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Chapter 10 - Hypoxic–Ischemic Brain Injury after Cardiac Arrest

Published online by Cambridge University Press:  27 May 2021

Matthew N. Jaffa
Affiliation:
Hartford Hospital, Connecticut
David Y. Hwang
Affiliation:
Yale University, Connecticut
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Summary

Mr. Jones is a 65-year-old man with a past medical history of coronary artery disease who is admitted after an unwitnessed pulseless electrical activity arrest at home. He achieved return of spontaneous circulation (ROSC) in the emergency department but now remains unconscious. Upon transfer to the intensive care unit, he is intubated, sedated, and undergoing targeted temperature management (TTM) targeting 36˚C. Over the next few days, sedation is discontinued as he completes TTM and controlled rewarming. Twenty-four hours after restoration of normothermia, he remains unconscious. His clinical examination is unchanged from prior: preserved pupillary and corneal reflexes bilaterally and a reflexive flexor response to painful stimuli. Continuous electroencephalography (EEG) reveals no seizures, preserved continuity, and unclear background reactivity to stimulation (Figure 10.1). Brain magnetic resonance imaging (MRI), obtained on day 4, is notable for restricted diffusion in the bilateral primary sensory cortices (Figure 10.2). Mr. Jones’s family requests a meeting to discuss his chances of achieving a “meaningful recovery.”

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Publisher: Cambridge University Press
Print publication year: 2021

