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Unexpected survival of sudden cardiac arrest patient with large multiple brain infarction after therapeutic hypothermia
American Journal of Emergency Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Unexpected survival of sudden cardiac arrest patient with large multiple brain infarction after therapeutic hypothermia☆ Abstract We report a case of moderate magnetic resonance imaging (MRI) finding due to anoxic encephalopathy in a 38-year-old patient who had nearly a full recovery. Total anoxic time was 64 minutes, and absolute anoxic time was around 3 minutes. He was defibrillated 9 times during the total cardiopulmonary resuscitation of 55 minutes. Mild therapeutic hypothermia for 24 hours was maintained as recommended. At day 15 after cardiac arrest, the patient remained in a stupor but made eye contact rarely in response to commands. At 18 days, he reacted periodically to commands and orientation returned. Subsequently, he was ambulatory with care worker's help and was discharged in an alert condition to a rehabilitation hospital. Increased diffusion and decreased apparent diffusion coefficient of brain MRI indicated multiple injury, in particular in the frontal, parietal, temporal, and occipital lobes, cerebellum, and basal ganglia. This case involving multiple cortical necrosis in brain MRI indicates that speculation of poor prognosis should be considered carefully with the use of multimodal prognostic tools. Diffusion-weighted magnetic resonance imaging (DWI) and apparent diffusion coefficient (ADC) depict cytotoxic edema of the brain related to prognosis in patients with cardiac arrest [1]. Although a qualitative magnetic resonance imaging (MRI) scoring system has been recently described as a tool to predict outcome, only diffuse cortical damages were described and multiple focal lesions of the cortex can still be challenging to interpret [2,3]. There is no documentation in the literature of complete neurologic recovery in a patient with moderate multifocal cortical necrosis by brain MRI after out-of-hospital cardiac arrest. We describe a patient with multiple cortical damages in DWI and ADC who demonstrated this remarkable change after therapeutic hypothermia because of ventricular fibrillation (VF) arrest. A previously healthy 38-year-old man suddenly collapsed while carrying material at dawn. A nontrained first responder initiated cardiopulmonary resuscitation (CPR) within 3 minutes. When an ambulance arrived 6 minutes after the emergency phone call, adequate CPR was in progress by an emergency medical technician. The initial cardiac rhythm was VF. The patient was defibrillated 4 times during the 22minute transport by ambulance to our hospital. On arrival hospital, cardiac rhythm was still VF, and he was defibrillated 5 more times during CPR that lasted 33 minutes. Sixty-four minutes after the cardiac arrest (relative anoxic time was 61 minutes), return of spontaneous circulation was temporarily achieved. Returned cardiac rhythm was
☆ Conflict of Interest: No potential conflict of interest relevant to this article was reported.
accelerated idioventricular rhythm. Further emergency echocardiography found severe left ventricle systolic dysfunction (ejection fraction 20%) with global hypokinesia and normal right ventricle size with hypokinetic right ventricle wall motion. The patient was hypotensive with a blood pressure 70/40 mm Hg, and arterial blood gases revealed both metabolic acidosis and respiratory acidosis (pH 6.9, PO2 58 mm Hg, PCO2 56 mm Hg, and bicarbonate 10.7 mEq/L). Initial neurologic examination revealed stupor, with a Glasgow Coma Scale score 6 (E1V1M4), motor grade III related to pain response from both sides, pupil reflex 3 +/3 +, negative corneal reflex, and abnormal doll's eye. In addition, mild brain swelling was observed, but gray matter/white matter ratio was 1.39 in a noncontrast head computed tomography scan. Therapeutic hypothermia was induced with a surface-cooling device 2 hours after emergency department admission. Core temperature was maintained 33°C for the next 24 hours. After rewarming, the patient still retained a stuporous mentality, but some neurologic examinations, such as corneal reflex, doll's eye, and gag reflex were improved. Progress of neurologic