The Vegetative State: Guidance on Diagnosis and Management
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Brain Death and the Cervical Spinal Cord: a Confounding Factor for the Clinical Examination
Spinal Cord (2010) 48, 2–9 & 2010 International Spinal Cord Society All rights reserved 1362-4393/10 $32.00 www.nature.com/sc REVIEW Brain death and the cervical spinal cord: a confounding factor for the clinical examination AR Joffe, N Anton and J Blackwood Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada Study design: This study is a systematic review. Objectives: Brain death (BD) is a clinical diagnosis, made by documenting absent brainstem functions, including unresponsive coma and apnea. Cervical spinal cord dysfunction would confound clinical diagnosis of BD. Our objective was to determine whether cervical spinal cord dysfunction is common in BD. Methods: A case of BD showing cervical cord compression on magnetic resonance imaging prompted a literature review from 1965 to 2008 for any reports of cervical spinal cord injury associated with brain herniation or BD. Results: A total of 12 cases of brain herniation in meningitis occurred shortly after a lumbar puncture with acute respiratory arrest and quadriplegia. In total, nine cases of acute brain herniation from various non-meningitis causes resulted in acute quadriplegia. The cases suggest that direct compression of the cervical spinal cord, or the anterior spinal arteries during cerebellar tonsillar herniation cause ischemic injury to the cord. No case series of brain herniation specifically mentioned spinal cord injury, but many survivors had severe disability including spastic limbs. Only two pathological series of BD examined the spinal cord; 56–100% of cases had upper cervical spinal cord damage, suggesting infarction from direct compression of the cord or its arterial blood supply. -
Forensic Medicine
YEREVAN STATE MEDICAL UNIVERSITY AFTER M. HERATSI DEPARTMENT OF Sh. Vardanyan K. Avagyan S. Hakobyan FORENSIC MEDICINE Handout for foreign students YEREVAN 2007 This handbook is adopted by the Methodical Council of Foreign Students of the University DEATH AND ITS CAUSES Thanatology deals with death in all its aspects. Death is of two types: (1) somatic, systemic or clinical, and (2) molecular or cellular. Somatic Death: It is the complete and irreversible stoppage of the circulation, respiration and brain functions, but there is no legal definition of death. THE MOMENT OF DEATH: Historically (medically and legally), the concept of death was that of "heart and respiration death", i.e. stoppage of spontaneous heart and breathing functions. Heart-lung bypass machines, mechanical respirators, and other devices, however have changed this medically in favor of a new concept "brain death", that is, irreversible loss of Cerebral function. Brain death is of three types: (1) Cortical or cerebral death with an intact brain stem. This produces a vegetative state in which respiration continues, but there is total loss of power of perception by the senses. This state of deep coma can be produced by cerebral hypoxia, toxic conditions or widespread brain injury. (2) Brain stem death, where the cerebrum may be intact, though cut off functionally by the stem lesion. The loss of the vital centers that control respiration, and of the ascending reticular activating system that sustains consciousness, cause the victim to be irreversibly comatose and incapable of spontaneous breathing. This can be produced by raised intracranial pressure, cerebral oedema, intracranial haemorrhage, etc.(3) Whole brain death (combination of 1 and 2). -
Piercing the Veil: the Limits of Brain Death As a Legal Fiction
University of Michigan Journal of Law Reform Volume 48 2015 Piercing the Veil: The Limits of Brain Death as a Legal Fiction Seema K. Shah Department of Bioethics, National Institutes of Health Follow this and additional works at: https://repository.law.umich.edu/mjlr Part of the Health Law and Policy Commons, and the Medical Jurisprudence Commons Recommended Citation Seema K. Shah, Piercing the Veil: The Limits of Brain Death as a Legal Fiction, 48 U. MICH. J. L. REFORM 301 (2015). Available at: https://repository.law.umich.edu/mjlr/vol48/iss2/1 This Article is brought to you for free and open access by the University of Michigan Journal of Law Reform at University of Michigan Law School Scholarship Repository. It has been accepted for inclusion in University of Michigan Journal of Law Reform by an authorized editor of University of Michigan Law School Scholarship Repository. For more information, please contact [email protected]. PIERCING THE VEIL: THE LIMITS OF BRAIN DEATH AS A LEGAL FICTION Seema K. Shah* Brain death is different from the traditional, biological conception of death. Al- though there is no possibility of a meaningful recovery, considerable scientific evidence shows that neurological and other functions persist in patients accurately diagnosed as brain dead. Elsewhere with others, I have argued that brain death should be understood as an unacknowledged status legal fiction. A legal fiction arises when the law treats something as true, though it is known to be false or not known to be true, for a particular legal purpose (like the fiction that corporations are persons). -
Coma Stimulation: Suggested Activities
