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Cardiac arrest survivors suffer the repercussions of anoxic brain injury, a critical factor influencing long-term prognosis. This injury is characterised by profound and enduring metabolic impairment. Ketone bodies, an alternative energetic resource in physiological states such as exercise, fasting, and extended starvation, are avidly taken up and used by the brain. Both the ketogenic diet and exogenous ketone supplementation have been associated with neuroprotective effects across a spectrum of conditions. These include refractory epilepsy, neurodegenerative disorders, cognitive impairment, focal cerebral ischemia, and traumatic brain injuries. Beyond this, ketone bodies possess a plethora of attributes that appear to be particularly favourable after cardiac arrest. These encompass anti-inflammatory effects, the attenuation of oxidative stress, the improvement of mitochondrial function, a glucose-sparing effect, and the enhancement of cardiac function. The aim of this manuscript is to appraise pertinent scientific literature on the topic through a narrative review. We aim to encapsulate the existing evidence and underscore the potential therapeutic value of ketone bodies in the context of cardiac arrest to provide a rationale for their use in forthcoming translational research efforts. [ABSTRACT FROM AUTHOR]

Emerging science continues to establish the detrimental effects of malnutrition in acute neurological diseases such as traumatic brain injury, stroke, status epilepticus and anoxic brain injury. The primary pathological pathways responsible for secondary brain injury include neuroinflammation, catabolism, immune suppression and metabolic failure, and these are exacerbated by malnutrition. Given this, there is growing interest in novel nutritional interventions to promote neurological recovery after acute brain injury. In this review, we will describe how malnutrition impacts the biomolecular mechanisms of secondary brain injury in acute neurological disorders, and how nutritional status can be optimized in both pediatric and adult populations. We will further highlight emerging therapeutic approaches, including specialized diets that aim to resolve neuroinflammation, immunodeficiency and metabolic crisis, by providing pre-clinical and clinical evidence that their use promotes neurologic recovery. Using nutrition as a targeted treatment is appealing for several reasons that will be discussed. Given the high mortality and both short- and long-term morbidity associated with acute brain injuries, novel translational and clinical approaches are needed. [ABSTRACT FROM AUTHOR]

Diffuse cortical diffusion changes on magnetic resonance imaging (MRI) are characteristically ascribed to global cerebral anoxia, typically after cardiac arrest. Far from being pathognomonic, however, this neuroimaging finding is relatively nonspecific, and can manifest in a myriad of disease states including hypoxia, metabolic derangements, infections, seizure, toxic exposures, and neuroinflammation. While these various conditions can all produce a neuroimaging pattern of widespread cortical diffusion restriction, many of these underlying causes do have subtly unique imaging features that are appreciable on MRI and can be of clinical and diagnostic utility. Specific populations of neurons are variably sensitive to certain types of injury, whether due to differences in perfusion, receptor type density, or the unique tropisms of infectious organisms. In this narrative review, we discuss a number of distinct etiologies of diffuse cortical diffusion restriction on MRI, the unique pathophysiologies responsible for tissue injury, and the resulting neuroimaging characteristics that can be of assistance in differentiating them. As widespread cortical injury from any cause often presents with altered mental status or coma, the differential diagnosis can be enhanced with rapid acquisition of MRI when clinical history or detailed physical examination is limited. In such settings, the distinct imaging features discussed in this article are of interest to both the clinician and the radiologist. [ABSTRACT FROM AUTHOR]

Palliative care (PC) teams commonly encounter patients with disorders of consciousness (DOC) following anoxic or traumatic brain injury (TBI). Primary teams may consult PC to help surrogates in making treatment choices for these patients. PC clinicians must understand the complexity of predicting neurologic outcomes, address clinical nihilism, and appropriately guide surrogates in making decisions that are concordant with patients' goals. The purpose of this article was to provide PC providers with a better understanding of caring for patients with DOC, specifically following anoxic or TBI. Many of the tips acknowledge the uncertainty of DOC and provide strategies to help tackle this dilemma. [ABSTRACT FROM AUTHOR]

