rCBF in impending brain death

Summary Regional cerebral blood flow (rCBF) was measured in three patients after relief of elevated intracranial pressure and restoration of normal cerebral perfusion pressure. Two patients, studied within 4 hours after closed head injury were found to have marked impairment of cortical blood flow and elevation of cerebrovascular resistance. We suggest that this picture is indicative of impending brain death, and may be the result of a long period of severe cerebral ischemia. The third patient, who had a shorter period of intracranial hypertension occurring during anaesthetic induction, responded to reduction of ICP quite differently with a transient relative hyperaemia. The physiopathological explanations for these two different types of flow response and their possible clinical significance are discussed.     

The function of the hypothalamo-pituitary axis in brain dead patients

Summary In order to find out the function of the hypothalamo-pituitary axis in brain dead patients, pituitary and hypothalamic hormone concentrations were measured and several anterior pituitary releasing tests were carried out in 39 brain dead patients. In addition, cerebral blood flow measurements were simultaneously performed. In almost all cases, the blood concentration of pituitary and hypothalamic hormones were above the sensitivity of the assay. Anterior pituitary releasing tests indicated that efficient functions of the hypothalamus were severely suppressed, while the normal secretory mechanism of the anterior pituitary was partially preserved in brain dead patients. Histological changes of hypothalamic neurons varied from barely detectable ghost cells to nearly normal cells even in the same case. Although, the remaining circulation seemed not to be sufficient enough to maintain integrated hypothalamo-pituitary function, as shown by the examinations of cerebral blood flow, the presence of hypothalamic hormones in the systemic circulation suggests that these hormones were released and carried from the hypothalamus by minimal flow which is preserved even after the diagnosis of brain death.     

多发创伤后垂体功能和甲状腺素改变及临床意义

目的 探讨多发性创伤后甲状腺和垂体功能的变化及意义。方法 应用放射免疫分析检测４０例多发创伤病人血清甲状腺激素（Ｔ３、Ｔ４）和垂体前叶激素（ＴＳＨ、ＧＨ、ＰＲＬ）的变化。结果 多发创伤的急性期血清Ｔ３、ＴＳＨ明显下降，ＰＲＬ明显升高，并发现这些激素的变化程度与病情轻重的密度关系，即ＩＳＳ分值与Ｔ３、ＴＳＨ呈负相关，与ＰＲＬ呈正相关。结论 多发创伤后甲状腺激素与垂体功能有明显变化。     

Hypothalamic pituitary function in brain death patients--from blood pituitary hormones and hypothalamic hormones

According to the report of the Health and Welfare Ministry's research committee on brain death (1985), "brain death is defined as an irreversible cessation of the total brain function including brain stem." However, in brain death patients, whether the hypothalamic function which belongs to the brain stem function has completely ceased or not is unknown. In order to evaluate the hypothalamic function in brain death patients, the blood levels of the pituitary hormones and hypothalamic hormones were measured, and anterior pituitary stimulation test with triple bolus injection (TRH 500 micrograms, LH-RH 100 micrograms, regular insulin 0.3-0.7 unit/kg) was performed. The subjects were 13 brain death patients whose clinical states fully satisfied the criteria proposed by the committee. 1) The average blood levels of anterior pituitary hormones in these brain death patients were within normal range, and that of growth hormone was more than the twice of the normal level. 2) The blood anterior pituitary hormones were detectable in almost all cases even several days after the diagnosis of the brain death. 3) LH reserve was maintained in three cases. FSH reserve was maintained in three cases. Prolactin reserve was maintained in two cases. TSH reserve was maintained in one case. 4) Blood ADH (antidiuretic hormones) were detectable in 7 cases out of 9 cases. The blood ADH level of one case, in particular, was rather high (above 10 pg/ml). 5) Histopathologically anterior pituitaries were examined in three autopsy cases. The central necrotic areas were observed in all cases, but normal pituitary tissues existed peripherally. And all anterior pituitary hormones could be recognized immunohistochemically. 6) The blood levels of the hypothalamic hormones (GRF, CRF, LH-RH) were measured in four cases. The hypothalamic hormones were detectable in all cases. In one case, the levels of GRF were within normal range even 9 or 15 days after the diagnosis of brain death.(ABSTRACT TRUNCATED AT 250 WORDS)     

Determination of brain death with123I-IMP and99mTc-HM-PAO

Brain imaging with radiolabeled amines,¹²³I-IMP and^99mTc-HM-PAO, is a rapid, safe, and specific bedside test for confirming brain death in the absence of cerebral blood flow. Therapeutic phenobarbital or thiopental levels do not interfere with the cerebral penetration ability of the lipophilic radiopharmacons.     