changes during admission is presented in Table 1. Three days after return of spontaneous circulation, brain MRI revealed ischemic brain injury in multiple cerebral and cerebellar cortices, both basal ganglia and right M1 narrowing (Figure). An electroencephalography revealed an approximately 4 Hz slow wave. Coronary angiography and somatosensory evoked potential examinations were offered but were refused by his guardians. At day 4, the patient remained stuporous although he displayed improved motor power IV to V in both sides and opened his eyes in response to pain. Complications after rewarming consisted of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia (white blood cell count, 14 940/μL) and multiorgan failure apparent as acute kidney injury (blood urea nitrogen, 56 mg/dL; creatinine, 5.1 mg/dL), hepatopathy (aspartate transaminase, 338 IU/L; alanine transaminase, 224 IU/L), pancreatitis (amylase, 338 IU/L; lipase 318, mOsm/kg), and prothrombin time/activated partial thromboplastin time prolongation without hemodynamic instability requiring norepinephrine. Kidney dysfunction (creatinine, 8.5 mg/dL) that required hemodialysis at day 7 and continuing MRSA infection prompted a tracheostomy at day 8, with the patients maintained on a mechanical ventilator until day 12. At day 15, the patient remained in a stupor but could rarely make eye contact in response to a command. At day 18, he was transferred to the general ward. He periodically reacted to commands, and orientation was regained. These responses became more frequent during family visits. He displayed aggression toward nurses at times. At day 20, he was alert and responsive to commands. He was able to drink some water but still often displayed a delirious mentality that could have been due to sleep deprivation. During the next several days after day 20, pulmonary edema and acute kidney disease resolved
http://dx.doi.org/10.1016/j.ajem.2016.05.066 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Lee JH, Unexpected survival of sudden cardiac arrest patient with large multiple brain infarction after therapeutic hypothermia, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.066
2
J.H. Lee / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Table 1 Timing and details of prognostic examinations Days after cardiac arrest Eye opening Consciousness Pupillary responses Corneal reflex Normal Doll's eye Gag reflex Motor grade related to pain Brain CT Brain MRI EEG
1 − Stupor + − − III/III Brain swelling
3 − Stupor + + + + IV/IV
4 + Stupor + + + + V/V
Multiple infarction Slow wave
6 + Stupor + + + + V/V
9 + Stupor + + + + V/V
15 + Eye contact
18 + Orientation
20 + Alert
36 + Walking
Slow wave
Abbreviations: CT, computed tomography; EEG, electroencephalography.
using hemodialysis. Anxiety, delirium, abdominal pain, and skin trouble were controlled with medications during rehabilitation that lasted for weeks. At day 36, he was ambulatory with care worker's help and dependently performing activities of daily living with neurologic impairments consisted of minimal to mild semantic memory deficits. At day 39, he was transferred to other rehabilitation hospital. The pivotal events are presented temporally in Table 2. Brain MRI abnormalities after cardiac arrest are time dependent. Patients who undergo MRI in the first 1 to 2 days showed DWI changes confined to the cerebellum and basal ganglia, which subsequently shift to the cortex around days 3 to 5, and then affect the subcortical white matter on days 6 to 12. In the early subacute period (days 1-5), cortical abnormalities predominate [4]. In addition, the ADC is most reduced at 8 to 32 hours and remains markedly reduced for 3 to 5 days [5]. We think that checking brain MRI in the 3 days after cardiac arrest event is better than early MRI examination (within 2 days) because cortical necrosis related with poor prognosis became more distinct in diffusion and ADC of brain MRI on days 3 to 5. Absent or mild DWI change seems to correlate with good outcome, whereas moderate or severe changes are associated with poor outcome [6]. In 1 study, DWI abnormalities were highly sensitive (98.5%) but only modestly specific (46.2%) for predicting poor neurologic outcome at 3 months [7]. Meanwhile, the reduction of ADC when it is more than 31% is associated with poor outcome in comatose cardiac arrest patients, whereas when it is below 27% it is associated with favorable outcome [8]. Another study showed that quantitative ADC values increased the specificity for predicting poor outcome to 100% while maintaining high sensitivity by using a diffusion/perfusion analysis program; patients with a brain volume greater than 10% had an ADC value less
