A.Earl Walker

PATHOLOGY OF BRAIN DEATH

A number of reports on the pathologic changes found in the brains of persons maintained on a respirator have appeared in the last few years.z. 3, 5 , 7. 8 v lo, 13, 19, 21, 23 These studies have emphasized the varied alterations that develop under such circumstances. To illustrate this point a brief summary of the findings in 226 brains from the Collaborative Study of Cerebral Death * will be presented.22

Ancillary studies in the diagnosis of brain death.

In patients who meet the clinical criteria of cerebral ‘I’ death, the usual confirmatory examination is an electroencephalogram (EEG) . However, resuscitative equipment, nursing services, and labile cardiorespiratory states of the patient introduce artefactual material into these records. For this reason, the interpretation of electrocerebral silence ( ECS) requires more than average experience in reading EEGs. Accordingly, if the clinical data are incomplete, or the EEG findings are equivocal, additional confirmatory tests are needed to substantiate the diagnosis of cerebral death. These ancillary examinations are measurements of cerebral metabolism, cerebral blood flow or cerebral potentials, each of which provides an independent estimate of cerebral death. In this presentation the discussion will be limited to the examination of tests which may confirm the diagnosis of a dead brain in a person who meets the basic clinical criteria of cerebral death-namely, apnea, unresponsivity, and absence of all cephalic reflexes. No attempt will be made to examine refinements of clinical determination of cerebral or brain-stem function such as the intravenous injection of atropine. Nor will the ancillary tests-such as electroencephalography (EEG), angiography, and bolus transit curves-that are discussed elsewhere in this volume be more than mentioned. Rather, those examinations of parameters of brain function that may provide absolute evidence of cerebral death will be surveyed in terms of accuracy, availability, and practical application. Such confirmatory evidence of a dead brain may be necessary only if a diagnosis is required within a few hours of an ictus or if other criteria are equivocal.

Long-term effects of severe penetrating head injury on psychosocial adjustment

The long-term effects of severe penetrating head injury on adjustment levels were studied. Forty-one World War II veterans who suffered penetrating injury to the brain were interviewed 40 years after their initial injury using the Washington Psycho-Social Seizure Inventory (WPSI). The results support a comparable behavioral impact of right and left hemispheric lesions. Similarly, no significant relations were found between anterior and posterior locus of damage and psychosocial difficulties, although the results pertaining to the right-anterior group could be interpreted as suggestive of much greater maladjustment in all life dimensions assessed by the WPSI. Findings are discussed in terms of theoretical positions on hemispheric specialization and long-term expectancies that hold implications for planning rehabilitation programs for such patients.

The electroencephalographic characteristics of the rhombencephalectomized cat

The electroencephalographic responses in the rhombencephalectomized cat after the application of photic and epileptogenic agents resemble those phenomena in the normal animal. The spontaneous EEG of the motor region had fewer beta waves, a slower alpha but more delta components than the presection record. The response to photic stimulation in the occipital cortex was similar before and after the rhombencephalectomy, although the initial waves were slightly delayed. Epileptic activity upon topical application or intravenous administration of epileptogenic agents was demonstrated in the sensorimotor cortex.

The evolution of the World Federation of Neurosurgical Societies

To summarize this report, it seems that the neurosurgical family has grown up. The children have gone their several ways to elaborate upon the teachings of their mentors and the old folks are being put on the shelf out of the way of the hustling young nut crackers anxious to get to the operating room. If you doubt this conclusion, note that at the Toronto Congress, only 4 of the 37 officers—the old guard—were listed to present papers on the scientific program. One wonders if the experience and wisdom of the older members is not being lost. Is there not a place on the broadening program for invited presentations by senior members? Finally to those who have so unselfishly given of their services to lighten my task in the past dozen years, I extend my thanks and gratitude. To those members, credit is due for any service which the historian may have been able to render to the World Federation of Neurosurgical Societies.

The falling sickness arises

This is an autobiographical sketch of a pioneering program in epilepsy carried out at the University of Chicago Clinics and the Johns Hopkins Hospital. Both the basic neuroscience and clinical investigations pursued are described as the program evolved from 1931 to 1972.