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Editorial
Clinical Value of Decompressive Craniectomy
Patients with a variety of intracranial disorders — including traumatic brain injury, stroke, subarachnoid hemorrhage, intracerebral hemorrhage, and brain tumors — often present with a progressive increase in intracranial pressure, leading to clinical deterioration and ultimately to death.…
Original Article
Decompressive Craniectomy in Diffuse Traumatic Brain Injury
Among patients who are hospitalized with severe traumatic brain injury, 60% either die or survive with severe disability.– Of Australia's population of 22 million, approximately 1000 patients annually sustain a severe traumatic brain injury, with associated lifetime costs estimated at $1 billion.…
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Review Article
Mechanisms of Disease: General Anesthesia, Sleep, and Coma
In the United States, nearly 60,000 patients per day receive general anesthesia for surgery. General anesthesia is a drug-induced, reversible condition that includes specific behavioral and physiological traits — unconsciousness, amnesia, analgesia, and akinesia — with concomitant stability of…
Clinical Therapeutics
Targeted Temperature Management for Comatose Survivors of Cardiac Arrest
Foreword. This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this therapy, and potential adverse effects are…
- CME
A 62-year-old man collapses on the street and is found to be in cardiac arrest. He is resuscitated at the scene by emergency medical personnel, but he is comatose. Targeted temperature management, which involves cooling the patient to a core body temperature of 32 to 34°C for 24 hours, is recommended.
Case Records of the Massachusetts General Hospital
Case 21-2010 — A Request for Retrieval of Oocytes from a 36-Year-Old Woman with Anoxic Brain Injury
Presentation of Case. The family of a 36-year-old woman with anoxic brain injury requested oocyte retrieval for the purpose of posthumous conception. The patient had been well until 11 days earlier, when she collapsed approximately 7 hours into an international airplane flight. She had taken…
A 36-year-old woman had severe anoxic brain damage due to a pulmonary embolus during a long airplane flight. She was admitted to the neurology intensive care unit but remained in a coma despite maximal medical therapy. On the ninth day, the family decided to institute comfort measures only. Later, they requested that maximal therapy be resumed, to permit consideration of oocyte retrieval for the purpose of posthumous conception of future offspring. A management decision was made.
Perspective
Treatment Decisions after Brain Injury — Tensions among Quality, Preference, and Cost
Many patients with sudden severe brain injury from stroke, trauma, or cardiac arrest die after family members and clinicians decide, given a poor prognosis, to withdraw treatment. Although it's difficult to estimate precisely how prevalent this trajectory to death is, as many as 60% of deaths from…
Original Article
Willful Modulation of Brain Activity in Disorders of Consciousness
In recent years, improvements in intensive care have led to an increase in the number of patients who survive severe brain injury. Although some of these patients go on to have a good recovery, others awaken from the acute comatose state but do not show any signs of awareness. If repeated…
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In this study involving 54 patients in a vegetative or minimally conscious state, the use of functional magnetic resonance imaging (MRI) to assess responses during mental-imagery tasks showed that 5 patients were able to willfully modulate their brain activation. These findings suggest that functional MRI can be used to demonstrate evidence of awareness and cognition that cannot be detected by means of clinical assessment.
Correspondence
Vision 1 Year after Gene Therapy for Leber's Congenital Amaurosis
To the Editor: Leber's congenital amaurosis, a common cause of blindness in infants and children, recently became the first human genetic retinal disease to show improved vision in response to treatment. Patients with mutations in the gene encoding retinal pigment epithelium–specific 65-kD…
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- Video
Correspondence
Case 15-2009: A Man with Coma after Cardiac Arrest
To the Editor: Kotton et al. (May 14 issue) present the case of a 25-year-old man with cardiac arrest. The initial rhythm was ventricular fibrillation. Despite successful resuscitation, brain death was declared and the heart was procured for transplantation. Although no structural abnormalities…
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Clinical Practice
Neurologic Prognosis after Cardiac Arrest
Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations. Stage. A 55-year-old…
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A 55-year-old man collapses while jogging through the park. A bystander finds him unconscious and without a pulse and initiates cardiopulmonary resuscitation while an ambulance is summoned. On arrival in the emergency room, the patient is in ventricular fibrillation. Spontaneous circulation is reestablished, but he remains comatose with absent pupillary reflexes. He remains unconscious after treatment with hypothermia for 24 hours. What would you advise regarding his neurologic prognosis?