Introduction: Out-of-hospital cardiac arrest (OHCA) is a major cause of death and disability in the United States. Cardiac arrest centers (CAC) are necessary for the management of these critically ill and complex post arrest patients due to their specialized services and provider expertise. We report the case of a patient with OHCA and the systems of care involved in his resuscitation and recovery. Case Report: Emergency medical services attended a 39-year-old male with ongoing bystander cardiopulmonary resuscitation (CPR) after a witnessed collapse. Despite receiving appropriate advanced cardiac life support, including three defibrillations, he remained in refractory ventricular fibrillation. A prehospital physician identified him as an extracorporeal cardiopulmonary resuscitation (ECPR) candidate due to his age, witnessed arrest, refractory rhythm, and functional status. He was expedited to a CAC but no longer qualified for ECPR due to the time limit. He was resuscitated by the multiple teams activated prior to his arrival. He eventually had sustained return of circulation, was taken to the catheterization lab for emergent percutaneous coronary intervention, and recovered with a good neurologic outcome. Conclusion: Cardiac arrest centers may be capable of advanced interventions including ECPR. However, the systems of care offered by these centers is itself a lifesaving intervention. As this case highlights, despite not receiving the specified intervention (ECPR) the systems of care required to offer such a resource led to this favorable outcome. [ABSTRACT FROM AUTHOR]

Severe acquired brain injury has long-term physical and cognitive effects. Identifying patient variables predictive of recovery in different brain injury populations would generate improved prognostic information and help rehabilitation teams set appropriate therapeutic goals. This cohort study of 447 NHS neurorehabilitation inpatients aimed to identify functional and cognitive predictors of recovery following severe acquired brain injury caused by trauma, stroke and anoxia. Motor and cognitive impairment ratings were collected at admission and discharge using the Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and injury-related and demographic data were collated from medical records. Predictors of physical, cognitive and overall recovery were identified via hierarchical regression analyses. Several key findings emerged. Firstly, on-admission motor skills predicted functional and overall outcomes across groups. Secondly, on-admission social interaction skills predicted cognitive discharge outcomes in stroke and trauma, and overall outcomes for stroke, but did not predict anoxia outcomes. Thirdly, age predicted all forms of recovery for stroke only. Further group-specific factors were also identified as predicting motor and cognitive recovery, indicating that factors key to the rehabilitation trajectory may differ between populations. These variables should be considered in rehabilitation goal planning, although further research is required to explore their contributions to recovery. [ABSTRACT FROM AUTHOR]

Anoxic brain injury following cardiac arrest causes serious neurological sequela and mortality. Cortical blindness is a known manifestation of anoxic brain injury. However, its delayed‐onset presentation is very rare. Here, we report two patients with an anoxic brain injury who were effectively resuscitated after cardiac arrest, and subsequently developed delayed‐onset cortical blindness and movement disorders. We also provide a literature review of previously reported similar cases. These cases highlight that even in successfully revived patients, anoxic brain injury‐related neurological deficits could appear late in the course and may be permanent in 25% of the cases. [ABSTRACT FROM AUTHOR]

This article highlights the possibility of positive outcomes associated with prolonged CPR and anoxic brain injury contesting the idea that such patients will invariably end up in a persistent vegetative state. [ABSTRACT FROM AUTHOR]

BACKGROUND: Hypoxic brain injury results in severe disabilities that require extensive acute inpatient and outpatient rehabilitation to promote maximal functional and cognitive recovery. Brain hypoxemia can result from a multitude of causes, including but not limited to cardiac arrest, drug overdose, and/or shock. While recovery from a hypoxic brain injury alone can be challenging, dealing with concurrent debilitative diagnoses such as Guillain Barré Syndrome (GBS) further complicates the recovery and rehabilitation course. CASE REPORT: The current case study highlights the acute inpatient rehabilitation course of a 16 year old male who presented with cerebral hypoxia secondary to strangulation and subsequently developed GBS. Physical examination of the patient upon rehabilitation consult was inconsistent with a purely hypoxic brain injury, including the absence of rectal tone. This prompted further potential spinal cord injury evaluation and work up, with diagnostic testing confirmatory of GBS. RELEVANCE: This case is important as, to our knowledge from literature review, the first known documented instance of hypoxic brain injury complicated by GBS. Moreover, it highlights the importance of identifying all potential causes of functional disability, particularly when presented with physical exam findings inconsistent with chief diagnosis, in order to maximize functional recovery and rehabilitative gains during acute inpatient rehabilitation. [ABSTRACT FROM AUTHOR]

