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Bencsik C, Josephson C, Soo A, Ainsworth C, Savard M, van Diepen S, Kramer A, Kromm J. The Evolving Role of Electroencephalography in Postarrest Care. Can J Neurol Sci 2024:1-13. [PMID: 38572611 DOI: 10.1017/cjn.2024.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Electroencephalography is an accessible, portable, noninvasive and safe means of evaluating a patient's brain activity. It can aid in diagnosis and management decisions for post-cardiac arrest patients with seizures, myoclonus and other non-epileptic movements. It also plays an important role in a multimodal approach to neuroprognostication predicting both poor and favorable outcomes. Individuals ordering, performing and interpreting these tests, regardless of the indication, should understand the supporting evidence, logistical considerations, limitations and impact the results may have on postarrest patients and their families as outlined herein.
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Affiliation(s)
- Caralyn Bencsik
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Colin Josephson
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Martin Savard
- Département de Médecine, Université Laval, Quebec City, QC, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andreas Kramer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Julie Kromm
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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2
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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3
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Horn J, Admiraal M, Hofmeijer J. Diagnosis and management of seizures and myoclonus after cardiac arrest. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:525-531. [PMID: 37486703 DOI: 10.1093/ehjacc/zuad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/13/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Janneke Horn
- Department of Intensive care Medicine, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Neurosciences Institute, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marjolein Admiraal
- Neurosciences Institute, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Neurology and Clinical Neurophysiology, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Technical Medical Center, Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
- Department of Neurology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
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4
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Rajajee V, Muehlschlegel S, Wartenberg KE, Alexander SA, Busl KM, Chou SHY, Creutzfeldt CJ, Fontaine GV, Fried H, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Montellano F, Sakowitz OW, Weimar C, Westermaier T, Varelas PN. Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest. Neurocrit Care 2023; 38:533-563. [PMID: 36949360 PMCID: PMC10241762 DOI: 10.1007/s12028-023-01688-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: "When counseling surrogates of comatose adult survivors of cardiac arrest, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of poor functional outcome assessed at 3 months or later?" Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format. RESULTS Eleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors. CONCLUSIONS These guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurology and Neurosurgery, 3552 Taubman Health Care Center, SPC 5338, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5338, USA.
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sherry H Y Chou
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keri S Kim
- Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Clinic Elzach, Elzach, Germany
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5
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Fordyce CB, Kramer AH, Ainsworth C, Christenson J, Hunter G, Kromm J, Lopez Soto C, Scales DC, Sekhon M, van Diepen S, Dragoi L, Josephson C, Kutsogiannis J, Le May MR, Overgaard CB, Savard M, Schnell G, Wong GC, Belley-Côté E, Fantaneanu TA, Granger CB, Luk A, Mathew R, McCredie V, Murphy L, Teitelbaum J. Neuroprognostication in the Post Cardiac Arrest Patient: A Canadian Cardiovascular Society Position Statement. Can J Cardiol 2023; 39:366-380. [PMID: 37028905 DOI: 10.1016/j.cjca.2022.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 04/08/2023] Open
Abstract
Cardiac arrest (CA) is associated with a low rate of survival with favourable neurologic recovery. The most common mechanism of death after successful resuscitation from CA is withdrawal of life-sustaining measures on the basis of perceived poor neurologic prognosis due to underlying hypoxic-ischemic brain injury. Neuroprognostication is an important component of the care pathway for CA patients admitted to hospital but is complex, challenging, and often guided by limited evidence. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate the evidence underlying factors or diagnostic modalities available to determine prognosis, recommendations were generated in the following domains: (1) circumstances immediately after CA; (2) focused neurologic exam; (3) myoclonus and seizures; (4) serum biomarkers; (5) neuroimaging; (6) neurophysiologic testing; and (7) multimodal neuroprognostication. This position statement aims to serve as a practical guide to enhance in-hospital care of CA patients and emphasizes the adoption of a systematic, multimodal approach to neuroprognostication. It also highlights evidence gaps.
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Affiliation(s)
- Christopher B Fordyce
- Division of Cardiology, Department of Medicine, Vancouver General Hospital, and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia.
| | - Andreas H Kramer
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia
| | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Julie Kromm
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Carmen Lopez Soto
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mypinder Sekhon
- Division of Critical Care, Department of Medicine, Vancouver General Hospital, Djavad Mowafaghian Centre for Brain Health, International Centre for Repair Discoveries, University of British Columbia, Vancouver, British Columbia
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Colin Josephson
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Jim Kutsogiannis
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta
| | - Michel R Le May
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Christopher B Overgaard
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Martin Savard
- Department of Neurological Sciences CHU de Québec - Hôpital de l'Enfant-Jésus Quebec City, Quebec, Canada
| | - Gregory Schnell
- Division of Cardiology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, Vancouver General Hospital, and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia
| | - Emilie Belley-Côté
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tadeu A Fantaneanu
- Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Adriana Luk
- Division of Cardiology, Department of Medicine, University of Toronto and the Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Mathew
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, and the Faculty of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Victoria McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, the Krembil Research Institute, Toronto Western Hospital, University Health Network, and Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laurel Murphy
- Departments of Emergency Medicine and Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jeanne Teitelbaum
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
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6
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Nutma S, Ruijter BJ, Beishuizen A, Tromp SC, Scholten E, Horn J, van den Bergh WM, van Kranen-Mastenbroek VH, Thomeer EC, Moudrous W, Aries M, van Putten MJ, Hofmeijer J. Myoclonus in comatose patients with electrographic status epilepticus after cardiac arrest: Corresponding EEG patterns, effects of treatment and outcomes. Resuscitation 2023; 186:109745. [PMID: 36822459 DOI: 10.1016/j.resuscitation.2023.109745] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVE To clarify the significance of any form of myoclonus in comatose patients after cardiac arrest with rhythmic and periodic EEG patterns (RPPs) by analyzing associations between myoclonus and EEG pattern, response to anti-seizure medication and neurological outcome. DESIGN Post hoc analysis of the prospective randomized Treatment of ELectroencephalographic STatus Epilepticus After Cardiopulmonary Resuscitation (TELSTAR) trial. SETTING Eleven ICUs in the Netherlands and Belgium. PATIENTS One hundred and fifty-seven adult comatose post-cardiac arrest patients with RPPs on continuous EEG monitoring. INTERVENTIONS Anti-seizure medication vs no anti-seizure medication in addition to standard care. MEASUREMENTS AND MAIN RESULTS Of 157 patients, 98 (63%) had myoclonus at inclusion. Myoclonus was not associated with one specific RPP type. However, myoclonus was associated with a smaller probability of a continuous EEG background pattern (48% in patients with vs 75% without myoclonus, odds ratio (OR) 0.31; 95% confidence interval (CI) 0.16-0.64) and earlier onset of RPPs (24% vs 9% within 24 hours after cardiac arrest, OR 3.86;95% CI 1.64-9.11). Myoclonus was associated with poor outcome at three months, but not invariably so (poor neurological outcome in 96% vs 82%, p = 0.004). Anti-seizure medication did not improve outcome, regardless of myoclonus presence (6% good outcome in the intervention group vs 2% in the control group, OR 0.33; 95% CI 0.03-3.32). CONCLUSIONS Myoclonus in comatose patients after cardiac arrest with RPPs is associated with poor outcome and discontinuous or suppressed EEG. However, presence of myoclonus does not interact with the effects of anti-seizure medication and cannot predict a poor outcome without false positives.
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Affiliation(s)
- Sjoukje Nutma
- Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede, the Netherlands; Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands.
| | - Barry J Ruijter
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands
| | - Albertus Beishuizen
- Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede, the Netherlands
| | - Selma C Tromp
- Departments of Neurology and Clinical Neurophysiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik Scholten
- Department of Critical Care, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Janneke Horn
- Department of Critical Care, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Elsbeth C Thomeer
- Department of Neurology and Clinical Neurophysiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Walid Moudrous
- Department of Neurology and Clinical Neurophysiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Marcel Aries
- Department of Critical Care, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Michel Jam van Putten
- Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede, the Netherlands; Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands
| | - Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands; Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
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7
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Baker AK, Griffith JL. To Treat or Not to Treat: Ethics of Management of Refractory Status Myoclonus Following Pediatric Anoxic Brain Injury. Semin Pediatr Neurol 2023; 45:101033. [PMID: 37003631 DOI: 10.1016/j.spen.2023.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
The development of status myoclonus (SM) in a postcardiac arrest patient has historically been thought of as indicative of not only a poor neurologic outcome but of neurologic devastation. In many instances, this may lead clinicians to initiate conversations about withdrawal of life sustaining therapies (WLST) regardless of the time from return of spontaneous circulation (ROSC). Recent studies showing a percentage of patients may make a good recovery has called into question whether a self-fulfilling prophecy has developed where the concern for a poor neurologic outcome leads clinicians to prematurely discuss WLST. The issue is only further complicated by changing terminology, lack of neuro-axis localization, and limited data regarding association with electroencephalogram (EEG) characteristics, all of which could aid in the understanding of the severity of neurologic injury associated with SM. Here we review the initial literature reporting SM as indicative of poor neurologic outcome, the studies that call this into question, the various definitions of SM and related terms as well as data regarding association with EEG backgrounds. We propose that improved prognostication on outcomes results from combining the presence of SM with other clinical variables (eg EEG patterns, MRI findings, and clinical exam). We discuss the ethical implications of using SM as a prognostic tool and its impact on decisions about life-sustaining care in children following cardiac arrest. We advocate for prognostication efforts to be delayed for at least 72 hours following ROSC and thus to treat SM in those early hours and days.
