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Abstracts of the 2nd INTERNATIONAL SYMPOSIUM ON BRAIN DEATH

(Havana, Cuba)

February 27-March 1, 1996 The Full Program of the Meeting is also available

Note: These abstracts need a lot of editing. Plase bear with us till we get them cleaned up.

BRAIN ONTOGENESIS. THE LIFE AND DEATH OF THE HUMAN BEING AND PERSON

Julius Korein
USA
The difficulties encountered in medicine in utilizing concepts relating to life and death in the human organism are related to inappropriate fundamental definitions. Fundamental
characteristics and evolution of living systems are discussed. A set of biological definitions based on the life cycle of the human organism is presented using a dual approach. Mutually exclusive sequential stages of the life cycle, as well as incrementally inclusive (nested) phases of the life cycle in the human organism are both explicitly defined. A brain centered approach requires emphasis on the ontogenesis of the structure and function of the brain. Operational definitions lead to a characterization of the different developmental periods of the human organism including phases designated as the "human being" and the "person". The brain centered concept is use to define the onset (brain life) and termination (brain death) of this critical system of the human being. The onset and termination of the human being occurs respectively with the beginning of the operation of the entire critical system (brain life), and with the end of the operation of the entire critical system (brain death). The onset is related to completion of the structural brain and the beginning of its function, while the termination is related to the destruction or irreversible dysfunction of the entire brain. These concepts contain a fundamental asymmetry. A self-consistent, practical, biologically based approach may provide a logical foundation for a large variety of medical, legal, ethical and social issues. Some of these topics are discussed using the proposed framework, including brain death, persistent vegetative states, abortion, and anencephaly. Key words: ontogenesis, life death, organism, life, cycle, human being, person, brain, stages, phases, persistent vegetative states, abortion.

A DEFENSE OF THE HIGHER BRAIN FORMULATION OF DEATH

Karen Gervais
USA
A definition or concept of death is a convention, a social construct that derives from metaphysical and value assumptions that can be clarified, analyzed, and criticized. Any criterion used to determine death presupposes a concept of death. Hence, one way to assess a criterion (e.g., the brain death criterion) is to surmise its underlying concept of death and ask what justifies this understanding of death, metaphysically and ethically. We rely on the measurement of the cessation of "vital" physiological functions to legitimize the claim that someone has died. Therefore, the use of technological stand-ins for these functions requires the question: Is the patient alive or dead? particularly when functions historically deemed "vital" persist despite irreversible, substantial loss of brain function. Significant agreement exists that brain death is human death. I shall argue that the metaphysical and ethical considerations supporting the use of the brain death criterion actually entail a consciousness-centered (higher brain criterion) concept of death; that worthy metaphysical and ethical arguments support a consciousness-based definition of human death, and that the pluralism of metaphysical and ethical perspectives among us should be honored by permitting individuals to choose to be declared dead on the basis of a higher brain death criterion.

DEATH AND THE RISE OF MEDICINE AS A SCIENCE

C.A. Defanti
1st Neurological Department, Ospedali Riuniti di Bergamo ITALY
As many historians have shown, the contemporary controversies about the ascertainment and definition of death (Is brain death really death? Is there any degree of uncertainty in its diagnosis?)are not an entirely new phenomenon: doubts about what the "signs of death" are and about the ability of physicians to make a correct "diagnosis" of death have always existed. These doubts have not been dispelled by the development of modern medicine: on the contrary, they have grown during certain periods of the history of the last three centuries. The panic over premature burial during the Age of Enlightenment is well known, but the causes of this social phenomenon are not well understood. However, as R. Pernick has shown, probably the development of the first, rudimentary resuscitation techniques along with the new knowledge about suspended animation in lower animals and the earliest experiments with electricity, raising the possibility to reverse states like death or death itself, were of paramount importance. During the Nineteenth Century, these controversies weakened, in parallel with the medical progress (the invention of diagnostic tools as the stethoscope is a case in point), but during the last decades of the same Century new controversies and doubts grew up, resulting in a new wave of panic. Here too, the scientific advances were instrumental: the possibility to keep organs alive in the laboratory, outside the organism, and later the possibility to culture cells and tissues "in vitro" and to transplant organs from an organism to another blurred the boundaries of death. Other social factors have probably been influential in this movement: for instance the rise of the non- orthodox medicine, of the anti-vaccination and anti-vivisection leagues. During the Twentieth Century, the medical progress initially contributed to dispel some doubts about death, through the introduction, in medical practice, of diagnostic tools as the EKG, which made the ascertainment of cardiac arrest wholly reliable, but after the Second World War the development of intensive care medicine blurred the boundaries of death again and forced the medical societies to propose new criteria of death. The famous paper issued by the Harvard Ad Hoc Committee (1958) had an enormous impact and gained worldwide acceptance, except in some countries, like Israel and Japan, where religious and philosophical perspectives still resist again this concept. Despite the large success of the concept of brain death, many doubts are lingering. At variance with the past, the point is no longer the diagnostic uncertainty, but the foundation of the concept itself. A growing number of scholars are embracing the concept of cortical death, whereas some, among them P. Singer, a former proponent of cortical death, think that a reversal to the old "cardiovascular" criteria is more advisable. Many factors are involved in the contemporary debate: they range from purely scientific issues (e.g. the difficulty to make a reliable diagnosis of permanent vegetative state), to moral quandaries concerning transplantation of organs and to philosophical puzzles about the definition of death.

