A 69-year-old woman was hospitalized due to progressive lethargy with hyperammonemia. Five months before the current admission, she was diagnosed with depression based on her low level of daily physical activity and thus began taking antidepressants. Abdominal computed tomography revealed a portosystemic shunt running between the left renal vein and inferior mesenteric vein. Balloon-occluded retrograde transvenous obliteration of the shunt vessel was performed, and the patient showed a remarkable clinical improvement. The possibility of a portosystemic shunt should be considered in the presence or absence of underlying liver disease and the ammonia level should be measured before diagnosing depression, as portosystemic encephalopathy may be reversible with interventional radiology treatment.
The recent advent of organ transplantation, including that of the heart, has moved the emphasis of the evidence of death of the donor from cardiac arrest to cessation of cerebral function. The decision as to whether changes in brain function are reversible or irreversible is not only necessary from the view point of donor selection, but is also required for deciding the limit of artificial respiration in the field of neurosurgery.The authors have had a considerable number of neurosurgical cases in which ordinary breathing ceased and which required artificial aid. Forty-two cases over the past three years that required artificial respiration for more than 24 hours were investigated. As a result, the significance of an abrupt fall in blood pressure as one of the indications of cerebral death became apparent. The authors therefore decided to conduct experimental investigations in dogs. It appeared that a sudden drop in pressure resulted from paralysis of the vasomotor centre in the brain stem. It is now stressed that this sign should be included as one of the important criteria for the decision of cerebral death. A method of deciding death of the brain that has been developed by the authors will also be reported.The examination of brain stem function is important as an indication of cerebral death.
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