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01 STR 5 6 707
01 STR 5 6 707
Abstract: • In brain death cases who showed nonfilling phenomena in the internal carotid angiograms,
To-and-Fro the blood flow velocity patterns of the common carotid arteries were characterized by involve-
Movement
and External ment of a single systolic peak and a marked reverse flow component which had never been
Escape of observed in healthy subjects.
Carotid Arterial The individuality of each blood flow velocity pattern in the common, internal and external
Blood in carotid arteries was made clear by placing the transducer in contact with the respective artery in
Brain Death
Cases. A a certain case. The Doppler signal from the internal carotid artery involving a signal from a
Doppler reverse flow was slightly detectable, even if the blood pressure was elevated by norepinephrine
Ultrasonic infusion and the external carotid artery was temporarily compressed. The blood flow velocity
Study pattern of the external carotid artery was similar to the pattern of the common carotid artery.
The peculiar flow pattern indicates that a brain death case has a to-and-fro movement in the in-
ternal carotid blood flow and an external carotid escape of common carotid arterial blood.
• Individuals with brain death have effectively lost arachnoid hemorrhage (three), subdural hematoma (two),
cerebral circulation. This evidence has been shown epidural hematoma (one) and intraperitoneal hemorrhage
(one). The criteria of brain death were followed according to
with angiography,1"4 the radioisotope method 512 and the Ad Hoc Committee of the Harvard Medical School.23
the N 2 O method.13 Carotid angiography, electroencephalography and Doppler
Since Satomura (I960)14 developed an ultrasonic flowmetry were performed in all cases.
flowmeter based upon the Doppler effect, and The carotid blood flow velocity pattern was detected by
Franklin (1961)16 used it in blood flow measurement of a directional Doppler rheogram (HITACHI EUD-2A, 5 M
animals, further progress in the instrumentation led to Hz). The method was originally described by Kato and
the development of a transcutaneous Doppler Izumi.24
flowmeter by which blood flow velocity was able to be
detected through the skin. Ultrasonic Doppler Results
technique as a noninvasive method has been used for The medical records of ten cases are summarized in
detecting carotid blood flow1620 and has been applied table 1. Age, sex, diagnosis, findings of carotid
to extracranial vascular diseases.21'22 It may be possi- angiogram (CAG) and electroencephalogram (EEG),
ble to assume cerebral hemodynamics by measure- pressure of cerebrospinal fluid (CSF) and systemic
ment of carotid blood flow velocity. arterial blood pressure were presented in this table. In
The purpose of the present investigation was to all cases, the carotid angiograms revealed nonfilling
study blood flow velocity patterns of carotid arteries in phenomena (figs. 1 and 2).
patients with brain death whose cerebral circulation Figures 3 through 6 show the blood flow velocity
was extremely disturbed. patterns of the common carotid arteries in cases 4, 6, 8
and 9. The blood flow velocity patterns in these four
Methods cases were characterized by a single systolic peak and
The series consisted of ten patients with brain death. The a reverse flow component. The patterns in the other
six cases also showed the same pattern as shown in
these figures (table 2).
From the *Department of Internal Medicine and the tlntensive It is possible that the transducer was placed in
Care Unit, Osaka University Hospital, Fukushima, Osaka-553,
Japan.
contact with the common, internal and external
Supported in part by Takeda Medical Research Foundation, carotid arteries of case 9. As shown in figure 6, the
No. 47-3, Osaka, Japan. blood flow velocity pattern of the common carotid
TABLE 1
artery in this case was similar to the transcutaneous systolic peaks (Si and Sj) and a following diastolic
Doppler pattern which consisted of a single systolic peak (D) and that a slight reverseflowbetween systole
peak and a reverse flow. The Doppler signal from the and diastole is sometimes observed26 (fig. 9). The
internal carotid artery producing the signal from reverse flow in patients with brain death was promi-
reverse flow was barely detectable. The blood flow nent in comparison with a slight reverse flow in
velocity pattern of the external carotid artery was healthy subjects. Matsuo and Nimura" described
similar to the pattern of the common carotid artery. patients with aortic valvular insufficiency (AI) and
With temporal compression of the external carotid
artery, the Doppler signal from the common carotid
artery became scarcely detectable (fig. 7). An increase
in systolic arterial blood pressure by norepinephrine
infusion (from 94/70 to 220/174 mm Hg) produced
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Discussion
It is known that the blood flow velocity pattern of the
common carotid artery in healthy subjects shows two
P1GURI 1 FIGURI2
Carotid angiogram of case I. Nonfilling phenomena of the internal Carotid angiogram of case S. Internal carotid angiogram did not
carotid angiogram and external carotid angiogram were observed. appear, while external carotid angiogram was observed.
A.carotis comm.