NEW CONTROVERSIES IN THE DEFINITION OF DEATH

Stuart J; Youngner, M.D
University Hospitals of Cleveland, 2074 Abington Road, Cleveland. USA
While brain death remains widely accepted in the United States after nearly three decades since its introduction medical progress, clinical experience, social change, new methods of organ retrieval, and unresolved conceptual issues have provided significant challenges to its early, almost unchallenged status. One of the reasons brain death was quickly accepted was that patients who met its criteria suffered irreversible asystole within a short time. Now, however, there are examples of brain dead patients being supported on ventilators for months and even years. Also, while brain death criteria call for irreversible cessation of all brain function, many persons who are declared brain dead retain significant brain functions such as production of arginine vasopressin. Tolerance of differing beliefs in a multicultural society has led the State of New Jersey to adopt a law which allows families to veto the declaration of brain death on religious grounds. These challenges will be reviewed with an eye to their implications for the future for countries now struggling to "catch up" by adopting and implementing traditional brain death criteria.

IN DEFENSE OF WHOLE-BRAIN DEFINITIONS OF DEATH

A.A. Howsepian, M.D.
University of California, San Francisco
Fresno Central San Joaquin Valley Medical Education Program USA
The primary thesis that I shall undertake to defend is this: All functions of the entire brain must be irreversibly lost in order for a (developmentally mature) human being to be dead. This is, by some lights, a remarkable undertaking. Robert M. Veatch, for example, finds such an undertaking to be literally incredible, for he imagines that, far from defending this thesis, no one really believes any such thing. According to Veatch, the "whole-brain definition of death" so construed, as well as related wholebrain definitions, have sustained irreparable conceptual damage at the hands of their critics and, hence, ought to be discarded. But the death of whole-brain definitions of death (WBDsD) has been grossly exaggerated. I intend to argue that, contrary to appearances, (i) critics of WBDsD including, among others, Veatch, D. Alan Shewmon, Michael Lockwood, and John H. Sorenson, have not presented an even remotely plausible case against their conceptual viability and (ii) the alternative (higher-brain-oriented) definitions of death advanced by Veatch, Lockwood, Shewmon, Sorenson and others are so defectively conceived that even if WBDsD were in conceptual disarray, we would have no good reason to adopt any extant higher-brain- oriented alternative.

REFRAMING THE DEATH DEBATE: FROM NEW JERSEY, NOW ENTERING THE MORIBUND ZONE

Alan J. Weisbard
University of Wisconsin
USA
Over the past quarter century, technological developments in medicine, particularly in the areas of artificial respiration and organ transplantation, prompted a societal reconsideration of the meaning of death, as well as a revision of both legal and medical criteria for determining whether and when the death of an individual had occurred. The resulting "redefinition" of death in terms of "whole brain death" was viewed as a great triumph of the bioethics movement. The new definition of death has itself influenced, in complex and often unacknowledged ways, the highly value-charged behaviors of foregoing life-sustaining treatment and removing organs from donors for purposes of transplantation. The "whole brain death" formulation has recently come under increasing attack from a number of quarters, and momentum is gathering for a new round of "redefining death". This presentation will explore the lessons of our earlier experience with redefining death, and suggest that the impending "next round" take a new direction, both in our conception of the meaning of death and in the legal, policy and behavioral implications that flow from it. This approach would recognize both the biological reality of a "zone of moribundity" and the moral reality that we are attached to competing and perhaps irreconcilable, visions of "personhood" and "biological life" as constitutive of human existence. Building on and extending the innovative approach pioneered by the New Jersey Bioethics Commission, the presentation will explore the conceptual and policy implications of permitting specified "death behaviors" to be initiated within this zone of moribundity, in accordance with the wishes and values of the individual patient.