Liu et al. used continuous EEG and CBF velocity monitoring to investigate neurovascular coupling in patients with stroke from large vessel occlusion (LVO). All ABI patients experienced rScO SB 2 sb desaturation as compared with 42% patients without ABI ( I p i = 0.04). Distortion-product otoacoustic emissions (DPOAEs) and transient evoked otoacoustic emissions (TEOAEs) were measured in cardiac arrest patients and 10 patients with myocardial infarction as controls. [Extracted from the article]

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. [ABSTRACT FROM AUTHOR]

Therapeutic hypothermia (TH) is a neuroprotective treatment post-cardiac arrest but is grossly underutilized. After TH induction, traditional biomarkers and parameters can no long predict clinical outcome due to a lack of understanding of hypothermic response. Innovative approaches to better understand the clinical effect of TH will help to prognosticate outcome and expand beneficial population. Protein glycosylation is an important extracellular post-translational modification, regulating various extracellular signaling pathways. Here, we used glycoproteomics to investigate the association of plasma glycoproteins with the prognosis of TH-treated cardiac arrest patients. Using lectin affinity chromatography and mass spectrometry, we identified 640 glycoproteins in the plasma of cardiac arrest patients undergoing TH treatment, of which 23 were up-regulated and 14 were down-regulated in good outcome patients as compared with poor outcome ones. Notably, two glycoproteins with antioxidant activity, ceruloplasmin (CP) and haptoglobin (HP), were found to be associated with favorable neurologic outcome. This was further supported by ELISA assay in a large patients cohort, in which glycosylated CP and HP enriched by concanavilin A (ConA) and wheat germ agglutinin (WGA) lectins were significantly increased in patients developing good outcome (ConA-CP: p = 0.033; ConA-HP: p = 0.04; WGA-HP: p = 0.021). Furthermore, ROC analysis demonstrated the predictive potential of ConA-CP, ConA-HP, and WGA-HP (ConA-CP: AUC = 0.732, p = 0.031; ConA-HP: AUC = 0.746, p = 0.022; WGA-HP: AUC = 0.714, p = 0.046) and combination of them improved the predictive power (AUC = 0.830, p = 0.002). Our results suggested that glycosylated CP and HP as well as other glycoproteins may play critical roles in neuroprotection and serve as sensitive prognostic markers for TH treatments. [ABSTRACT FROM AUTHOR]