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Affiliation(s)
- Alyson K Baker
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE; Children's Hospital and Medical Center, Omaha, NE.
| | - Jennifer L Griffith
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO; Department of Neurology, Washington University School of Medicine, St. Louis, MO
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8
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Neurophysiological and Clinical Correlates of Acute Posthypoxic Myoclonus. J Clin Neurophysiol 2023; 40:117-122. [PMID: 36521068 DOI: 10.1097/wnp.0000000000000937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
SUMMARY Prognostication following cardiorespiratory arrest relies on the neurological examination, which is supported by neuroimaging and neurophysiological testing. Acute posthypoxic myoclonus (PHM) is a clinical entity that has prognostic significance and historically has been considered an indicator of poor outcome, but this is not invariably the case. "Malignant" and more "benign" forms of acute PHM have been described and differentiating them is key in understanding their meaning in prognosis. Neurophysiological tests, electroencephalogram in particular, and clinical phenotyping are crucial in defining subtypes of acute PHM. This review describes the neurophysiological and phenotypic markers of malignant and benign forms of acute PHM, a clinical approach to evaluating acute PHM following cardiorespiratory arrest in determining prognosis, and gaps in our understanding of acute PHM that require further study.
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9
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Asghar A, Barnes B, Aburahma A, Khan S, Primera G, Ravikumar N. Post hypoxic myoclonus: A tale of two minds. Epilepsy Behav Rep 2023; 21:100589. [PMID: 36747905 PMCID: PMC9898587 DOI: 10.1016/j.ebr.2023.100589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/14/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023] Open
Abstract
Post hypoxic myoclonus (PHM) is considered a poor prognostic sign and may influence decisions regarding withdrawal of treatment. PHM is generally categorized in literature as either acute or chronic (also commonly referred to as Lance-Adams Syndrome) based on the onset of myoclonus. However, it may be more accurate to differentiate between the various presentations of PHM based on the clinical characteristics and electroencephalogram (EEG) findings for prognostication. Here, we describe a case of a 33-year-old female who presented after a cardiopulmonary arrest. MRI of the brain and cervical spine on admission were unremarkable. Twelve hours later, she developed generalized, stimulus-sensitive myoclonus suggestive of acute PHM. Various medications were trialed, and her symptoms eventually improved on clonazepam. On day 14, she started having resting and intention myoclonus, and dysarthria, consistent with LAS. Several adjustments were again made to her regimen, and she was eventually switched from clonazepam to baclofen which improved her resting myoclonus. This case highlights that PHM can present differently and have a markedly different outcome. It is important to develop a better understanding of the various types of PHM so as to avoid premature withdrawal of care.
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10
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Muacevic A, Adler JR, Helfman B. A Rare Case of Lance-Adams Syndrome: Status Post-Successful Cardiopulmonary Resuscitation. Cureus 2022; 14:e32604. [PMID: 36654619 PMCID: PMC9840882 DOI: 10.7759/cureus.32604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
Lance-Adams syndrome (LAS), also known as chronic post-hypoxic myoclonus (PHM), is a rare condition that may present with intention myoclonus in a patient who has regained consciousness after cardiorespiratory arrest. This case report describes a patient who received successful cardiopulmonary resuscitation (CPR) after going into cardiac arrest. And regaining consciousness, the patient developed myoclonic jerks diagnosed as LAS. The patient responded well to treatment with clonazepam and physical rehabilitation.
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11
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Olson V, Chang IJ, Merritt 2nd JL, Mingbunjerdsuk D. Refractory Myoclonus as a Presentation of Metabolic Stroke in A Child With Cobalamin B Methylmalonic Acidemia After Liver and Kidney Transplant. J Mov Disord 2022; 15:281-283. [PMID: 35614015 PMCID: PMC9536905 DOI: 10.14802/jmd.21196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/20/2022] [Accepted: 02/15/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Valerie Olson
- Section of Neurology, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Irene J Chang
- Division of Genetic Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - J Lawrence Merritt 2nd
- Division of Genetic Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Dararat Mingbunjerdsuk
- Division of Pediatric Neurology, Department of Neurology, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
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12
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Guo Y, Xiao Y, Chen LF, Yin DH, Wang RD. Lance Adams syndrome: two cases report and literature review. J Int Med Res 2022; 50:3000605211059933. [PMID: 35220777 PMCID: PMC8894979 DOI: 10.1177/03000605211059933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Hypoxic myoclonus, also known as Lance Adams syndrome, is a rare syndrome that results from the serious brain damage caused by cerebral hypoxia that often follows cardiopulmonary resuscitation. This current case report describes two patients with post-hypoxic myoclonus, both of whom received cardiopulmonary resuscitation. The neurological symptoms of these two patients were significantly improved by the administration of clonazepam and sodium valproate sustained-release tablets. The report presents a literature review detailing the pathogenesis, diagnosis and treatment of Lance Adams syndrome. The timely diagnosis and treatment of Lance Adams syndrome can significantly improve the quality of life of patients. Valproic acid, clonazepam and other antiepileptic drugs can be used. Whether levetiracetam is effective for cortical myoclonus requires further clinical study.
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Affiliation(s)
- Yu Guo
- Department of Neurology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Yan Xiao
- Department of Neurology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Li-Fa Chen
- Department of Neurology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - De-Hui Yin
- Department of Neurology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Ruo-Dan Wang
- Department of Neurology, Second Affiliated Hospital of Army Medical University, Chongqing, China
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Ben Hadj Salem O, Jamme M, Paul M, Guillemet L, Dumas F, Pène F, Chiche JD, Charpentier J, Mira JP, Outin H, Azabou E, Cariou A. Post-cardiac arrest myoclonus and in ICU mortality: insights from the Parisian Registry of Cardiac Arrest (PROCAT). Neurol Sci 2022; 43:533-540. [PMID: 33895885 PMCID: PMC7670102 DOI: 10.1007/s10072-021-05276-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Post-cardiac arrest myoclonus (PCAM) is a frequent finding in resuscitated patients after cardiac arrest (CA), with rather poor prognostic significance. In this study, we evaluated the association of PCAM within intensive care unit (ICU) mortality from a university hospital CA patients' registry. METHODS Clinical data of consecutive CA survivors admitted in the intensive care unit (ICU) between January and December 2016 at the Paris Cochin University Hospital were assessed from the Parisian registry of cardiac arrest (PROCAT) and analyzed. Neurologic outcome was assessed using the Cerebral Performance Categories (CPC) scale at ICU discharge. Prevalence of PCAM and their association with mortality at ICU discharge were computed. RESULTS One hundred thirty-two (132) patients were included (73.5% males), median age of 66 years. Among them, 37 (28%) developed PCAM during their ICU stay. Only two patients with PCAM survived (5.4%). PCAM was strongly associated with mortality at ICU discharge (odds ratio 17.5 [4.2-123.2]). Sensitivity, specificity, PPV, and NPV of PCAM for prediction of death were 41%, 96%, 95%, and 46%, respectively. CONCLUSION PCAM was observed in nearly one-third of CA patients admitted in ICU. Patients with PCAM had a significantly higher likelihood of ICU mortality and a low likelihood of a good outcome. The prognostic value of PCAM seems rather bleak but remains nuanced and merits study in larger-scale prospective studies taking into account confounding factors.
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Affiliation(s)
- Omar Ben Hadj Salem
- Medical Critical Care Unit, Cochin Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
- Intensive Care Unit, Centre Hospitalier Intercommunal Meulan- Les Mureaux, Meulan-en-Yvelines, France
| | - Matthieu Jamme
- Medical Critical Care Unit, Cochin Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
| | - Marine Paul
- Medical Critical Care Unit, Cochin Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
- UFR de Médecine, Paris-Descartes-Sorbonne-Paris-Cité, Paris, France
| | - Lucie Guillemet
- Medical Critical Care Unit, Cochin Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
- UFR de Médecine, Paris-Descartes-Sorbonne-Paris-Cité, Paris, France
| | - Florence Dumas
- UFR de Médecine, Paris-Descartes-Sorbonne-Paris-Cité, Paris, France
- Paris Sudden-Death-Expertise-Centre, Paris, France
- Emergency Department, Cochin Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
| | - Frédéric Pène
- Medical Critical Care Unit, Cochin Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
- UFR de Médecine, Paris-Descartes-Sorbonne-Paris-Cité, Paris, France
| | - Jean-Daniel Chiche
- Medical Critical Care Unit, Cochin Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
- UFR de Médecine, Paris-Descartes-Sorbonne-Paris-Cité, Paris, France
| | - Julien Charpentier
- Medical Critical Care Unit, Cochin Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
- UFR de Médecine, Paris-Descartes-Sorbonne-Paris-Cité, Paris, France
| | - Jean-Paul Mira
- Medical Critical Care Unit, Cochin Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
- UFR de Médecine, Paris-Descartes-Sorbonne-Paris-Cité, Paris, France
| | - Hervé Outin
- Intensive Care Unit, Poissy-Saint Germain en Laye, Centre Hospitalier Intercommunal, Poissy, France
| | - Eric Azabou
- Clinical Neurophysiology and Neuromodulation Unit, Raymond Poincaré Hospital, Assistance Publique -Hôpitaux de Paris, Garches, France.