SOMATIC INTEGRATIVE UNITY: A NONVIABLE RATIONALE FOR "BRAIN DEATH"

D. Alan Shewmon
655 Levering Ave, Los Angeles, CA 90024
USA
The term +brain death + was introduced in the late 1960s primarily in response to the increasing feasibility of organ transplantation. Initially there was little agreement concerning the meaning of the term, and many experts did not equate it with death. Nevertheless, pragmatic pressures led to the neurological revision of laws on death before any true consensus was reached concerning the reasons why +brain death+ might be death. Post facto attempts to rationalize the legislative changes have followed one of basically two lines of argument: +brain death+ is death because it entails either (a) the loss of somatic integrative unity or (b) the loss of personhood. The latter rationale has been consistently rejected by the mainstream as a radical re-conceptualization of death rather than as a neurological instantiation of it. For nearly two decades, the former position has been accepted as +party-line+ and parroted by the medical and legal communities, largely without critical analysis. It is argued here that the notion of the brain as the +integrating organ+ of the body is contradicted by clinical evidence, and that loss of somatic integrative unity occurs only after some critical point in the irreversible progression of
multi-system, not purely neurological, failure.

DEATH OF THE PERSON OR DEATH OF THE ORGANISM?

Daniel Wikler
Professor, University of Wisconsin Medical School Three rival definitions of death have occupied center stage in the debates of recent years: the traditional cardiopulmonary definition, the "whole brain" definition (and its brainstem variant); and the "higher brain" definition based on capacity for consciousness. The "whole brain" definition has won nearly universal endorsement by governments and medical organizations, but some groups continue to insist on cardiopulmonary definitions, while a number of scholars have supported a higher brain definition. What, precisely, is the dispute about? Is there any biological claim which one group affirms and the others deny? Or, if there is agreement on the neurophysiology of death, do the groups differ on moral issues? One possible interpretation of the dispute is that adherents of both the cardiopulmonary and whole- brain definitions of death are defining death of the BODY, while adherents of the higher brain definition are defining death of the PERSON. If this is the case, there is no real disagreement on the definition of death. They might both agree on what defines death of the body and what defines death of the person, while disagreeing on whether law and clinical practice should be based on death of the body or on death of the person. A more recent line of argument, however, holds that there is (and can be) but one death, death of the ORGANISM, and any definition of death which does not define death of the ORGANISM is conceptually confused. I believe that this perspective logically implies that cardiopulmonary death is the single defensible definition of death. However, I defend the higher brain definition against its two alternatives.

A NEW DEFINITION OF DEATH BASED ON THE BASIC MECHANISMS OF CONSCIOUSNESS GENERATION IN HUMAN BEINGS

Calixto Machado, M.D., Ph.D. (CUBA)
Institute of Neurology and Neurosurgery, Havana, Cuba E.mail: braind@infomed.sld.cu
There are three basic schools about the definition of human death: Those centered on how much of the brain needs to be dead, before a person can be declared dead on neurological grounds? Those referring to the "loss of specifically human properties" and those arguing the "loss of integrative unity of the body". Regarding the first school, there are three subdivisions: whole brain, brainstem death and higher brain formulations of death". The second school has been powerfully defended by Veatch, who proposed to search for the essential properties that characterizes life in humans: "What is it about human life, and that its loss is so essential, that the individual who loses it ought be called dead?" According to the third school, Bernat has proposed to "define death as the permanent cessation of functioning of the organism as a whole". Some authors combine these main schools when presenting their definitions of human death. It is discussed that consciousness, with its neural framework delineated in the so-called reticular formation-cortex unit, provides the essential human attributes, and it is the most integrative function of the organism. As a conclusion, a new definition of human death is proposed, that answers and integrates the three brain-oriented schools on the definition of death. Responding to "how much of the brain needs to be dead, before a person can be declared dead on neurological grounds?", the answer is: the irreversible destruction of the so-called reticular formation-cortex unit. Answering to those referring to the "loss of specifically human properties", the irreversible loss of consciousness (capacity and content) abolishes the essential human attributes. Replying to those arguing the "loss of integrative unity of the body", consciousness is the most integrative function of the body, ordering intra and extra-brain functions. There is only one kind of human death: "The irreversible loss of both components of consciousness, arousal and awareness".

NON-HEART BEATING CADAVERS AND THE DEFINITION OF DEATH

Robert Arnold
Division of General Internal Medicine, Center for Medical Ethics, University of Pittsburgh
USA
Recent proposals aim to increase the donor pool by using patients declared dead by cardiopulmonary, rather than neurological- oriented criteria. These patients are referred to as non-heart beating cadaver donors (NHBCDs) because their hearts are no longer beating at the time of procurement. Investigators have developed various methods for limiting warm ischemia and increasing the viability of the organs procured from NHBCD. These include in situ preservation using cold perfusant, restoration of cardiopulmonary function after "death" with CPR, bypass, or total body cooling , or rapid retrieval after death following withdrawal of life sustaining treatment. While these policies may increase the donor pool, they raise various ethical problems. This presentation will concentrate on the problems NHBCD raise regarding the determination of death. NHBCD policies highlight current confusion regarding the role of "irreversibility" in the definition of death and the lack of empirical data underlying the cardiopulmonary criteria. The policies also point out the current paradox that one may be declared dead in the United States using cardiac criteria but alive by neurological criteria. By moving the declaration of death as close as possible to the moment when cardiopulmonary function ceases, NHBCD risk taking organs from patients who are not yet dead.

