Electroencephalography is required to make a diagnosis of brain death in Japan, and thus it is possible to differentiate brain stem death from brain death. Brain stem death has been recognized as a transient stage leading to total brain death. However, some authors have insisted that brain stem death has a different etiology from brain death. Brain stem death occurs under restricted conditions, such as when intracranial pressure is controlled, and supratentorial cerebral ischemia is prevented. An apnea test, in which breathing is assessed objectively by visual inspection of chest movement, must be performed to diagnose brain death. Here we report a case of spontaneous breathing detected using a spirometer in spite of brain death criteria being almost completely satisfied. A 68-year-old male was admitted with sudden onset of coma. A computed tomography (CT) scan revealed a large cerebellar hematoma and acute hydrocephalus. Bilateral ventricular drainage and barbiturate therapy were performed, however, since intracranial pressure was maintained under 20mmHg, the patient failed to meet the criteria for comatose on the Japan Coma Scale 300. The authors examined the patient for brain death 8 times before he was pronounced dead on day 137. The EEG was positive until day 45 and the atropine test was positive throughout. Moreover, even though brain death criteria were satisfied on day 117, spontaneous breathing was detected using a spirometer.
A 61-year-old man developed physical signs (fever, headache, fatigue and loss of appetite) and neurological signs (delirium and ataxia) during his stay in a malarial area. Blood smears showed the presence of Plasmodium falciparum. He was treated with antimalarial agents (quinine, chloroquine diphosphate, etc.), and the clinical symptoms except ataxia subsided. As he became negative for malarial parasite, antimalarial agents were discontinued. However, he had a recurrence of delirium and exacerbation of ataxia. Treatment with psychotropic agents (haloperidol and flunitrazepam) induced recovery with no neurological residue. The delay between onset of the clinical signs of falciparum malaria and the second occurrence of delirium was 24 days. Diffuse capillary occlusion caused by parasitized erythrocytes, an effect of the parasite itself, drug effect and other infectious diseases could be excluded as the cause of the second phase of neurological signs. The most likely pathogenic mechanism was a delayed immune reaction, for example, immunologic damage to blood vessels due to immune complex deposition.
A case of eclampsia associated with cerebral vasospasms is reported. A 24-year-old woman experienced a generalized seizure a few minutes after vaginal delivery of an infant. She was immediately tranferred to our hospital. On admission, she was drowsy, and had an obvious right hemiplegia. Computed tomography (CT) revealed increased intracranial pressure and multiple low-density areas in the parietal and occipital lobe and in the basal ganglia. Magnetic resonance imaging (MRI) showed abnormal hyperintense lesions on T2-weighted images in the same areas as the CT findings. Cerebral angiography on day 10 showed multi-segmental vasospasm of both anterior circulation. CT performed on day 30 after delivery and the attack showed that all abnormal findings had resolved. The patient was discharged without any neurological deficits. The mechanisms of the eclampsia remain uncertain, vasospasm and cosequent cerebral ischemia are the main pathogenetic mechanisms of eclampsia.
Three unusual injuries of the cervical spine in wearers of three-point seat belts are reported. In two cases, the presence of bruising under the chin indicated their involvement in the mechanism of the injury. In the remaining one case, a seat belt might have been related to the injury because there was no other complication. The pattern of spinal injury and neck bruising suggest that the responsible flexion force was enhanced in some way by seat belt fixation at the mid-cervical region. We suggest that neck bruising should arouse suspicion of cervical spinal trauma.