Evolution of criteria for determination of brain death in Japan

Summary In 1974, the Japanese EEG Society's Ad Hoc Committee on Brain Death published criteria for determining brain death only in cases of acute gross primary brain lesions. In 1983, a new brain death study group was organized to re-evaluate these criteria. During a 6-month period from March 1, 1984, 217 neurosurgical and neurological clinics and emergency services throughout Japan reported 718 brain deaths caused not only by primary lesions but also by secondary brain lesions and diagnosed as such on the basis of the 1974 criteria excluding the condition of abrupt fall of blood pressure followed by persistent hypotension. The data derived from the 718 cases in this collaborative study were pooled and analyzed, and it became known that the 1974 criteria still are generally reliable. Some changes have been made, however, and new criteria for determination of brain death adopted.     

Medical and legal considerations of brain death

Brain death was first defined in 1968, and since then laws on determining death have been implemented in all countries with active organ transplantation programs. As a prerequisite, the aetiology of brain death has to be known, and all reversible causes of coma have to be excluded. The regulations for the diagnosis of brain death are most commonly given by the national medical associations, and they vary between countries. Thus, the guidelines given in the medical textbooks are not universally applicable. The diagnosis is based on clinical examination, but confirmatory tests, such as angiography or EEG, are allowed on most occasions. Brain death is followed by cardiovascular and hormonal changes, which have implications in the management of a potential organ donor. Spinal reflexes are preserved, and motor and haemodynamic responses are frequently observed in brain dead patients.     

脑死亡患者血清神经元特异性烯醇化酶的变化

目的 探讨脑死亡后血清神经元特异性烯醇化酶(NSE)的变化。方法 28例脑死亡患者,分别于临床确定脑死亡后 12、24、48 h测定血清 NSE含量,以 20例正常人及重型颅脑损伤患者作为对照组,也行血清NSE测定。对各组血清NSE含量进行统计学分析。结果 脑死亡患者血清 NSE含量呈持续升高,其各时间段的血清 NSE含量差异有显著性(P<0.05),与重型颅脑损伤组及正常人组血清 NSE含量差异也有显著性(P<0.05)。重型颅脑损伤组血清 NSE含量也明显升高,但低于脑死亡组而且其各时间段的 NSE含量差异也无显著性(P>0.05)。结论 血清NSE 浓度的检测可为脑死亡的诊断提供客观的依据。     

No association of serum gonadal or pituitary hormones with prognostic parameters in stages T1 to T3 PN0M0 prostate cancer

PURPOSE: Recent reports suggest a possible association of the clinical aggressiveness of prostate cancer with low serum testosterone, and high serum levels of lutenizing hormone (LH) and/or follicle-stimulating hormone (FSH). This hypothesis was tested in the current study. MATERIALS AND METHODS: Serum levels of testosterone, LH, FSH, estradiol and sex hormone-binding globulin were determined as well as the calculated ratio of testosterone-to-sex hormonebinding globulin in 370 patients with newly diagnosed, stages T1 to T3 pN0M0 prostate cancer. The results were related to T category, Gleason score and serum prostate specific antigen (PSA). RESULTS: No statistically significant association was found for the serum levels of testosterone, LH, FSH, estradiol, sex hormone-binding globulin or the testosterone-to-sex hormone-binding globulin ratio with T category, Gleason score or PSA. In contrast to expectations, serum testosterone values within the lowest quartile were not associated with elevated LH. Of the 370 patients 17 (5%) had serum testosterone below the normal range (8 nmol./l. or less) and only 3 of these 17 showed elevated LH levels. CONCLUSIONS: Serum levels reflecting the pituitary-gonadal axis at diagnosis are not associated with clinically used measures of tumor aggressiveness (T category, Gleason score or PSA) in patients with newly diagnosed T1 to T3 pN0M0 prostate cancer.     