Brain Death and Technological Change: Personal Identity, Neural Prostheses and Uploading

James J. Hughes
University of Chicago

The death at issue in the brain death debate is not an empiric reality, but a social category, "social death." It is a question of which bodies we are comfortable using and disposing of in certain ways, and not comfortable giving medicine or food as if they were "alive." Until recently both mind and body stopped functioning at the same time, and this "death" and "social death" were generally seen as one phenomenon. There were important exceptions, however, in many cultures where particular diseases and disabilities earned a social death definition before the physical death had occurred.
In the modern world, whole brain definitions of death arose as a result of the technological deconstruction of death as a unitary phenomenon. The whole brain definition was at the outset a compromise between those who prefer a neocortical definition, and those who prefer the whole body definition. This paper argues that the whole brain definition of death is an unwieldy, historical compromise which will unravel as 21st century technologies permit the repair, replacement and manipulation of body, and especially brain, tissue. These technologies will present anomalies to the whole brain definition which will force us towards, and then beyond, a neocortical definition of death. New biological and cybernetic technologies will make clear that social life is properly attributed to any biological system with a particular set of subjective experiences - personhood. These technologies will also create tremendous material incentives for the living to stop treating the permanently unconscious as socially alive.

MUERTE ENCEFALICA. EXPERIENCIA CAMAG\EYANA EN EL BIENIO 1993-1994

Angel La Cerda Gallardo; Sergio Vega Basulto;
Rubiel Lopez Delgado; Ingrid Melendi Alvarez Hospital "Manuel Ascunce Domenech", Camaguey CUBA
Se realiz" un estudio de 57 pacientes con el diagn"stico presuntivo de muerte encef lica, en el servicio de Neurocirug!a del Hospital "Manuel Ascunce Domenech" de Camaguey, durante el per!odo enero 1993 a diciembre de 1994. Los pacientes fueron sometidos a examen neurol"gico repetido y a investigaciones que permitieron comprobar el diagn"stico de muerte encef lica. Presentaron alto valor predictivo la abolici"n de todos los reflejos de tallo cerebral, la prueba de la atropina, hiperventilaci"n apneica, oculograma cal"rico, el registro electroencef lico y la angiograf!a cerebral. El trabajo describe todo diagn"stico
m s que permite valorar indirectamente el estado de la circulaci"n cerebral. Se propone un algoritmo que describe la din mica utilizada en nuestro servicio y que entre otras ventajas incluye la validaci"n del diagn"stico cl!nico, adem s de demostrar utilidad para su uso por un sistema nacional de trasplantes en la identificaci"n de posibles donantes.

NEUROPATHOLOGICAL EVIDENCES IN PATIENTS CLINICALLY JUDGED TO BE IN STATE OF BRAIN DEATH

Fusahiro Ikuta; Shigeki Takeda
Department of Pathology, Brain Research Institute, Niigata University
JAPAN
Japanese 84 autopsied patients were pathoanatomically investigated and what had happened in their brains and spinal cords before the judgment was evaluated. 1) Severe increased intracranial pressure (IICP) induced by edema or swelling with secondary hemorrhages involving the brain stem tegmentum was observed in all the brains without exception. Some showed very severe and rapid IICP due to acute edema and swelling caused mostly by liver dysfunction or injury, and the brain stem tegmentum revealed only microscopic hemorrhagic foci. This means cessation of cerebral blood flow had followed immediately after the hemorrhages; the red foamy blood cells in and around the blood vessels showed autolysis similar in intensity. 2) Autolysis was observed in all brains, most severely in the brain stems, but not in the visceral organs (Vos). This and 1) indicate that cerebral blood flow had unexceptionally ceased at least in the brain stem tegmentum before the judgments. The brain stem had first fallen into death since autolysis never occurs before death of cells. 3). Like the Vos, the spinal cord still vividly lived even after the judgments. 4) Many neurons of the hypothalamus lived for 3 to 4 days even after the judgments.