- INSERM UMR1173 Infection and Inflammation (2I), University of Versailles-Saint Quentin (UVSQ), Paris Saclay University, 104 Boulevard Raymond Poincaré, 92380, Garches, Paris, France.
| | - Alain Cariou
- Medical Critical Care Unit, Cochin Hospital, Assistance Publique -Hôpitaux de Paris, Paris, France
- UFR de Médecine, Paris-Descartes-Sorbonne-Paris-Cité, Paris, France
- Paris Sudden-Death-Expertise-Centre, Paris, France
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Du L, Zheng K, Feng L, Cao Y, Niu Z, Song Z, Liu Z, Liu X, Xiang X, Zhou Q, Xiong H, Chen F, Zhang G, Ma Q. The first national survey on practices of neurological prognostication after cardiac arrest in China, still a lot to do. Int J Clin Pract 2021; 75:e13759. [PMID: 33098255 DOI: 10.1111/ijcp.13759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/04/2020] [Indexed: 02/05/2023] Open
Abstract
AIMS To investigate current awareness and practices of neurological prognostication in comatose cardiac arrest (CA) patients. METHODS An anonymous questionnaire was distributed to 1600 emergency physicians in 75 hospitals which were selected randomly from China between January and July 2018. RESULTS 92.1% respondents fulfilled the survey. The predictive value of brain stem reflex, motor response and myoclonus was confirmed by 63.5%, 44.6% and 31.7% respondents, respectively. Only 30.7% knew that GWR value < 1.1 indicated poor prognosis and only 8.1% know the most commonly used SSEP N20. Status epilepticus, burst suppression and suppression were considered to predict poor outcome by only 35.0%, 27.4% and 20.9% respondents, respectively. Only 46.7% knew NSE and only 24.7% knew S-100. Only a few respondents knew that neurological prognostication should be performed later than 72 hours from CA either in TTM or non-TTM patients. In practice, the most commonly used method was clinical examination (85.4%). Only 67.9% had used brain CT for prognosis and 18.4% for MRI. NSE (39.6%) was a little more widely used than S-100β (18.0%). However, SSEP (4.4%) and EEG (11.4%) were occasionally performed. CONCLUSIONS Neurological prognostication in CA survivors had not been well understood and performed by emergency physicians in China. They were more likely to use clinical examination rather than objective tools, especially SSEP and EEG, which also illustrated that multimodal approach was not well performed in practice.
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Affiliation(s)
- Lanfang Du
- Emergency Department, The Peking University Third Hospital, Beijing, China
| | - Kang Zheng
- Emergency Department, The Peking University Third Hospital, Beijing, China
| | - Lu Feng
- Emergency Department, The Peking University Third Hospital, Beijing, China
| | - Yu Cao
- Emergency Department, West China Hospital, Chengdu City, China
| | - Zhendong Niu
- Emergency Department, West China Hospital, Chengdu City, China
| | - Zhenju Song
- Emergency Department, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhi Liu
- Emergency Department, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xiaowei Liu
- Emergency Department, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xudong Xiang
- Emergency Department, Second Xiangya Hospital, Central South University, Changsha, China
| | - Qidi Zhou
- Emergency Department, Peking University Shenzhen Hospital, Shenzhen City, China
| | - Hui Xiong
- Emergency Department, Peking University First Hospital, Beijing, China
| | - Fengying Chen
- Emergency Department, The Affiliated Hospital of Innor Mongolia Medical University, Huherhaote City, China
| | - Guoqiang Zhang
- Emergency Department, China-Japan Friendship Hospital, Beijing, China
| | - Qingbian Ma
- Emergency Department, The Peking University Third Hospital, Beijing, China
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16
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 468] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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17
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 385] [Impact Index Per Article: 128.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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18
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Roman-Pognuz E, Elmer J, Guyette FX, Poillucci G, Lucangelo U, Berlot G, Manganotti P, Peratoner A, Pellis T, Taccone F, Callaway C. Multimodal Long-Term Predictors of Outcome in Out of Hospital Cardiac Arrest Patients Treated with Targeted Temperature Management at 36 °C. J Clin Med 2021; 10:jcm10061331. [PMID: 33807041 PMCID: PMC8005130 DOI: 10.3390/jcm10061331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/05/2021] [Accepted: 03/17/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction: Early prediction of long-term outcomes in patients resuscitated after cardiac arrest (CA) is still challenging. Guidelines suggested a multimodal approach combining multiple predictors. We evaluated whether the combination of the electroencephalography (EEG) reactivity, somatosensory evoked potentials (SSEPs) cortical complex and Gray to White matter ratio (GWR) on brain computed tomography (CT) at different temperatures could predict survival and good outcome at hospital discharge and six months after the event. Methods: We performed a retrospective cohort study including consecutive adult, non-traumatic patients resuscitated from out-of-hospital CA who remained comatose on admission to our intensive care unit from 2013 to 2017. We acquired SSEPs and EEGs during the treatment at 36 °C and after rewarming at 37 °C, Gray to white matter ratio (GWR) was calculated on the brain computed tomography scan performed within six hours of the hospital admission. We primarily hypothesized that SSEP was associated with favor-able functional outcome at distance and secondarily that SSEP provides independent information from EEG and CT. Outcomes were evaluated using the Cerebral Performance Category (CPC) scale at six months from discharge. Results: Of 171 resuscitated patients, 75 were excluded due to missing data or uninterpretable neurophysiological findings. EEG reactivity at 37 °C has been shown the best single predictor of good out-come (AUC 0.803) while N20P25 was the best single predictor for survival at each time point. (AUC 0.775 at discharge and AUC 0.747 at six months follow up). The predictive value of a model including EEG reactivity, average GWR, and SSEP N20P25 amplitude was superior (AUC 0.841 for survival and 0.920 for good out-come) to any combination of two tests or any single test. Conclusions: Our study, in which life-sustaining treatments were never suspended, suggests SSEP cortical complex N20P25, after normothermia and off sedation, is a reliable predictor for survival at any time. When SSEP cortical complex N20P25 is added into a model with GWR average and EEG reactivity, the predictivity for good outcome and survival at distance is superior than each single test alone.
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Affiliation(s)
- Erik Roman-Pognuz
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Strada di Fiume 447, 34100 Trieste, Italy; (U.L.); (G.B.); (A.P.)
- Correspondence: ; Tel.: +39-3394879119
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; (J.E.); (F.X.G.); (C.C.)
| | - Frank X. Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; (J.E.); (F.X.G.); (C.C.)
| | - Gabriele Poillucci
- Department of Radiology, Azienda Sanitaria Universitaria Giuliano Isontina, 34128 Trieste, Italy;
| | - Umberto Lucangelo
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Strada di Fiume 447, 34100 Trieste, Italy; (U.L.); (G.B.); (A.P.)
| | - Giorgio Berlot
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Strada di Fiume 447, 34100 Trieste, Italy; (U.L.); (G.B.); (A.P.)
| | - Paolo Manganotti
- Department of Neurology, University of Trieste, 34100 Trieste, Italy;
| | - Alberto Peratoner
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Strada di Fiume 447, 34100 Trieste, Italy; (U.L.); (G.B.); (A.P.)
| | - Tommaso Pellis
- Department of Intensive Care, Azienda Sanitaria Friuli Occidentale Tommaso, 33170 Pordenone, Italy;
| | - Fabio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Bruxelles, Belgium;
| | - Clifton Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; (J.E.); (F.X.G.); (C.C.)
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Song J, Kang W, Ohn SH, Jung KI, Bashir S, Yoo WK. An Exploration of the Neural Network of Lance-Adams Syndrome: a Case Report. BRAIN & NEUROREHABILITATION 2020; 14:e1. [PMID: 36742106 PMCID: PMC9879414 DOI: 10.12786/bn.2021.14.e1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 11/08/2022] Open
Abstract
Lance-Adams syndrome (LAS) is a rare neurological disorder that may occur after cardiopulmonary resuscitation. The LAS is usually caused by hypoxic changes. Neuroimaging studies show that the brain pathology of LAS patients is not uniform, and the pathophysiology of the myoclonus can vary from patient to patient. Our case study contributes to this etiological heterogeneity by neuroimaging and transcranial magnetic stimulation (TMS). In patients with rare brain conditions such as LAS, a combination of brain stimulation methods, such as TMS, and diffusion tensor imaging can provide insights into this condition's pathophysiology. These insights can facilitate the development of more effective therapies.
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Affiliation(s)
- Jimin Song
- Department of Physical Medicine and Rehabilitation, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Wonil Kang
- Department of Physical Medicine and Rehabilitation, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Suk Hoon Ohn
- Department of Physical Medicine and Rehabilitation, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kwang-Ik Jung
- Department of Physical Medicine and Rehabilitation, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Shahid Bashir
- Neuroscience Center, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Woo-Kyoung Yoo
- Department of Physical Medicine and Rehabilitation, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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20
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Anand P, Zakaria A, Benameur K, Ong C, Putman M, O'Shea S, Greer D, Cervantes-Arslanian AM. Myoclonus in Patients With Coronavirus Disease 2019: A Multicenter Case Series. Crit Care Med 2020; 48:1664-1669. [PMID: 32804787 PMCID: PMC7448712 DOI: 10.1097/ccm.0000000000004570] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To describe the risk factors for and outcomes after myoclonus in a cohort of patients with coronavirus disease 2019. DESIGN Multicenter case series. SETTING Three tertiary care hospitals in Massachusetts, Georgia, and Virginia. PATIENTS Eight patients with clinical myoclonus in the setting of coronavirus disease 2019. INTERVENTIONS & MEASUREMENTS AND MAIN RESULTS Outcomes in patients with myoclonus were variable, with one patient who died during the study period and five who were successfully extubated cognitively intact and without focal neurologic deficits. In five cases, the myoclonus completely resolved within 2 days of onset, while in three cases, it persisted for 10 days or longer. Seven patients experienced significant metabolic derangements, hypoxemia, or exposure to sedating medications that may have contributed to the development of myoclonus. One patient presented with encephalopathy and developed prolonged myoclonus in the absence of clear systemic provoking factors. CONCLUSIONS Our findings suggest that myoclonus may be observed in severe acute respiratory syndrome coronavirus 2 infected patients, even in the absence of hypoxia. This association warrants further evaluation in larger cohorts to determine whether the presence of myoclonus may aid in the assessment of disease severity, neurologic involvement, or prognostication.
