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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
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2
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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3
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Ahmed HS. Post-hypoxic myoclonus; what we know and gaps in knowledge. Trop Doct 2023; 53:460-463. [PMID: 37287278 DOI: 10.1177/00494755231181153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Post-hypoxic myoclonus (PHM) is a rare neurological complication having two different variants depending on acute or chronic onset after cardiopulmonary resuscitation following cardiac arrest: myoclonic status epilepticus (MSE) and Lance-Adams syndrome (LAS) respectively. Clinical and simultaneous electro-encephalographic (EEG) and electromyographic (EMG) tracing can distinguish between the two. Anecdotal treatment with benzodiazepines and anaesthetics (in the case of MSE) have been tried. Although limited evidence is available, valproic acid, clonazepam and levetiracetam, either in combination with other drugs or alone, have shown to control epilepsy associated with LAS effectively. Deep brain stimulation is a novel and promising advance in LAS treatment.
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Affiliation(s)
- H Shafeeq Ahmed
- Department of Medicine, Bangalore Medical College and Research Institute, Bangalore, India
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4
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Horn J, Admiraal M, Hofmeijer J. Diagnosis and management of seizures and myoclonus after cardiac arrest. Eur Heart J Acute Cardiovasc 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] [What about the content of this article? (0)] [Affiliation(s)] [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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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: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Freund BE, Kaplan PW. Neurophysiological and Clinical Correlates of Acute Posthypoxic Myoclonus. J Clin Neurophysiol 2023; 40:117-22. [PMID: 36521068 DOI: 10.1097/WNP.0000000000000937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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8
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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9
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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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10
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Chakraborty T, Braksick S, Rabinstein A, Wijdicks E. Status Myoclonus with Post-cardiac-arrest Syndrome: Implications for Prognostication. Neurocrit Care 2021. [PMID: 34595685 DOI: 10.1007/s12028-021-01344-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Status myoclonus (SM) after cardiac arrest (CA) may signify devastating brain injury. We hypothesized that SM correlates with severe neurologic and systemic post-cardiac-arrest syndrome (PCAS). METHODS Charts of patients admitted with CA to Mayo Clinic Saint Marys Hospital between 2005 and 2019 were retrospectively reviewed. Data included the neurologic examination, ancillary neurologic tests, and systemic markers of PCAS. Nonsustained myoclonus was clinically differentiated from SM. The cerebral performance category score at discharge was assessed; poor outcome was a cerebral performance category score > 2 prior to withdrawal of life-sustaining therapies or death. RESULTS Of 296 patients included, 276 (93.2%) had out-of-hospital arrest and 202 (68.5%) had a shockable rhythm; the mean time to return of spontaneous circulation was 32 ± 19 min. One hundred seventy-six (59.5%) patients had a poor outcome. One hundred one (34.1%) patients had myoclonus, and 74 (73.2%) had SM. Neurologic predictors of poor outcome were extensor or absent motor response to noxious stimulus (p = 0.02, odds ratio [OR] 3.8, confidence interval [CI] 1.2-12.4), SM (p = 0.01, OR 10.3, CI 1.5-205.4), and burst suppression on EEG (p = 0.01, OR 4.6, CI 1.4-17.4). Of 74 patients with SM, 73 (98.6%) had a poor outcome. A nonshockable rhythm (p < 0.001, OR 4.5, CI 2.6-7.9), respiratory arrest (p < 0.001, OR 3.5, CI 1.7-7.2), chronic kidney disease (p < 0.001, OR 3.1, CI 1.6-6.0), and a pressor requirement (p < 0.001, OR 4.4, CI 1.8-10.6) were associated with SM. No patients with SM, anoxic-ischemic magnetic resonance imaging findings, and absent electroencephalographic reactivity had a good outcome. CONCLUSIONS Sustained status myoclonus after CPR is observed in patients with other reliable indicators of severe acute brain injury and systemic PCAS. These clinical determinants should be incorporated as part of a comprehensive approach to prognostication after CA.