THE CASE OF RESPIRATOR BRAIN AFTER INTRACRANIUM INJURY

T. Sawaguchi; S. Nakamura; O. Ohue; M. Kobayashi; A. Sawaguchi Department of Legal Medicine; Department of Pathology, Tokyo Womens Medical College, Tokyo
JAPAN
A case of an intracranial injury suffered in a fall is reported here. The patient fell down and knocked his head in an accident during the filming of a television program. He was admitted to the hospital and remained on a respirator for one week before expiring. No operation was performed. The legislative autopsy was performed because this was considered to be a case of involuntary work-related manslaughter. Brain softening was apparent in the brain stem and the cerebellum. Red blood cells in the blood vessels appeared foamy after autolysis. Microglias appeared in places. On the cerebellum granule cells appeared status bullous. In another case, maintained under mechanical ventilation for one and a half months after a traffic accident without intracranial injury, the autolysis of the brain was less than in this case. Generally, it was supposed that in cases of respiratory maintenance with intracranial injury the autolysis and necrosis of the brain occur faster than in cases without intracranial injury. This was true in this case.

ESTUDIO CLINICO PATOLOGICO DE LA MUERTE ENCEFALICA. EXPERIENCIAS DEL HOSPITAL PROVINCIAL "SATURNINO LORA" DE SANTIAGO DE CUBA

ctor N#$ez Gil; Noya Moya Gonzalez;
Mabel Blanco Granda; Aurelio Rodr!guez Fern ndez Hospital Provincial "Saturnino Lora", Santiago de Cuba CUBA
Se presenta la experiencia del Hospital Provincial "Saturnino Lora" de Santiago de Cuba, en el estudio cl!nico patol"gico de la muerte encef lica. Se estudiaron 27 casos ingresados entre los a$os 1994 y 1995. En el 74,07% se realiz" extracci"n de "rganos. El grupo et reo m s afectado fue entre 20 y 29 a$os con 15 pacientes, para un 55,55% y predomin" el sexo masculino con un 81,5%. Los traumatismos craneoencef licos en general fueron las causas m s frecuentes, destac ndose, entre ellos, la contusi"n cerebral severa con un 33,3% y la contusi"n primaria de tallo encef lico con un 25,9%. Diez casos (37,03%) permanecieron en muerte encef lica entre 1 y 5 horas, un paciente se mantuvo hasta 36 horas. La sepsis respirtoria con un 52% fue la morbilidad asociada m s frecuente. La tomograf!a axial computarizada y los estudios radiol"gicos simples fueron las pruebas imagenol"gicas m s realizadas. Se destacan entre los hallazgos anatomopatol"gicos el edema cerebral severo presente en el ciento por ciento de los casos de necropsias.

MUERTE ENCEFALICA. APLICACION DE CRITERIOS CUBANOS DE DIAGNOSTICO

Matilde Estrada Suarez;
Efra!n Chiv s Ponce;
s
Hospital Cl!nico Quir#rgico "Dr. Luis D!az Soto", La Habana CUBA
Al aceptar el estad!o cl!nico muerte encef lica como una nueva forma de diagn"stico de la muerte del ser humano, tiene gran importancia al permitir obtener "rganos y tejidos para ser utilizados en trasplantes, mejorar el estado psicol"gico de familiares y personal de la salud relacionados, as! como disminuir los gastos en aquellos pacientes sin posibilidades de recuperaci"n. Se realiza una evaluaci"n del uso de los criterios cubanos para el diagn"stico de muerte encef lica en los pacientes con coma arreactivo, atendidos en la Unidad de Cuidados Intensivos de adultos de nuestro hospital durante los a$os 1993 hasta 1995.

MUERTE ENCEFALICA EN UTI. EXPERIENCIA DE 2 A%OS EN EL HOSPITAL "ARNALDO MILIAN CASTRO" DE VILLA CLARA

Mario A. Dom!nguez Perera; Armando Caballero L"pez; rez; Mauro L"pez Ortega;
Roberto Valledor Trist
Hospital "Arnaldo Mili n Castro", Villa Clara CUBA
Durante el per!odo comprendido entre enero de 1994 a diciembre de 1995, ingresaron 259 pacientes en coma en la UTI del Hospital "Arnaldo Mili n Castro" de Villa Clara, de ellos, 50 (19,3%) evolucionaron hacia la muerte encef lica. Los criterios diagn"sticos utilizados fueron eminentemente cl!nicos y fueron los siguientes: 1) coma de causa conocida, sin ning#n tipo de respuesta, excluyendo formas reversibles de coma; 2) ausencia de reflejos de tallo encef lico; 3) prueba de la atropina negativa y 4) test de apnea positivo.
falo, el diagnostico se confirm" con EEG y/o `PETC. Las causas m s presentes fueron los traumatismos craneoencef licos de cirug!a sobre el SNC, 8 pacientes (16%). Predomin" el sexo masculino (68%) y el grupo de edad m s afectado fue el comprendido entre 45 y 59 a$os (32%). De los 50 pacientes con muerte encef lica, 25 donaron sus "rganos.