Drowning is a leading cause of accidental injury and death in young children. Anoxic brain injury (ABI) is a common consequence of drowning and can cause severe neurological morbidity in survivors. Assessment of functional status and prognostication in drowning victims can be extremely challenging, both acutely and chronically. Structural neuroimaging modalities (CT and MRI) have been of limited clinical value. Here, we tested the utility of resting-state functional MRI (rs-fMRI) for assessing brain functional integrity in this population. Eleven children with chronic, spastic quadriplegia due to drowning-induced ABI were investigated. All were comatose immediately after the injury and gradually regained consciousness, but with varying ability to communicate their cognitive state. Eleven neurotypical children matched for age and gender formed the control group. Resting-state fMRI and co-registered T1-weighted anatomical MRI were acquired at night during drug-aided sleep. Network integrity was quantified by independent components analysis (ICA), at both group- and per-subject levels. Functional-status assessments based on in-home observations were provided by families and caregivers. Motor ICNs were grossly compromised in ABI patients both group-wise and individually, concordant with their prominent motor deficits. Striking preservations of perceptual and cognitive ICNs were observed, and the degree of network preservation correlated ( ρ = 0.74) with the per-subject functional status assessments. Collectively, our findings indicate that rs-fMRI has promise for assessing brain functional integrity in ABI and, potentially, in other disorders. Furthermore, our observations suggest that the severe motor deficits observed in this population can mask relatively intact perceptual and cognitive capabilities. Hum Brain Mapp 38:4813-4831, 2017. © 2017 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Cardiac arrest is the most common cause of death in North America. An organized bundle of neurocritical care interventions can improve chances of survival and neurological recovery in patients who are successfully resuscitated from cardiac arrest. Therefore, resuscitation following cardiac arrest was chosen as an Emergency Neurological Life Support protocol. Key aspects of successful early post-arrest management include: prevention of secondary brain injury; identification of treatable causes of arrest in need of emergent intervention; and, delayed neurological prognostication. Secondary brain injury can be attenuated through targeted temperature management (TTM), avoidance of hypoxia and hypotension, avoidance of hyperoxia, hyperventilation or hypoventilation, and treatment of seizures. Most patients remaining comatose after resuscitation from cardiac arrest should undergo TTM. Treatable precipitants of arrest that require emergent intervention include, but are not limited to, acute coronary syndrome, intracranial hemorrhage, pulmonary embolism and major trauma. Accurate neurological prognostication is generally not appropriate for several days after cardiac arrest, so early aggressive care should never be limited based on perceived poor neurological prognosis. [ABSTRACT FROM AUTHOR]

Objectives: To assess post-procedural outcomes when Impella 2.5 percutaneous left ventricular assist device (pLVAD) support is initiated either prior to or after percutaneous coronary intervention (PCI) on unprotected left main coronary artery (ULMCA) culprit lesion in the context of acute myocardial infarction cardiogenic shock (AMICS).Background: Initiation of Impella 2.5 pLVAD prior to PCI is associated with significant survival benefit in the setting of AMICS. Outcomes of those presenting with a ULMCA culprit lesion in this setting have not been well characterized.Methods: Thirty-six consecutive patients in the cVAD Registry supported with Impella 2.5 pLVAD for AMICS who underwent PCI on ULMCA culprit lesion were included in our multicenter study.Results: The average age was 69.8 ± 14.2 years, 77.8% were male, 72.7% were in CS at admission, 44.4% sustained one or multiple cardiac arrests, and 30.6% had anoxic brain injury. Baseline characteristics were comparable between the Pre-PCI group (n = 20) and Post-PCI group (n = 16). Non-ST segment elevation myocardial infarction and greater coronary disease burden were significantly more frequent in the Pre-PCI group but they had significantly better survival to discharge (55.0% vs 18.8%, P = 0.041). Kaplan-Meier 30-day survival analysis showed very poor survival in Post-PCI group (48.1% vs 12.5%, Log-Rank P = 0.004).Conclusions: Initiation of Impella 2.5 pLVAD prior to as compared with after PCI of ULMCA for AMICS culprit lesion is associated with significant early survival. As previously described, patients supported after PCI appear to have very poor survival at 30 days. [ABSTRACT FROM AUTHOR]

A 63-year-old woman was hospitalized for rehabilitation from the aftereffects of an anoxic brain injury. In addition to a general cognitive decline, agraphia of kana and kanji was noted at the time of admission, which had advanced to agraphia which is dominant in kanji at the time of hospital discharge. Brain magnetic resonance imaging revealed no stroke lesions, and brain perfusion scintigraphy found a decreased blood flow in the bilateral parietal lobes. We hereby report on this case because case reports on agraphia caused by anoxic brain injury are extremely rare. [ABSTRACT FROM AUTHOR]