than 650 × 10 −6mm 2/s, and all had poor outcomes [1]. In another study, whole-brain ADC depression less than 665 × 10 − 6mm 2/s all had poor outcomes [9]. Increased DWI and decreased ADC in MRI of cardiac arrest patients were related with poor prognosis like this. A note of caution is that all the normal finding of DWI is not always associated with a favorable outcome [10,11]. Two patients in a study did not have any specific cause having an unfavorable outcome [12]. Patients with cortical involvement in MRI 3 to 5 days after cardiac arrest were reported to have high rates of mortality and severe neurologic impairment [4,13]. Especially, the parietal, temporal, and occipital cortices were more frequently injured in the deceased patients than were the frontal cortices [14]. In another study, cortical structures, in particular the occipital and temporal lobes and the putamen, exhibited the most profound ADC reductions as a poor outcome indicator [15]. On the other hand, patients who recovered had most of their brain lesions in the basal ganglia, cerebellum, and the cortex of the frontal lobes [16]. This study also reported that patients with increased diffusion particularly in the parietal lobe and thalamus had poor prognosis. When compared with normal controls in other study, good outcome patients exhibited increased diffusivity in ADC, in particular in the hippocampus, temporal, and occipital lobes and corona radiate [15]. Unlike previous studies, our patient unexpectedly had a good neurological outcome, like cerebral performance category 1, although a large amount of brain cortices were injured at multiple areas sporadically. He was discharged from the hospital ambulatory with moderate hypoxic brain damage evident in brain MRI after therapeutic hypothermia management. His recovery does suggest that multiple lesions, especially the parietal, temporal, and occipital lobes, evident in the brain MRI may not always portend a poor prognosis. In addition, interpretation of multiple
Figure. Upper images: DWI obtained 3 days after a cardiac arrest showing hyperintensities located in his brain that was sparsely dotted with through parietal, frontal, temporal, occipital lobe. Lower images: ADC obtained at the same time from the patient with reduced diffusion showing widespread areas involving the multiple cortices of both hemispheres.
Please cite this article as: Lee JH, Unexpected survival of sudden cardiac arrest patient with large multiple brain infarction after therapeutic hypothermia, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.066
J.H. Lee / American Journal of Emergency Medicine xxx (2016) xxx–xxx Table 2 Timing and description of important events Days after cardiac arrest 1 2 4 7 8 12 15 18 20 36 39
Start therapeutic hypothermia Intensive care unit admission Eye opening related to pain, MRSA pneumonia and multiorgan failure Hemodalysis due to acute kidney injury Tracheostomy done Ventilator weaning Eye contact sometimes To general ward, orientation sometimes, aggressive act Alert, delirium often Alert, walking assisted Discharge
cortical necrosis in regard to prognosis should be reconsidered, and other prognostic tools like neurologic examination, somatosensory evoked potential, and electroencephalography by sound stimulation will be needed in cases with confusing and difficult judgments. Additional research is needed to further characterize the overall prognostic significance of multiple cortical necrosis for estimating prognosis in brain MRI of patients receiving induced hypothermia. Although our patient seemed overall and cerebrally impaired when a brain MRI was performed 3 days after his cardiac arrest, he has almost completely recovered. Determination of the prognosis after cardiac arrest may be more difficult after therapeutic hypothermia, and variables such as multiple cortical necrosis in brain MRI should perhaps be reconsidered if it is a poor prognosis.
