Motricidade reflexa na morte cerebral

Sanvito, Wilson L.

doi:10.1590/S0004-282X1972000100004

Resumos

O diagnóstico de morte cerebral está baseado em critérios clínicos, eletrencefalográficos e angiográficos. Do ponto de vista clínico deve ser evidenciado o seguinte quadro: coma profundo, midríase paralítica bilateral, ausência de reação a qualquer estímulo externo, apnéia, arreflexia superficial e profunda. Do ponto de vista eletrencefalográfico são necessários dois registros, separados por um intervalo de 24 horas, evidenciando traçados iselétricos. No presente trabalho são estudados 15 pacientes com morte cerebral comprovada do ponto de vista clínico e eletrencefalográfico. Em 8 pacientes havia persistência de atividade reflexa durante a fase de morte cerebral (reflexos profundos e/ou superficiais). Fenômenos de automatismos medulares também foram verificados em 3 pacientes.

The diagnosis of brain death is based in clinical, electroencephalographic and angiographic data. The criteria for diagnosis of brain death are: deep coma with unreceptivity and unresponsiveness, no movements or breathing (the patient's respiration must be maintained artificially), bilateral dilated and fixed pupils, absence of corneal reflexes, no response to caloric test, absence of deep tendon reflexes and of the superficial abdominal and plantar reflexes, isoelectric EEG maintained for twenty-four hours. The purpose of this study was to observe the natural clinical courses of 15 patients with brain death, specially the data concerning the deep and superficial reflexes. From 15 patients fulfilling the criteria of brain death, 8 maintained spinal reflexes up to the time of cardiac arrest; in five of these patients the superficial abdominal reflexes were present and the reflexes of spinal automatism could be elicited. These results show that the absence of deep and superficial reflexes can't be considered as essencial for the diagnosis of brain death.

Motricidade reflexa na morte cerebral

The reflex activity in the brain death

Wilson L. Sanvito

Serviço de Neurologia do Hospital do Servidor Público do Estado de São Paulo: ex-Médico Assistente

RESUMO

O diagnóstico de morte cerebral está baseado em critérios clínicos, eletrencefalográficos e angiográficos. Do ponto de vista clínico deve ser evidenciado o seguinte quadro: coma profundo, midríase paralítica bilateral, ausência de reação a qualquer estímulo externo, apnéia, arreflexia superficial e profunda. Do ponto de vista eletrencefalográfico são necessários dois registros, separados por um intervalo de 24 horas, evidenciando traçados iselétricos. No presente trabalho são estudados 15 pacientes com morte cerebral comprovada do ponto de vista clínico e eletrencefalográfico. Em 8 pacientes havia persistência de atividade reflexa durante a fase de morte cerebral (reflexos profundos e/ou superficiais). Fenômenos de automatismos medulares também foram verificados em 3 pacientes.

SUMMARY

The diagnosis of brain death is based in clinical, electroencephalographic and angiographic data. The criteria for diagnosis of brain death are: deep coma with unreceptivity and unresponsiveness, no movements or breathing (the patient's respiration must be maintained artificially), bilateral dilated and fixed pupils, absence of corneal reflexes, no response to caloric test, absence of deep tendon reflexes and of the superficial abdominal and plantar reflexes, isoelectric EEG maintained for twenty-four hours. The purpose of this study was to observe the natural clinical courses of 15 patients with brain death, specially the data concerning the deep and superficial reflexes. From 15 patients fulfilling the criteria of brain death, 8 maintained spinal reflexes up to the time of cardiac arrest; in five of these patients the superficial abdominal reflexes were present and the reflexes of spinal automatism could be elicited. These results show that the absence of deep and superficial reflexes can't be considered as essencial for the diagnosis of brain death.

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Departamento de Medicina Disciplina de Neurologia Faculdade de Ciências Médicas da Santa Casa de Misericórdia Rua Cesário Motta Junior 112 01221 São Paulo, SP Brasil.