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Affiliation(s)
- Pria Anand
- Department of Neurology, Boston University Medical Center, Boston, MA
| | - Asma Zakaria
- Critical Care Medicine, INOVA Fairfax Medical Campus, Falls Church, VA
| | - Karima Benameur
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Charlene Ong
- Department of Neurology, Boston University Medical Center, Boston, MA
| | - Maryann Putman
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Sarah O'Shea
- Department of Neurology, Boston University Medical Center, Boston, MA
| | - David Greer
- Department of Neurology, Boston University Medical Center, Boston, MA
| | - Anna M Cervantes-Arslanian
- Department of Neurology, Boston University Medical Center, Boston, MA
- Department of Medicine (Infectious Diseases), Boston University Medical Center, Boston, MA
- Department of Neurosurgery, Boston University Medical Center, Boston, MA
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21
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Neuro-anatomical localization of EEG identical bursts in patients with and without post-anoxic myoclonus. Resuscitation 2020; 162:314-319. [PMID: 33127440 DOI: 10.1016/j.resuscitation.2020.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The electroencephalograph (EEG) pattern of burst suppression with identical bursts (BSIB), with or without myoclonus, occurs often after resuscitation from cardiac arrest. These patterns are associated with severe brain injury but their neuropathological basis is unknown. Using EEG source localization, we tested whether post-cardiac arrest myoclonus was associated with specific anatomical distribution of BSIB. METHODS We performed a single center, case-control study of EEG-monitored post-cardiac arrest patients with BSIB. We determined the presence of myoclonus from clinical notes and video recordings. We generated normalized source density maps (sLORETA) for the first 0.5 s of each burst projected onto a standard anatomic model, and compared proportion of EEG power in the precentral gyrus (motor cortex) to the rest of the brain. RESULTS We included 20 patients, 10 with and 10 without myoclonus. Patients with myoclonus had greater electrical activation localized to the precentral gyrus compared to those without (median 3.25 [IQR 2.74-3.59] vs 2.68 [IQR 2.66-2.71], P = 0.04). There was no difference between groups in region of burst origin. CONCLUSION Among patients with BSIB after cardiac arrest, those with clinical myoclonus have more electrocortical activation in the precentral gyrus.
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Lupton JR, Kurz MC, Daya MR. Neurologic prognostication after resuscitation from cardiac arrest. J Am Coll Emerg Physicians Open 2020; 1:333-341. [PMID: 33000056 PMCID: PMC7493528 DOI: 10.1002/emp2.12109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/28/2020] [Accepted: 05/01/2020] [Indexed: 12/11/2022] Open
Abstract
Out-of-hospital cardiac arrest remains a leading cause of mortality in the United States, and the majority of patients who die after achieving return of spontaneous circulation die from withdrawal of care due to a perceived poor neurologic prognosis. Unfortunately, withdrawal of care often occurs during the first day of admission and research suggests this early withdrawal of care may be premature and result in unnecessary deaths for patients who would have made a full neurologic recovery. In this review, we explore the evidence for neurologic prognostication in the emergency department for patients who achieve return of spontaneous circulation after an out-of-hospital cardiac arrest.
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Affiliation(s)
| | | | - Mohamud R Daya
- Oregon Health and Science University Portland Oregon USA
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23
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Guedes B, Manita M, Rita Peralta A, Catarina Franco A, Bento L, Bentes C. Prognostic significance of specific EEG patterns after cardiac arrest in a Lisbon Cohort. Clin Neurophysiol Pract 2020; 5:147-151. [PMID: 32885107 PMCID: PMC7451827 DOI: 10.1016/j.cnp.2020.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 06/10/2020] [Accepted: 07/05/2020] [Indexed: 01/31/2023] Open
Abstract
Objective To evaluate if EEG patterns considered highly malignant are reliable predictors not only of poor neurological outcome but also reliable predictors of death. Methods Retrospectively, EEGs from Cardiac Arrest (CA) patients of two teaching hospitals in Lisbon were classified into 3 groups: highly malignant, malignant, and benign groups. Outcome was assessed at 6 months after CA by CPC (Cerebral Performance Categories) scale. We evaluated the accuracy of these patterns to predict poor neurological outcome and death. Results We included 106 patients for analysis. All patients with a highly malignant EEG (n = 37) presented a poor neurological outcome. Those patterns were also associated with death. Malignant EEG patterns were not associated with poor neurological outcome. Benign EEG patterns were associated with good neurological recovery (p < 0.0001). Conclusion Highly malignant EEG patterns were strongly associated with poor neurological outcome and can be considered to be predictors of death. Significance This study increased the knowledge about the value of EEG as a tool in outcome prediction of patients after cardiac arrest.
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Affiliation(s)
- Beatriz Guedes
- Área de Neurociências, Unidade de Neurofisiologia Clínica, Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Manuel Manita
- Área de Neurociências, Unidade de Neurofisiologia Clínica, Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Ana Rita Peralta
- Laboratório EEG/Sono - Unidade de Monitorização Neurofisiológica, Departamento de Neurociências e Saúde Mental, Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, Lisboa, Portugal.,Centro de Referência para Epilepsia Refratária (from the European Reference Network-EpiCARE), Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Ana Catarina Franco
- Laboratório EEG/Sono - Unidade de Monitorização Neurofisiológica, Departamento de Neurociências e Saúde Mental, Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, Lisboa, Portugal.,Centro de Referência para Epilepsia Refratária (from the European Reference Network-EpiCARE), Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Luís Bento
- Área de Urgência e Cuidados Intensivos, Unidade de Urgência Médica, Hospital de São José, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Carla Bentes
- Laboratório EEG/Sono - Unidade de Monitorização Neurofisiológica, Departamento de Neurociências e Saúde Mental, Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, Lisboa, Portugal.,Centro de Referência para Epilepsia Refratária (from the European Reference Network-EpiCARE), Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
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Abstract
Tremor and myoclonus are two common hyperkinetic movement disorders. Tremor is characterized by rhythmic oscillatory movements while myoclonic jerks are usually arrhythmic. Tremor can be classified into subtypes including the most common types: essential, enhanced physiological, and parkinsonian tremor. Myoclonus classification is based on its anatomic origin: cortical, subcortical, spinal, and peripheral myoclonus. The clinical presentations are unfortunately not always classic and electrophysiologic investigations can be helpful in making a phenotypic diagnosis. Video-polymyography is the main technique to (sub)classify the involuntary movements. In myoclonus, advanced electrophysiologic testing, such as back-averaging, coherence analysis, somatosensory-evoked potentials, and the C-reflex can be of additional value. Recent developments in tremor point toward a role for intermuscular coherence analysis to differentiate between tremor subtypes. Classification of the movement disorder based on clinical and electrophysiologic features is important, as it enables the search for an etiological diagnosis and guides tailored treatment.
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Affiliation(s)
- R Zutt
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - J W Elting
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - M A J Tijssen
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands.
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25
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Geocadin RG, Callaway CW, Fink EL, Golan E, Greer DM, Ko NU, Lang E, Licht DJ, Marino BS, McNair ND, Peberdy MA, Perman SM, Sims DB, Soar J, Sandroni C. Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e517-e542. [DOI: 10.1161/cir.0000000000000702] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Significant improvements have been achieved in cardiac arrest resuscitation and postarrest resuscitation care, but mortality remains high. Most of the poor outcomes and deaths of cardiac arrest survivors have been attributed to widespread brain injury. This brain injury, commonly manifested as a comatose state, is a marker of poor outcome and a major basis for unfavorable neurological prognostication. Accurate prognostication is important to avoid pursuing futile treatments when poor outcome is inevitable but also to avoid an inappropriate withdrawal of life-sustaining treatment in patients who may otherwise have a chance of achieving meaningful neurological recovery. Inaccurate neurological prognostication leading to withdrawal of life-sustaining treatment and deaths may significantly bias clinical studies, leading to failure in detecting the true study outcomes. The American Heart Association Emergency Cardiovascular Care Science Subcommittee organized a writing group composed of adult and pediatric experts from neurology, cardiology, emergency medicine, intensive care medicine, and nursing to review existing neurological prognostication studies, the practice of neurological prognostication, and withdrawal of life-sustaining treatment. The writing group determined that the overall quality of existing neurological prognostication studies is low. As a consequence, the degree of confidence in the predictors and the subsequent outcomes is also low. Therefore, the writing group suggests that neurological prognostication parameters need to be approached as index tests based on relevant neurological functions that are directly related to the functional outcome and contribute to the quality of life of cardiac arrest survivors. Suggestions to improve the quality of adult and pediatric neurological prognostication studies are provided.