Intratumoural cyst formation in pituitary macroadenomas

Summary Twenty-one patients with various types of pituitary macroadenomas underwent hypophysectomy at the Chaim Sheba Medical Centre between 1985 to 1987. Intraoperative fine needle aspiration of the tumoural content was attempted prior to tumour excision. Although none of the patients had a history compatible with pituitary apoplexy, intratumoural fluid suggestive of a cyst within the tumour was found in 57% of the patients. Analysis of the hormones in the aspirated fluid revealed variable elevations in hormone levels, some reaching 3,000 times the equivalent plasma levels. Concomitant elevated levels of other pituitary hormones found in the cyst fluid support the concept of mixed secretory potential of pituitary adenomas, including the apparently non-functioning tumours. Six out of seven patients (86%) who received preoperative treatment with bromocriptine had an intratumoural cyst while only seven out of fourteen patients (50%) who were not treated with this drug prior to surgery had a cyst within the tumour. The implications of these observations on current theories concerning the pathophysiology of pituitary adenomas are discussed.     

利奈唑胺用于肝移植术后抗结核治疗一例临床分析

利奈唑胺是一种嗯唑烷酮类抗生素,在轻至中度肝肾功能不全时应用该药是安全的,且利奈唑胺与经细胞色素P450代谢的药物之间不存在相互作用,而移植受者使用的免疫抑制剂基本上均经过该酶代谢,故利奈唑胺在移植术后尤其是肝、肾移植术后有着一定的临床应用价值。既往临床经验及药物说明书中,均无移植受者应用利奈唑胺抗结核疗效的描述,但笔者在临床工作中发现,利奈唑胺对于肝移植术后受者抗结核治疗效果较好,现将相关病例及经验报道如下。     

脑死亡状态对大鼠肝脏损伤的影响

目的　探讨大鼠脑死亡状态与肝脏损伤之间的关系。方法　将 50只大鼠随机分为空白对照组 (C)、低血压状态假手术组 (E1 )、脑死亡实验组 (E2 )。各组动物分别于辅助呼吸 1、3h采血检测丙氨酸氨基转移酶 (ALT)、天冬氨酸氨基转移酶 (AST)及透明质酸 (HA)、内皮素 1 (ET 1 ) ,辅助呼吸 4h取肝组织行形态学检查。结果　 1、3h血清ALT、AST以及HA、ET 1水平E2组较C、E1组显著升高 (P <0 .0 5) ;E2组中 3h较 1h显著升高 (P <0 .0 5)。电镜下E2组大鼠肝脏Kuffer细胞明显活化 ,肝窦内皮细胞与基质部分脱落、肝窦内皮窗孔扩大 ;C、E1组Kuffer细胞活化不明显 ,内皮细胞基本完整。结论　大鼠脑死亡状态能明显导致肝实质细胞与非实质细胞损伤     

改良大鼠渐进性脑死亡模型的制作

目的 总结制作大鼠渐进性脑死亡模型的技巧并改良此模型的制作方法.方法 对经典Pratschke术式的麻醉、插管、颅内加压、脑死亡判断等环节进行探讨,建立Wistar大鼠的渐进性脑死亡模型.结果 所有动物在诱导脑死亡过程中均出现较一致的血压变化规律:诱导后期平均动脉压开始急剧升高,于颅内加压后(11±2)min时达到峰值(190±15)mm Hg,其后血压急剧下降,(20±3)min时达到谷值(70±16)mm Hg,与诱导前平均动脉压(110±18)mm Hg比较,其峰值和谷值差异均具有统计学意义(P＜0.05).共诱导40例大鼠脑死亡,37例能成功维持正常血压达6 h,手术成功率92.5%(37/40).结论 与经典Pratschke术式比较,该术式降低难度,提高手术成功率,是一种较稳定、可靠的大鼠脑死亡模型.     

Somatosensory evoked potentials aiding the diagnosis of brain death

SEP were recorded in 14 patients, who fulfilled the clinical and electroencephalographic criteria of brain death. The results are compared with the respective ones in healthy subjects. Beside the absence of cortical N 20 in each brain dead patient, reduction of amplitude or absence of near field negativity (N 13b) from upper neck regardless of the position of the reference electrode represents the predominant result. The near field potential from the lower neck (N 13a) was unaffected. The counterpart in the far field potential recorded from F z was amplitude reduction of P 13. These results suggest that the dissociation of N 13a and N 13b can confirm the diagnosis of brain death. Moreover these results support the view of two independent generators of N 13a and N 13b despite their identical amplitude and latency.     