Jae Hoon Lee, MD Department of Emergency Medicine, Dong-A University Medical Center Busan, South Korea ⁎Corresponding author at: Department of Emergency Medicine Dong-A university College of Medicine, 26 Daesin Gonwon-Ro Seo-Gu, Busan 602–714, South Korea Tel.: +82 51 240 5590; fax: +82 51 240 5309 E-mail address: [email protected]
3
References [1] Wijman CA, Mlynash M, Caulfield AF, Hsia AW, Eyngorn I, Bammer R, et al. Prognostic value of brain diffusion-weighted imaging after cardiac arrest. Ann Neurol 2009;65:394–402. [2] Park JS, Lee SW, Kim H, Min JH, Kang JH, Yi KS, et al. Efficacy of diffusion-weighted magnetic resonance imaging performed before therapeutic hypothermia in predicting clinical outcome in comatose cardiopulmonary arrest survivors. Resuscitation 2015;88:132–7. [3] Hirsch KG, Mlynash M, Jansen S, Persoon S, Eyngorn I, Krasnokutsky MV, et al. Prognostic value of a qualitative brain MRI scoring system after cardiac arrest. J Neuroimaging 2015;25:430–7. [4] Greer D, Scripko P, Bartscher J, Sims J, Camargo E, Singhal A, et al. Serial MRI changes in comatose cardiac arrest patients. Neurocrit Care 2011;14:61–7. [5] Schaefer PW, Grant PE, Gonzalez RG. Diffusion-weighted MR imaging of the brain. Radiology 2000;217:331–45. [6] Greer DM, Rosenthal ES, Wu O. Neuroprognostication of hypoxic–ischaemic coma in the therapeutic hypothermia era. Nat Rev Neurol 2014;10:190–203. [7] Greer D, Scripko P, Bartscher J, Sims J, Camargo E, Singhal A, et al. Clinical MRI interpretation for outcome prediction in cardiac arrest. Neurocrit Care 2012;17:240–4. [8] Oualha M, Gatterre P, Boddaert N, Dupic L, De Saint BL, Hubert P, et al. Early diffusion-weighted magnetic resonance imaging in children after cardiac arrest may provide valuable prognostic information on clinical outcome. Intensive Care Med 2013;39:1306–12. [9] Wu O, Sorensen AG, Benner T, Singhal AB, Furie KL, Greer DM. Comatose patients with cardiac arrest: predicting clinical outcome with diffusion-weighted MR imaging. Radiology 2009;252:173–81. [10] Boichot C, Walker PM, Durand C, Grimaldi M, Chapuis S, Gouyon JB, et al. Term neonate prognoses after perinatal asphyxia: contributions of MR imaging, MR spectroscopy, relaxation times, and apparent diffusion coefficients. Radiology 2006;239: 839–48. [11] Barrett KM, Freeman WD, Weindling SM, Brott TG, Broderick DF, Heckman MG, et al. Brain injury after cardiopulmonary arrest and its assessment with diffusionweighted magnetic resonance imaging. Mayo Clin Proc 2007;82:828–35. [12] Choi SP, Park KN, Park HK, Kim JY, Youn CS, Ahn KJ, et al. Diffusion-weighted magnetic resonance imaging for predicting the clinical outcome of comatose survivors after cardiac arrest: a cohort study. Crit Care 2010;14:R17. http://dx.doi.org/10. 1186/cc8874 Epub 2010 Feb 12. [13] Wijdicks EF, Campeau NG, Miller GM. MR imaging in comatose survivors of cardiac resuscitation. AJNR 2001;22:1561–5. [14] Els T, Kassubek J, Kubalek R, Klisch J. Diffusion-weighted MRI during early global cerebral hypoxia: a predictor for clinical outcome? Acta Neurol Scand 2004;110: 361–7. [15] Mlynash M, Campbell DM, Leproust EM, Fischbein NJ, Bammer R, Eyngorn I, et al. Temporal and spatial profile of brain diffusion-weighted MRI after cardiac arrest. Stroke 2010;41:1665–72. [16] Järnum H, Knutsson L, Rundgren M, Siemund R, Englund E, Friberg H, et al. Diffusion and perfusion MRI of the brain in comatose patients treated with mild hypothermia after cardiac arrest: a prospective observational study. Resuscitation 2009;80: 425–30.