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2. APPEL, J. Z. Ethical and legal questions posed by recent advances in Medicine. JAMA 205:513, 1968.
3. ARFEL, G. Problčmes électroencéphalographiques de la mort. Masson & Cie., Paris, 1970.
4. ARNOLD, J. D.; ZIMMERMAN, T. F. & MARTIN, D. C. Public attitudes and the diagnosis of death. JAMA 206:1949, 1968.
5. BECKER, D. P.; CAVETT, M. R. Jr.; NELSON, J. R. & STERN, E. W. An evaluation of the definition of cerebral death. Neurology (Minneapolis) 20: 459, 1970.
6. BEECHER, H. K. Ethical problems created by the hopelessly unconscious patient. New Engl. J. Med. 278:1425, 1968.
7. BEECHER, H. K. After the "definition" of irreversible coma. New Engl. J. Med. 281:1070, 1969.
8. Behöver vi ett nytt dödsbegrepp? Läkartidningen 63:2014, 1966.
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10. BICKFORD, R. G.; DAWSON, B. & TAKESHITA, H. EEG evidence of neurologic death. Electroenceph. Clin. Neurophysiol. 18:513, 1965.
11. BIÖRCK, G. On the definitions of death. Wold Med. J. 14:137, 1967.
12. BIRD, T. D. & PLUM, F. Recovery from barbiturate overdose coma with a prolonged isoelectric electroencephalogram. Neurology (Minneapolis) 18:456, 1968.
13. BLEGVAD, B. Caloric vestibular reaction in unconscious patients. Arch. Otolaryng. 75:506, 1962.
14. BOREL, D. M. Defining death. GP (Kansas City) 39:171, 1969.
15. BOTTINELLI, M. D. Los movimientos oculares reflexos en el coma. InTrastornos oculomotores en la Clinica Neurologica. Seminario realizado en el Instituto de Neurologia de Montevideo (30 octubre-1.ş noviembre de 1962). Editorial Delta Panamericana, Montevideo-Buenos Aires, 1962.
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17. BRONISCH, F. W. Zum reflexverhalten in Hirntod. Nervenarzt 40:592, 1969.
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19. COUNCIL INTERNATIONAL ORGANIZATION MEDICAL SCIENCES (CIOMS) (compte rendu résumé de la séance des 13 et 14 juin 1968) Sur la greffe du coeur. Presse Méd. 76:1390, 1968.
20. CRAFOORD, C. C. Cerebral death and the transplantation era. Dis. Chest 55:141, 1969.
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22. GEETS, W. La mort cérébrale: a propos de deux observations. Acta neurol. Belg. 69:946, 1969.
23. GOODMAN, J. M.; MISHKIN, F. S. & DYKEN, M. Determination of brain death by isotope angiography. JAMA 12:1869, 1969.
24. GORDON, I. The biological definition of death. J. Forensic Med. 15:6, 1968.
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29. HAMLIN, H. Life or death by EEG. JAMA, 190:112, 1964.
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33. JUUL-JENSEN, P. Criteria of Brain Death. E. Munksgaard, Copenhagen, 1970.
34. KÄUFER, C. & PENIN, H. Todeszeitbestimmung beim dissoziierten Hirntod. Klinische und elektroenzephalographische Kriterien. Dtsch. Med. Wschr. 93:679, 1968.
35. KIMURA, J.; GERBER, H. W. & McCORMICK, W. F. The isoelectric electroencephalogram. Significance in establishing death in patients maintained on mechanical respirators. Arch. int. Med. 121:511, 1968.
36. KOHLHAAS, M. Zur feststellung des Todeszeipunkts. Deutsch. Med. Wschr. 93:1575, 1968.
37. KOREIN, J. & MACCARIO, M. On the diagnosis of cerebral death a prospective study. Electroenceph. Clin. Neurophysiol. 27:700, 1969.
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⁶¹
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Datas de Publicação

Publicação nesta coleção
19 Abr 2013
Data do Fascículo
Mar 1972

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. ADAMS, R. D. & JÉQUIER, M. The brain death syndrome: hypoxemic panencephalopathy. Schweiz. Med. Wschr. 99:65, 1969.

[2] 2. APPEL, J. Z. Ethical and legal questions posed by recent advances in Medicine. JAMA 205:513, 1968.

[3] 3. ARFEL, G. Problčmes électroencéphalographiques de la mort. Masson & Cie., Paris, 1970.

[4] 4. ARNOLD, J. D.; ZIMMERMAN, T. F. & MARTIN, D. C. Public attitudes and the diagnosis of death. JAMA 206:1949, 1968.

[5] 5. BECKER, D. P.; CAVETT, M. R. Jr.; NELSON, J. R. & STERN, E. W. An evaluation of the definition of cerebral death. Neurology (Minneapolis) 20: 459, 1970.

[6] 6. BEECHER, H. K. Ethical problems created by the hopelessly unconscious patient. New Engl. J. Med. 278:1425, 1968.

[7] 7. BEECHER, H. K. After the "definition" of irreversible coma. New Engl. J. Med. 281:1070, 1969.

[8] 8. Behöver vi ett nytt dödsbegrepp? Läkartidningen 63:2014, 1966.

[9] 9. BENTAL, E. & LEIBOWTTZ, V. Flat EEG during 28 days in a case of encephalitis. Electroenceph. Clin. Neurophysiol. 13:457, 1961.