Background: Existing studies of quantitative electroencephalography (qEEG) as a prognostic tool after cardiac arrest (CA) use methods that ignore the longitudinal pattern of qEEG data, resulting in significant information loss and precluding analysis of clinically important temporal trends. We tested the utility of group-based trajectory modeling (GBTM) for qEEG classification, focusing on the specific example of suppression ratio (SR).Methods: We included comatose CA patients hospitalized from April 2010 to October 2014, excluding CA from trauma or neurological catastrophe. We used Persyst®v12 to generate SR trends and used semi-quantitative methods to choose appropriate sampling and averaging strategies. We used GBTM to partition SR data into different trajectories and regression associate trajectories with outcome. We derived a multivariate logistic model using clinical variables without qEEG to predict survival, then added trajectories and/or non-longitudinal SR estimates, and assessed changes in model performance.Results: Overall, 289 CA patients had ≥36 h of EEG yielding 10,404 h of data (mean age 57 years, 81 % arrested out-of-hospital, 33 % shockable rhythms, 31 % overall survival, 17 % discharged to home or acute rehabilitation). We identified 4 distinct SR trajectories associated with survival (62, 26, 12, and 0 %, P < 0.0001 across groups) and CPC (35, 10, 4, and 0 %, P < 0.0001 across groups). Adding trajectories significantly improved model performance compared to adding non-longitudinal data.Conclusions: Longitudinal analysis of continuous qEEG data using GBTM provides more predictive information than analysis of qEEG at single time-points after CA. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND AND PURPOSE To develop a qualitative brain magnetic resonance imaging (MRI) scoring system for comatose cardiac arrest patients that can be used in clinical practice. METHODS Consecutive comatose postcardiac arrest patients were prospectively enrolled. Routine MR brain sequences were scored by two independent blinded experts. Predefined brain regions were qualitatively scored on the fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) sequences according to the severity of the abnormality on a scale from 0 to 4. The mean score of the raters was used. Poor outcome was defined as death or vegetative state at 6 months. RESULTS Sixty-eight patients with 88 brain MRI scans were included. Median time from the arrest to the initial MRI was 77 hours (IQR 58-144 hours). At 100% specificity, the 'cortex score' performed best in predicting unfavorable outcome with a sensitivity of 55%-60% (95% CI 41-74) depending on time window selection. When comparing the 'cortex score' with historically used predictors for poor outcome, MRI improved the sensitivity for poor outcome over conventional predictors by 27% at 100% specificity. CONCLUSIONS A qualitative MRI scoring system helps assess hypoxic-ischemic brain injury severity following cardiac arrest and may provide useful prognostic information in comatose cardiac arrest patients. [ABSTRACT FROM AUTHOR]

Objective: Intrathecal baclofen therapy (ITB) has been used in the treatment of spasticity and dystonia. In our pediatric movement disorder clinic, we noted a delay in referral of patients for consideration of ITB. Often, only after years of failed medical therapy, a baclofen pump is considered. This study attempts to investigate the prevalence, length and causes of the delay. Methods: A retrospective, outcome analysis was performed. We conducted a survey of 30 pediatric patients who received baclofen pumps between the ages of 5 and 23. Patients were divided into two groups (before and after ITB approval by the US Food and Drug Administration in 1996) (FDA/Center for Drug Evaluation and Research, ; Ridley and Rawlins, J Neurosci Nurs 38:72-82, ; Medical Advisory Secretariat, Ont Health Technol Assess Ser 5:1-93, ). Information was collected regarding their onset of spasticity, attempted treatments, pump referral, satisfaction, and resulting change in the quality of life. Results: There was a delay in referral in most cases investigated. Average time to baclofen pump implantation, after initial onset of spasticity, was 5.14 years (group A) and 11.7 years (group B). Out of the subjects who reported diminished effects or no effect of pharmacological treatment, 93 % of these respondents reported that ITB had a dramatic long-lasting effect on their spasticity. Of 30 patients, 28 reported effectiveness of ITB, and 26 of 30 subjects reported an improved quality and ease of life. Conclusion: Despite the limitations of this subjective retrospective analysis of outcomes and delay in referral, the opinions of the parents and caregivers should be considered. Earlier referral for ITB therapy may better treat severe spasticity in pediatric patients. [ABSTRACT FROM AUTHOR]