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11
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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12
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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 2021; 43:533-540. [PMID: 33895885 DOI: 10.1007/s10072-021-05276-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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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13
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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: 386] [Impact Index Per Article: 128.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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14
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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: 315] [Impact Index Per Article: 105.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Gudenkauf JC, Geocadin RG. Post-anoxic myoclonus: How can something unclear and unvalidated define early prognosis in cardiac arrest survivors? Resuscitation 2021; 162:412-414. [PMID: 33592230 DOI: 10.1016/j.resuscitation.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 02/02/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Julie C Gudenkauf
- Department of Neurology, Johns Hopkins University School of Medicine, United States
| | - Romergryko G Geocadin
- Department of Neurology, Johns Hopkins University School of Medicine, United States; Department of Anesthesiology-Critical Care Medicine, Johns Hopkins University School of Medicine, United States; Department of Neurosurgery, Johns Hopkins University School of Medicine, United States.
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16
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Sandroni C, D'Arrigo S, Cacciola S, Hoedemaekers CWE, Kamps MJA, Oddo M, Taccone FS, Di Rocco A, Meijer FJA, Westhall E, Antonelli M, Soar J, Nolan JP, Cronberg T. Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med 2020; 46:1803-1851. [PMID: 32915254 PMCID: PMC7527362 DOI: 10.1007/s00134-020-06198-w] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/15/2020] [Indexed: 12/17/2022]
Abstract
Purpose To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3–5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA). Methods PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013–April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. Results Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2–5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors. Conclusion In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169) Electronic supplementary material The online version of this article (10.1007/s00134-020-06198-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sonia D'Arrigo
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Sofia Cacciola
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | - Marlijn J A Kamps
- Intensive Care Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Mauro Oddo
- Department of Intensive Care Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arianna Di Rocco
- Department of Public Health and Infectious Disease, Sapienza University, Rome, Italy
| | - Frederick J A Meijer
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Erik Westhall
- Department of ClinicalSciences, Clinical Neurophysiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jasmeet Soar
- Critical Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
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17
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Scheibe F, Neumann WJ, Lange C, Scheel M, Furth C, Köhnlein M, Mergenthaler P, Schultze-Amberger J, Triebkorn P, Ritter P, Kühn AA, Meisel A. Movement disorders after hypoxic brain injury following cardiac arrest in adults. Eur J Neurol 2020; 27:1937-1947. [PMID: 32416613 DOI: 10.1111/ene.14326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Post-hypoxic movement disorders and chronic post-hypoxic myoclonus are rare complications after cardiac arrest in adults. Our study investigates the clinical spectrum, neuroimaging results, therapy and prognosis of these debilitating post-hypoxic sequelae. METHODS This retrospective study included 72 patients from the neurological intensive care unit at a university hospital, who were diagnosed with hypoxic-ischaemic encephalopathy after cardiac arrest between January 2007 and September 2018. Clinical records were screened for occurrence of post-hypoxic movement disorders and chronic post-hypoxic myoclonus. Affected patients were further analysed for applied neuroprognostic tests, administered therapy and treatment response, and the outcome of these movement disorders and neurological function. RESULTS Nineteen out of 72 screened patients exhibited post-hypoxic motor symptoms. Basal ganglia injury was the most likely neuroanatomical correlate of movement disorders as indicated by T1 hyperintensities and hypometabolism of this region in magnetic resonance imaging and positron emission tomography computed tomography. Levomepromazine and intrathecal baclofen showed first promising and mostly prompt responses to control these post-hypoxic movement disorders and even hyperkinetic storms. In contrast, chronic post-hypoxic myoclonus best responded to co-application of clonazepam, levetiracetam and primidone. Remission rates of post-hypoxic movement disorders and chronic post-hypoxic myoclonus were 58% and 50%, respectively. Affected patients seemed to present a rather good recovery of cognitive functions in contrast to the often more severe physical deficits. CONCLUSIONS Post-hypoxic movement disorders associated with pronounced basal ganglia dysfunction might be efficiently controlled by levomepromazine or intrathecal baclofen. Their occurrence might be an indicator for a more unfavourable, but often not devastating, neurological outcome.