[10] 10. BICKFORD, R. G.; DAWSON, B. & TAKESHITA, H. EEG evidence of neurologic death. Electroenceph. Clin. Neurophysiol. 18:513, 1965.

[11] 11. BIÖRCK, G. On the definitions of death. Wold Med. J. 14:137, 1967.

[12] 12. BIRD, T. D. & PLUM, F. Recovery from barbiturate overdose coma with a prolonged isoelectric electroencephalogram. Neurology (Minneapolis) 18:456, 1968.

[13] 13. BLEGVAD, B. Caloric vestibular reaction in unconscious patients. Arch. Otolaryng. 75:506, 1962.

[14] 14. BOREL, D. M. Defining death. GP (Kansas City) 39:171, 1969.

[15] 15. BOTTINELLI, M. D. Los movimientos oculares reflexos en el coma. InTrastornos oculomotores en la Clinica Neurologica. Seminario realizado en el Instituto de Neurologia de Montevideo (30 octubre-1.ş noviembre de 1962). Editorial Delta Panamericana, Montevideo-Buenos Aires, 1962.

[16] 16. BROCK, M.; SCHÜRMANN, K. & HADJIDIMOS, A. Cerebral blood flow and cerebral death. Acta Neurochir. (Wien) 20:195, 1969.

[17] 17. BRONISCH, F. W. Zum reflexverhalten in Hirntod. Nervenarzt 40:592, 1969.

[18] 18. CONTREIRAS, C. Ch. & SEPULVEDA, F. Diagnóstico eletrencefalográfico da morte do sistema nervoso central. Tribuna Médica 341:56, 1968.

[19] 19. COUNCIL INTERNATIONAL ORGANIZATION MEDICAL SCIENCES (CIOMS) (compte rendu résumé de la séance des 13 et 14 juin 1968) Sur la greffe du coeur. Presse Méd. 76:1390, 1968.

[20] 20. CRAFOORD, C. C. Cerebral death and the transplantation era. Dis. Chest 55:141, 1969.

[21] 21. FERNANDEZ, G. J.; MALOSETTI, H. & FRECCERO, F. M. Sindromes comatosos: fisiopatologia, diagnostico y tratamiento. 2.Ş Edicion Editorial Delta Panamericana, Buenos Aires, 1967.

[22] 22. GEETS, W. La mort cérébrale: a propos de deux observations. Acta neurol. Belg. 69:946, 1969.

[23] 23. GOODMAN, J. M.; MISHKIN, F. S. & DYKEN, M. Determination of brain death by isotope angiography. JAMA 12:1869, 1969.

[24] 24. GORDON, I. The biological definition of death. J. Forensic Med. 15:6, 1968.

[25] 25. GOULON, M.; NOUAILHAT, F.; LEVY-ALCOVER, M. A. & DORDAIN, G. Comas toxiques avec sidération végétative d'éevolution favorable. Rev. Neurol. (Paris) 116:297, 1967.

[26] 26. GROS, C.; VLAHOVITCH, B.; FRČREBEAU, P.; KUHNER, A.; BILLET, M.; SAHUT, G. & GAVAND, G. Critčres artériographiques des comas dépassés en Neurochirurgie. Neurochirurgie (Paris) 15:477, 1969.

[27] 27. HAGBARTH, K. E. & KÜGELBERG, E. Plasticity of the human abdominal skin reflex. Brain 81:305, 1958.

[28] 28. HAIDER, I.; OSWALD, I. & MATTHEW, H. EEG signs of death. Brit. med. J. 3:314, 1968.

[29] 29. HAMLIN, H. Life or death by EEG. JAMA, 190:112, 1964.

[30] 30. HOCKADAY, J. M.; POTTS, F.; EPSTEIN, E.; BONAZZI, A. & SCHWAB, R. S. Electroencephalographic changes in acute cerebral anoxia from cardiac or respiratory arrest. Electroenceph. Clin. Neurophysiol. 18:575, 1965.

[31] 31. INGVAR, D. H. & WIDEN, L. Hjärnans död-människans död. Läkartidningen 64:4899, 1967.

[32] 32. JONKMAN, E. J. Cerebral death and isoelectric EEG (Review of literature). Electroenceph. Clin. Neurophysiol. 27:215, 1969.

[33] 33. JUUL-JENSEN, P. Criteria of Brain Death. E. Munksgaard, Copenhagen, 1970.

[34] 34. KÄUFER, C. & PENIN, H. Todeszeitbestimmung beim dissoziierten Hirntod. Klinische und elektroenzephalographische Kriterien. Dtsch. Med. Wschr. 93:679, 1968.

