Brain death in three neurosurgical units.

The validity of clinical criteria for diagnosing brain death has been investigated in three ways. A total of 447 published cases were reviewed. In three neurosurgical units (Cambridge, Glasgow, and Swansea) 609 patients diagnosed clinically as brain dead were studied; 326 had final cardiac asystole while still being ventilated, and ventilation was discontinued in the remainder. No patient recovered. The median time in hospital before the heart finally stopped was 3 1/2-4 1/2 days, with 30-40 hours on the ventilator. Analysis of prospective data from three countries on patients with severe head injuries showed that not one of 1003 survivors would ever have been suspected of being brain dead even in their worst state soon after injury. Recovery after supposed brain death has been alleged in patients who were thought to be brain dead but in fact were not and in cases where reflex movements in the limbs were mistaken for signs of life. The safeguards in diagnosing brain death include establishing irreversible structural brain damage, excluding the effects of drugs, and allowing enough time to elapse to establish the diagnosis beyond doubt. The studies reported here show that the clinical criteria used in the United Kingdom are reliable. There is no need for confirmatory tests such as an electroencephalogram provided that all the conditions for clinical diagnosis have been fulfilled and all the tests carried out.     

Brain stem death and organ donation.

Organs for donation are in short supply in the United Kingdom, resulting in allegations that relatives of potential donors are not being asked for consent. Legislation on "required request" has been proposed to overcome this. The incidence, causes, complications, and patterns of organ donation in brain stem dead patients in one referral centre were studied over 12 months. Data were collected on all patients fulfilling criteria for brain stem death or considered suitable for donating organs after circulatory arrest. Forty two patients fulfilled the criteria for brain stem death, and in 10 further patients circulatory arrest occurred before formal testing was finished. The major causes of brain stem death were head injury (28) and intracranial haemorrhage (17). Consent to organ donation was obtained for 24 potential donors, and organs were donated by 23 of them. Twenty nine patients did not donate organs. The commonest reasons for failure to donate were medical unsuitability (13) and the coroner not releasing the body (eight). Consent was not sought in three cases, and the relatives refused consent in the remaining five. This study suggests that required request will not considerably increase the supply of donor organs.     

Brain amine metabolism is reflected in cerebral ventricular CSF

The choroid plexuses are suspended within the ventricles and account for approximately 75% of CSF production. The sodium-potassium ATPase operates within the choroidal epithelial cells and moves sodium ions towards the ventricular surface and potassium ions in the direction of the stroma. Water flows into CSF along osmotic gradient produced by sodium pump. The existence of extracellular channels by which brain metabolites could passively diffuse into the ventriculosubarachnoid space suggests an excretory role for CSF. Removal of solutes from the CSF could occur across the choroidal epithelium or arachnoid membrane into the blood. Systematically administered monoamine metabolites do not cross the blood-brain or the blood-CSF barrier. The regional concentrations of amine metabolites in the CSF is in part a reflection of the concentration of catecholamines and indoleamines in the immediately adjacent neuronal parenchyma. In order to illustrate the validity of monoamine metabolite determinations in cerebral ventricular CSF we developed a device which allowed for a continuous third ventricular CSF withdrawal in freely moving (or anesthetized) rats at a constant flow of 1 microliter/min. The elevation of biogenic amine metabolites in CSF by probenecid or their decline by monoamine oxidase inhibition was used to assess the rate of turnover of amines. Pharmacological manipulations (yohimbine, haloperidol, ouabain) resulted in mono-amine metabolite fluctuations in CSF similar to those previously described in brain tissue. Insulin administration caused an abrupt decrease in CSF glucose and elevated dopamine and serotonin metabolites in rats which had no access to food. These studies demonstrate the adaptation of in vivo analysis of CSF in rats but also exemplify the usefulness of monoamine metabolite determination in the CSF as indicators of brain function.     

Brain mechanism of selective listening reflected by event-related potentials

Stimulus selection during selective listening on the basis of simple physical stimulus features is reflected by an event-related potential (ERP) component called the processing negativity (PN). PN has been proposed to indicate a matching or comparison process between the physical features of the stimulus and an ‘attentional trace’, an actively formed and maintained temporary neuronal representation of the features defining the relevant stimuli. According to this theory, the smaller is the difference between the eliciting stimulus and that represented by the attentional trace, the longer time is the stimulus processed, and thus the larger in amplitude and longer in duration is the PN elicited. The relevant stimuli, perfectly matching with the attentional trace, and therefore eliciting the largest and longest-duration PN, are selected for further processing. In the present study, the relevant and irrelevant stimuli differed in pitch, and the magnitude of this pitch separation was varied between different stimulus blocks. The results support the afore-mentioned matching or comparison hypothesis of selective attention by showing that PN is not elicited only by the relevant stimuli but even by irrelevant stimuli, and further that the latter PN is larger in amplitude and longer in duration the more similar the irrelevant stimuli are to the relevant stimuli. This PN, however, was smaller than that to the relevant stimuli even for very small separations, reflecting high accuracy of the discrimination function of the attentional trace mechanism proposed to underly selective listening. The termination of the PN to the irrelevant stimuli was followed by a positivity which thus partly explained the difference (Nd) between the ERPs to the relevant and irrelevant stimuli.     

Task demand as reflected in catecholamine excretion and heart rate.

Immediate effects and aftereffects of exposure to a color-word conflict task were studied in two groups of subjects, one of which performed the task without auditory interference ("single conflict"), the other with auditory interference ("double conflict"). Physiological arousal indices were more susceptible than performance measures to the level of task demand. Thus, the higher demand imposed by the double-conflict task was reflected in relatively larger increases of adrenaline excretion and heart rate, both during the conflict task and during the subsequent arithmetic task, whereas the performance measures remained unaffected.     

Sperm quality as reflected through morphology in salmon alternative life histories.

Male salmon exhibit alternative mating strategies, as both older anadromous adults and precocious juveniles (parr) participate in the spawning of a single female. This study tested the following hypotheses: 1) different intensities of sperm competition may reflect different sperm tail optima; 2) long spermatozoa are superior to short ones, with an associated cost on sperm longevity; and 3) a disfavored role in sperm competition selects for parr investing more in sperm quality. Comparisons included sperm morphological traits, whereas sperm quality was investigated by motility duration observations, measurement of the sperm adenylate system, and fertilization experiments. No evidence of different adaptive sperm dimensions between the male types was found. Positive association between spermatocrit and energy charge was, however, detected. Sperm length parameters correlated positively with ATP, energy charge, and fertilization success, whereas no evidence for an effect of sperm morphology on longevity was found. Male parr had greater spermatocrit than adults and fertilized equal proportions of eggs as adults despite a pronounced numerical subordinance in the fertilization experiments. It is concluded that a long sperm tail and midpiece may be selected to optimize energetic demands under conditions of increased sperm competition intensity.