MUERTE ENCEFALICA EN EL HOSPITAL "ARNALDO MILIAN CASTRO" DE VILLA CLARA (SEPTIEMBRE-91 A DICIEMBRE-95)

Mario A. Dom!nguez Perera: Leonel Fuentes Herrera; rrez Ronquillo; Mauro L"pez Ortega; Rafael Cruz Abascal Hospital "Arnaldo Mili n Castro", Villa Clara CUBA
Durante el per!odo comprendido entre septiembre de 1991 y diciembre de 1995, se diagnosticaron 176 casos de muerte encef lica en el Hospital "Arnaldo Mili n Castro" de Villa Clara. De ellos, 73 casos (41,4%) correspondieron a ingresados en la UTI y 103 (58,6%) en la UCI. Los criterios diagn"sticos utilizados fueron: 1) coma de causa conocida, sin ning#n tipo de respuesta, excluyendo formas reversibles de coma; 2) ausencia de reflejos del tallo encef lico; 3) prueba de la atropina negativa y 4) test de apnea positivo. En dos casos con coma sin destrucci"n falo, el diagn"stico se confirm" con EEG y/o ETC. Las causas m s frecuentes de muerte encef lica fueron el trauma craneoencef lico y la enfermedad cerebrovascular hemorr gica con un 37,5% y 35,8% respectivamente; predomin" el sexo masculino con un 67% de los casos y el grupo de edad m s afectado fue el comprendido entre los 45 y 59 a$os de edad (31,8%). De los 101 pacientes con muerte encef lica diagnosticados a partir de enero de 1994 en este hospital, 46 (45,5%) donaron sus "rganos.

BRAIN DEATH IN CROATIA

Aksentijevich Dragand and Dubravka Sepic Grahovac CROATIA
Research is critical review of brain death diagnostic criteria in world and in Croatia. During period from 1984, until 1991, 117 patients were observed in Anesthesiological and Reanimatological Department of Rejika Hospital. These characteristics were taken from medical history of each patient: diagnosis, age, sex, specificity of neurological examination, electroencephalographic pattern, cerebral angiography, scintigraphy, computerizated tomography, atropine and apnea test, and other valid information. Also, it was observed duration of irreversible coma; decision specification of Ad Hoc Commission was analysed with confrontations that were present when Commissions members tried to get permission for organ donation. Information was correlated with regression analysis as statistical method. Diagnosis of brain death was made after 60 h (2, 5 days) in reanimation area. Age, sex, level of consciousness expressed with Glasgow Coma Score (GCS) were without influence on duration of coma irreversibility. Electroencephalographic isoelectric pattern that was registered three times, after six hours interval, was main criteria for brain death diagnosis decision. Spinal reflexes sometimes were present when isoelectric pattern and obstruction of cerebral circulation was found. Spinal reflexes were not so important for decision and diagnosis of brain death. Maximal correlation was found between isoelectric
electroencephalogram and absence of brain reflexes; some electroencephalograms have had positive correlation with atropine test (r=0,002). These results are important for support of conception that death of brain stem is death of whole brain. That concept can save time for diagnostic duration and hospitalization of patients on artificial ventilation and on that way indirect increase number of potential donors. Organ exploitation for donation in analysed population of irreversibility coma was low (44,4%). Limited donation is not expression of uneducated populations level about problems of organs transplantations and transplantation medicine. Emotional reactions of patients family were the most important reasons for so low level of donations when they don't want to believe that their brain death member is "object of society" (res communitatis).

CRITERIOS PARA EL DIAGNOSTICO DE LA MUERTE ENCEFALICA EN EL HOSPITAL UNIVERSITARIO "GENERAL CALIXTO GARCIA". (MODIFICADOS) 1996

Armando Gonz lez Rivera; Armando Cabrera Rojo;
Lionel D!az Rodriguez
Hospital "General Calixto Garc!a", La Habana CUBA
En el hospital "General Calixto Garc!a" centro que mayor n#mero de casos de muerte encef lica diagnostica anualmente en Cuba, se realiza un revisi"n de los criterios diagn"sticos de muerte encef lica ajust ndose a las condiciones actuales de la instituci"n, definiendo las precondiciones de evaluaci"n: paciente en coma profundo; paciente ventilado en modalidad controlada; existencia de una lesi"n encef lica capaz de producir da$o irreversible, completamente documentada y sin respuesta favorable a los tratamientos recomendados; ausencia de causas reversibles de depresi"n de la funci"n encef lica. Se puntualizan los criterios cl!nicos y se hacen consideraciones sobre el coma arreactivo, la ausencia de reflejos integrados en el tronco encef lico, la negatividad de la prueba de atropina, la apnea comprobada mediante la prueba de oxigenaci"n apneica cnica y definici"n de par metros
tricos y de tiempo) y el criterio de irreversibilidad. n se definen los criterios para las pruebas instumentales: electroencefalograma, potenciales evocados multimodales, panangiograf!a cerebral, tomograf!a axial computarizada con el uso de contraste, todos aplicables a los pacientes que no presentan una alteraci"n estructural encef lica primaria, a quienes tienen contraindicada la prueba de oxigenaci"n apneica y a algunos casos complejos de lesiones aisladas infratentoriales. nes realizan la certificaci"n de la
muerte encef lica.

