Klaus Berek

Early Determination of Neurological Outcome After Prehospital Cardiopulmonary Resuscitation

BACKGROUND AND PURPOSE Although there are various methods of determining neurological prognosis after cardiopulmonary resuscitation, the final outcome of patients often remains unclear for quite a long time. METHODS We investigated 30 consecutively admitted patients who had been successfully resuscitated by the team of the local mobile intensive care unit after cardiac arrest. Determinations of the period of anoxia and of the cardiopulmonary resuscitation time, clinical investigation, echocardiography, electroencephalography, evoked potentials, magnetic resonance imaging, and magnetic resonance spectroscopy were performed. RESULTS Demonstration of brain lactate in proton magnetic resonance spectroscopy (P < .01) and absent N20 waves in short-latency somatosensory evoked potentials (P < .01) proved to be significant in terms of a poor prognosis. Correlations between both duration of anoxia and cardiopulmonary resuscitation time and neurological outcome could be shown as well (both P < .05). CONCLUSIONS Proton magnetic resonance spectroscopy and short-latency evoked potentials are of great benefit in the prognostic evaluation after cardiopulmonary resuscitation.

The Prognostication of Cerebral Hypoxia after Out-of-Hospital Cardiac Arrest in Adults

Early determination of outcome after out-of-hospital cardiopulmonary resuscitation is a common problem with great ethical, economic, social and legal consequences. Although there has been a fulminant development of emergency medicine during the last three decades, severe cerebral damage sometimes cannot be avoided. For neurological outcome prediction after cardiac arrest clinical neurological signs, electrophysiological examinations, neuroimaging tests, and laboratory parameters in serum and cerebrospinal fluid are used today, nevertheless, there still remains a considerable degree of uncertainty. However, although prognostic criteria which enable the clinician to stop treatment cannot be given at the present time, useful applications of early prognostication after cardiac arrest range from counseling of families, triage decisions, and do-not-resuscitate decisions to future clinical investigations of brain resuscitative measures.

The prognostic significance of coma-rating, duration of anoxia and cardiopulmonary resuscitation in out-of-hospital cardiac arrest

Abstract Early determination of outcome after successful prehospital cardiopulmonary resuscitation (CPR) is a common problem with great ethical, economic, social, and legal consequences. We prospectively investigated 112 adult patients who had been resuscitated after out-of-hospital cardiac arrest (CA). The aim of our study was to determine whether coma rating by the mobile intensive care unit (MICU) is a useful tool for outcome prediction. For neurological assessment the Innsbruck Coma Scale (ICS) was used initially and after return of spontaneous circulation (ROSC) or 20–30 min after the start of CPR, before any sedating drugs were given. The duration of anoxia and CPR were determined with the automatically recorded emergency call protocol of the dispatch centre and the protocol of the MICU. For estimation of cerebral outcome at the time of discharge from hospital we used the Glasgow-Pittsburgh Cerebral Performance Categories (CPC). Restoration of spontaneous circulation was achieved in 42 patients (37%), and 15 (13%) were discharged from hospital. The first coma rating performed immediately at the time of arrival on scene had no significant prognostic value for prediction of neurological outcome (P = 0.204) and survival (P = 0.103). The second coma rating (performed after ROSC or 20–30 min after the start of CPR), however, demonstrated a significant correlation with neurological outcome (P = 0.0000) and survival (P = 0.0000), a correlation which was comparable to both duration of anoxia and duration of CPR. In patients with out-of-hospital cardiac arrest prognostic information could be obtained with the ICS as early as 20– 30 min after the start of cardiopulmonary resuscitation.

Hemispheric disconnection in Marchiafava-Bignami disease: Clinical, neuropsychological and MRI findings

We report a single-case study of a patient suffering from Marchiafava-Bignami disease (MBD), a rarely intra vitam diagnosed syndrome with focal demyelination in the corpus callosum, which is usually found in patients with chronic alcohol abuse. Our study explored a variety of motor, sensory and visual functions. Striking features were left apraxia caused by two lesions in the rostral area, and left hemidyslexia related to a large splenial lesion demonstrated by MRI. As symptoms of disconnection may remain undetected clinically, MRI is a most useful tool for the diagnosis of MBD.