Anoxic brain injury (ABI) often results in severe memory impairment and other cognitive and behavioral deficits, although limited information is available regarding pediatric cases. This study reported the neuropsychological outcomes in six children and adolescents who sustained ABI. Profiles were compared by mechanism of injury (ischemic vs. hypoxemic) and three cases were evaluated more than once. Severe intellectual, attention, memory, and behavioral impairments were observed in all six cases although academic achievement, internalizing behavioral problems, and visuospatial deficits were in general less severe than other cognitive and behavioral deficits. The longitudinal case studies varied but showed steady increases in memory and intellectual performance in the younger children with strongest improvement in nonverbal abilities and little change in parent-reported behavior. This study raises several possible hypotheses about specific cognitive and behavioral outcomes observed in pediatric ABI. [ABSTRACT FROM AUTHOR]

A major challenge in the diagnosis of disorders of consciousness is the differential diagnosis between the vegetative state (VS) and the minimally conscious state (MCS). Clinically, VS is defined by complete unawareness, whereas MCS is defined by the presence of inconsistent but clearly discernible behavioural signs of consciousness. In healthy individuals, pain cries have been reported to elicit functional activation within the pain matrix of the brain, which may be interpreted as empathic reaction. In this study, pain cries were presented to six VS patients, six MCS patients, and 17 age-matched healthy controls. Conventional task-related functional magnetic resonance imaging (fMRI) showed no significant differences in functional activation between the VS and MCS groups. In contrast to this negative finding, the application of a novel data-driven technique for the analysis of the brain's global functional connectivity yielded a positive result. The weighted global connectivity (WGC) was significantly greater in the MCS group compared to the VS group ( p < 0.05, family-wise error corrected). Using areas of significant WGC differences as 'seed regions' in a secondary connectivity analysis revealed extended functional networks in both MCS and healthy groups, whereas no such long-range functional connections were observed in the VS group. These results demonstrate the potential of functional connectivity MRI (fcMRI) as a clinical tool for differential diagnosis in disorders of consciousness. [ABSTRACT FROM AUTHOR]

Background: Therapeutic hypothermia (TH) improves outcomes in comatose patients resuscitated from cardiac arrest. However, nonconvulsive status epilepticus (NCSE) may cause persistent coma. The frequency and timing of NCSE after cardiac arrest is unknown. Methods: Review of consecutive subjects treated with TH and receiving continuous EEG (cEEG) monitoring between 8/1/2009 and 11/16/2010. Demographic data, survival, and functional outcome were prospectively recorded. Each cEEG file was analyzed using standard definitions to define NCSE. Data were analyzed using descriptive and nonparametric statistics. Results: Mean age of the 101 subjects was 57 years (SD 15) with most subjects being male ( N = 55, 54%) and experiencing out-of-hospital cardiac arrest ( N = 78; 77%). Ventricular fibrillation was the initial cardiac rhythm in 39 (38%). All subjects received TH. Thirty subjects (30%) awoke at a median of 41 h (IQR 30, 61) after cardiac arrest. A total of 29/30 (97%) subjects surviving to hospital discharge were awake. Median interval from arrest to placement of cEEG was 9 h (IQR 6, 12), at which time the mean temperature was 33.9°C. NCSE occurred in 12 (12%) subjects. In 3/12 (25%) subjects, NCSE was present when the cEEG recording began. In 4 subjects, NCSE occurred within 8 h of cEEG recording. One (8%) subject with NCSE survived in a vegetative state. Conclusions: NCSE is common in comatose post-cardiac arrest subjects receiving TH. Most seizures occur within the first 8 h of cEEG recording and within the first 12 h after resuscitation from cardiac arrest. Outcomes are poor in those who experience NCSE. [ABSTRACT FROM AUTHOR]

Anoxic brain injury can lead to death or permanent neurological defects involving memory, personality, vision, and language. It is well established that magnetic resonance imaging (MRI), specifically diffusion-weighted imaging (DWI), allows for earlier and more accurate diagnosis than computed tomography for this type of insult. Here we describe three cases of diffuse cerebral anoxia in which conventional MRI in the early subacute phase demonstrated near normal findings and abnormalities were most evident on DWI and apparent diffusion coefficient maps. The cases presented are unique and instructive as these abnormalities could be mistakenly interpreted as normal due to their uniform and symmetric appearance. [ABSTRACT FROM AUTHOR]