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26
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Hypoxic Encephalopathy in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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27
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Kavi T, Desai M, Yilmaz FM, Kakadia B, Burakgazi-Dalkilic E, Shrestha GS. Inter-predictability of Neuroprognostic Modalities After Cardiac Arrest. Cureus 2019; 11:e4489. [PMID: 31259107 PMCID: PMC6581415 DOI: 10.7759/cureus.4489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Introduction At present, there is an emphasis on a multi-modal approach to neuro-prognostication after cardiac arrest using clinical examination, neurophysiologic testing, laboratory biomarkers, and radiological studies. However, this necessitates significant resource utilization and can be challenging in under-resourced clinical settings. Hence, we sought to determine the inter-predictability and correlation of prognostic tests performed in patients after cardiac arrest. Methods Fifty patients were included through neurophysiology laboratory data for this retrospective study. Clinical, radiological and neurophysiological data were collected. Neurophysiological data were re-evaluated by a board-certified neurophysiologist for the purpose of the study. Chi-square testing was used to evaluate the correlation between different diagnostic modalities. Results We found that a non-reactive electroencephalogram (EEG) had a predictive value of 79% for absent bilateral cortical responses (N20) with somatosensory evoked potentials (SSEP). On the other hand, absent bilateral cortical responses N20 had 87% predictive value for a non-reactive EEG. Also, absent cortical responses and non-reactive EEG had predictive values of 78% and 72% for anoxic injury on magnetic resonance imaging (MRI) brain respectively with a non-significant difference on chi-square testing. Individually, absent bilateral N20 SSEP, a non-reactive EEG and anoxic brain injury on MRI studies were highly predictive of poor outcome [modified Rankin scale (mRS) > 4] at hospital discharge. Conclusion Neuroprognostication in a post-cardiac arrest setting is often limited by self-fulfilling prophecy. Given the lack of absolute correlation between different modalities used in post-cardiac arrest patients, the value of the multi-modal approach to neuro-prognostication is highlighted by this study.
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Affiliation(s)
- Tapan Kavi
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Masoom Desai
- Neurology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Furkan M Yilmaz
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Bhavika Kakadia
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | | | - Gentle S Shrestha
- Critical Care, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, NPL
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28
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Nguyen PL, Alreshaid L, Poblete RA, Konye G, Marehbian J, Sung G. Targeted Temperature Management and Multimodality Monitoring of Comatose Patients After Cardiac Arrest. Front Neurol 2018; 9:768. [PMID: 30254606 PMCID: PMC6141756 DOI: 10.3389/fneur.2018.00768] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/24/2018] [Indexed: 01/14/2023] Open
Abstract
Out-of-hospital cardiac arrest (CA) remains a leading cause of sudden morbidity and mortality; however, outcomes have continued to improve in the era of targeted temperature management (TTM). In this review, we highlight the clinical use of TTM, and provide an updated summary of multimodality monitoring possible in a modern ICU. TTM is neuroprotective for survivors of CA by inhibiting multiple pathophysiologic processes caused by anoxic brain injury, with a final common pathway of neuronal death. Current guidelines recommend the use of TTM for out-of-hospital CA survivors who present with a shockable rhythm. Further studies are being completed to determine the optimal timing, depth and duration of hypothermia to optimize patient outcomes. Although a multidisciplinary approach is necessary in the CA population, neurologists and neurointensivists are central in selecting TTM candidates and guiding patient care and prognostic evaluation. Established prognostic tools include clinal exam, SSEP, EEG and MR imaging, while functional MRI and invasive monitoring is not validated to improve outcomes in CA or aid in prognosis. We recommend that an evidence-based TTM and prognostication algorithm be locally implemented, based on each institution's resources and limitations. Given the high incidence of CA and difficulty in predicting outcomes, further study is urgently needed to determine the utility of more recent multimodality devices and studies.
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Affiliation(s)
- Peggy L Nguyen
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Laith Alreshaid
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Roy A Poblete
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Geoffrey Konye
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jonathan Marehbian
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Gene Sung
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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29
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Seder DB, Riker RR. Understanding post-cardiac arrest myoclonus. Resuscitation 2018; 131:A3-A4. [PMID: 30086375 DOI: 10.1016/j.resuscitation.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/01/2018] [Indexed: 10/28/2022]
Affiliation(s)
- David B Seder
- Maine Medical Center Department of Critical Care Services and Neuroscience Institute, Portland, Maine, United States; Tufts University School of Medicine, Boston, Massachusetts, United States.
| | - Richard R Riker
- Maine Medical Center Department of Critical Care Services and Neuroscience Institute, Portland, Maine, United States; Tufts University School of Medicine, Boston, Massachusetts, United States
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30
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Giant somatosensory evoked potentials are uncommon in patients with post-anoxic coma and paroxysmal electroencephalographic activity. Neurophysiol Clin 2018. [DOI: 10.1016/j.neucli.2018.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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31
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Reynolds AS, Rohaut B, Holmes MG, Robinson D, Roth W, Velazquez A, Couch CK, Presciutti A, Brodie D, Moitra VK, Rabbani LE, Agarwal S, Park S, Roh DJ, Claassen J. Early myoclonus following anoxic brain injury. Neurol Clin Pract 2018; 8:249-256. [PMID: 30105165 DOI: 10.1212/cpj.0000000000000466] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 03/06/2018] [Indexed: 11/15/2022]
Abstract
Background It is unknown whether postanoxic cortical and subcortical myoclonus are distinct entities with different prognoses. Methods In this retrospective cohort study of 604 adult survivors of cardiac arrest over 8.5 years, we identified 111 (18%) patients with myoclonus. Basic demographics and clinical characteristics of myoclonus were collected. EEG reports, and, when available, raw video EEG, were reviewed, and all findings adjudicated by 3 authors blinded to outcomes. Myoclonus was classified as cortical if there was a preceding, time-locked electrographic correlate and otherwise as subcortical. Outcome at discharge was determined using Cerebral Performance Category. Results Patients with myoclonus had longer arrests with less favorable characteristics compared to patients without myoclonus. Cortical myoclonus occurred twice as often as subcortical myoclonus (59% vs 23%, respectively). Clinical characteristics during hospitalization did not distinguish the two. Rates of electrographic seizures were higher in patients with cortical myoclonus (43%, vs 8% with subcortical). Survival to discharge was worse for patients with myoclonus compared to those without (26% vs 39%, respectively), but did not differ between subcortical and cortical myoclonus (24% and 26%, respectively). Patients with cortical myoclonus were more likely to be discharged in a comatose state than those with subcortical myoclonus (82% vs 33%, respectively). Among survivors, good functional outcome at discharge was equally possible between those with cortical and subcortical myoclonus (12% and 16%, respectively). Conclusions Cortical and subcortical myoclonus are seen in every sixth patient with cardiac arrest and cannot be distinguished using clinical criteria. Either condition may have good functional outcomes.
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Affiliation(s)
- Alexandra S Reynolds
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - Benjamin Rohaut
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - Manisha G Holmes
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - David Robinson
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - William Roth
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - Angela Velazquez
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - Caroline K Couch
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - Alex Presciutti
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - Daniel Brodie
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - Vivek K Moitra
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - LeRoy E Rabbani
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - Sachin Agarwal
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - Soojin Park
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - David J Roh
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
| | - Jan Claassen
- Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York
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Shmuely S, Bauer PR, van Zwet EW, van Dijk JG, Thijs RD. Differentiating motor phenomena in tilt-induced syncope and convulsive seizures. Neurology 2018; 90:e1339-e1346. [DOI: 10.1212/wnl.0000000000005301] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 01/08/2018] [Indexed: 12/14/2022] Open
Abstract
ObjectiveWe assessed motor phenomena in syncope and convulsive seizures to aid differential diagnosis and understand the pathophysiologic correlates.MethodsWe studied video-EEG recordings of tilt-induced syncope and convulsive seizures in participants aged 15 years and older. Syncope was defined as (1) loss of consciousness (video-assessed), (2) circulatory changes (accelerating blood pressure decrease with or without bradycardia/asystole), and (3) EEG changes (“slow” or “slow-flat-slow”). We assessed myoclonic jerks and tonic postures of the arms and noted time of occurrence, laterality, synchrony, and rhythmicity (mean consecutive differences of interclonic intervals).ResultsVideo-EEG records of 65 syncope cases and 50 convulsive seizures were included. In syncope, postures occurred in 42 cases (65%) and jerks in 33 (51%). Fewer jerks occurred in syncope (median 2, range 1–19) compared to convulsive seizures (median 48, range 20–191; p < 0.001). Jerks were more rhythmic in seizures compared to syncope (p < 0.001). Atonia was seen in all syncope cases, while this was not observed in any seizure. Jerks predominantly occurred during the slow and postures during the flat EEG phase.ConclusionsJerks and tonic postures were common in syncope, but semiology differed from convulsive seizures. The lack of overlap in the number of jerks suggests that less than 10 indicates syncope and more than 20 a convulsive seizure: the “10/20 rule.” Loss of tone strongly favors syncope. The EEG correlates imply that jerks in syncope are likely of cortical origin, whereas tonic postures may result from brainstem disinhibition.