http://dx.doi.org/10.1016/j.ajem.2016.05.066
Please cite this article as: Lee JH, Unexpected survival of sudden cardiac arrest patient with large multiple brain infarction after therapeutic hypothermia, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.066
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Unexpected survival of sudden cardiac arrest patient with large multiple brain infarction after therapeutic hypothermia☆ Abstract We report a case of moderate magnetic resonance imaging (MRI) finding due to anoxic encephalopathy in a 38-year-old patient who had nearly a full recovery. Total anoxic time was 64 minutes, and absolute anoxic time was around 3 minutes. He was defibrillated 9 times during the total cardiopulmonary resuscitation of 55 minutes. Mild therapeutic hypothermia for 24 hours was maintained as recommended. At day 15 after cardiac arrest, the patient remained in a stupor but made eye contact rarely in response to commands. At 18 days, he reacted periodically to commands and orientation returned. Subsequently, he was ambulatory with care worker's help and was discharged in an alert condition to a rehabilitation hospital. Increased diffusion and decreased apparent diffusion coefficient of brain MRI indicated multiple injury, in particular in the frontal, parietal, temporal, and occipital lobes, cerebellum, and basal ganglia. This case involving multiple cortical necrosis in brain MRI indicates that speculation of poor prognosis should be considered carefully with the use of multimodal prognostic tools. Diffusion-weighted magnetic resonance imaging (DWI) and apparent diffusion coefficient (ADC) depict cytotoxic edema of the brain related to prognosis in patients with cardiac arrest [1]. Although a qualitative magnetic resonance imaging (MRI) scoring system has been recently described as a tool to predict outcome, only diffuse cortical damages were described and multiple focal lesions of the cortex can still be challenging to interpret [2,3]. There is no documentation in the literature of complete neurologic recovery in a patient with moderate multifocal cortical necrosis by brain MRI after out-of-hospital cardiac arrest. We describe a patient with multiple cortical damages in DWI and ADC who demonstrated this remarkable change after therapeutic hypothermia because of ventricular fibrillation (VF) arrest. A previously healthy 38-year-old man suddenly collapsed while carrying material at dawn. A nontrained first responder initiated cardiopulmonary resuscitation (CPR) within 3 minutes. When an ambulance arrived 6 minutes after the emergency phone call, adequate CPR was in progress by an emergency medical technician. The initial cardiac rhythm was VF. The patient was defibrillated 4 times during the 22minute transport by ambulance to our hospital. On arrival hospital, cardiac rhythm was still VF, and he was defibrillated 5 more times during CPR that lasted 33 minutes. Sixty-four minutes after the cardiac arrest (relative anoxic time was 61 minutes), return of spontaneous circulation was temporarily achieved. Returned cardiac rhythm was
☆ Conflict of Interest: No potential conflict of interest relevant to this article was reported.
accelerated idioventricular rhythm. Further emergency echocardiography found severe left ventricle systolic dysfunction (ejection fraction 20%) with global hypokinesia and normal right ventricle size with hypokinetic right ventricle wall motion. The patient was hypotensive with a blood pressure 70/40 mm Hg, and arterial blood gases revealed both metabolic acidosis and respiratory acidosis (pH 6.9, PO2 58 mm Hg, PCO2 56 mm Hg, and bicarbonate 10.7 mEq/L). Initial neurologic examination revealed stupor, with a Glasgow Coma Scale score 6 (E1V1M4), motor grade III related to pain response from both sides, pupil reflex 3 +/3 +, negative corneal reflex, and abnormal doll's eye. In addition, mild brain swelling was observed, but gray matter/white matter ratio was 1.39 in a noncontrast head computed tomography scan. Therapeutic hypothermia was induced with a surface-cooling device 2 hours after emergency department admission. Core temperature was maintained 33°C for the next 24 hours. After rewarming, the patient still retained a stuporous mentality, but some neurologic examinations, such as corneal reflex, doll's eye, and gag reflex