Cerebral reperfusion in brain death of a newborn. Case report

A case of sudden infant death after 15 minutes of successful resusciation of cardiovascular function is presented. While apnoic cranial nerve areflexia and electrocerebral silence persisted, angiography and transcranial Doppler sonography demonstrated nearly normal cerebral perfusion, which even increased day by day inspite of the persistence of other signs of brain death. The phenomenon cerebral reperfusion is concluded to be compatible with the diagnosis of brain death.     

基于器官捐献视角论我国脑死亡标准的立法

近年来我国器官捐献事业快速发展,然而我国尚未对脑死亡标准进行立法确认。本文介绍了国内外脑死亡标准立法现状和我国现阶段公民逝世后器官捐献实行的死亡判定标准,从器官捐献视角探讨了我国进行脑死亡标准立法的必要性,并基于实际国情对脑死亡标准立法的形式和内容提出了建议,旨在为开展脑死亡标准立法工作提供参考。     

多巴胺预处理对脑死亡大鼠肾免疫原性的影响

目的　观察用多巴胺预处理对脑死亡大鼠肾免疫原性的影响。方法　对脑死亡大鼠静脉内持续滴注多巴胺 ,剂量分别为 2、6、10和 14 μg·kg-1·ml-1,6h后取出肾脏 ,进行免疫组化分析。结果　用多巴胺预处理后 ,脑死亡大鼠的肾脏单核吞噬细胞浸润、主要组织相容性复合物Ⅱ类抗原的表达以及P 选择素的表达受到抑制 ,其抑制程度随多巴胺的用量增加而加大。结论　多巴胺的预处理可以明显降低脑死亡大鼠肾脏的免疫原性     

我国大陆肝移植与脑死亡立法进展

我国是肝病大国,各种肝病发展至终末期均会导致正常肝功能的丧失,国内外普遍认为肝移植是治疗各种终末期肝病使患者重新获得正常肝功能的最佳选择.近年来我国肝移植取得快速发展,各种相关技术均已比较成熟,但肝脏来源作为一个瓶颈问题始终没有得到妥善解决,而采取脑死亡标准并立法加以规范是解决该问题的一个有效途径.我国的脑死亡标准仍没有法律依据,从而影响了可用于移植的肝脏来源,进而限制肝移植的发展.制定规范的脑死亡标准并对其立法规范必定能对增加器官来源给予极大帮助,促进肝移植的健康规范发展.     

缓慢间断颅内加压法家兔脑死亡模型的建立及其病理生理变化

目的 探讨缓慢间断颅内加压法家兔脑死亡模型建立的方法及其病理生理变化.方法 80只新西兰家兔随机分为假手术组(n=20)和脑死亡组(n=60).假手术组麻醉后仅行开颅术并颅内放置Foley气囊导管,不建立脑死亡模型.脑死亡组应用改进的缓慢间断颅内加压法建立脑死亡模型,通过呼吸、循环支持维持家兔脑死亡状态.监测2组动物各时间点平均动脉压(mean artery pressure,MAP)、心率(heart rate,HR)变化.结果 脑死亡组56只家兔成功建立脑死亡模型,2只家兔因麻醉意外死亡,另2只因加压不当死亡,手术成功率93.3％(56/60);通过呼吸、循环支持可维持家兔脑死亡状态10h.与假手术组比较,脑死亡组颅内加压后MAP和HR变化显著:MAP和HR随着间断颅内加压呈波浪式上升和下降,总体呈升高趋势.颅内加压过程中峰值MAP(400.24±18.36)mm Hg(1 mm Hg=0.133 kPa)和HR(258.00±25.70)次/min,与颅内加压前、后对应时间点MAP和HR比较,差异有统计学意义(P＜0.05).结论 用改进的缓慢间断颅内加压法可成功制作家兔脑死亡模型.其MAP和HR呈特征性变化.经有效的呼吸和循环支持,能稳定地维持家兔脑死亡状态10 h.该模型有助于进一步研究脑死亡状态下家兔器官变化.