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van Zijl JC, Beudel M, de Jong BM, van der Naalt J, Zutt R, Lange F, van den Bergh WM, Elting JWJ, Tijssen MAJ. The interrelation between clinical presentation and neurophysiology of posthypoxic myoclonus. Ann Clin Transl Neurol 2018; 5:386-396. [PMID: 29687017 PMCID: PMC5899907 DOI: 10.1002/acn3.514] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 11/20/2017] [Indexed: 11/16/2022] Open
Abstract
Objective Posthypoxic myoclonus (PHM) in the first few days after resuscitation can be divided clinically into generalized and focal (uni‐ and multifocal) subtypes. The former is associated with a subcortical origin and poor prognosis in patients with postanoxic encephalopathy (PAE), and the latter with a cortical origin and better prognosis. However, use of PHM as prognosticator in PAE is hampered by the modest objectivity in its clinical assessment. Therefore, we aimed to obtain the anatomical origin of PHM with use of neurophysiological investigations, and relate these to its clinical presentation. Methods This study included 20 patients (56 ± 18 y/o, 68% M, 2 survived, 1 excluded) with EEG‐EMG‐video recording. Three neurologists classified PHM into generalized or focal PHM. Anatomical origin (cortical/subcortical) was assessed with basic and advanced neurophysiology (Jerk‐Locked Back Averaging, coherence analysis). Results Clinically assessed origin of PHM did not match the result obtained with neurophysiology: cortical PHM was more likely present in generalized than in focal PHM. In addition, some cases demonstrated co‐occurrence of cortical and subcortical myoclonus. Patients that recovered from PAE had cortical myoclonus (1 generalized, 1 focal). Interpretation Hypoxic damage to variable cortical and subcortical areas in the brain may lead to mixed and varying clinical manifestations of myoclonus that differ of those patients with myoclonus generally encountered in the outpatient clinic. The current clinical classification of PHM is not adequately refined to play a pivotal role in guiding treatment decisions to withdraw care. Our neurophysiological characterization of PHM provides specific parameters to be used in designing future comprehensive studies addressing the potential role of PHM as prognosticator in PAE.
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Affiliation(s)
- Jonathan C van Zijl
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Martijn Beudel
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Bauke M de Jong
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Joukje van der Naalt
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Rodi Zutt
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Fiete Lange
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands.,Department of Clinical Neurophysiology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Walter M van den Bergh
- Department of Critical Care University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Jan-Willem J Elting
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands.,Department of Clinical Neurophysiology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Marina A J Tijssen
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
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Kongpolprom N, Cholkraisuwat J. Neurological Prognostications for the Therapeutic Hypothermia among Comatose Survivors of Cardiac Arrest. Indian J Crit Care Med 2018; 22:509-518. [PMID: 30111926 PMCID: PMC6069316 DOI: 10.4103/ijccm.ijccm_500_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Currently, there are limited data of prognostic clues for neurological recovery in comatose survivors undergoing therapeutic hypothermia (TH). We aimed to evaluate clinical signs and findings that could predict neurological outcomes, and determine the optimal time for the prognostication. Materials and Methods We retrospectively reviewed database of postarrest survivors treated with TH in our hospital from 2006 to 2014. Cerebral performance category (CPC), neurological signs and findings in electroencephalography (EEG) and brain computed tomography (CT) were evaluated. In addition, the optimal time to evaluate neurological status was analyzed. Results TH was performed in 51 postarrest patients. Approximately 53% of TH patients survived at discharge and 33% of the hospital survivors had favorable outcome (CPC1-2). The prognostic clues for unfavorable outcome (CPC3-5) at discharge were lack of pupillary light response (PLR) and/or gag reflex after rewarming, and the absence of at least one of the brainstem reflexes, no eye-opening, or abnormal motor response on the 7th day. Myoclonus and seizure could not be used to indicate poor prognosis. In addition, prognostic values of EEG and CT findings were inconclusive. Conclusions Our study showed the simple neurological signs helped predict short-term neurological prognosis. The most reliable sign determining unfavorable outcome was the lack of PLR. The optimal time to assess prognosis was either at 48-72 h or 7 days after return of spontaneous circulation.
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Affiliation(s)
- Napplika Kongpolprom
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Thailand
| | - Jiraphat Cholkraisuwat
- Division of Pulmonary and Critical Care Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Thailand
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Mikhaeil-Demo Y, Gavvala JR, Bellinski II, Macken MP, Narechania A, Templer JW, VanHaerents S, Schuele SU, Gerard EE. Clinical classification of post anoxic myoclonic status. Resuscitation 2017; 119:76-80. [DOI: 10.1016/j.resuscitation.2017.07.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/17/2017] [Accepted: 07/31/2017] [Indexed: 11/26/2022]
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Abstract
Prognostication after cardiac arrest often depends primarily on neurological function, and characterizing the extent of neurological injury hinges on neurophysiological testing and clinical neurological examination. The presence of early posthypoxic myoclonus (PHM) following cardiac arrest had been invariably associated with poor outcome, but more recent studies have shown that those with early PHM may survive with good neurological function. Electroencephalographic patterns suggestive of severe brain injury may be more valuable than the presence of PHM itself in portending poor functional status, and phenotyping PHM may also be useful in delineating benign and malignant forms. Patients with early PHM should be evaluated similarly to others who suffer cardiac arrest by using a multimodal approach in determining prognosis until further studies are performed that better characterize early PHM subtypes and their outcomes.
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Affiliation(s)
- Brin Freund
- 1Johns Hopkins Hospital, Department of Neurology, Baltimore, MD
| | - Peter W. Kaplan
- 2Johns Hopkins Bayview Medical Center, Department of Neurology, Baltimore, MD
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You KM, Suh GJ, Kwon WY, Kim KS, Ko SB, Park MJ, Kim T, Ko JI. Epileptiform discharge detection with the 4-channel frontal electroencephalography during post-resuscitation care. Resuscitation 2017; 117:8-13. [DOI: 10.1016/j.resuscitation.2017.05.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/11/2017] [Accepted: 05/12/2017] [Indexed: 11/17/2022]
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Postreanimationsbehandlung. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0331-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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van Zijl JC, Beudel M, Elting JWJ, de Jong BM, van der Naalt J, van den Bergh WM, Rossetti AO, Tijssen MAJ, Horn J. The Inter-rater Variability of Clinical Assessment in Post-anoxic Myoclonus. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2017; 7:470. [PMID: 28966876 PMCID: PMC5618111 DOI: 10.7916/d81r6xbv] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 06/01/2017] [Indexed: 12/01/2022]
Abstract
Background Acute post-anoxic myoclonus (PAM) can be divided into an unfavorable (generalized/subcortical) and more favorable ((multi)focal/cortical) outcome group that could support prognostication in post-anoxic encephalopathy; however, the inter-rater variability of clinically assessing these PAM subtypes is unknown. Methods We prospectively examined PAM patients using a standardized video protocol. Videos were rated by three neurologists who classified PAM phenotype (generalized/(multi)focal), stimulus sensitivity, localization (proximal/distal/both), and severity (Clinical Global Impression-Severity Scale (CGI-S) and Unified Myoclonus Rating Scale (UMRS)). Results Poor inter-rater agreement was found for phenotype and stimulus sensitivity (κ=−0.05), moderate agreement for localization (κ=0.46). Substantial agreement was obtained for the CGI-S (intraclass correlation coefficient (ICC)=0.64) and almost perfect agreement for the UMRS (ICC=0.82). Discussion Clinical assessment of PAM is not reproducible between physicians, and should therefore not be used for prognostication. PAM severity measured by the UMRS appears to be reliable; however, the relation between PAM severity and outcome is unknown.
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Affiliation(s)
- Jonathan C van Zijl
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Martijn Beudel
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Jan-Willem J Elting
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands.,Department of Clinical Neurophysiology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Bauke M de Jong
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Walter M van den Bergh
- Intensive Care Medicine, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Marina A J Tijssen
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Janneke Horn
- Intensive Care Medicine, Amsterdam Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
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Freund B, Kaplan PW. Post-hypoxic myoclonus: Differentiating benign and malignant etiologies in diagnosis and prognosis. Clin Neurophysiol Pract 2017; 2:98-102. [PMID: 30214979 PMCID: PMC6123861 DOI: 10.1016/j.cnp.2017.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/15/2017] [Accepted: 03/17/2017] [Indexed: 01/19/2023] Open
Abstract
Myoclonus status epilepticus may be reflected by generalized epileptiform discharges and burst suppression on EEG. Patients with Lance-Adams syndrome often demonstrate focal epileptiform activity at the vertex on EEG. EEG is vital in evaluating post-hypoxic myoclonus; studies are needed to assess its utility in predicting outcomes.
Neurological function following cardiac arrest often determines prognosis. Objective tests, including formal neurological examination and neurophysiological testing, are performed to provide medical providers and decision-makers information to help guide care based on the extent of neurologic injury. The demonstration of post-hypoxic myoclonus on examination has been described to portend poor outcome after cardiac arrest, but recent studies have challenged this idea given that different forms of post-hypoxic myoclonus predict disparate prognoses. The presence of myoclonus status epilepticus (MSE) usually signals a poor outcome, especially if generalized. Lance-Adams syndrome (LAS), another form of post-hypoxic myoclonus, carries a better prognosis. Differentiating subtypes of post-hypoxic myoclonus is therefore critical. This can be difficult in the acute setting with clinical examination alone due to the use of sedation to facilitate mechanical ventilation, and neurophysiological studies may be more reliable. In this review, we describe and compare clinical and neurophysiological features of MSE and LAS. Generalized epileptiform activity and burst suppression on electroencephalography tend to be more common in MSE, and focal epileptiform activity at the vertex may define LAS. Those with multifocal MSE may have better outcomes than those with generalized MSE. We conclude that neurophysiological testing is vital acutely after cardiac arrest when post-hypoxic myoclonus is present to help determine prognostication and guide decision-making.