ALGUNOS RESULTADOS EN RELACION CON LA MUERTE ENCEFALICA EN UNA UNIDAD DE CUIDADOS INTENSIVOS NEUROQUIRURGICOS

Alejandro D. Jorr!n Sim"n; Armando E. Gonz lez Rivera Hospital Universitario "General Calixto Garc!a", La Habana CUBA
Se trata de un estudio descriptivo que relaciona los fallecidos y la muerte encef lica (M.E.) en la U.C.I.N.Q. del Hospital "General Calixto Garc!a", donde se ingresaron 20 pacientes, el 75% con trauma craneoencef lico grave, todos con Glasgow de n ventilatorio y/o
hemodin mico, teniendo una mortalidad de 50%, llegando el 70% de los fallecidos a la M.E. con edad promedio de 42,8 a$os y ndose como donantes multiorg nicos cinco de ellos, siendo rechazados dos por hipertensi"n arterial severa. De los cinco pacientes que sufrieron lesi"n craneoencef lica por accidente en ciclo, fallecieron 4 (40%) y todos llegaron a la M.E. (57,1%), as! como el 66,6% de los que ingresaron por accidente vascular encef lico hemorr gico. Seis de los fallecidos (60%), ingresaron con Glasgow en tres puntos y 4 de ellos llegaron a la M.E. (57,1%). Ingresaron cinco pacientes con nivel de lesi"n protuberancial o por debajo de este, todos fallecidos en M.E. Las complicaciones m s frecuentes en los pacientes en M.E. fueron las arritmias cardiacas, la herniaci"n trancalvaria, la hipopotasemia y la hiperglicemia en tres casos respectivamente. La asociaci"n de edema, contusi"n cerebral y hematoma subdural estuvo presente en tres de los casos con M.E. (28,5%) y en tres de los fallecidos que no llegaron a la misma, siendo la asociaci"n de diagn"sticos m s frecuentes entre los #ltimos la contusi"n y el edema cerebral, que estuvo presente en el 50%. La estad!a de los pacientes con M.E. fue menor de 2 d!as en todos los casos y de tres o m s en el 66,6% del resto de los fallecidos.

DIAGNOSTICO DE LA MUERTE ENCEFALICA Y MANEJO INTENSIVO DEL DONANTE

E. Medina Herrera; R. Aguilar Casanovas; F. Dura$ona Roque; s
Instituto Superior de Medicina Militar "Dr. Luis D!az Soto", La Habana
CUBA
Se presentan los resultados obtenidos en el tratamiento intensivo y el diagn"stico de la muerte encef lica (ME) en 10 pacientes recibidos en la Unidad de Traumatolog!a. En todos los casos se cumplieron las medidas de soporte vital establecidas en el manejo intensivo y se realizaron pruebas cl!nicas, neurofisiol"gicas e imagenol"gicas seg#n criterios cubanos para el diagn"stico de la ME. Entre los principales resultados se observaron: valor m!nimo de 3 puntos en la Escala del Coma de Glasgow; nivel de disfunci"n neurol"gica protuberancial o inferior, no respuesta a ica y vestibulares
cal"ricas. La angiograf!a carotidea present" detenci"n intravascular de la columna de contraste. En los estudios neurofisiol"gicos realizados se observ" abolici"n del potencial evocado visual con preservaci"n del electrorretinograma, adem s de la existencia de silencio electrocerebral en el electroencefalograma. Se intervinieron quir#rgicamente
6 pacientes previa autorizaci"n familiar. De los 12 ri$ones, s"lo dos no fueron #tiles. En el estudio anatomo-patol"gico de lulas "no viables".
Los 10 ri$ones #tiles fueron implantados en diferentes dicas del pa!s, con una sobrevivencia del 90% de los pacientes receptores renales. La causa de muerte del receptor renal fallecido no est relacionada con el trasplante renal.