Coma stimulation: suggested activities Headway’s publications are all available to freely download from the information library on the charity’s website, while individuals and families can request hard copies of the booklets via the helpline. As a charity, we rely on donations from people like you to continue providing free information to people affected by brain injury. Donate today: www.headway.org.uk/donate. Introduction It is quite common for family members to feel ‘useless’ when a relative is in a coma, and to be desperate to do something to help. A coma stimulation programme (sometimes called a coma arousal programme) is an approach based on stimulating the unconscious person’s senses of hearing, touch, smell, taste and vision individually in order to help their recovery. There is still controversy over how effective it is to try to stimulate a person in coma. However, most would say that such programmes have some beneficial effect, even if only to provide something constructive for the family to do. It is very important that the activities used would have been enjoyable for the patient before the injury. For example, only play music they like and talk to them about subjects they are interested in. Try not to do anything for too long in order to avoid tiring the person out. A stimulation programme must only be started after discussion with the clinical staff, who will advise you what might be appropriate at any particular stage in the recovery process. Activity suggestions Here are some examples of activities that could form part of a coma stimulation programme: • Make sure that a few friends and family members visit regularly, rather than in large groups at a time. -
Book of Abstracts
IAPDD 2018 ABSTRACTS A Fate Worse Than Death Todd Karhu ............................................................................................................................................. 3 Ancient Lessons on the Norms of Grief Emilio Comay del Junco ........................................................................................................................ 4 Beyond Morality and the Clinic: Contemplating End-Of-Life Decisions Yael Lavi .................................................................................................................................................. 5 Brainstem Death, Cerebral Death, or Whole-Brain Death? Personal Identity and the Destruction of the Brain Lukas Meier ............................................................................................................................................ 6 Choosing Immortality Tatjana von Solodkoff ............................................................................................................................ 7 Death and Grief Piers Benn ................................................................................................................................................ 8 Death and Possibility Roman Altshuler .................................................................................................................................... 9 Does Death Render Life Absurd? Joshua Thomas .................................................................................................................................... -
Evaluation and Management in an Urgent Care Setting
Syncope Evaluation and Management in an Urgent Care Setting Urgent message: When a patient presents to urgent care after a syncopal event, the clinician’s charge is to determine whether the episode was of benign or potentially life-threatening etiology and whether the patient should be transferred for further evaluation. Kenneth V. Iserson, MD, MBA, FACEP, FAAEM, Professor of Emergency Medicine, The University of Arizona, Tucson, AZ Introduction yncope is a sudden, transient loss of consciousness with a loss of postural tone (typically, falling). It results from an abrupt, transient, and diffuse cerebral Smalfunction and is quickly followed by sponta- neous recovery. The term syncope excludes seizures, coma, shock, or other states of altered consciousness. Many patients will ascribe their syncopal episode to a sit- uationally mediated vasovagal episode. Despite this, the goals in the urgent care setting include the following: Ⅲ Determining whether the patient’s episode was actually a syncopal or presyncopal event, and if it could have a life-threatening etiology Ⅲ Stabilizing the patient Ⅲ Transferring those patients who need further diag- nostic studies or therapeutic interventions © John Bolesky, Artville © John Bolesky, Epidemiology Syncope accounts for up to 3% of emergency depart- common in young adults, while cardiac syncope ment (ED) visits and up to 6% of hospital admissions becomes increasingly more frequent with advancing each year in the United States.1,2 At some time in their age.4 The chance of having at least one syncopal episode lives, up to about half the population (12% to 48%) of in childhood is between 15% and 50%.5 Though a people may experience syncope.3 benign cause is usually found, syncope in children war- Syncope occurs in all age groups, but it is most com- rants prompt detailed evaluation.6 mon in adults. -
Locked-In' Syndrome, the Persistent Vegetative State and Brain Death
