Cases reported "Brain Death"

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1/41. Auditory brain-stem responses in brain death.

    Auditory brain-stem responses were measured by far-field recording techniques in 27 patients fulfilling the criteria of brain death. The responses were either absent or consisted of the presence of just the initial component (Wave I). Wave I, when present, was of normal amplitude but prolonged in latency. Four patients were followed over several days from a state of coma with evidence of preserved brain-stem and cerebral functions to a clinical state compatible with brain death. Auditory brain-stem responses were initially intact and then showed a decrease in amplitude and a prolongation of latency of the later components until finally Wave I was alone. Auditory brain-stem responses are an objective measure of one of the sensory pathways traversing the brain-stem and can be used to evaluate the functional states of the brain-stem in patients in whom the question of brain death has been raised.
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2/41. Cerebral arteriovenous malformation in pregnancy: presentation and neurologic, obstetric, and ethical significance.

    Cerebral arteriovenous malformations infrequently complicate pregnancy. We sought to determine the neurologic, obstetric, and ethical significance of such malformations. We present the clinical course of 2 pregnant women with arteriovenous malformations who experienced cerebral hemorrhage and a loss of capacity for decision making. We also review the neurologic and obstetric significance of arteriovenous malformations in pregnancy. Various treatment options with concern for pregnancy and the prognosis for arteriovenous malformations are outlined. The ethical issues involved for pregnant patients whose decisional capacity is compromised as a result of cerebral injury are explored. A review of persistent vegetative state and brain death (death by neurologic criteria) occurring in pregnancy allows us to explore many issues that are applicable to decisionally incapacitated but physiologically functioning pregnant women. We outline a document, the purpose of which is to obtain advance directives from pregnant women regarding end-of-life decisions and to appoint a surrogate decision maker. We believe that evaluation and treatment of the arteriovenous malformation may be undertaken without regard for the pregnancy and that the pregnancy should progress without concern for the arteriovenous malformation.
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3/41. diffusion-weighted magnetic resonance imaging in brain death.

    BACKGROUND; Traditionally the diagnosis of brain death is established on the basis of a combination of clinical signs and paraclinical methods. diffusion-weighted MRI is a new method sensitive to cerebral ischemia. Its value in brain death has not been demonstrated until now. CASE DESCRIPTION: A patient was referred to MRI with suspicion of a brain stem stroke. Echo-planar whole-brain, multislice, diffusion-weighted MRI was performed in addition to conventional sequences and MR angiography sequences. In addition to the extensive bilateral hyperintensities observed on T2-weighted images, diffusion-weighted MRI showed diffuse hyperintensities involving both hemispheres as well as a severe drop in the apparent diffusion coefficient in both affected hemispheres. There was also transtentorial herniation with compression of the brain stem as well as absence of flow voids on the T2-weighted images and absence of intracranial vessels on MR angiography. On the basis of the clinical and imaging findings, it was concluded that the patient was in a state of brain death. The patient died the same day. CONCLUSIONS: With the use of new fast techniques such as diffusion-weighted imaging, now MRI can not only display anatomic changes associated with severe brain suffering but can also demonstrate ultrastructural changes secondary to brain death and differentiate them from edematous changes seen on T2-weighted images.
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4/41. Fatal cerebroembolism from nonbacterial thrombotic endocarditis in a trauma patient: case report and review.

    Nonbacterial thrombotic endocarditis (NBTE) is a rare condition that may result in an unexpected and usually fatal cerebroembolism. It occurs in a variety of clinical situations, including malignancy, immune disorders, and sepsis, but it has rarely been reported after trauma. The formation of NBTE appears to require a hypercoagulable state and changes in valvular morphology, e.g., during a hyperdynamic state. patients with disseminated intravascular coagulation have a 21% incidence of NBTE. Although NBTE is usually found at autopsy, premorbid detection by echocardiography is currently possible and feasible. Untreated patients have a high incidence of embolic events, but anticoagulation with heparin may be life-saving. A lethal case of NBTE in a severely injured patient is reported here with the purpose of increasing awareness among medical personnel caring for trauma patients. Recommendations have been made for surveillance echocardiography in high-risk patients, e.g., critically ill patients with sepsis or disseminated intravascular coagulation.
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5/41. Fulminant guillain-barre syndrome mimicking cerebral death: case report and literature review.