Objectives: Induced hypothermia (HT) after cardiac arrest improved outcomes in randomized trials. Current post–cardiac arrest treatment guidelines advocate HT; however, utilization in practice remains low. One reported barrier to adoption is clinician concern over potential technical difficulty of HT. We hypothesized that using a standardized order set, clinicians could achieve HT target temperature in routine practice with equal or better efficiency than that observed in randomized trials. Methods: After a multidisciplinary HT education program, we implemented a standardized order set for HT induction and maintenance including sedation and paralysis, intravenous cold saline infusion, and an external cooling apparatus, with a target temperature range of 33–34°C. We performed a retrospective analysis of a prospectively compiled and maintained registry of cardiac arrest patients with HT attempted (intent-to-treat) over the first year of implementation. The primary outcome measures were defined a priori by extrapolating treatment arm data from the largest and most efficacious randomized trial: 1) successful achievement of target temperature for ≥85% of patients in the cohort and 2) median time from return of spontaneous circulation (ROSC) to achieving target temperature <8 hours. Results: Clinicians attempted HT on 23 post–cardiac arrest patients (arrest location: 78% out-of-hospital, 22% in-hospital; initial rhythm: 26% ventricular fibrillation/tachycardia, 70% pulseless electrical activity or asystole) and achieved the target temperature in 22/23 (96%) cases. Median time from ROSC to target temperature was 4.4 (interquartile range 2.8–7.2) hours. Complication rates were low. Conclusions: Using a standardized order set, clinicians can achieve HT target temperature in routine practice. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has precipitated the need for frequent end-of-life discussions. The circumstances surrounding these conversations are quite atypical. Here, I describe one such goals-of-care discussion during the pandemic and how I relied on the precedent of prior goals-of-care discussions to guide me through an unprecedented situation. [ABSTRACT FROM AUTHOR]

Primary objective: To determine the neuropsychological profile of persons with anoxic brain injury.Methods and procedures: A retrospective study on a population of persons with anoxic brain injury admitted to a Brain Injury Unit (Institut Guttmann, Spain) from 1995–2003. The sample was divided according to physiopathological mechanisms in two sub-groups: ischemic anoxia (21 cases) and hypoxemic anoxia (11 cases). Functions assessed included orientation, attention, language, visuo-perceptive and visuo-constructive processing and verbal memory.Results: Neuropsychological assessment showed diffuse cognitive impairment in all assessed functions. Episodes of ischemic anoxia caused more severe verbal memory and learning problems than episodes of hypoxemic anoxia.Conclusions: This study shows that memory problems are the most prominent and relevant impairment, although all other cognitive functions are also impaired, affecting both memory itself and general behaviour. Statistical analysis also provides preliminary evidence on the different profile of memory impairment whether cerebral anoxia had hypoxic or ischemic origin. [ABSTRACT FROM AUTHOR]

Primary objective : To describe the outcome of near-drowning and rehabilitation contexts for recovery. Methods and procedures : Standardized measures were used to emphasize the functional impact of deficits over the first year post-injury in three children <2 years. Multimodal contexts for meaningful interplay were early adapted to the three cases. Main outcomes and results : The clinical pathways of recovery are identified. Initially all three cases manifested a generalized dystonia. Case 1 exhibited a good outcome with transient dyskinetic-dystonic syndrome; subsequently Bálint's syndrome emerged. In this case, the rehabilitation approach was organized on the pickup of direct perception of task-specific affordances. Cases 2 and 3 had poor outcomes presenting the worsening of torsion dystonia (status dystonicus) that hindered rehabilitation intervention. Conclusions : The dynamic reaggregation of spatial organization through meaningful interaction in specific ecological contexts is the principal goal of rehabilitation intervention. Status dystonicus represents the worst feature for recovery. [ABSTRACT FROM AUTHOR]

