Early loss of gray-white differentiation and swelling of the brain on computed tomography
(CT) imaging after resuscitation from cardiac arrest are ominous signs,
- Esdaille C.J.
- Coppler P.J.
- Faro J.W.
- et al.
Pittsburgh Post Cardiac Arrest Service. Duration and clinical features of cardiac
arrest predict early severe cerebral edema.
- Sandroni C.
- D'Arrigo S.
- Cacciola S.
- et al.
Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a
but at Maine Medical Center, our therapeutic nihilism about cerebral edema after
cardiac arrest was tempered by the case of a 24 year-old man treated in 2020 who suffered
a prolonged PEA arrest and delayed cardiopulmonary resuscitation following an accidental
opioid overdose. He presented in transfer from another institution with profound aspiration-related
ARDS, a low-voltage and nonreactive EEG exhibiting very high suppression ratio, and
cerebral edema by head CT, manifested by loss of gray-white differentiation, narrowing
and distortion of the cisternal spaces, and bilateral uncal herniation. Eleven hours
after resuscitation, we placed a right frontal parenchymal fiberoptic intracranial
pressure (ICP) and brain tissue oxygen (PbtO2
) monitor. The ICP was 25 cm H2
O and PbtO2
< 5 mmHg despite FiO2
1.0. The ICP corrected with 50 grams of mannitol, but only after the patient was
placed in prone, reverse-Trendelenburg positioning with the head up at 30 degrees,
resulting in profound improvement in his systemic oxygenation, did the brain oxygen
normalize. Over the next 24 hours, at 33 °C, we maintained ICP < 20 cm H2
O, cerebral perfusion pressure (CPP) > 60 mmHg, and PbtO2
> 20 mmHg. We also delayed rewarming due to the ICP elevation, completing a full
48 hours at 33 °C, and then rewarmed the patient at 0.25 °C/hr until he reached 36.5 °C.
At this point sedation was weaned and he awakened, was rapidly extubated, and within
24 hours left the hospital against medical advice. The case had not gone as expected,
and we were left wondering if cerebral edema after cardiac arrest was in fact a plausible
target for therapy.