Spinal Cord (1998) 36, 741 ± 743 ã 1998 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/98 $12.00 http://www.stockton-press.co.uk/sc Moral Dilemmas Moral dilemmas of tetraplegia; the `locked-in' syndrome, the persistent vegetative state and brain death R Firsching Director and Professor, Klinik fuÈr Neurochirurgie, UniversitaÈtsklinikum, Leipziger Str. 44; 39120 Magdeburg, Germany Keywords: tetraplegia; `locked-in' syndrome; persistent vegetative state; brain death Lesions of the upper part of the spinal cord, the persistent vegetative state (PVS) stand on less safe medulla oblongata or the brain stem have dierent grounds and greater national dierences may be neurological sequelae depending on their exact location discerned: The causes may be variable, ranging from and extent. trauma to hemorrhage, hypoxia and infection. The High tetraplegia with a lesion at the level of the C3 pathomorphology is a matter of debate.5 Findings segment will leave the patient helpless but fully from the most famous PVS patient, KA Quinlan, conscious of his situation, and communication is revealed severe destruction of the thalamus,6 also usually possible. destruction of white matter and extensive destruction The patient who is `locked in' suers from a lesion of the cerebral cortex has been reported. The level of of the pyramidal tract, mostly at the upper pontine ± consciousness in these patients cannot be clari®ed, as cerebral peduncle ± level.1 Communication is reduced they are unresponsive. They are certainly not to vertical eye movements and blinking. comatose, as they open their eyes, and the kind of The persistent vegetative state is a quite hetero- pain perception that these patients have is similarly genous entity, and the underlying lesions are variable. -
Pitfalls in the Diagnosis of Brain Death
Neurocritical Care Society Neurocrit Care DOI 10.1007/s12028-009-9231-y REVIEW ARTICLE Pitfalls in the Diagnosis of Brain Death Katharina M. Busl Æ David M. Greer Ó Humana Press Inc. 2009 Abstract Since the establishment of the concept of death, i.e., brain death. The criteria included unrespon- declaring death by brain criteria, a large extent of variability siveness, absence of movement or breathing, and absence in the determination of brain death has been reported. There of brainstem reflexes. In addition, an isoelectric EEG was are no standardized practical guidelines, and major differ- recommended, and hypothermia and drug intoxication ences exist in the requirements for the declaration of were to be excluded [2]. brain death throughout the USA and internationally. The In 1981, the President’s Commission for the Study of American Academy of Neurology published evidence- Ethical Problems in Medicine and Behavioral Research based practice parameters for the determination of brain issued a landmark report on ‘‘Defining Death’’ and rede- death in adults in 1995, requiring the irreversible absence of fined the criteria for the diagnosis of brain death in adults, clinical brain function with the cardinal features of coma, encompassing the complete cessation of all functions of the absent brainstem reflexes, and apnea, as well as the exclu- entire brain (i.e., ‘‘whole brain concept’’), and its irre- sion of reversible confounders. Ancillary tests are versibility [3]. The Uniform Determination of Death Act, recommended in cases of uncertainty of the clinical diag- which was subsequently adopted as federal legislation by nosis. Every step in the determination of brain death bears most states in the USA, is based on these recommenda- potential pitfalls which can lead to errors in the diagnosis of tions. -
Primary Brainstem Death
J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.51.5.646 on 1 May 1988. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry 1988;51:646-650 Primary brainstem death: a clinico-pathological study J OGATA,* M IMAKITA,t C YUTANI,t S MIYAMOTO4, H KIKUCHII From the Research Institute, *Department ofPathology, tDepartment ofNeurosurgery, INational Cardiovascular Centre, Osaka, Japan SUMMARY A case of primary brainstem death in a man with surgically treated cerebellar hae- morrhage is reported. Necropsy revealed extensive necrosis confined to the brainstem and cere- bellum. The absence of diabetes insipidus and the persistence of electroencephalographic activity were the characteristic clinical features of the case. This differentiates the condition from so-called "whole brain death". Analysis of three further cases with acute vascular lesions of the brainstem or cerebellum, shown at necropsy, revealed that primary brainstem death with prolonged somatic survival can occur in specific circumstances after surgical intervension Brainstem death, as encountered in clinical practice, Case report is nearly always a secondary phenomenon. It is the infratentorial repercussion of supratentorial events A 47 year old hypertensive man was found on lying the floor.Protected by copyright. and has been described as the "physiological core" of In 10 minutes, he became unresponsive. The blood pressure "whole brain death" and as the main determinant of measured in a nearby hospital was 270/140 mmHg. Within its clinical features and cardiac prognosis.' Lesions to an hour, he was intubated because spontaneous respiration the upper and lower brainstem which deprive it of its ceased. The blood pressure fell at one stage to 80/52 mmHg. -
Factors Predicting Acute Brain Injury in Cases of Carbon Monoxide Poisoning: a Prospective Registry-Based Study