[35] 35. KIMURA, J.; GERBER, H. W. & McCORMICK, W. F. The isoelectric electroencephalogram. Significance in establishing death in patients maintained on mechanical respirators. Arch. int. Med. 121:511, 1968.

[36] 36. KOHLHAAS, M. Zur feststellung des Todeszeipunkts. Deutsch. Med. Wschr. 93:1575, 1968.

[37] 37. KOREIN, J. & MACCARIO, M. On the diagnosis of cerebral death a prospective study. Electroenceph. Clin. Neurophysiol. 27:700, 1969.

[38] 38. KUBICKI, S. & RIEGER, H. L'EEG au cours des intoxications aigués par somniféres. Rev. Neurol. (Paris) 117:532, 1967.

[39] 39. KUGELBERG, E. & HAGBARTH, K. E. Spinal mechanism of the abdominal and erector spinal skin reflexes. Brain 81:290, 1958.

[40] 40. KURTZ, D.; FEUERSTEIN, J.; WEBER, M.; REEB, M. & ROHMER, F. Intéręt de la surveillance électroencéphalographique dans le cadre de la réanimation des comas par intoxication médicamenteuse aigué. Rev. Neurol. (Paris) 117: 531, 1967.

[41] 41. LANGTON, B. Legala aspekter pa transplantion och synpunkter pa dödsbegreppet. Läkartidningen 64:2371, 1967.

[42] 42. LEENSTRA-BORSJE, H.; BOONSTRA, S.; BLOKZIJL, E. J. & NOTERMANS, S. L. H. A retrospective investigation of the clinical symptoms and course of patients with a complete or incomplete isoelectrical EEG. Electroenceph. Clin. Neurophysiol. 27:215, 1969.

[43] 43. LINDGREN, S.; PETEREN, I. & ZWETNOW, N. Prediction of in serious brain damage. Acta Chir. Scand. 134:405, 1968.

[44] 44. LOEB, C. Contribuiçăo da eletrencefalografia ao problema da chamada morte cerebral. Resenha Clínico-Científica 5/6:119, 1970.

[45] 45. LORENZ, R. Kriterien der Hirntatigkeit in Lebensbedrohten zustanden: ein Beitrag zur Frage des zentralen Todes. Acta Neurochir. (Wien) 20:309, 1969.

[46] 46. MAGEE, K. R. Clinical analysis of reflexes. InVinken, P. G. & Bruyn, G. W.: Disturbances of Nervous Function Handbook of Clinical Neurology, vol. I North-Holland Publishing, Amsterdam, 1969.

[47] 47. MALHERBE, J. Medicine et Droit Moderne. Masson & Cie., Paris, 1969.

[48] 48. MANTZ, J. M.; KURTZ, D.; OTTENI, J. C. & ROHMER, F. EEG aspects of six cases of severe barbiturate coma. Electroenceph. Clin. Neurophysiol. 18: 426, 1965.

[49] 49. MANTZ, J. M.; STORCK, D.; TEMPE, J. D. & HAMANN, B. Le coma dépassé. InPaget, M. & Hartmann, L.: Les Comas. Etudes cliniques et biologiques. L'Expansion, Paris, 1966.

[50] 50. MELLERIO, F. Problčmes posés par les aspects de silence cérébral électrique en toxicologie (ŕ propos d'une observation au cours d'une intoxication aigué). Rev. Neurol. (Paris) 120:481, 1969.

[51] 51. MOLLARET, P. Les ultimes possibilités de la réanimation ou las frontičres actuelles entre vie et mort. Anesth. Analg. (Paris) 20:1, 1963.

[52] 52. MOLLARET, P.; BERTRAND, I. & MOLLARET, H. Coma dépassé et nécroses nerveuses centrales massives. Rev. Neurol. (Paris) 101:116, 1959.

[53] 53. MOLLARET P. & GOULON, M. Le coma dépassé. Rev. Neurol. (Paris) 101:3, 1959.

[54] 54. MOLLARET, P. & VIC-DUPONT, V. Les limites morales de la réanimation. Presse Méd. 77:1541, 1969.

[55] 55. MULLER, P. H. Legal medicine and the delimitation of death. World med. J. 14:140, 1967.

[56] 56. MULLER, H. R. & KAESER, H. E. Résultats ŕ longue échéance aprčs réanimation par massage cardiaque transthoracique (observations EEG et EMG). Rev. Neurol. (Paris) 117:515, 1967.

[57] 57. NATHANSON, M. & BERGMAN, Ph. S. The evaluation of the unconscious patient including oculo-cephalic and vestibulo-ocular testing. InBender, M. B.: The Approach to Diagnosis in Modern Neurology. Grune & Stratton, New York and London, 1967.

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