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Affiliation(s)
- Brin Freund
- Johns Hopkins Hospital, Department of Neurology, Baltimore, MD, USA
| | - Peter W Kaplan
- Johns Hopkins Bayview Medical Center, Department of Neurology, Baltimore, MD, USA
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Lybeck A, Friberg H, Aneman A, Hassager C, Horn J, Kjærgaard J, Kuiper M, Nielsen N, Ullén S, Wise MP, Westhall E, Cronberg T. Prognostic significance of clinical seizures after cardiac arrest and target temperature management. Resuscitation 2017; 114:146-151. [DOI: 10.1016/j.resuscitation.2017.01.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/20/2017] [Accepted: 01/22/2017] [Indexed: 11/25/2022]
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Prognosis of neurologic complications in critical illness. HANDBOOK OF CLINICAL NEUROLOGY 2017. [PMID: 28190446 DOI: 10.1016/b978-0-444-63599-0.00041-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Neurologic complications of critical illness require extensive clinical and neurophysiologic evaluation to establish a reliable prognosis. Many sequelae of intensive care unit (ICU) treatment, such as delirium and ICU-acquired weakness, although highly associated with adverse outcomes, are less suitable for prognostication, but should rather prompt clinicians to seek previously unnoticed persisting underlying illnesses. Prognostication can be confounded by drug administration particularly because its clearance is abnormal in critical illness. Some neurological complications are severe, and can last for months or years after discharge from ICU. The most important ethical aspects regarding neurologic complications in critically ill patients are prevention, recognition, and identification, and prevention of self-fulfilling prophecies. This chapter summarizes the tool of prognostication of major neurological complications of critical illness.
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Reynolds AS, Holmes MG, Agarwal S, Claassen J. Phenotypes of early myoclonus do not predict outcome. Ann Neurol 2017; 81:475-476. [DOI: 10.1002/ana.24890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 11/29/2016] [Accepted: 12/01/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Alexandra S. Reynolds
- Division of Neurocritical Care; Department of Neurology, Columbia University Medical Center
| | - Manisha G. Holmes
- Division of Epilepsy; Department of Neurology, NYU Langone Medical Center; New York NY
| | - Sachin Agarwal
- Division of Neurocritical Care; Department of Neurology, Columbia University Medical Center
| | - Jan Claassen
- Division of Neurocritical Care; Department of Neurology, Columbia University Medical Center
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Taccone FS, Baar I, De Deyne C, Druwe P, Legros B, Meyfroidt G, Ossemann M, Gaspard N. Neuroprognostication after adult cardiac arrest treated with targeted temperature management: task force for Belgian recommendations. Acta Neurol Belg 2017; 117:3-15. [PMID: 28168412 DOI: 10.1007/s13760-017-0755-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/25/2017] [Indexed: 12/27/2022]
Abstract
The prognosis of patients who are admitted to the hospital after cardiac arrest often relies on neurological examination, which could be significantly influenced by the use of sedative drugs or the implementation of targeted temperature management. The need for early and accurate prognostication is crucial as up to 15-20% of patients could be considered as having a poor outcome and may undergo withdrawal of life-sustaining therapies while a complete neurological recovery is still possible. As current practice in Belgium is still based on a very early assessment of neurological function in these patients, the Belgian Society of Intensive Care Medicine created a multidisciplinary Task Force to provide an optimal approach for monitoring and refine prognosis of CA survivors. This Task Force underlined the importance to use a multimodal approach using several additional tools (e.g., electrophysiological tests, neuroimaging, biomarkers) and to refer cases with uncertain prognosis to specialized centers to better evaluate the extent of brain injury in these patients.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Ingrid Baar
- Department of Neurology, Antwerp University Hospital, 2650, Edegem, Belgium
| | - Cathy De Deyne
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg ZOL, Schiepse Bos 6, 3600, Genk, Belgium
| | - Patrick Druwe
- Department of Intensive Care, Ghent University Hospital, De Pintelaan, 185, 9000, Ghent, Belgium
| | - Benjamin Legros
- Department of Neurology, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Geert Meyfroidt
- Department of Intensive Care, UZ Leuven, Herestraat 49, box 7003 63, 3000, Leuven, Belgium
| | - Michel Ossemann
- Department of Neurology, CHU UCL Namur, Université Catholique de Louvain, Avenue Gaston Thérasse, 1, 5530, Yvoir, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
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Abstract
Acute posthypoxic myoclonus portends a poor prognosis. Another form of posthypoxic myoclonus, Lance-Adams syndrome, is associated with a better outcome. Differentiating these two entities is important in prognostication and guiding further medical intervention. This can be difficult in the acute setting after hypoxic brain injury but the use of neurophysiologic studies may be helpful. In this article, we present a case of a patient who presented after pulseless electrical activity arrest, underwent targeted temperature management and subsequently developed Lance-Adams syndrome. The neurologic and electroencephalographic findings in Lance-Adams syndrome are discussed with an updated review.
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Affiliation(s)
- Brin Freund
- 1 Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Raoul Sutter
- 2 Department of Neurology and Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Peter W Kaplan
- 3 Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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The Benefit of Neuromuscular Blockade in Patients with Postanoxic Myoclonus Otherwise Obscuring Continuous Electroencephalography (CEEG). Crit Care Res Pract 2017; 2017:2504058. [PMID: 28265468 PMCID: PMC5317108 DOI: 10.1155/2017/2504058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/08/2017] [Accepted: 01/18/2017] [Indexed: 12/04/2022] Open
Abstract
Introduction. Myoclonus status epilepticus is independently associated with poor outcome in coma patients after cardiac arrest. Determining if myoclonus is of cortical origin on continuous electroencephalography (CEEG) can be difficult secondary to the muscle artifact obscuring the underlying CEEG. The use of a neuromuscular blocker can be useful in these cases. Methods. Retrospective review of CEEG in patients with postanoxic myoclonus who received cisatracurium while being monitored. Results. Twelve patients (mean age: 53.3 years; 58.3% male) met inclusion criteria of clinical postanoxic myoclonus. The initial CEEG patterns immediately prior to neuromuscular blockade showed myoclonic artifact with continuous slowing (50%), burst suppression with myoclonic artifact (41.7%), and continuous myogenic artifact obscuring CEEG (8.3%). After intravenous administration of cisatracurium (0.1 mg–2 mg), reduction in artifact improved quality of CEEG recordings in 9/12 (75%), revealing previously unrecognized patterns: continuous EEG seizures (33.3%), lateralizing slowing (16.7%), burst suppression (16.7%), generalized periodic discharges (8.3%), and, in the patient who had an initially uninterpretable CEEG from myogenic artifact, continuous slowing. Conclusion. Short-acting neuromuscular blockade is useful in determining background cerebral activity on CEEG otherwise partially or completely obscured by muscle artifact in patients with postanoxic myoclonus. Fully understanding background cerebral activity is important in prognostication and treatment, particularly when there are underlying EEG seizures.
