Long-Term Neurological Complications after Hypoxic-Ischemic Encephalopathy

ABSTRACT

Hypoxic-ischemic encephalopathy accompanying cardiac arrest is a common cause of long-term neurological dysfunction. With the improvement in prehospital emergency systems, larger numbers of people are resuscitated from cardiac arrests, although with the increased prospect of neurological sequelae. Neurological impairment after cardiac arrest is dependent on the degree of brain damage suffered during the arrest. Although the duration and severity of brain ischemia is often difficult to determine, clinicians are often faced with difficult issues related to predicting outcome related to awakening and long-term neurological deficits after the arrest. Neurological impairments range from mild cognitive deficits to severe motor and cognitive deficits that preclude independence in many activities of daily living. Several neurological syndromes have been described in patients who awaken from hypoxic-ischemic coma with lasting motor and cognitive deficits. This review will address many of the common syndromes after hypoxic-ischemic encephalopathy, including persistent vegetative states, seizures, myoclonus, movement disorders, cognitive dysfunction, and other neurological abnormalities.

Hypoxic-ischemic encephalopathy - cardiac arrest - persistent vegetative state - seizures - posthypoxic myoclonus - myoclonus - movement disorders - delayed posthypoxic demyelination

REFERENCES

• 1 Eisenberg M, Bergner L, Hallstrom A, Cummins R. Sudden cardiac death.  Sci Am. 1986;  254 37-43
• 2 Lown B. Sudden cardiac death: the major challenge confronting contemporary cardiology.  Am J Cardiol. 1979;  43 313-328
• 3 Gray W A, Capone R J, Most A S. Unsuccessful emergency medical resuscitation: are continued efforts in the emergency department justified?.  N Engl J Med. 1991;  325 1393-1398
• 4 Maiese K, Caronna J. Coma following cardiac arrest: a review of the clinical features, management and prognosis.  J Intensive Care Med. 1988;  3 153-163
• 5 Longstreth Jr W T, Inui T S, Cobb L A, Copass M K. Neurologic recovery after out-of-hospital cardiac arrest.  Ann Intern Med. 1983;  98 588-592
• 6 Zandbergen E G, de Haan R J, Reitsma J B, Hijdra A. Survival and recovery of consciousness in anoxic-ischemic coma after cardiopulmonary resuscitation.  Intensive Care Med. 2003;  29 1911-1915
• 7 Brain Resuscitation Clinical Trial II Study Group . A randomized clinical study of a calcium-entry blocker (lidoflazine) in the treatment of comatose survivors of cardiac arrest.  N Engl J Med. 1991;  324 1225-1231
• 8 Brain Resuscitation Clinical Trial I Study Group . Randomized clinical study of thiopental loading in comatose survivors of cardiac arrest.  N Engl J Med. 1986;  314 397-403
• 9 Levy D E, Caronna J J, Singer B H, Lapinski R H, Frydman H, Plum F. Predicting outcome from hypoxic-ischemic coma.  JAMA. 1985;  253 1420-1426
• 10 Eisenberg M S, Cummins R O, Larsen M P. Numerators, denominators, and survival rates: reporting survival from out-of-hospital cardiac arrest.  Am J Emerg Med. 1991;  9 544-546
• 11 Torphy D E, Minter M G, Thompson B M. Cardiorespiratory arrest and resuscitation of children.  Am J Dis Child. 1984;  138 1099-1102
• 12 Lewis J K, Minter M G, Eshelman S J, Witte M K. Outcome of pediatric resuscitation.  Ann Emerg Med. 1983;  12 297-299
• 13 Orlowski J P. The effectiveness of pediatric cardiopulmonary resuscitation.  Am J Dis Child. 1984;  138 1097-1098
• 14 Longstreth Jr W T. Neurological Complications of Cardiac Arrest. 2nd ed. New York; Churchill Livingstone 1995
• 15 Jennett B, Bond M. Assessment of outcome after severe brain damage.  Lancet. 1975;  1 480-484
• 16 Jennett B, Plum F. Persistent vegetative state after brain damage: a syndrome in search of a name.  Lancet. 1972;  1 734-737
• 17 The Multi-Society Task Force on PVS . Medical aspects of the persistent vegetative state (1).  N Engl J Med. 1994;  330 1499-1508
• 18 Levy D E, Bates D, Caronna J J et al.. Prognosis in nontraumatic coma.  Ann Intern Med. 1981;  94 293-301
• 19 Bricolo A, Turazzi S, Feriotti G. Prolonged posttraumatic unconsciousness: therapeutic assets and liabilities.  J Neurosurg. 1980;  52 625-634