Anoxic brain injury is a common outcome after cardiac arrest. Despite substantial research into the pathophysiology and management of this injury, a beneficial treatment modality has not been previously identified. Recent studies show that induced hypothermia reduces mortality and improves neurological outcomes in patients resuscitated from ventricular fibrillation. This article reviews the literature on induced hypothermia for anoxic brain injury and summarizes a treatment algorithm proposed by the Canadian Association of Emergency Physicians Critical Care Committee for hypothermia induction in cardiac arrest survivors. [ABSTRACT FROM AUTHOR]

Though a pastime rarely considered rough or dangerous, sledding is not risk-free. The presentation of several serious injuries to Rainbow Babies and Children’s Hospital in Cleveland, Ohio, led us to examine our emergency department and admitting records to determine the incidence of neurological injury among children involved in sledding accidents. We discovered 24 children who had sustained brain or spine injuries as sequelae to sledding mishaps during a 5-year period. The ages ranged from 3 months to 15 years. Injuries included multiple skull fractures, 2 epidural hematomas, 1 subdural hematoma, 1 odontoid fracture and 1 anoxic brain injury. There was 1 death. Twenty-one of 24 patients incurred their injuries by colliding with fixed objects. Both improvised crafts and models intended for sledding were involved in the injuries. Only 3 sleds possessed steering capability. Eight of the 9 children who sustained a serious neurosurgical injury were supervised by an adult. Only 2 children had received instruction before sledding. The lack of awareness of the potential for injury together with the dearth of instruction and lack of control over a vehicle dashing down a hill studded with obstacles can change a carefree pastime into a hazardous activity. Copyright © 2004 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

This is a retrospective study to investigate the results of using zolpidem and lorazepam in persons with disorders of consciousness (DoC) and to provide practical information for clinical application and further studies. The cohort included 146 patients (11 hemorrhagic stroke, 87 traumatic brain injury (TBI), 48 anoxic brain injury (ABI)) admitted to a specialized DoC rehabilitation program. A positive trial indicated a patient responded to either zolpidem or lorazepam with prominent functional improvements necessitating routine use of the medication. Non-responders had equivocal or negative (i.e., went to sleep) responses. Eleven patients with a stroke who had either medication were all non-responders. Of the remaining 135 patients, 95 received at least one medication trial. The overall positive rate was 11.6% (11/95), with 6.3% (5/79) for zolpidem and 14.0% (6/43) for lorazepam. Among TBI patients, the positive rate of the zolpidem trial (10.2%, 5/49) was slightly higher than that of the lorazepam trial (6.9%, 2/29; p > 0.05). Among ABI patients, the positive rate of the lorazepam trial (28.6%, 4/14) was significantly higher than that of the zolpidem trial (0%, 0/30; p = 0.007). Following a positive trial, most patients were continued on the medications on a regular basis before eventual discontinuation. Our results suggested the etiology of DoC, considering traumatic vs. anoxic injuries, may serve in guiding the clinical application of these medications in the treatment of DoC and in future prospective studies. We advocate for screening all patients with DoC using zolpidem and/or lorazepam. [ABSTRACT FROM AUTHOR]

Background: Plantar flexion with plantar stimulation has been well described in brain death, and is compatible with brain death. However, plantar flexion with stimulation to the dorsal surface of the foot has not been reported previously in brain dead patients. Methods: Case report with Technetium-99 m hexamethylpropyleneamine oxime brain scan and video. Results: A 46-year-old woman suffered severe anoxic brain injury following massive pulmonary embolism 5 days after arthroscopic knee surgery. Neurologic examination was consistent with brain death, with the exception of plantar flexion when noxious stimulation was applied to the dorsal surface of the great toe on each side. Ancillary testing with a technetium-99 m nuclear scan demonstrated absence of cerebral perfusion, supporting the diagnosis of brain death. Conclusions: Noxious stimulation to the dorsal surface of the foot may trigger spinally mediated plantar flexion in patients with brain death. [ABSTRACT FROM AUTHOR]

An 18-year-old boy with anoxic brain injury, suffering from severe psychomotor inhibition, tetrarigidity and dystonia, was treated with amantadine in order to ameliorate his symptoms. Neuropsychological tests showed improvement in motor and cognitive functions. [ABSTRACT FROM AUTHOR]