Seminars in neurology
-
Seminars in neurology · Sep 2006
ReviewElectrophysiological prognostication and brain injury from cardiac arrest.
Anoxic coma after cardiorespiratory arrest warrants precocious investigation to establish probable outcome. Electroencephalogram (EEG) may uncover subclinical seizures; EEG grades have provided accurate prognosis of poor and favorable outcomes, but are weakest in those patients in between. ⋯ Combining clinical examination with electrophysiology has increasingly yielded multimodality approaches to early prognostication of coma after cardiorespiratory arrest, with more recent studies using event-related and middle-latency potentials showing promise for distinguishing good outcome (to consciousness), from awake but vegetative states. Further studies are warranted for this multimodality approach which, hopefully, may yield more widespread practical use of these testing modalities.
-
Seminars in neurology · Sep 2006
ReviewEthical issues in critical care and cardiac arrest: clinical research, brain death, and organ donation.
Cardiac arrest results in global hypoxic-ischemic brain injury from which there is a range of possible neurological outcomes. In most cases, patients may require a surrogate to make decisions regarding end-of-life care, including the withdrawal of life-sustaining therapies. This article reviews ethical considerations that arise in the clinical care of patients following cardiac arrest, including decisions to continue or withdraw life-sustaining therapies; brain death determination; and organ donation in the context of brain death and cardiac death (so-called non-heart-beating donation). This article also discusses ethical concerns pertaining to the design and conduct of resuscitation research that is necessary for the development of effective therapies to prevent anoxic brain injury or promote neurological recovery.
-
Seminars in neurology · Sep 2006
ReviewTherapeutic hypothermia for brain injury after cardiac arrest.
Morbidity and mortality in patients successfully resuscitated from cardiac arrest primarily depends on neurological outcome. Clinical trials of therapies directed toward reducing the extent of neuronal damage by means of pharmacological agents have been disappointing. To date, the only clinically effective tool for amelioration of brain damage by ischemia and reperfusion is mild to moderate induced hypothermia. The pathophysiology of global hypoxic-ischemic brain injury, the mechanisms by which hypothermia confers neuroprotection, and the encouraging beneficial effects of mild to moderate hypothermia in experimental studies and clinical trials are discussed.
-
Seminars in neurology · Sep 2006
ReviewPostresuscitative intensive care: neuroprotective strategies after cardiac arrest.
Cardiac arrest is a common disease in the United States, and many patients will die as a result of the neurological damage suffered during the anoxic period, or will live in a neurologically debilitated state. When cardiopulmonary-cerebral resuscitation results in the return of spontaneous circulation, intensive care is required to optimize neurological recovery. Such "brain-oriented" therapies include routine care, such as positioning and maintenance of volume status; optimization of cerebral perfusion, with the use of vasopressors if needed; management of increased intracranial pressure with agents such as hypertonic saline; assuring adequate oxygenation and avoiding hypercapnia; aggressive fever control; intensive glucose control, with the use of an insulin drip if needed; and management of seizures if they occur. ⋯ Induced moderate therapeutic hypothermia is utilized as a neuroprotective maneuver. Future treatment options and advanced monitoring techniques are also discussed. Further study to optimize neuroprotective strategies when treating patients who survive cardiac arrest is needed.
-
Seminars in neurology · Sep 2006
ReviewBiomarkers and neuroimaging of brain injury after cardiac arrest.
Unfortunately, it remains a difficult task to predict with certainty which patients will have a poor neurological outcome following cardiac arrest. Finding a quantitative prognostic model of outcome has become the objective of many intensivists to assist grieving families in making early difficult decisions regarding withdrawal of life support. An ideal prognostic test should be readily available, easily reproducible, and associated with a high degree of specificity for poor outcome. ⋯ Each serum or radiological marker has its pros and cons. To accurately prognosticate following cardiac arrest, a multimodal scale or algorithm that incorporates serum markers, radiological markers, and the neurological exam is clearly needed. As these techniques are being evaluated more closely and as imaging modalities increase in sensitivity and portability, physicians will continue to assist families by providing some guidance as to which patients have no chance of meaningful recovery.