Superficial siderosis of the central nervous system: report of three cases and review of the literature

We present 3 cases and a review of the literature to demonstrate the current state of clinical diagnosis and therapy of superficial siderosis of the central nervous system. Typical symptoms were progressive cerebellar ataxia, spasticity and hearing loss. Repeated subarachnoid hemorrhage was indicated by persistent xanthochromia of the cerebrospinal fluid and confirmed by the presence of erythrophages, siderophages and iron-containing pigments. Deposition of free iron and hemosiderin in pial and subpial structures leads to intoxication of the central nervous system and represents the pathophysiological mechanism of superficial siderosis. Hypointensity of the marginal zones of the central nervous system on T2 weighted MR images indicates an iron-induced susceptibility effect and seems pathognomonic for superficial siderosis. In 39 of the 43 previously described cases superficial siderosis was verified by biopsy or autopsy. Today magnetic resonance imaging enables diagnosis at an early stage of the disease. Therapeutic management requires the elimination of any potential source of bleeding. In patients with unknown etiology no proofed therapy is yet available.

Thrombolysis and clinical outcome in patients with stroke after implementation of the Tyrol Stroke Pathway: a retrospective observational study

BACKGROUND Intravenous thrombolysis for ischaemic stroke remains underused worldwide. We aimed to assess whether our statewide comprehensive stroke management programme would improve thrombolysis use and clinical outcome in patients. METHODS In 2008-09, we designed the Tyrol Stroke Pathway, which provided information campaigns for the public and standardised the entire treatment pathway from stroke onset to outpatient rehabilitation. It was commenced in Tyrol, Austria, as a long-term routine-care programme and aimed to include all patients with stroke in the survey area. We focused on thrombolysis use and outcome in the first full 4 years of implementation (2010-13). FINDINGS We enrolled 4947 (99%) of 4992 patients with ischaemic stroke who were admitted to hospitals in Tyrol; 675 (14%) of the enrollees were treated with alteplase. Thrombolysis administration in Tyrol increased after programme implementation, from 160 of 1238 patients (12·9%, 95% CI 11·1-14·9) in 2010 to 213 of 1266 patients (16·8%, 14·8-19·0) in 2013 (ptrend 2010-13<0·0001). Differences in use of thrombolysis in the nine counties of Tyrol in 2010 (range, 2·2-22·6%) were reduced by 2013 (12·1-22·5%). Median statewide door-to-needle time decreased from 49 min (IQR 35-60) in 2010 to 44 min (29-60) in 2013; symptomatic post-thrombolysis intracerebral haemorrhages occurred in 28 of 675 patients (4·1%, 95% CI 2·8-5·9) during 2010-13. In four Austrian states without similar stroke programmes, thrombolysis administration remained stable or declined between 2010 and 2013 (mean reduction 14·4%, 95% CI 10·9-17·9). Although the 3-month mortality was not affected by our programme (137 [13%] of 1060 patients in 2010 vs 143 [13%] of 1069 patients in 2013), 3-month functional outcome significantly improved (modified Rankin Scale score 0-1 in 375 [40%] of 944 patients in 2010 vs 493 [53%] of 939 in 2013; score 0-2 in 531 [56%] patients in 2010 and 615 [65%] in 2013; ptrend 2010-13<0·0001). INTERPRETATION During the period of implementation of our comprehensive stroke management programme, thrombolysis administration increased and clinical outcome significantly improved, although mortality did not change. We hope that these results will guide health authorities and stroke physicians elsewhere when implementing similar programmes for patients with stroke. FUNDING Reformpool of the Tyrolean Health Care Fund.

Electrophysiological findings in a case of severe intrathecal baclofen overdose

Multimodality evoked potentials were examined in a case of serious accidental intrathecal baclofen overdose in a patient who suffered from severe spasticity due to a traumatic brain lesion. Electrophysiological findings during, before and after the intoxication were compared. Transcranial electrical stimulation up to 750 V did not evoke any responses in thenar muscles on the first day of intoxication. An improvement to normal values was observed within 3 days, paralleled by an amelioration of the patients clinical condition. Cervical electrical stimulation was largely unaffected by baclofen. Median nerve somatosensory and brain-stem acoustic evoked potentials revealed few or no differences during intoxication compared to pre- and post-intoxication responses.