ECG
5KHz
i.
base line
Reverse flow
ECG
Isec
F10UU 1
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The blood flow velocity pattern of case 5. Moderate reverse flow and a single systolic peak were observed in the common
carotid artery.
with idiopathic hypertrophic subaortic stenosis mal subjects appeared in the common and external
(IHSS) who had a reverse flow component in their carotid arteries of brain death cases.
common carotid artery. The cases in this study did not In one case (case 9) whose bloodflowvelocity was
have AI and IHSS. A single systolic peak of the blood measured by placing the transducer in contact with the
flow velocity pattern which was not observed in nor- carotid arteries, the blood flow velocity pattern of the
common carotid artery producing the reverseflowwas
similar to the pattern of the external carotid artery.
The Doppler signal from the internal carotid artery
TABLE 2
producing the signal from reverseflowcould be barely
Blood Flow Velocity Patterns of Common Carotid Arteries detected, even if arterial blood pressure was elevated.
of Cases With Brain Death With temporal compression of the external carotid
Cai» no. Ravar»e flow Singla •y«tollc pmak artery, the Doppler signal from the common carotid
artery became scarcely detectable. These findings in-
1 + + dicated that almost all of the blood of the common
2 + + carotid artery flowed into the external carotid artery.
3 ++ + In other words, there was an external carotid escape of
4 ++ + common carotid arterial blood. It is accepted in brain
5 ++ +
6 +++ + death that the cerebral angiogram shows nonfilling
7 ++ + phenomena1"4 and that cerebral blood flow is ex-
8 +++ + tremely reduced.*"' It also is known that the in-
9 + + tracranial pressure of patients with brain death
10 + + increases to the same level as arterial blood pres-
sure.'1 "• " Therefore, the cerebral perfusion pressure
+ : Mild reverse flow, +-)-: moderate reverse flow, + + + :
marked reverse flow.
is equal to or near zero. The previous reports about
A. carotis comm.
4 KHz
base line
1
2
ECG
* KHz
3
i 2
1
'
w If
rtevws* f l o w '
base U n a
1
2
ECG
FIOUM 3
flow *»"
The blood flow velocity pattern of case 8. The blood flow velocity
pattern of the common carotid artery showed marked reverse flow
ECG and a single systolic peak.
FIOUM 4
A.M., 2 9, male Brain death after head injury with contused wound of the neck
4 KHz
!
2
Impossible to detect
4 KHz
3
?
> •
Reverse flow
A *
Reverse flow
JL 1
l»bas* line
1
Reverse flow
The blood flow velocity pattern of case 9. "Direct" showed the blood flow velocity pattern that a transducer was placed in contact with the
common, internal and external carotid arteries respectively. Doppler signal from the internal carotid artery was slightly detectable.
R. A. carotis comm.
Reverse flow
• r" »
R. A. carotis comm.
R. A. carotis int.
Reverse flow
Reverse flow
ECG
A /I
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E C G
-
R. A. carotis int. R. A. carotis ext.
' , . ^
Reverse flow
Reverse flow
ECG
ECG
FIGURE S
The blood flow velocity pattern of case 9 at compression of the The blood flow velocity pattern of case 9 at elevation of arterial
external carotid artery. Doppler signal from the common carotid blood pressure (from 94/70 to 220/174 mm Hg). The blood flow
artery was scarcely detected. velocity pattern of the internal carotid artery was barely observed.
It had been reported that percutaneous injection by Doppler frequency shift of back-scattered ultrasound.
of 133Xe, even if it was performed selectively into the Science 134:564-565 (Aug) 1961
internal carotid artery with the catheter tip near to the 16. Goldberg RE: Doppler physics and preliminary report of a
siphon, was always followed by extracranial tracer test for carotid insufficiency. In Goldberg RE, Sarin LK (eds):
contamination and clearance."110 It was considered, Ultrasonics in Ophthalmology; Diagnostic and Therapeutic
therefore, that the blood flow velocity pattern of the Applications. Philadelphia, WB Sounders, pp 199-200, 1967
internal carotid artery indicated a to-and-fro move- 17. Grossman Bt, Wood EH: Evaluation of cerebrovascular dis-
ment of internal carotid arterial blood synchronizing ease utilizing a transcutaneous Doppler technique.
with each heart beat. The blood flow velocity pattern Radiology 90:586-587 (Mar) 1968
18. Kristensen JK: Carotid and vertebral blood flow evaluation
of the common carotid artery may originate from a
by means of ultrasound. Acta Neurol Scond 4 3 (Suppl
to-and-fro movement of the blood in the internal 31):116, 1967
carotid artery and some factors in the periphery of the 19. Miyazaki M, Kato K: Measurement of cerebral blood flow by
external carotid artery. ultrasonic Doppler technique. Hemodynamic comparison of
right and left carotid artery in patients with hemiplegia. Jap
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