    A 45-year-old woman was admitted to the intensive care unit (ICU) for respiratory arrest. One day prior to admission, she had been nauseated and in a state of total exhaustion. On the night of admission she was unresponsive and developed gasping respiration. The patient was comatose with absent brainstem reflexes and appeared brain dead. Blood chemistry findings and brain magnetic resonance imaging were normal. Electroencephalogram revealed an alpha rhythmical activity unresponsive to painful or visual stimuli. The cerebrospinal fluid showed an albuminocytological dissociation. guillain-barre syndrome (GBS) was suspected. The electrophysiological evaluation revealed an inexcitability of all nerves. The pathological findings of the sural nerve biopsy indicated an axonal degeneration secondary to severe demyelination. GBS can very rarely present with coma and absent brainstem reflexes. This case illustrates the importance of electrophysiological tests and laboratory and imaging studies in patients with suspected brain death where a cause is not clearly determined.
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6/41. pneumothorax and pneumoperitoneum during the apnea test: how safe is this procedure?

    apnea test is a crucial requirement for determining the diagnosis of brain death (BD). There are few reports considering clinical complications during this procedure. We describe a major complication during performing the apnea test. We also analyse their practical and legal implications, and review the complications of this procedure in the literature. A 54 year-old man was admitted for impaired consciousness due to a massive intracerebral hemorrhage. Six hours later, he had no motor response, and all brainstem reflexes were negative. The patient fulfilled American Academy of neurology (AAN) criteria for determining BD. During the apnea test, the patient developed pneumothorax, pneumoperitoneum, and finally cardiac arrest. apnea test is a necessary requirement for the diagnosis of brain death. However, it is not innocuous and caution must be take in particular clinical situations. Complications during the apnea test could be more frequent than reported and may have practical and legal implications. Further prospective studies are necessary to evaluate the frequency and nature of complications during this practice.
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7/41. Irreversible maternal brain injury during pregnancy: a case report and review of the literature.

    Maternal brain death or massive injury leading to persistent vegetative state during pregnancy is a rare event. Since 1979, 11 cases, including the current one, of irreversible maternal brain damage in pregnancy have been reported. In all but one, the pregnancies were prolonged with a goal of achieving delivery of a viable infant. Current advances in medicine and critical care enable today's physician to offer prolonged life-support to maximize the chances for survival in the neonate whose mother is technically brain dead. We present a case at our institution and review all previously published cases in the English literature for comparison as well as make management recommendations.
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8/41. Isolated medulla oblongata function after severe traumatic brain injury.

    The objective was to report the first pathologically confirmed case of partly functionally preserved medulla oblongata in a patient with catastrophic traumatic brain injury.A patient is described with epidural haematoma with normal breathing and blood pressure and a retained coughing reflex brought on only by catheter suctioning of the carina. Multiple contusions in the thalami and pons were found but the medulla oblongata was spared at necropsy. In conclusion, medulla oblongata function may persist despite rostrocaudal deterioration. This comatose state ("medulla man") closely mimics brain death.
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9/41. Facial myokymia in brain death.

    BACKGROUND: brain death (BD) is the irreversible loss of all functions of the brain and brainstem. Spontaneous and reflex movements of the limbs have been described in this condition. However, facial myokymia (FM) in BD has not been previously reported. The origin of that motor phenomenon in alive patients is still uncertain, since supranuclear, nuclear and peripheral mechanisms have been proposed. OBJECTIVE: We describe the presence of FM in a patient who fulfilled the criteria for BD. A 40-year-old-man had right-sided weakness and impaired consciousness. After 14 h admission, he fulfilled the criteria for BD. A CT scan of the head showed a large putaminal hemorrhage. The EEG was isoelectric. At that time, fine spontaneous twitches of the left cheek were noticed. They consisted of repetitive and rhythmic movements in groups of 3-5 lasting for < 5 s. These movements appeared every 2-10 min during 6 h. DISCUSSION: Spinal reflexes have been described in BD. The presence of any movements other than the recognized reflexes may question this diagnosis and limit organ procurement for transplantation. The recognition of FM as an accepted movement in BD patients has practical and legal implications.
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10/41. Auditory brainstem response and temporal bone pathology findings in a brain-dead infant.

    The criteria for assessing adult brain death have been already established, but those for infant brain death have not been yet established in japan. We report auditory brainstem response (ABR) and postmortem pathology of the temporal bone and brain of a brain-dead 9-month-old female. During the comatose state, her ABR showed only waves I and II bilaterally. autopsy revealed the presence of a left cerebellar astrocytoma, herniation and anoxic encephalopathy. The pathological examination of the temporal bone revealed the destruction of the inner ear particularly on the left side. In the auditory pathway of brain-dead patients, degeneration occurs first in the cerebrum, followed by the cochlear nerve. Thus, ABR is one of the useful means to assess brain death even in infants.
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