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New pathophysiological problems : Two confusing manifestations in the diagnosis of brain death.

新的病理生理学问题：脑死亡诊断中的两种令人困惑的表现。

基本信息

批准号：
01570808
负责人：
SUGIMOTO Tsuyoshi
金额：
$ 1.47万
依托单位：
Osaka University
依托单位国家：
日本
项目类别：
Grant-in-Aid for General Scientific Research (C)
财政年份：
1989
资助国家：
日本
起止时间：
1989 至 1991
项目状态：
已结题

来源：
https://kaken.nii.ac.jp/grant/KAKENHI-PROJECT-01570808/
关键词：
Brain Death Vasopressin (ADH)Insulin Hypothalamic Spinal Reflex Autopsy 脳死判定 CRH GRH LHーRH

项目摘要

We found another two important facts during our series of studies in the brain dead patients with long-term stable circulation maintained by our vasopressin(ADH)and catecholamine method. One fact is that hypothalamic hormones still present in the serum of brain dead patients, though they met all the criteria of brain death, even several days after the diagnosis. The other is that body movement induced by painful stimuli and/or various types of voluntary movement are seen in brain dead patients. These two facts might contradict to the definition of the brain death ; "irreversible cessation of all functions of entire brain". In this study, we aimed to explain the meaning of these two facts.We have got following results through this study :## Results I ## Hypothalamic hormones, such as CRH, GRH and LH-RH, were detected in the serum of brain dead patients as long as 17 days after brain death. All brains, however, showed necrotic autolysis at most 7 days after brain death. This suggests the … More se hormones should be derived from any other tissues than the hypothalamus. Hypothalamic stimulation tests by insulin-induced hypoglycemia and arginine infusion showed absence of reacting secretion of CRH, ACTH, cortisol or GRH from hypothalamus. The serum endogenous ADH level decreased rapidly just after the brain death and had never increased in spite of abnormally high serum osmotic pressure. This means neither production of ADH in the hypothalamus nor commands from the upper nervous system to the pituitary gland is seen after brain death. These results do not contradict to the concept of brain death.## Results 2 ## Various spinal reflexes disappeared temporally just after the brain death but were frequently observed again 5 to 10 days after brain death. Autopsy showed necrotic autolysis of the spinal cord which started from the upper cervical cord and developed downward to various level. All of them, however, were thought to be derived from the residual intact cord. We found a new autonomic reflex elicited by passive neck flexion for the first time in the world which is characterized by hemodynamic response such as marked increase of blood pressure and tachyeardia. This reflex was seen frequently in brain death(in 10 of 12 cases)and never seen in any other patients than brain death. Furthermore, this reflex was seen even in patients whose upper thoracic cord were degenerated, and depressed completely by a ganglion blocker. This reflex, therefore, is considered specific for brain death and to be a peripheral autonomic reflex including sympathetic ganglia. In the somatosensory evoked potential by stimulating the nervus medianus, the N13 peak, which was initially seen obviously, became dull gradually and disappeared 7 to 10 days after brain death. The N13 peak is thought to be derived from the upper cervical spinal cord. This suggests that the necrotic autolysis of the spinal cord is caused within 2 or 3 days after brain death and that of the lower cord 7 to 10 days later. Less

在我们对脑死亡患者进行的一系列研究中，我们发现了另外两个重要的事实，我们的抗利尿激素（ADH）和儿茶酚胺方法维持了长期稳定的循环。一个事实是，脑死亡患者的血清中仍然存在下丘脑激素，尽管他们符合脑死亡的所有标准，即使在诊断后几天。另一种观点认为，在脑死亡患者中可以看到由疼痛刺激引起的身体运动和/或各种类型的自主运动。这两个事实可能与脑死亡的定义相矛盾；“整个大脑所有功能的不可逆转的停止”。在本研究中，我们旨在解释这两个事实的意义。通过本研究，我们得到了以下结果：##结果I ##脑死亡患者在脑死亡后17天的血清中检测到下丘脑激素，如CRH、GRH和LH-RH。所有脑均在脑死亡后最多7天出现坏死性自溶。这表明更多的肾上腺素应该来自于其他组织而不是下丘脑。胰岛素诱导的低血糖和精氨酸输注下丘脑刺激试验显示，下丘脑没有反应性分泌CRH、ACTH、皮质醇或GRH。脑死亡后血清内源性ADH水平迅速下降，尽管血清渗透压异常高，但从未升高。这意味着在脑死亡后，下丘脑中既没有产生ADH，也没有从上神经系统向脑垂体发出指令。这些结果与脑死亡的概念并不矛盾。脑死亡后，各种脊髓反射暂时消失，但在脑死亡后5 ~ 10天再次观察到。尸检显示脊髓坏死自溶，从上颈髓开始，向下发展到不同水平。然而，所有这些都被认为是来自残余的完整脐带。我们在国际上首次发现被动屈颈引起的一种新的自主神经反射，其特征是血压和心动过速明显升高等血流动力学反应。这种反射在脑死亡中很常见（12例中有10例），除了脑死亡外，在其他患者中从未见过。此外，这种反射甚至在上胸索退行性变的患者中也能看到，并被神经节阻滞剂完全抑制。因此，这种反射被认为是脑死亡特有的，是一种包括交感神经节在内的外周自主神经反射。在刺激正中神经的体感诱发电位中，最初明显的N13峰在脑死亡后7 ~ 10天逐渐变暗，消失。N13峰被认为来自颈上脊髓。这表明脊髓的坏死性自溶发生在脑死亡后的2 - 3天内，下脊髓的自溶发生在7 - 10天后。少