Case Records of the Massachusetts General Hospital
Case 15-2009 — A 25-Year-Old Man with Coma after Cardiac Arrest
Presentation of Case. Dr. Mathias Lichterfeld (Infectious Disease): A 25-year-old man was admitted to this hospital because of coma after cardiac arrest. He had been well until 4 hours before admission, when he was seen to have had seizurelike movements and to have collapsed, without pulse or…
A 25-year-old man was admitted to this hospital because of coma after cardiac arrest. Cardiopulmonary resuscitation was performed, and a junctional rhythm was established. On admission, the patient remained unconscious. Despite aggressive measures, the patient met criteria for brain death, and his family agreed to organ donation. During the procurement procedure, a thickened region of the colon was seen. A diagnostic procedure was performed.
Clinical Decisions
Care of an Unresponsive Patient with a Poor Prognosis — Polling Results
In late January, we presented the case of an unresponsive, 56-year-old homeless patient who had a ruptured aneurysm, a high probability of cancer, and a best prognosis of severe disability that would leave him dependent on care by others in Clinical Decisions, an interactive feature designed to…
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Clinical Decisions
Care of an Unresponsive Patient with a Poor Prognosis
Case Vignette. A 56-year-old homeless man was found having a seizure and was transported to the hospital. He was found to have a subarachnoid hemorrhage and acute hydrocephalus. He underwent intubation, and mechanical ventilation was started. A shunt was placed to relieve the hydrocephalus;…
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Original Article
Brief Report: Pediatric Heart Transplantation after Declaration of Cardiocirculatory Death
Pediatric heart transplantation after the declaration of brain death in donors has been performed for more than 25 years in more than 6000 recipients. The first successful heart-transplant procedure in an infant was reported 20 years ago, and decades-long survival has been reported. The average…
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This report describes transplantation of hearts from three infant donors (mean age at donation, 3.7 days) who had died from cardiocirculatory causes. The recipients (mean age, 2.2 months) all survived to 6 months with excellent left ventricular function. This approach to transplantation has been controversial but offers the prospect of expanding the donor pool.
Perspective
Donating Hearts after Cardiac Death — Reversing the Irreversible
Organ Donation after Cardiac Death. In this issue of the Journal, Boucek et al. (pages 709–714) report on three cases of heart transplantation from infants who were pronounced dead on the basis of cardiac criteria. The three Perspective articles and a video roundtable discussion at www.nejm.org…
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Perspective
The Dead Donor Rule and Organ Transplantation
Organ Donation after Cardiac Death. In this issue of the Journal, Boucek et al. (pages 709–714) report on three cases of heart transplantation from infants who were pronounced dead on the basis of cardiac criteria. The three Perspective articles and a video roundtable discussion at www.nejm.org…
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Original Article
Hypothermia Therapy after Traumatic Brain Injury in Children
Hypothermia therapy significantly improves survival and the neurologic outcome in rodent models of traumatic brain injury. An early case series involving 18 children suggested that hypothermia therapy could improve survival and the neurologic outcome among children with traumatic brain injury.…
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In this randomized trial of hypothermia in children with severe traumatic brain injury, severe disability, a persistent vegetative state, or death occurred in 31% of patients who were treated with hypothermia for 24 hours and in 22% of controls. These findings suggest that hypothermia is not a beneficial therapy for children with traumatic brain injury.
Original Article
Efficacy and Safety of Recombinant Activated Factor VII for Acute Intracerebral Hemorrhage
Intracerebral hemorrhage is the most devastating form of stroke. Approximately 40% of patients with intracerebral hemorrhage die within 30 days, and the majority of survivors are left with severe disability. Hematoma growth occurs in up to 70% of patients who have intracerebral hemorrhage…
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In a previous phase 2 placebo-controlled trial, recombinant activated factor VII (rFVIIa) reduced growth of the hematoma and improved survival and functional outcome in patients with intracerebral hemorrhage. Those findings were not reproduced in this phase 3 trial, in which rFVIIa reduced hematoma growth but did not improve clinical outcomes.
Original Article
Rapid Disuse Atrophy of Diaphragm Fibers in Mechanically Ventilated Humans
Mechanical ventilation is a critical component of modern intensive care medicine, but the process of discontinuing mechanical ventilation can be difficult. Laboratory studies have shown that the combination of diaphragmatic inactivity and mechanical ventilation for prolonged periods (more than 18…
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Weaning patients from mechanical ventilation after modest periods of diaphragmatic inactivity can be difficult. In this study, changes in the cross-sectional area and biochemical composition of biopsy specimens from brain-dead patients with inactive diaphragms at the time of organ donation were compared with similar measurements from patients undergoing thoracic surgery. The data were consistent with atrophy of the diaphragm after periods of inactivity on the order of a day.
Editorial
Effect of Mechanical Ventilation on the Diaphragm
It is widely assumed that respiratory-muscle weakness, either intrinsic or due to fatigue, leads to respiratory failure. For the past 30 years, attention has been focused on whether the diaphragm muscle is especially susceptible to fatigue in patients with chronic pulmonary disease and critical…
