion or if~b~ patient is h ~ o ~ h e ~ i c ~r i~ pro~ f ~ t ~ cardiova~zu|ar ~h¢~:k~ ~ rn~icuh~ t ~ e is the eff~t d varic~ central ne~'ou~, s~tem depte~ms. The patients w|~o have te~ep¢,~.tan o v e ¢ ~ e of d~te~;mts ma~
A
B l/g. 3. Pam~u 3, ~A~ E,da~ed r@d.~:O~e,+.',, C~" ~++~es+h,ya, m~
&+~si~ya~ad)+~i~lm,nxs prca++nz'Jo~ad.tgi+m in ~b~+a + ~ n p+tra:i~m+¢
C
Ha.da c~ a}: l~a'+~m~c (7I" +++~k+++m[k++sh '+2I
w~d~ ~vet¢ ~tn~+r,~| braw+ ++|am~c v:ho were pre:+umed m
be "|,ram dea& ~ Brada¢ ~md Sims.+ HL ~+:quL-t a~d B+:t~,,~r6m 12L a+~d .,,ever,+}others- |x,~rmcd ceu;bral ar~+
A
B F++¢4+ P,,++mmt4+ CA} R+q+,d+++c~,+e+~++ ~CF i.~+g~+~,>++m++NF~++++++:+:J
cereS3 p~qus#m O+J
+N++,t+++~ ,&¢~<+'+tc+++,+&m
~:~¢,~ted de++ +l~m+:nt t,+,+,:~+
i++a +leo +~n+++u~l+gm++~+++#u+hi+ ¢|¢c+++~+++++~b*+a+++
++,+:+as+~++e++
exhibit ptof~mnd ~nree~msiveness and +pne~+ and have an +mmk~:uic ekxtt~+~o~alc+am, but the+++re pt~entia|ly c~rable+ as wiines~d in h t i e n t 4+ Even in ~ t i e n t s m+ho meet the ¢|iniea| criten+ of ~ i n dead~+ confinn~tor~+studies to establish the d ~ i s are still requested by m ~ t ph.>~ieians+ Since death of the brain is inevitable ff cerebral ¢i~uhtiota is total|~+ a for a
bLil v¢:~e~|* A+~i~ra#~c non~lhn~+ hmvevc~ m;w bc due tO a techI+d+cd++aih+te+ ~+ +;+re+++it r+r+V~+¢++ {br ~++l~+mwn r~+ammsm ram+net, with n+#+++a!~+eua+h++:icald+m,+&'> tg)+ In add++ion+ mjecl~m imo +he ,tome +r+h or +c+++c++b e+,:<~ cat,mid and venebral in+eeti+m. ~m b.+th ~.id+ are ++cce>.+-+++ to c+mfim+ totM arre:.t of F+'rt+i+im+through the inmL ~+v+nd autho+> h+vc u+d radio+met+de an~hmtaph+ li+r the purr+am+ ~4 evah+atmg patient+ with +,t~+W~:ctedhain death )7+ 81+ Althou~th th+~.tc.~t ++nommam+e +rod pemms + on+de e+rimathm~~4 cerebral citeuL+ti+m++r<+¢iattcmaution is rather r++~+rand ~ ditlk+tcNia+h m d it~tema| tm+n extcmat c;mn id ¢~rcu|ation a.d at~ evalt+ati~m o|'+++¢+|ation through the vertebroba>i|++ a+terial +;;>tern +ire difl+¢~dt w+th tidies med-a-d~ Xenon 13) eh:+mmce tedmiq~le~+ t~ mea~ir¢~ re¢itma~ ce+eb++ l.k~+ flow have a++o|+.en u.ed m +tudyinmp.mer,t+~ in profotmd corn+ [ | , L 5]+ M++t +uthor> have umvJ ;m m+ traearutid iN~-altm d xenon I ~3 an,I extema| ~omnin~f~r t}li~ puI~me+ thus the ~*~h~M m.df is mva++,ivc+Rcccmiy deve|o~d Mlem~tive method- +S~tN;m imraveu~m~ injt~::+ tion o+ inhah|hm ~+fxeno~ 13 ~ are nomm+asive; how+++ver~ dm ~+ib+e omtaminatio++ tff tl+ d.+++obt+med }W the d; f a t s +l+¢xtracmniM Fire+ flow+ which w+|i probable in + erea+ wile+++the inttmctmiia| ¢i+¢+i:+tim+ i+ +nc+~cd+ |me to +erkm+l+ considered with the+: meth~-+ brahe+more+ with the ptemm +-tmu+of t~,chnolo+,¢, external mo+litorin~ f01|owing either h~tn+carotid injection+ intravelums inj+~:+ lion+ or inhM~tion ofdii~asable r,~dioactivc +tacet~&,e~ no+ pt:m~it estim:ation of I:,h~d flow through ~he hmin stem+ which is imp+arrant in patterers wkh eaaspvcted brain death 161, Various indirect metlu~Js of determh~ing cerebral bkx~3 flow+ such as rheoencepl~alola~a0v¢~edu~neephMo+~r/hv+ measurements d ophtha|mi¢ ~rteW b f o ~ Ik~w+ and dec+ trt)retiflok++ph}++ h~V¢ b+e~ +~|M~++tf+ldi~+~+J+}~om?e+]e++ me+lit+ are inconsistent+ with falm Ix+sitive++ raise ned+at+yes+ t+r ¢~u>ingpg~i~[ ¢or,tehatioe+++a++dthese t~i+~el~+d*+ate hardh+ ~commendM ~ ~ reliable method to demotes+ate bndn d~th+ Wi~h the ~eent po~lari:ation d C W vcannin~+ it~ value in diagnosin~ b~ain death ~++n+ m Fm wtmh t¢+6n+:+ \g+ith the s~ati¢ ~ im~g~ t~ken w i t h ~ l enntra,'a er~a~cement+ prima+ imr+:nm++I rat change+, +t~dh a+ hen+of ~+g~+ infant+on+ and ¢onmskm+ are easit+' clemens+rated+ R,adbeN and lun& ||01 {ai|+d m find an+ definite c h a n ~ in tb+ attenuation vMms t i t h e brain in their corn + atem patients with anN¢~m+phica||++do
422
5~++~+c++iNvm,+k+~v V,++ ~7 N++ ~+kin,, ~'+'2
p¢i~t +v a jy~+ami~ ~(~J,~ p~oviJcs miom~a{u~+} o~ ~he r~b m a ~ ~ ,rod ~++'~mda~y ~,r~amc cha~m,o o| ~hc mua¢~af~a~
RaJherg ;rod S~¢~hmJh .h~,we3 ~emamm~ pim~ ~ff a
¢~t¢dali~m i ea+-vw.mg dyi~amvc >~d~¢~ A {~=hcr advantage ~g {hi ~+~.hmqu¢ is ~)mt +he ¢ir+,°ulali~m ~hmugh <:he
\~%e+~ +by ,4i¢e )eve) +~ adeq~ateiv ~:k
m