were improved. Progress of neurologic changes during admission is presented in Table 1. Three days after return of spontaneous circulation, brain MRI revealed ischemic brain injury in multiple cerebral and cerebellar cortices, both basal ganglia and right M1 narrowing (Figure). An electroencephalography revealed an approximately 4 Hz slow wave. Coronary angiography and somatosensory evoked potential examinations were offered but were refused by his guardians. At day 4, the patient remained stuporous although he displayed improved motor power IV to V in both sides and opened his eyes in response to pain. Complications after rewarming consisted of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia (white blood cell count, 14 940/μL) and multiorgan failure apparent as acute kidney injury (blood urea nitrogen, 56 mg/dL; creatinine, 5.1 mg/dL), hepatopathy (aspartate transaminase, 338 IU/L; alanine transaminase, 224 IU/L), pancreatitis (amylase, 338 IU/L; lipase 318, mOsm/kg), and prothrombin time/activated partial thromboplastin time prolongation without hemodynamic instability requiring norepinephrine. Kidney dysfunction (creatinine, 8.5 mg/dL) that required hemodialysis at day 7 and continuing MRSA infection prompted a tracheostomy at day 8, with the patients maintained on a mechanical ventilator until day 12. At day 15, the patient remained in a stupor but could rarely make eye contact in response to a command. At day 18, he was transferred to the general ward. He periodically reacted to commands, and orientation was regained. These responses became more frequent during family visits. He displayed aggression toward nurses at times. At day 20, he was alert and responsive to commands. He was able to drink some water but still often displayed a delirious mentality that could have been due to sleep deprivation. During the next several days after day 20, pulmonary edema and acute kidney disease resolved
http://dx.doi.org/10.1016/j.ajem.2016.05.066 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Lee JH, Unexpected survival of sudden cardiac arrest patient with large multiple brain infarction after therapeutic hypothermia, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.066
2
J.H. Lee / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Table 1 Timing and details of prognostic examinations Days after cardiac arrest Eye opening Consciousness Pupillary responses Corneal reflex Normal Doll's eye Gag reflex Motor grade related to pain Brain CT Brain MRI EEG
1 − Stupor + − − III/III Brain swelling
3 − Stupor + + + + IV/IV
4 + Stupor + + + + V/V
Multiple infarction Slow wave
6 + Stupor + + + + V/V
9 + Stupor + + + + V/V
15 + Eye contact
18 + Orientation
20 + Alert
36 + Walking
Slow wave
Abbreviations: CT, computed tomography; EEG, electroencephalography.
using hemodialysis. Anxiety, delirium, abdominal pain, and skin trouble were controlled with medications during rehabilitation that lasted for weeks. At day 36, he was ambulatory with care worker's help and dependently performing activities of daily living with neurologic impairments consisted of minimal to mild semantic memory deficits. At day 39, he was transferred to other rehabilitation hospital. The pivotal events are presented temporally in Table 2. Brain MRI abnormalities after cardiac arrest are time dependent. Patients who undergo MRI in the first 1 to 2 days showed DWI changes confined to the cerebellum and basal ganglia, which subsequently shift to the cortex around days 3 to 5, and then affect the subcortical white matter on days 6 to 12. In the early subacute period (days 1-5), cortical abnormalities predominate [4]. In addition, the ADC is most reduced at 8 to 32 hours and remains markedly reduced for 3 to 5 days [5]. We think that checking brain MRI in the 3 days after cardiac arrest event is better than early MRI examination (within 2 days) because cortical necrosis related with poor prognosis became more distinct in diffusion and ADC of brain MRI on days 3 to 5. Absent or mild DWI change seems to correlate with good outcome, whereas moderate or severe changes are associated with poor outcome [6]. In 1 study, DWI abnormalities were highly sensitive (98.5%) but only modestly specific (46.2%) for predicting poor neurologic outcome at 3 months [7]. Meanwhile, the reduction of ADC when it is more than 31% is associated with poor outcome in comatose cardiac arrest patients, whereas when it is below 27% it is associated with favorable outcome [8]. Another study showed that quantitative ADC values increased the specificity for predicting poor outcome to 100% while maintaining high sensitivity by using a diffusion/perfusion analysis program; patients with a brain volume greater than 10% had an ADC value less
