Cerebral hypoxia, missing cortical somatosensory evoked potentials and recovery of consciousness.

BACKGROUND: Bilaterally absent N20 components of the sensory evoked potentials (SEP) from the median nerve are regarded as accurately predicting poor outcome after cardiac arrest. CASE PRESENTATION: We are reporting on a patient, who regained consciousness despite this ominous finding. Early after cardiac arrest, MRI showed signal alterations in diffusion weighted imaging (DWI) bilaterally in the primary visual and sensorimotor cortex and in the basal ganglia. SEP were repeatedly absent. The patient survived shut out form sensory and visual experience and locked in for voluntary movements, but kept her verbal competence in several languages. CONCLUSION: SEP inform about integrity only of a narrow cortical strip. It is unguarded, but common practice, to conclude from absent SEP, that a patient has suffered diffuse cortical damage after cardiac arrest. Cerebral MRI with DWI helps to avoid this prognostic error and furthers understanding of the sometimes very peculiar state of mind after cardiac arrest.

A patient questionnaire for radiation-induced brachial plexopathy.

We analyzed the usefulness of a symptom questionnaire to screen for radiation-induced brachial plexopathy (RIBP) after breast cancer treatment. Four questions addressed distal and proximal paresis: impaired hand functions, problems raising the arm, carrying weights, and lifting objects from a high shelf. Eighty-one relapse-free patients were neurologically examined. Treatment was mastectomy (51%) or breast-conserving surgery (49%), radiotherapy to the supraclavicular +/- axilla with median 60 Gy maximum dose. Sixty-five subsequent control patients had breast-conserving surgery and radiotherapy to the breast only with 55 Gy median dose. Median follow up was 10 and 7.4 years, respectively. Sixteen patients had RIBP, 7 had Radiation Therapy Oncology Group (RTOG) grade 1, 4 grade 2, 3 grade 3, and 2 grade 4 RIBP. Thirty-seven patients had fibrosis and 32 had arm edema. Four patients with RIBP had no fibrosis (n = 2) or fibrosis of the axilla only (n = 2). Specificity of the question "impaired hand functions" for RIBP was 0.66 (95% confidence interval [CI], 0.51-0.78); sensitivity was 0.80 (95% CI, 0.52-0.96). Specificity of the question "raising the arm" was 0.98 (95% CI, 0.9-0.99) and sensitivity was 0.18 (95% CI, 0.04-0.45); the rate of false-positive control patients was 3%. In multivariate analysis, "impaired hand functions" and fibrosis were independent indicators of RIBP (P <0.005). Patients with breast irradiation only stated moderate/pronounced impaired hand functions; and problems carrying weights and lifting objects from a high shelf in 38%, 58%, and 77%, not significantly different from patients with RIBP or the patients with supraclavicular radiation. RIBP is not necessarily associated with fibrosis. The aim of the questionnaire was screening of a population at risk for RIBP. In this group, the question "problems raising the arm" detected severe RIBP with high specificity. Negation of "impaired hand functions" excludes RIBP. Both questions should be included in follow-up questionnaires.

Endovascular therapy of acute vertebrobasilar occlusion: early treatment onset as the most important factor.

In view of the poor prognosis for patients with acute intracranial vertebrobasilar occlusion (VBO), factors were sought that predict survival and good neurologic outcome after acute endovascular treatment by means of local intra-arterial fibrinolysis (LIF) and percutaneous transluminal angioplasty (PTA). LIF was performed in 83 patients with angiographically established acute VBO. A significant residual stenosis after LIF was treated by additional PTA in 8 patients. The types of occlusion were classified as either embolic occlusion (EO) or atherothrombotic occlusion (AO). Outcome was evaluated after 3 months by the Barthel Index (BI) as favorable (BI >90), unfavorable (BI <90) or death and compared for each of 3 diagnostic or treatment variables: recanalization success, occlusion type and time to treatment. Four fibrinolytic treatment modes [urokinase, low-dose and high-dose recombinant tissue-type plasminogen activator (rt-PA), rt-PA + Lys-plasminogen] were also analyzed. The outcome was favorable in 19 patients (23%), unfavorable in 14 (17%) and 50 died (60%). Recanalization was successful in 54 patients (66%). The neurologic outcome was better in recanalized than in nonrecanalized patients (favorable outcome: 30 vs. 10%, mortality: 54 vs. 72%; p = 0.118). The neurologic outcome was better in EO than in AO (favorable outcome: 31 vs. 17%, mortality: 47 vs. 70%, p = 0.112). Under combined treatment by LIF and PTA in 8 patients with AO, 4 survived, 3 with a favorable outcome (38%). Early treatment onset (6 h; favorable outcome: 36 vs. 7%, mortality: 52 vs. 70%, p = 0.005). Although no statistically significant differences were found between the types of fibrinolytic agents, treatment with rt-PA and Lys-plasminogen tended toward better results. Early treatment onset proved to be the most important factor for successful endovascular therapy in acute VBO, whereas recanalization and presence of an embolic occlusion also tended toward better results. Additional PTA may be a promising therapy in cases of significant residual stenosis after LIF.