NEUROANATOMIA FUNCIONAL DEL TRONCO ENCEFALICO Y SU IMPORTANCIA EN LA DETERMINACION DE LA MUERTE

J.M. Cuba
Instituto de Ciencias Neurol"gicas, Lima PERU
Siguiendo a la embriolog!a, en el tubo neuronal se desarrolla una primera envoltura que cubre el Canal Neuronal o Central Grey Core" (Szentagothai). Luego, el "core reticular" y en fin la "envoltura de integraci"n". Estas tres envolturas las encontramos en la neuroanatom!a funcional y las denominaremos: Arqui-tronco a las que corresponden las formaciones nucleares vegetativas y que se extienden hasta el hipot lamo, y en el rea postrema, estas tienen funciones en la bioqu!mica de la sangre, cardiacas, respiratorias, digestivas, con el dolor y aprendizaje. Si esta rea se lesiona ocurre la muerte. El Paleo-tronco, es el
rea en donde mediante m"dulos especializados ocurren los fen"menos de la relaci"n del hombre con el mundo exterior. Si esta rea se lesiona se pierde esta relaci"n. Por #ltimo, a la "envoltura de integraci"n" la denominamos Neotronco. Es la n
n en los
estudios del desarrollo del sistema nervioso de los sistemas arquineuronal, paleoneuronal y neoneural. Nuestras deducciones cl!nicas se apoyan en las observaciones cl!nicas desde comienzo de siglo. En fin, las #ltimas investigaciones de la neuroqu!mica tica, apoya la tesis de que el tronco cerebral en el hombre es el rea en donde est inscrita su personalidad.

TWO STANDARDS OF DEATH IN DENMARK. DEATH IN DENMARK IS EITHER CARDIAC DEATH OR BRAIN DEATH

E.O. Jorgensen
Medical Department P, The Copenhagen City Hospital, Bispebjerg Hospital, DK-2400 NV.
DENMARK
Criteria of brain death had been disputed in Denmark for more than 20 years when the Danish Parliament in May 1990 finally passed a law on declaration of death, postmortem examination and transplantation of organs. The new law introduced criteria of brain death as supplementary to the criteria of cardiac death. A memorandum issued by a task-force appointed by the Danish Medical Association introduced the new code to the medical profession with the following statements :(a) it is now legally accepted to forego treatment of brain dead patients, (b) treatment by heart and liver transplant is made possible, and (c ) the result of kidney and pancreas transplant surgery is expected to improve. In the early 1970's Danish medical scientists had created a fund of knowledge on brain death which contributed significantly to the thinking about brain death in other countries. Criteria of brain death could have been introduced in Denmark at that time but it did not happen. Actually, Denmark became the last of the European countries to legalize criteria of brain death. In my opinion, brain death was recognized with such an extreme delay and two sets of criteria of death legally recommended because (a) the statute on brain death had been discussed and proposed together with a new law on transplantation, and because (b) reactionary minority groups who had great authority argued strongly against the reappraisal of the concept and criteria of death.

SPINAL MAN AFTER BRAIN DEATH
THE UNILATERAL EXTENSION-PRONATION REFLEX OF THE UPPER LIMB AS AN ULTIMATE INDICATOR OF BRAIN DEATH

E. O. Jorgensen
Medical Department P, The Copenhagen City Hospital, Bispebjerg Hospital, DK-2400 NV.
DENMARK
Definition and diagnosis of brain death. Brain death is defined by the irreversible cessation of brain functions. Two decades ago, it was commonly stated that the diagnosis of brain death could only be made when repeated clinical investigations had established irremediable losses of both cranial nerve reflexes and electrocortical activity and serial cerebral (four vessel) angiographies had demonstrated no venous filing within the brain to ascertain that conditions for brain life were no longer present. Nowadays, it has become widely accepted that the critical component of brain death is death of the brain stem; and, that brain stem death is reliably diagnosed at the bedside when specific requirements are fulfilled : (a) The patient must be unresponsive and on a ventilator as a consequence of a know structutal brain lesion, (b) reversible cause of brain stem dysfunction (such as drug intoxication, hypothermia and metabolic disorders) must be excluded, and (c) each of two examinations separated by hours must show no cranial nerve reflex activity and persistent apnoea; neither EEG nor cerebral angiography are needed. However, the diagnosis of brain death can be ascertained by a simple test for autonomous spinal activities which are unique in the sense that they emerge exclusively after brain death: the unilateral extension-pronation reflex of the upper limb as an ultimate indicator of brain death.

THE BRAIN DEATH STATE IN MEDICAL SCIENCES

K. Takeuchi and T. Shiogai Department of Neurosurgery, Kyorin University
School of Medicine, Mitaka, Tokyo 181, Japan
Since H. Cushing originally described the state of brain death in 1902, in terms of the field of medical science, brain death has a history of nearly one full century. In many cases, since the brain death state frequently follows severe increased intracranial pressure, nearly every neurosurgeon has experienced it. In addition, neurologist, emergency care physicians and intensivists may also experience the brain death state. It is unlikely, however, that all clinicians will encounter this condition. Thus, there are still a significant number of persons even in the medical profession that lack a correct awareness of this condition. Needless to say, there is even greater confusion among members of general public. In Japan discussions on brain death have not progressed yet, since our first and only occasion of heart transplantation in 1968. The same ideas are repeatedly taken up over and over again. As the authors themselves have witnessed the course that has been followed thus far, we have no choice but to think that a similar situation will most likely continue in the future as well.