Images in Clinical Medicine

Fatal Cerebral Hypoxemia after Cardiac Arrest

Jesper Kelsen, M.D., and Annette Obel, M.D.

N Engl J Med 2003; 348:817February 27, 2003

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A 50-year-old woman suddenly became unconscious during her birthday celebration; there was no measurable pulse or blood pressure. Breathing and circulation returned spontaneously within a few minutes, but the exact time was unknown. On admission, she was comatose with bilateral dilated pupils and pronated limbs. Electrocardiography revealed signs of acute inferior myocardial ischemia and sinus tachycardia. The creatine kinase level was 770 U per liter; the level of the MB isoenzyme of creatine kinase was 44 U per liter; and the troponin T level was 0.65 per liter. A computed tomographic (CT) scan of the brain obtained one hour after presentation (Panel A) showed cerebral edema; progressive hypodense areas were seen on an additional CT scan obtained four hours later.

The patient was intubated and moved to a unit where she could receive neurointensive treatment and monitoring. Further neurologic examination revealed the lack of a gag reflex, the lack of corneal reflexes bilaterally, and the lack of response to painful stimulation. The blood pressure was 74/48 mm Hg. A CT scan obtained eight hours after presentation (Panel B) revealed signs of acute cerebral infarction involving the anterior and posterior circulation of both hemispheres. Comparison of the CT scan in Panel B with that in Panel A shows that the cerebral sulci are absent and ventricles are compressed. These findings strongly suggested anoxic encephalopathy. It was thought that further treatment was unwarranted, and with the family's permission, the patient was extubated and died shortly thereafter.

Jesper Kelsen, M.D.
Annette Obel, M.D.
University Hospital of Aarhus, DK-8000 Aarhus C, Denmark

Citing Articles (2)

Citing Articles

1. 1

   Charles D. Deakin, Laurie J. Morrison, Peter T. Morley, Clifton W. Callaway, Richard E. Kerber, Steven L. Kronick, Eric J. Lavonas, Mark S. Link, Robert W. Neumar, Charles W. Otto, Michael Parr, Michael Shuster, Kjetil Sunde, Mary Ann Peberdy, Wanchun Tang, Terry L. Vanden Hoek, Bernd W. Böttiger, Saul Drajer, Swee Han Lim, Jerry P. Nolan. (2010) Part 8: Advanced life support. Resuscitation 81:1, e93-e174
   CrossRef

2. 2

   (2003) Diffuse Cerebral Infarction after Cardiac Arrest. New England Journal of Medicine 348:26, 2689-2689
   Full Text

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