• 20 Gillies J D, Seshia S S. Vegetative state following coma in childhood: evolution and outcome.  Dev Med Child Neurol. 1980;  22 642-648
• 21 Levy D E, Knill-Jones R P, Plum F. The vegetative state and its prognosis following nontraumatic coma.  Ann NY Acad Sci. 1978;  315 293-306
• 22 Ingvar D H, Brun A, Johansson L, Samuelsson S M. Survival after severe cerebral anoxia with destruction of the cerebral cortex: the apallic syndrome.  Ann NY Acad Sci. 1978;  315 184-214
• 23 Dougherty Jr J H, Rawlinson D G, Levy D E, Plum F. Hypoxic-ischemic brain injury and the vegetative state: clinical and neuropathologic correlation.  Neurology. 1981;  31 991-997
• 24 The Multi-Society Task Force on PVS . Medical aspects of the persistent vegetative state (2).  N Engl J Med. 1994;  330 1572-1579
• 25 Andrews K. Recovery of patients after four months or more in the persistent vegetative state.  BMJ. 1993;  306 1597-1600
• 26 Snyder B, Cranford R, Rubens A, Brundlie S, Rockswold G. Delayed recovery from postanoxic persistent vegetative state.  Ann Neurol. 1983;  14 152 (Abstract)
• 27 Rosenberg G, Johnson S, Brenner R. Recovery of cognition after prolonged vegetative state.  Ann Neurol. 1977;  2 167-168
• 28 Kriel R L, Krach L E, Jones-Saete C. Outcome of children with prolonged unconsciousness and vegetative states.  Pediatr Neurol. 1993;  9 362-368
• 29 Sherrington C. Decerebrate rigidity, and reflex coordination of movements.  J Physiol. 1898;  22 319-332
• 30 Madison D, Niedermeyer E. Epileptic seizures resulting from acute cerebral anoxia.  J Neurol Neurosurg Psychiatry. 1970;  33 381-386
• 31 Krumholz A, Stern B J, Weiss H D. Outcome from coma after cardiopulmonary resuscitation: relation to seizures and myoclonus.  Neurology. 1988;  38 401-405
• 32 Snyder B D, Ramirez-Lassepas M, Lippert D M. Neurologic status and prognosis after cardiopulmonary arrest: I. A retrospective study.  Neurology. 1977;  27 807-811
• 33 Snyder B D, Hauser W A, Loewenson R B, Leppik I E, Ramirez-Lassepas M, Gumnit R J. Neurologic prognosis after cardiopulmonary arrest: III. Seizure activity.  Neurology. 1980;  30 1292-1297
• 34 Pampiglione G, Harden A. Resuscitation after cardiocirculatory arrest: prognostic evaluation of early electroencephalographic findings.  Lancet. 1968;  1 1261-1265
• 35 Snyder B, Daroff R. Hypoxic/Anoxic and Ischemic Encephalopathies. Vol. 2. 4th ed. Philadelphia; Elsevier 2004
• 36 Markand O N. Electroencephalography in diffuse encephalopathies.  J Clin Neurophysiol. 1984;  1 357-407
• 37 Moller M, Holm B, Sindrup E, Nielsen B L. Electroencephalographic prediction of anoxic brain damage after resuscitation from cardiac arrest in patients with acute myocardial infarction.  Acta Med Scand. 1978;  203 31-37
• 38 Scollo-Lavizzari G, Bassetti C. Prognostic value of EEG in post-anoxic coma after cardiac arrest.  Eur Neurol. 1987;  26 161-170
• 39 Edgren E, Hedstrand U, Nordin M, Rydin E, Ronquist G. Prediction of outcome after cardiac arrest.  Crit Care Med. 1987;  15 820-825
• 40 Jorgensen E O, Malchow-Moller A. Natural history of global and critical brain ischaemia: part I. EEG and neurological signs during the first year after cardiopulmonary resuscitation in patients subsequently regaining consciousness.  Resuscitation. 1981;  9 133-153
• 41 Simon R P, Aminoff M J. Electrographic status epilepticus in fatal anoxic coma.  Ann Neurol. 1986;  20 351-355
• 42 Calhoun C L, Ettinger M G. Unusual EEG in coma after cardiac arrest.  Electroencephalogr Clin Neurophysiol. 1966;  21 385-388
• 43 Treiman D M, De Giorgio C MA, Salisbury S M, Wickboldt C L. Subtle generalized convulsive status epilepticus.  Epilepsia. 1984;  25 653 (Abstract)
• 44 Ganji S S, Palliyath S, Chemmale J, Devrajan V N, McDonald L. Periodic complexes, absence-like status and suppression-burst pattern in coma following cardiorespiratory arrest.  Clin Electroencephalogr. 1997;  28 76-86
• 45 Cranford R E, Leppik I E, Patrick B, Anderson C B, Kostick B. Intravenous phenytoin: clinical and pharmacokinetic aspects.  Neurology. 1978;  28 874-880