MRI of cerebral hypoxia

MRI findings are described in 24 cases of hypoxic coma. In this study hypoxic damage has occurred as a consequence of diverse conditions such as cardiac arrest, anaesthetic accidents, carbon monoxide poisoning, high altitude brain oedema, drowning, suicidal hanging, hypo-glycaemia and shock. The main forms of cerebral damage were watershed infarction and bilateral selective neuronal necrosis within the globus pallidus, putamen, nucleus cau-datus, thalamus, parahippocampal gyrus, hippocampus, cerebellum and brainstem nuclei. Whereas watershed infarction indicated failure of circulation, the pattern of damage within the basal ganglia, thalami, temporal lobe and brain stem could not be related to any of the underlying pathogenetic processes. No typical pattern of lesion could be found in regard to the cause of the disease. However, arterial boundary zone involvement indicates the underlying pathogenetic mechanism. The sensitivity of MRI in the detection of hypoxic lesions was greatly superior to that of CT, while specificity based on signal behaviour allowed differentiation of acute and chronic alterations. Based on serial MRI studies prediction of prognostic outcome will be improved.

Syndrome of the anterior spinal artery as the primary manifestation of aspergillosis

SummaryAspergillosis of the central nervous system (CNS) is an uncommon infection, mainly occurring in immunocompromised patients. Beside cerebral involvement spinal cord lesions are extremely rare. To our knowledge, aspergillosis initially presenting with acute paraplegia due to mycotic thrombosis of the anterior spinal artery in a formerly healthy patient has, so far, not been reported. Neither a primary focus nor an underlying disease had been detected.ZusammenfassungEine Aspergillose des zentralen Nervensystems (vorwiegend cerebrum) ist eine ungewöhnliche Infektion, die hauptsächlich bei immunkompromittierten Patienten vorkommt. Eine Aspergillose, die sich initial als akutes A. spinalis anterior Syndrom präsentiert — bei mykotischer Thrombose — wurde bis jetzt noch nicht mitgeteilt. In diesem sonst gesunden Patienten war kein Fokus gefunden worden.Aspergillosis of the central nervous system (CNS) is an uncommon infection, mainly occurring in immunocompromised patients. Beside cerebral involvement spinal cord lesions are extremely rare. To our knowledge, aspergillosis initially presenting with acute paraplegia due to mycotic thrombosis of the anterior spinal artery in a formerly healthy patient has, so far, not been reported. Neither a primary focus nor an underlying disease had been detected. Eine Aspergillose des zentralen Nervensystems (vorwiegend cerebrum) ist eine ungewöhnliche Infektion, die hauptsächlich bei immunkompromittierten Patienten vorkommt. Eine Aspergillose, die sich initial als akutes A. spinalis anterior Syndrom präsentiert — bei mykotischer Thrombose — wurde bis jetzt noch nicht mitgeteilt. In diesem sonst gesunden Patienten war kein Fokus gefunden worden.

Positionspapier der Österreichischen Gesellschaft für Schlaganfallforschung

ZusammenfassungDer Schlaganfall ist weltweit die dritthäufigste Todesursache und die häufigste Ursache für eine schwere Behinderung im Erwachsenenalter. Jedes Jahr erkranken in Österreich rund 20.000 Menschen daran, etwa 60.000 leiden unter den Schlaganfallfolgen. Neue Erkenntnisse zur Pathophysiologie und Klinik des Schlaganfalls sowie die Einführung moderner diagnostischer Verfahren haben das Management von Schlaganfallpatienten wesentlich geändert.Basierend auf den aktuellen wissenschaftlichen Erkenntnissen und in der Praxis bewährten Verfahren hat die Österreichische Gesellschaft für Schlaganfallforschung ein Positionspapier zu wichtigen Themenbereichen der Versorgung von Schlaganfallpatienten erarbeitet. Die Daten wurden von Arbeitsgruppen in einem systematischen Review gesammelt und im Expertengremium diskutiert, wobei für die Einstufung in Evidenzgrad und Empfehlungsstärke die EFNS-Kriterien verwendet wurden. Es ist geplant, weitere Themen aufzunehmen und das hier vorgestellte Positionspapier alle zwei Jahre einer Überarbeitung zu unterziehen.AbstractStroke is the third most frequent cause of death in the world overall, and the most common reason for severe disablement in adulthood. Every year, a good 20,000 people in Austria suffer strokes, and about 60,000 suffer from sequelae of strokes. New insights into the pathophysiology and clinical aspects of stroke and the introduction of modern diagnostic techniques have led to substantial changes in the management of stroke patients.Based on the current scientific knowledge and techniques that have been tried and tested in practice, the Austrian Society of Stroke Research has prepared a position paper on important subject areas in the treatment of stroke patients. The data were collected by working groups in a systematic review and discussed by the expert committee, the EFNS criteria being used for the classification by level of evidence and strength of recommendations. There are plans to pursue new topics, and to review the position paper presented here every two years.