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Levy ZD. Exam 3 Questions. ABSOLUTE NEUROCRITICAL CARE REVIEW 2017. [PMCID: PMC7123328 DOI: 10.1007/978-3-319-64632-9_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Which of thefollowing is true regarding the Barrow classification system for carotid cavernous fistulae?Type A shunts are indirect shunts between branches of the internal carotid artery (ICA) and cavernous sinus Type B shunts are direct shunts between the ICA and cavernous sinus Type C shunts are indirect shunts between branches of the external carotid artery (ECA) and cavernous sinus Type D shunts are high-flow shunts All of the above
A 80-year-old male with an intracranial neoplasm presents to the emergency department with weight loss, drowsiness, and tachypnea for 1 month. On examination, his respiratory rate is 28 breaths/minute with a normal oxygen saturation. His lungs are clear to auscultation. An arterial blood gas reveals the following: pH 7.60, PCO2 14 mmHg, PaO2 115 mmHg. A chest x-ray, bedside echocardiogram, and EKG are all unremarkable. No other pulmonary, metabolic, or pharmacologic etiologies for the breathing pattern are found. What is the most likely diagnosis?Central neurogenic hyperventilation Cheyne-Stokes respirations Apneustic breathing Ataxic breathing Cluster breathing
A 48-year-old female is admitted to the ICU with a Hunt-Hess 2 modified Fisher 2 subarachnoid hemorrhage (SAH). She remains intact neuro-cognitively, but has transcranial doppler (TCD) mean flow velocities up to 150 cm/s, and a serum platelet count twice her baseline. You are worried about vasospasm and impending delayed cerebral ischemia. Which of the following should be performed next?An additional 100 mL/h of normal saline should be given on top of maintenance fluids CT perfusion scan to assess for any ongoing hypoperfusion Evaluate volume status with hemodynamic monitoring and give fluid boluses accordingly Induce hypertension to a systolic pressure of 160 mmHg Conventional angiography
A 25-year-old male is currently in the ICU with an anoxic brain injury after diving into shallow waters and suffering a high cervical cord transection. Two weeks after his injury, he remains comatose, has diffuse loss of gray-white differentiation on noncontrast head CT, and exhibits myoclonic status epilepticus. The family is devastated by his poor prognosis, and distraught by his uncontrollable shaking. What is your rationale behind your decision about starting an antiepileptic regimen?Phenytoin and propofol will be used, and escalated until eradication of his myoclonus to assess his underlying brain damage Levetiracetam and lacosamide will be used, and escalated until eradication of his myoclonus to assess his underlying brain damage If EEG reveals dyssynchronous spikes on a severely slow background, myoclonus invariably portends death or a vegetative state, and midazolam should only be used for palliative purposes Regardless of EEG or clinical exam, half of patients in myoclonic status epilepticus will have a good neurologic recovery by 90 days Regardless of EEG or clinical exam, myoclonic status epilepticus is always ominous, not amenable to treatment. and should lead to immediate withdrawal of life-support
An 18-year-old female presents to the emergency department with several months of progressive left-sided hearing loss and tinnitus. An MRI of the brain is performed, demonstrating bilateral enhancing dumbbell shaped lesions extending from the auditory canal to the cerebellopontine angle. Which of the following genetic disorders is associated with this finding?Von Hippel-Lindau syndrome Neurofibromatosis type II Tuberous sclerosis Schwannomatosis Alport syndrome
A 23-year-old female is brought to the emergency department by her boyfriend with difficulty breathing. She cannot provide her history, but her boyfriend states that she has asthma, although he is unsure of her medications. On physical exam the woman is noted to have nasal flaring, is diaphoretic, cannot lie flat, and is breathing at a rate of 40 breaths/minute. She is given short acting ß2 agonist treatments with no obvious relief of her symptoms. Serial arterial blood gases are done and show a pCO2 that has increased from 25 to 40. What is the next best step in the patient’s management?Continue short-acting ß2 agonist treatment, as her pCO2 is normalizing, and continue observation in the emergency department Intubate the patient and admit to the ICU Administer intravenous corticosteroids and admit to the general medical ward Place the patient on non-invasive positive pressure ventilation and admit to the general medical ward Administer a long-acting ß2 agonist agent and admit to the general medical ward
Cerebellar hypoplasia without displacement through the foramen magnum is best described as a:Chiari I malformation Chiari II malformation Chiari III malformation Chiari IV malformation Chiari V malformation
A 77-year-old female with a history of hypertension, atrial fibrillation, and diabetes mellitus has recently been taken off of warfarin due to frequent falls and gait instability. She has not had any prior significant bleeding or ischemic events. A recent echocardiogram demonstrates moderate aortic regurgitation with grossly preserved systolic and diastolic function. Which of the following elements is not a stroke risk factor in this patient?Age Female gender Hypertension Diabetes mellitus Aortic regurgitation
Which of the following is the most effective measure to prevent aspiration in an intubated patient?Elevation of the head of the bed Subglottic drainage Gastric volume monitoring Nasogastric tube placement Percutaneous endoscopic gastrotomy
Which of the following is a unique feature of Comprehensive Stroke Centers?Dedicated stroke unit availability 24/7 ability to administer tPA 24/7 interventional neuroradiology availability 24/7 CT angiography availability Ambulance receiving capability
Which of the following segments of the internal carotid artery is farthest from it’s origin?Ophthalmic segment Petrous segment Cavernous segment Clinoid segment Lacerum segment
A 44-year-old male is intubated secondary to a high-grade subarachnoid hemorrhage, and is admitted to the ICU. On the sixth postoperative day, he develops worsening hypoxemia and bilateral interstitial infiltrates on his chest x-ray, consistent with acute respiratory distress syndrome (ARDS). Which of the following interventions has not been demonstrated to improve outcomes in ARDS in a prospective randomized trial?Prone positioning Lung-protective ventilation Extracorporeal membrane oxygenation (ECMO) Neuromuscular blocking agents High-frequency oscillatory ventilation (HFOV)
A 56-year-old female is currently intubated in the ICU following a left basal ganglia hemorrhage. The nurse reports the patient is having copious thick secretions, and you are considering initiating inhaled N-acetylcysteine therapy. What element of the patient’s past medical history may serve as a relative contraindication to this treatment?Amiodarine-induced pulmonary fibrosis Newly diagnosed metastatic adenocarcinoma of the lung Recent course of outpatient antibiotics for community-acquired pneumonia Poorly controlled asthma All of the above
An 18-year-old female is currently being evaluated for amenorrhea. In addition, she endorses fatigue, cold intolerance, polyuria and dizziness upon standing. On examination, she is thin but appears well hydrated. Blood pressure and heart rate when supine are 90/60 mmHg and 80 beats/minute, respectively. When standing, they are 60/40 mmHg and 120 beats/minute, respectively. Pubic and axillary hair growth is sparse. Eye examination reveals an asymmetric bitemporal hemianopsia. Imaging reveals a cystic, calcified suprasellar mass. Which of the following statements is true regarding the most likely diagnosis?Medical management is the mainstay of treatment Recovery of pituitary function is common This patient likely has the papillary subtype of this neoplasm This neoplasm has a bimodal age distribution This neoplasm arises from modified glial cells that reside in the infundibular neurohypophysis
A 55-year-old female presents to the emergency department after collapsing at home. The patient was arguing with her husband before she suddenly became unresponsive. The patient is intubated, and a non-contrast head CT is performed (see Image 1). The patient then undergoes conventional angiography, revealing occlusion of the proximal bilateral middle cerebral and anterior cerebral arteries with extensive collateral vessels noted. All of the following are true regarding the most likely diagnosis except:The disease can be either congenital or acquired Patients may suffer recurrent infarcts, or remain completely asymptomatic There are no effective surgical interventions available It is more commonly seen in women than in men Patients may initially present with persistent headaches
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Mulder M, Geocadin RG. Neurology of cardiopulmonary resuscitation. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:593-617. [PMID: 28190437 DOI: 10.1016/b978-0-444-63599-0.00032-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This chapter aims to provide an up-to-date review of the science and clinical practice pertaining to neurologic injury after successful cardiopulmonary resuscitation. The past two decades have seen a major shift in the science and practice of cardiopulmonary resuscitation, with a major emphasis on postresuscitation neurologic care. This chapter provides a nuanced and thoughtful historic and bench-to-bedside overview of the neurologic aspects of cardiopulmonary resuscitation. A particular emphasis is made on the anatomy and pathophysiology of hypoxic-ischemic encephalopathy, up-to-date management of survivors of cardiopulmonary resuscitation, and a careful discussion on neurologic outcome prediction. Guidance to practice evidence-based clinical care when able and thoughtful, pragmatic suggestions for care where evidence is lacking are also provided. This chapter serves as both a useful clinical guide and an updated, thorough, and state-of-the-art reference on the topic for advanced students and experienced practitioners in the field.
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Affiliation(s)
- M Mulder
- Department of Critical Care and the John Nasseff Neuroscience Institute, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN, USA
| | - R G Geocadin
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine and Departments of Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abstract
Complications involving the central and peripheral nervous system are frequently encountered in critically ill patients. All components of the neuraxis can be involved including the brain, spinal cord, peripheral nerves, neuromuscular junction, and muscles. Neurologic complications adversely impact outcome and length of stay. These complications can be related to underlying critical illness, pre-existing comorbid conditions, and commonly used and life-saving procedures and medications. Familiarity with the myriad neurologic complications that occur in the intensive care unit can facilitate their timely recognition and treatment. Additionally, awareness of treatment-related neurologic complications may inform decision-making, mitigate risk, and improve outcomes.
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA
| | - Sean Ruland
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA.
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Leão RN, Ávila P, Cavaco R, Germano N, Bento L. Therapeutic hypothermia after cardiac arrest: outcome predictors. Rev Bras Ter Intensiva 2016; 27:322-32. [PMID: 26761469 PMCID: PMC4738817 DOI: 10.5935/0103-507x.20150056] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/06/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The determination of coma patient prognosis after cardiac arrest has clinical, ethical and social implications. Neurological examination, imaging and biochemical markers are helpful tools accepted as reliable in predicting recovery. With the advent of therapeutic hypothermia, these data need to be reconfirmed. In this study, we attempted to determine the validity of different markers, which can be used in the detection of patients with poor prognosis under hypothermia. METHODS Data from adult patients admitted to our intensive care unit for a hypothermia protocol after cardiac arrest were recorded prospectively to generate a descriptive and analytical study analyzing the relationship between clinical, neurophysiological, imaging and biochemical parameters with 6-month outcomes defined according to the Cerebral Performance Categories scale (good 1-2, poor 3-5). Neuron-specific enolase was collected at 72 hours. Imaging and neurophysiologic exams were carried out in the 24 hours after the rewarming period. RESULTS Sixty-seven patients were included in the study, of which 12 had good neurological outcomes. Ventricular fibrillation and electroencephalographic theta activity were associated with increased likelihood of survival and improved neurological outcomes. Patients who had more rapid cooling (mean time of 163 versus 312 minutes), hypoxic-ischemic brain injury on magnetic resonance imaging or neuron-specific enolase > 58ng/mL had poor neurological outcomes (p < 0.05). CONCLUSION Hypoxic-ischemic brain injury on magnetic resonance imaging and neuron-specific enolase were strong predictors of poor neurological outcomes. Although there is the belief that early achievement of target temperature improves neurological prognoses, in our study, there were increased mortality and worse neurological outcomes with earlier target-temperature achievement.
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Affiliation(s)
- Rodrigo Nazário Leão
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Paulo Ávila
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Raquel Cavaco
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Nuno Germano
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Luís Bento
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
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