toxics Article Factors Predicting Acute Brain Injury in Cases of Carbon Monoxide Poisoning: A Prospective Registry-Based Study Hoon Lim 1,†, Young Hwan Lee 1,†, Sangun Nah 1 , Sungwoo Choi 1 , Young Soon Cho 1, Gi Woon Kim 1, Ji Eun Moon 2 and Sangsoo Han 1,* 1 Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Korea; [email protected] (H.L.); [email protected] (Y.H.L.); [email protected] (S.N.); [email protected] (S.C.); [email protected] (Y.S.C.); [email protected] (G.W.K.) 2 Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Korea; [email protected] * Correspondence: [email protected] † Hoon Lim and Young Hwan Lee contributed equally to this work. Abstract: Carbon monoxide (CO) is one of the most common poisoning substances worldwide. Since acute brain injury (ABI) is an important determinant of the neurological outcome in CO poisoning, screening for patients at a high risk of developing ABI is essential for the proper treatment. This study identified predictors of ABI in patients with CO poisoning. This prospective registry-based study was conducted in patients who visited a tertiary care hospital for CO poisoning from August 2016 to June 2020. ABI was defined as the presence of acute hypoxic lesions on diffusion-weighted magnetic resonance imaging. Multiple logistic regression analysis was performed to identify the predictors of ABI. Of 231 patients, 64 (27.7%) showed ABI. Multiple logistic regression analysis showed that a Citation: Lim, H.; Lee, Y.H.; Nah, S.; Glasgow Coma Scale (GCS) score <9 at presentation (odds ratio [OR] 3.28, 95% confidence interval Choi, S.; Cho, Y.S.; Kim, G.W.; Moon, (CI) 1.08–10.01), creatinine level >1.2 mg/dL (OR 3.04, 95% CI 1.16–8.01), and C-reactive protein J.E.; Han, S. -
Hypothesis Spinal Shock and `Brain Death': Somatic Pathophysiological
Spinal Cord (1999) 37, 313 ± 324 ã 1999 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/99 $12.00 http://www.stockton-press.co.uk/sc Hypothesis Spinal shock and `brain death': Somatic pathophysiological equivalence and implications for the integrative-unity rationale DA Shewmon*,1 1Pediatric Neurology, UCLA Medical School, Los Angeles, California, USA The somatic pathophysiology of high spinal cord injury (SCI) not only is of interest in itself but also sheds light on one of the several rationales proposed for equating `brain death' (BD) with death, namely that the brain confers integrative unity upon the body, which would otherwise constitute a mere conglomeration of cells and tissues. Insofar as the neuropathology of BD includes infarction down to the foramen magnum, the somatic pathophysiology of BD should resemble that of cervico-medullary junction transection plus vagotomy. The endocrinologic aspects can be made comparable either by focusing on BD patients without diabetes insipidus or by supposing the victim of high SCI to have pre-existing therapeutically compensated diabetes insipidus. The respective literatures on intensive care for BD organ donors and high SCI corroborate that the two conditions are somatically virtually identical. If SCI victims are alive at the level of the `organism as a whole', then so must be BD patients (the only signi®cant dierence being consciousness). Comparison with SCI leads to the conclusion that if BD is to be equated with death, a more coherent reason must be adduced than that the body as a biological organism is dead. Keywords: brain death; spinal cord injury; spinal shock; integrative functions; somatic integrative unity; organism as a whole Introduction Spinal shock is a transient functional depression of the society; its legal de®nition is culturally relative, and structurally intact cord below a lesion, following acute most modern societies happen to have chosen to spinal cord injury (SCI). -
Pdfs/Brainstemdeath.Pdf Disturbances Must Be Excluded As the Cause of Continuation of 12 Wijdicks EF
J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.74.suppl_3.iii16 on 21 August 2003. Downloaded from NEUROLOGICAL CONSULTATIONS IN THE MEDICAL INTENSIVE CARE UNIT Saif S M Razvi, Ian Bone iii16* J Neurol Neurosurg Psychiatry 2003;74(Suppl III):iii16–iii23 ritical care therapy has advanced over the past two decades, treating more patients and pro- viding more complex care. However, the improved survival from septic shock, adult respira- Ctory distress syndrome (ARDS), and multiple organ system failure results in critically ill patients facing a spectrum of new complications secondary to both illness and treatment. A third of intensive care unit (ICU) admissions have a neurological complication detrimental to outcome.1 Neurological status (mainly depressed consciousness) is the major contributor to prolonged ventilation in a third of those who need it and is a significant factor in an additional 40%. Neurological complications double both the length of stay in hospital and the likelihood of death; the mortality rate for patients with neurological complications is 55% compared to 29% for those without. It is therefore unsurprising that neurologists are being increasingly called upon to review patients on the medical intensive care unit (MICU). A neurological opinion is usually requested: c to assess neurological manifestations of the primary disease process c to evaluate the consequences of critical care therapy c to offer a prognosis, or c determine brain death. The neurologist must approach these complex patients in a logical,