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References

Benjamin, E.J., Muntner, P., Alonso, A., et al. Heart disease and stroke statistics-2019 update: a Report From the American Heart Association. Circulation, 2019; 139(10): e56e528.Google Scholar
Xiong, Y., Zhan, H., Lu, Y., et al. Out-of-hospital cardiac arrest without return of spontaneous circulation in the field: Who are the survivors? Resuscitation, 2017; 112: 2833.CrossRefGoogle ScholarPubMed
Rajan, S., Folke, F., Hansen, S.M., et al. Incidence and survival outcome according to heart rhythm during resuscitation attempt in out-of-hospital cardiac arrest patients with presumed cardiac etiology. Resuscitation, 2017; 114: 157–63.CrossRefGoogle ScholarPubMed
Wang, C.H., Huang, C.H., Chang, W.T., et al. Monitoring of serum lactate level during cardiopulmonary resuscitation in adult in-hospital cardiac arrest. Critical Care, 2015; 19: 344.Google Scholar
Lee, T.R., Kang, M.J., Cha, W.C., et al. Better lactate clearance associated with good neurologic outcome in survivors who treated with therapeutic hypothermia after out-of-hospital cardiac arrest. Critical Care, 2013; 17(5): R260.CrossRefGoogle ScholarPubMed
Huang, C.H., Tsai, M.S., Ong, H.N., W. et al. Association of hemodynamic variables with in-hospital mortality and favorable neurological outcomes in post-cardiac arrest care with targeted temperature management. Resuscitation, 2017; 120: 146–52.CrossRefGoogle ScholarPubMed
Nobile, L., Taccone, F.S., Szakmany, T., et al. The impact of extracerebral organ failure on outcome of patients after cardiac arrest: an observational study from the ICON database. Critical Care, 2016; 20(1): 368.CrossRefGoogle ScholarPubMed
Rossetti, A. O., Carrera, E., Oddo, M.. Early EEG correlates of neuronal injury after brain anoxia. Neurology, 2012; 78(11): 796802.Google Scholar
van den Brule, J.M., Vinke, E., van Loon, L.M., et al. Middle cerebral artery flow, the critical closing pressure, and the optimal mean arterial pressure in comatose cardiac arrest survivors: an observational study. Resuscitation, 2017; 110: 85–9.Google Scholar
Lemiale, V., Huet, O., Vigue, B., et al. Changes in cerebral blood flow and oxygen extraction during post-resuscitation syndrome. Resuscitation, 2008; 76(1): 1724.CrossRefGoogle ScholarPubMed
van Putten, M.J., Hofmeijer, J.. Generalized periodic discharges: pathophysiology and clinical considerations. Epilepsy & Behavior: E&B 2015; 49: 228–33.Google Scholar
van Putten, M.J., Hofmeijer, J.. EEG monitoring in cerebral ischemia: basic concepts and clinical applications. Journal of Clinical Neurophysiology, 2016; 33(3): 203–10.CrossRefGoogle ScholarPubMed
Bernard, S.A., Gray, T.W., Buist, M.D., et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. New England Journal of Medicine, 2002; 346(8): 557–63.CrossRefGoogle ScholarPubMed
Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. New England Journal of Medicine, 2002; 346(8): 549–56.Google Scholar
Nielsen, N., Wetterslev, J., Cronberg, T., et al. Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. New England Journal of Medicine, 2013; 369(23): 2197–206.CrossRefGoogle Scholar
Lascarrou, J.B., Merdji, H., Le Gouge, A., et al. Targeted temperature management for cardiac arrest with nonshockable rhythm. New England Journal of Medicine,. 2019; 381: 2327–37.CrossRefGoogle ScholarPubMed
Safar, P.. Resuscitation after brain ischemia. Brain Failure and Resuscitation, 1981; 155: 184.Google Scholar
Sandroni, C., Cavallaro, F., Callaway, C.W., et al. Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermia. Resuscitation, 2013; 84(10): 1324–38.Google Scholar
Sandroni, C., Cavallaro, F., Callaway, C.W., et al. Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: A systematic review and meta-analysis. Part 1: Patients not treated with therapeutic hypothermia. Resuscitation, 2013; 84(10): 1310–23.Google Scholar
Oddo, M., Sandroni, C., Citerio, G., et al. Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study. Intensive Care Medicine, 2018; 44(12): 2102–11.CrossRefGoogle ScholarPubMed
Maciel, C.B., Youn, T.S., Barden, M.M., et al. Corneal reflex testing in the evaluation of a comatose patient: an ode to precise semiology and exmination skills. Neurocritical Care, 2020; 33(2): 399404.Google Scholar
Beretta, S., Coppo, A., Bianchi, E., et al. Neurologic outcome of postanoxic refractory status epilepticus after aggressive treatment. Neurology, 2018; 91(23): e2153–e62.CrossRefGoogle ScholarPubMed
Elmer, J., Rittenberger, J.C., Faro, J., et al. Clinically distinct electroencephalographic phenotypes of early myoclonus after cardiac arrest. Annals of Neurology, 2016; 80(2): 175–84.Google Scholar
Nolan, J.P., Soar, J., Cariou, A., et al. European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care. Intensive Care Medicine, 2015; 41(12): 2039–56.Google Scholar
Maciel, C.B., Morawo, A.O., Tsao, C.Y., et al. SSEP in Therapeutic Hypothermia Era. Journal of Clinical Neurophysiology, 2017; 34(5): 469–75.Google Scholar
Cristia, C., Ho, M.L., Levy, S., et al. The association between a quantitative computed tomography (CT) measurement of cerebral edema and outcomes in post-cardiac arrest-a validation study. Resuscitation, 2014; 85(10): 1348–53.CrossRefGoogle ScholarPubMed
Greer, D., Scripko, P., Bartscher, J., et al. Clinical MRI interpretation for outcome prediction in cardiac arrest. Neurocritical Care, 2012; 17(2): 240–4.CrossRefGoogle ScholarPubMed
Oddo, M., Rossetti, A.O.. Early multimodal outcome prediction after cardiac arrest in patients treated with hypothermia. Critical Care Medicine, 2014; 42(6): 1340–7.CrossRefGoogle ScholarPubMed
Wiberg, S., Hassager, C., Stammet, P., et al. Single versus serial measurements of neuron-specific enolase and prediction of poor neurological outcome in persistently unconscious patients after out-of-hospital cardiac arrest - A TTM-Trial Substudy. PLoS ONE, 2017; 12(1): e0168894.Google Scholar
Moseby-Knappe, M., Mattsson, N., Nielsen, N., et al. Serum neurofilament light chain for prognosis of outcome after cardiac arrest. JAMA Neurology, 2019; 76(1): 6471.CrossRefGoogle ScholarPubMed
Wijdicks, E.F., Hijdra, A., Young, G.B., et al. Quality Standards Subcommittee of the American Academy of N. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 2006; 67(2): 203–10.Google Scholar
Panchal, A.R., Bartos, J.A., Cabañas, J.G., et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2020; 142(16 Suppl 2): S366–468.CrossRefGoogle ScholarPubMed
Zhou, S.E., Maciel, C.B., Ormseth, C.H., et al. Distinct predictive values of current neuroprognostic guidelines in post-cardiac arrest patients. Resuscitation, 2019; 139: 343–50.Google Scholar
Geocadin, R.G., Peberdy, M.A., Lazar, R.M.. Poor survival after cardiac arrest resuscitation: a self-fulfilling prophecy or biologic destiny?. Critical Care Medicine, 2012; 40(3): 979–80.CrossRefGoogle ScholarPubMed
Grossestreuer, A.V., Abella, B.S., Leary, M., et al. Time to awakening and neurologic outcome in therapeutic hypothermia-treated cardiac arrest patients. Resuscitation, 2013; 84(12): 1741–6.CrossRefGoogle ScholarPubMed
Zanyk-McLean, K., Sawyer, K.N., Paternoster, R., et al. Time to awakening is often delayed in patients who receive targeted temperature management after cardiac arrest. Therapeutic Hypothermia and Temperature Management, 2017; 7(2): 95100.CrossRefGoogle ScholarPubMed
Greer, D.M.. Unexpected good recovery in a comatose post-cardiac arrest patient with poor prognostic features. Resuscitation, 2013; 84(6): e81–2.Google Scholar
Cronberg, T., Brizzi, M., Liedholm, L.J., et al. Neurological prognostication after cardiac arrest--Recommendations from the Swedish Resuscitation Council. Resuscitation, 2013; 84(7): 867–72.Google Scholar

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