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Affiliation(s)
- F Scheibe
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - W J Neumann
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - C Lange
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - M Scheel
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - C Furth
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - M Köhnlein
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - P Mergenthaler
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - P Triebkorn
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Bernstein Center for Computational Neuroscience, Berlin, Germany
| | - P Ritter
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Bernstein Center for Computational Neuroscience, Berlin, Germany
| | - A A Kühn
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - A Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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18
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Abstract
A 7-year-old child who suffered from symptomatic focal epilepsy as a sequel to perinatal hypoxia used to have frequent seizures. This time she developed prolonged status epilepticus lasting for over 5 hours. She received a treatment in the form of intravenous midazolam and reinitiation of sodium valproate and clobazam that were discontinued previously. Seizures were controlled over a couple of hours, but she remained unresponsive. Later, she developed acute onset dystonia (day 3 post-status epilepticus) and also myoclonic jerks. She presented to us after 3 weeks of onset of these complaints and we considered hypoxic encephalopathy resulting from prolonged status epilepticus or acute encephalitis or non-convulsive status epilepticus. However, acute onset dystonia and periodicity of myoclonic jerks were pointers against it, and on evaluation, she was diagnosed with atypical fulminant subacute sclerosing panencephalitis (SSPE). Knowing the atypical presentations of SSPE is important in planning management and prognostication.
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19
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van Putten MJ, Jansen C, Tjepkema-Cloostermans MC, Beernink TM, Koot R, Bosch F, Beishuizen A, Hofmeijer J. Postmortem histopathology of electroencephalography and evoked potentials in postanoxic coma. Resuscitation 2019; 134:26-32. [DOI: 10.1016/j.resuscitation.2018.12.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/17/2018] [Accepted: 12/10/2018] [Indexed: 02/04/2023]
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20
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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: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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21
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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] [What about the content of this article? (0)] [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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22
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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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23
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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 Other Hyperkinet Mov (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] [What about the content of this article? (0)] [Affiliation(s)] [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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24
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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: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Jayant N Acharya
- Department of Neurology, Penn State University Hershey Medical Center, 30 Hope Drive, EC037, Hershey, PA 17033, 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] [What about the content of this article? (0)] [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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Gupta HV, Caviness JN. Post-hypoxic Myoclonus: Current Concepts, Neurophysiology, and Treatment. Tremor Other Hyperkinet Mov (N Y) 2016; 6:409. [PMID: 27708982 PMCID: PMC5039948 DOI: 10.7916/d89c6xm4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/16/2016] [Indexed: 12/18/2022]
Abstract
Background Myoclonus may occur after hypoxia. In 1963, Lance and Adams described persistent myoclonus with other features after hypoxia. However, myoclonus occurring immediately after hypoxia may demonstrate different syndromic features from classic Lance–Adams syndrome (LAS). The aim of this review is to provide up-to-date information about the spectrum of myoclonus occurring after hypoxia with emphasis on neurophysiological features. Methods A literature search was performed on PubMed database from 1960 to 2015. The following search terms were used: “myoclonus,” “post anoxic myoclonus,” “post hypoxic myoclonus,” and “Lance Adams syndrome.” The articles describing clinical features, neurophysiology, management, and prognosis of post-hypoxic myoclonus cases were included for review. Results Several reports in the literature were separated clinically into “acute post-hypoxic myoclonus,” which occurred within hours of severe hypoxia, and “chronic post-hypoxic myoclonus,” which occurred with some recovery of mental status as the LAS. Acute post-hypoxic myoclonus was generalized in the setting of coma. Chronic post-hypoxic myoclonus presented as multifocal cortical action myoclonus that was significantly disabling. There was overlap of neurophysiological findings for these two syndromes but also different features. Treatment options for these two distinct clinical–neurophysiologic post-hypoxic myoclonus syndromes were approached differently. Discussion The review of clinical and neurophysiological findings suggests that myoclonus after hypoxia manifests in one or a combination of distinct syndromes: acute and/or chronic myoclonus. The mechanism of post-hypoxic myoclonus may arise either from cortical and/or subcortical structures. More research is needed to clarify mechanisms and treatment of post-hypoxic myoclonus.
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Affiliation(s)
- Harsh V Gupta
- Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
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