Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany.
Center for Transdisciplinary Neurosciences Rostock (CTNR), Rostock University Medical Center, Rostock, Germany.
Can J Anaesth. 2022 Jul;69(7):900-906. doi: 10.1007/s12630-022-02265-6. Epub 2022 May 18.
Brain death/death by neurologic criteria (BD/DNC) may be determined in many countries by a clinical examination that shows coma, brainstem areflexia, and apnea, provided the conditions causing reversible loss of brain function are excluded a priori. To date, accounts of recovery from BD/DNC in adults have been limited to noncompliance with guidelines.
We report the case of a 72-yr-old man with a combined primary infratentorial (hemorrhagic) and secondary global (anoxic) brain lesion in whom decompressive craniectomy of the posterior fossa and six-hour therapeutic hypothermia (33-34°C) followed by 8-hour rewarming to ≥ 36°C were conducted. Thirteen hours later, clinical findings of brain function loss were documented in addition to guideline-compliant exclusion of reversible causes (arterial hypotension, intoxication, depressant drug effects, relevant metabolic or endocrine disequilibrium, chronic hypercapnia, neuromuscular disorders, and administration of a muscle relaxant). Since a primary infratentorial brain lesion was present, German guidelines required further ancillary testing. Doppler ultrasonography revealed some preserved cerebral circulation, and BD/DNC was not diagnosed. Approximately 24 hr after rewarming to ≥ 36°C, the patient exhibited respiratory efforts. He continued with assisted respiration until final asystole/apnea, without regaining additional brain function other than mild signs of hemispasticity. Follow-up computed tomography showed partial herniation of the cerebellum through the craniectomy gap of the posterior fossa, alleviating caudal brain stem compression.
Therapeutic decompressive craniectomy of the posterior fossa may allow for delayed reversal of apnea. In these patients, proof of cerebral circulatory arrest should be mandatory for diagnosing BD/DNC.
在许多国家，通过临床检查可以确定脑死亡/神经标准死亡（BD/DNC），该检查显示昏迷、脑干反射消失和呼吸暂停，但前提是排除了先前可逆性脑功能丧失的条件。迄今为止，关于成人从 BD/DNC 中恢复的报道仅限于不符合指南的情况。
我们报告了一例 72 岁男性的病例，他患有原发性颅后窝（出血性）和继发性全脑（缺氧性）脑损伤，随后进行了颅后窝减压颅骨切除术和 6 小时的治疗性低温（33-34°C），然后再升温至≥36°C 8 小时。13 小时后，除了符合指南排除可逆性原因（动脉低血压、中毒、抑制药物作用、相关代谢或内分泌失衡、慢性高碳酸血症、神经肌肉疾病和肌肉松弛剂的使用）外，还记录了脑功能丧失的临床发现。由于存在原发性颅后窝脑损伤，德国指南要求进行进一步的辅助测试。多普勒超声显示一些保留的脑循环，因此未诊断为 BD/DNC。大约在升温至≥36°C 24 小时后，患者出现呼吸努力。他继续接受辅助呼吸，直到最终出现心搏停止/无呼吸，除了轻度偏瘫迹象外，没有恢复其他脑功能。后续的计算机断层扫描显示小脑通过颅后窝的颅骨切除术间隙部分疝出，缓解了颅底脑干的压迫。
颅后窝的治疗性减压颅骨切除术可能允许呼吸暂停的延迟逆转。在这些患者中，诊断 BD/DNC 必须要有脑循环停止的证据。
