Congenital and Acquired Brain Injury. 5. Emerging Concepts in Prognostication, Evaluation, and Treatment

Ethical controversies at end of life after traumatic brain injury: defining death and organ donation

Death is more than a mere biological occurrence. It has important legal, medical, and social ramifications that make it imperative that those who are responsible for determination of death be accurate and above suspicion. The medical and legal definitions of death have evolved to include consideration of such concepts as loss of integration of the whole organism, loss of autonomy, and loss of personhood. Development of the concept of brain death coincided with advances in medical technology that facilitated artificial ventilation and organ transplantation. More recently, the process of "timed" death with subsequent organ donation (controlled donation after cardiac death transplantation) has raised controversial questions having to do with the limits of treatments that facilitate organ transplant but might hasten death, and the duration of cardiac arrest necessary for declaration of death and the commencement of organ procurement. In this review, we discuss the background and ethical ramifications of the concepts of brain death, and of controversies involved in controlled donation after cardiac death organ transplantation.

Clinical findings in the chronic phase of traumatic brain injury: data from 12 years' experience in the Cognitive Neurology Outpatient Clinic at the University of Leipzig

BACKGROUND

There are many unresolved issues in the diagnosis and treatment of persons with traumatic brain injury (TBI) in its post-acute and chronic phases. This article deals with two problems of clinical importance: (i) the interrelationships between structural brain damage, brain function, and clinical outcome, and (ii) post-traumatic epilepsy.

METHODS

Exploratory, retrospective analysis of clinical, neuroradiological (MRI), and neuropsychological data of all patients with TBI who were treated in a cognitive neurology outpatient clinic of a German university hospital over a period of 12 years (n=320).

RESULTS

156 patients (48.8%) had brain contusions, 83 of them (25.9%) as the sole neuroradiological abnormality. Traumatic micro-hemorrhages were seen in 148 patients (46.2%) and were the sole neuroradiological abnormality in 79 of them (24.7%). 49 patients (15.3%) had no structural brain lesion. There was no obvious correlation between the neuroradiological findings and the clinical outcome, as measured either by a general outcome parameter such as the extended Glasgow Outcome Scale (GOSE) or by neuropsychological testing. 47 patients (14.7%) had post-traumatic epilepsy; its occurrence was positively correlated with the presence of brain contusions, but not with an isolated diagnosis of diffuse axonal injury (DAI).

CONCLUSION

A comparison of the findings of neuroradiological studies and neuropsychological tests among patients in the chronic phase of traumatic brain injury does not reveal any simple relationship between structural and functional brain abnormalities. Diffuse axonal injury is often present in combination with other findings, and it may well be the only structural abnormality in many cases; therefore, all symptomatic patients should undergo MRI of the brain. Patients with isolated DAI seem to be less prone to post-traumatic epilepsy than those with brain contusions.