than 650 × 10 −6mm 2/s, and all had poor outcomes [1]. In another study, whole-brain ADC depression less than 665 × 10 − 6mm 2/s all had poor outcomes [9]. Increased DWI and decreased ADC in MRI of cardiac arrest patients were related with poor prognosis like this. A note of caution is that all the normal finding of DWI is not always associated with a favorable outcome [10,11]. Two patients in a study did not have any specific cause having an unfavorable outcome [12]. Patients with cortical involvement in MRI 3 to 5 days after cardiac arrest were reported to have high rates of mortality and severe neurologic impairment [4,13]. Especially, the parietal, temporal, and occipital cortices were more frequently injured in the deceased patients than were the frontal cortices [14]. In another study, cortical structures, in particular the occipital and temporal lobes and the putamen, exhibited the most profound ADC reductions as a poor outcome indicator [15]. On the other hand, patients who recovered had most of their brain lesions in the basal ganglia, cerebellum, and the cortex of the frontal lobes [16]. This study also reported that patients with increased diffusion particularly in the parietal lobe and thalamus had poor prognosis. When compared with normal controls in other study, good outcome patients exhibited increased diffusivity in ADC, in particular in the hippocampus, temporal, and occipital lobes and corona radiate [15]. Unlike previous studies, our patient unexpectedly had a good neurological outcome, like cerebral performance category 1, although a large amount of brain cortices were injured at multiple areas sporadically. He was discharged from the hospital ambulatory with moderate hypoxic brain damage evident in brain MRI after therapeutic hypothermia management. His recovery does suggest that multiple lesions, especially the parietal, temporal, and occipital lobes, evident in the brain MRI may not always portend a poor prognosis. In addition, interpretation of multiple
Figure. Upper images: DWI obtained 3 days after a cardiac arrest showing hyperintensities located in his brain that was sparsely dotted with through parietal, frontal, temporal, occipital lobe. Lower images: ADC obtained at the same time from the patient with reduced diffusion showing widespread areas involving the multiple cortices of both hemispheres.
Please cite this article as: Lee JH, Unexpected survival of sudden cardiac arrest patient with large multiple brain infarction after therapeutic hypothermia, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.066
J.H. Lee / American Journal of Emergency Medicine xxx (2016) xxx–xxx Table 2 Timing and description of important events Days after cardiac arrest 1 2 4 7 8 12 15 18 20 36 39
Start therapeutic hypothermia Intensive care unit admission Eye opening related to pain, MRSA pneumonia and multiorgan failure Hemodalysis due to acute kidney injury Tracheostomy done Ventilator weaning Eye contact sometimes To general ward, orientation sometimes, aggressive act Alert, delirium often Alert, walking assisted Discharge
cortical necrosis in regard to prognosis should be reconsidered, and other prognostic tools like neurologic examination, somatosensory evoked potential, and electroencephalography by sound stimulation will be needed in cases with confusing and difficult judgments. Additional research is needed to further characterize the overall prognostic significance of multiple cortical necrosis for estimating prognosis in brain MRI of patients receiving induced hypothermia. Although our patient seemed overall and cerebrally impaired when a brain MRI was performed 3 days after his cardiac arrest, he has almost completely recovered. Determination of the prognosis after cardiac arrest may be more difficult after therapeutic hypothermia, and variables such as multiple cortical necrosis in brain MRI should perhaps be reconsidered if it is a poor prognosis.
Jae Hoon Lee, MD Department of Emergency Medicine, Dong-A University Medical Center Busan, South Korea ⁎Corresponding author at: Department of Emergency Medicine Dong-A university College of Medicine, 26 Daesin Gonwon-Ro Seo-Gu, Busan 602–714, South Korea Tel.: +82 51 240 5590; fax: +82 51 240 5309 E-mail address: [email protected]
3
References [1] Wijman CA, Mlynash M, Caulfield AF, Hsia AW, Eyngorn I, Bammer R, et al. Prognostic value of brain diffusion-weighted imaging after cardiac arrest. Ann Neurol 2009;65:394–402. [2] Park JS, Lee SW, Kim H, Min JH, Kang JH, Yi KS, et al. Efficacy of diffusion-weighted magnetic resonance imaging performed before therapeutic hypothermia in predicting clinical outcome in comatose cardiopulmonary arrest survivors. Resuscitation 2015;88:132–7. [3] Hirsch KG, Mlynash M, Jansen S, Persoon S, Eyngorn I, Krasnokutsky MV, et al. Prognostic value of a qualitative brain MRI scoring system after cardiac arrest. J Neuroimaging 2015;25:430–7. [4] Greer D, Scripko P, Bartscher J, Sims J, Camargo E, Singhal A, et al. Serial MRI changes in comatose cardiac arrest patients. Neurocrit Care 2011;14:61–7. [5] Schaefer PW, Grant PE, Gonzalez RG. Diffusion-weighted MR imaging of the brain. Radiology 2000;217:331–45. [6] Greer DM, Rosenthal ES, Wu O. Neuroprognostication of hypoxic–ischaemic coma in the therapeutic hypothermia era. Nat Rev Neurol 2014;10:190–203. [7] Greer D, Scripko P, Bartscher J, Sims J, Camargo E, Singhal A, et al. Clinical MRI interpretation for outcome prediction in cardiac arrest. Neurocrit Care 2012;17:240–4. [8] Oualha M, Gatterre P, Boddaert N, Dupic L, De Saint BL, Hubert P, et al. Early diffusion-weighted magnetic resonance imaging in children after cardiac arrest may provide valuable prognostic information on clinical outcome. Intensive Care Med 2013;39:1306–12. [9] Wu O, Sorensen AG, Benner T, Singhal AB, Furie KL, Greer DM. Comatose patients with cardiac arrest: predicting clinical outcome with diffusion-weighted MR imaging. Radiology 2009;252:173–81. [10] Boichot C, Walker PM, Durand C, Grimaldi M, Chapuis S, Gouyon JB, et al. Term neonate prognoses after perinatal asphyxia: contributions of MR imaging, MR spectroscopy, relaxation times, and apparent diffusion coefficients. Radiology 2006;239: 839–48. [11] Barrett KM, Freeman WD, Weindling SM, Brott TG, Broderick DF, Heckman MG, et al. Brain injury after cardiopulmonary arrest and its assessment with diffusionweighted magnetic resonance imaging. Mayo Clin Proc 2007;82:828–35. [12] Choi SP, Park KN, Park HK, Kim JY, Youn CS, Ahn KJ, et al. Diffusion-weighted magnetic resonance imaging for predicting the clinical outcome of comatose survivors after cardiac arrest: a cohort study. Crit Care 2010;14:R17. http://dx.doi.org/10. 1186/cc8874 Epub 2010 Feb 12. [13] Wijdicks EF, Campeau NG, Miller GM. MR imaging in comatose survivors of cardiac resuscitation. AJNR 2001;22:1561–5. [14] Els T, Kassubek J, Kubalek R, Klisch J. Diffusion-weighted MRI during early global cerebral hypoxia: a predictor for clinical outcome? Acta Neurol Scand 2004;110: 361–7. [15] Mlynash M, Campbell DM, Leproust EM, Fischbein NJ, Bammer R, Eyngorn I, et al. Temporal and spatial profile of brain diffusion-weighted MRI after cardiac arrest. Stroke 2010;41:1665–72. [16] Järnum H, Knutsson L, Rundgren M, Siemund R, Englund E, Friberg H, et al. Diffusion and perfusion MRI of the brain in comatose patients treated with mild hypothermia after cardiac arrest: a prospective observational study. Resuscitation 2009;80: 425–30.
http://dx.doi.org/10.1016/j.ajem.2016.05.066
Please cite this article as: Lee JH, Unexpected survival of sudden cardiac arrest patient with large multiple brain infarction after therapeutic hypothermia, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.066