• 46 Alving J, Moller M, Sindrup E, Nielsen B L. “Alpha pattern coma” following cerebral anoxia.  Electroencephalogr Clin Neurophysiol. 1979;  47 95-101
• 47 Chokroverty S. “Alpha-like” rhythms in electroencephalograms in coma after cardiac arrest.  Neurology. 1975;  25 655-663
• 48 Vignaendra V, Wilkus R J, Copass M K, Chatrian G E. Electroencephalographic rhythms of alpha frequency in comatose patients after cardiopulmonary arrest.  Neurology. 1974;  24 582-588
• 49 Westmoreland B F, Klass D W, Sharbrough F W, Reagan T J. Alpha-coma: electroencephalographic, clinical, pathologic, and etiologic correlations.  Arch Neurol. 1975;  32 713-718
• 50 Sananman M L. The use of EEG in the prognosis of coma.  Clin Electroencephalogr. 1983;  14 47-52
• 51 Grindal A B, Suter C, Martinez A J. Alpha-pattern coma: 24 cases with 9 survivors.  Ann Neurol. 1977;  1 371-377
• 52 Iragui V J, McCutchen C B. Physiologic and prognostic significance of “alpha coma”.  J Neurol Neurosurg Psychiatry. 1983;  46 632-638
• 53 Swanson P D, Luttrell C N, Magladery J W. Myoclonus: a report of 67 cases and review of the literature.  Medicine (Baltimore). 1962;  41 339-356
• 54 Lance J W, Adams R D. The syndrome of intention or action myoclonus as a sequel to hypoxic encephalopathy.  Brain. 1963;  86 111-136
• 55 Niedermeyer E, Bauer G, Burnite R, Reichenbach D. Selective stimulus-sensitive myoclonus in acute cerebral anoxia: a case report.  Arch Neurol. 1977;  34 365-368
• 56 Van Cott A C, Blatt I, Brenner R P. Stimulus-sensitive seizures in postanoxic coma.  Epilepsia. 1996;  37 868-874
• 57 Lance J W, Adams R D. Negative myoclonus in posthypoxic patients: historical note.  Mov Disord. 2001;  16 162-163
• 58 Hallett M. Physiology of human posthypoxic myoclonus.  Mov Disord. 2000;  15(suppl 1) 8-13
• 59 Werhahn K J, Brown P, Thompson P D, Marsden C D. The clinical features and prognosis of chronic posthypoxic myoclonus.  Mov Disord. 1997;  12 216-220
• 60 Frucht S, Fahn S. The clinical spectrum of posthypoxic myoclonus.  Mov Disord. 2000;  15(suppl 1) 2-7
• 61 Wijdicks E F, Parisi J E, Sharbrough F W. Prognostic value of myoclonus status in comatose survivors of cardiac arrest.  Ann Neurol. 1994;  35 239-243
• 62 Jumao-as A, Brenner R P. Myoclonic status epilepticus: a clinical and electroencephalographic study.  Neurology. 1990;  40 1199-1202
• 63 Arnoldus E P, Lammers G J. Postanoxic coma: good recovery despite myoclonus status.  Ann Neurol. 1995;  38 697-698
• 64 Agarwal P, Frucht S J. Myoclonus.  Curr Opin Neurol. 2003;  16 515-521
• 65 Krauss G L, Bergin A, Kramer R E, Cho Y W, Reich S G. Suppression of post-hypoxic and post-encephalitic myoclonus with levetiracetam.  Neurology. 2001;  56 411-412
• 66 Hawker K, Lang A E. Hypoxic-ischemic damage of the basal ganglia: case reports and a review of the literature.  Mov Disord. 1990;  5 219-224
• 67 Murray R S, Stensaas S S, Anderson R E, Matsuo F. Bilateral basal ganglia necrosis following diffuse hypoxic-ischemic injury.  Arch Neurol. 1987;  44 897
• 68 Bhatia K P, Marsden C D. The behavioural and motor consequences of focal lesions of the basal ganglia in man.  Brain. 1994;  117 859-876
• 69 Govaerts A, Van Zandijcke M, Dehaene I. Posthypoxic midbrain tremor.  Mov Disord. 1998;  13 359-361
• 70 Janavs J L, Aminoff M J. Dystonia and chorea in acquired systemic disorders.  J Neurol Neurosurg Psychiatry. 1998;  65 436-445
• 71 Bhatt M H, Obeso J A, Marsden C D. Time course of postanoxic akinetic-rigid and dystonic syndromes.  Neurology. 1993;  43 314-317
• 72 Scott B L, Jankovic J. Delayed-onset progressive movement disorders after static brain lesions.  Neurology. 1996;  46 68-74
• 73 Kuoppamaki M, Bhatia K P, Quinn N. Progressive delayed-onset dystonia after cerebral anoxic insult in adults.  Mov Disord. 2002;  17 1345-1349
• 74 Boylan K B, Chin J H, DeArmond S J. Progressive dystonia following resuscitation from cardiac arrest.  Neurology. 1990;  40 1458-1461
• 75 Scholz W. Selective neuronal necrosis and its topistic patterns in hypoxemia and oligemia.  J Neuropathol Exp Neurol. 1953;  12 249-261
• 76 Pulsinelli W A. Selective neuronal vulnerability: morphological and molecular characteristics.  Prog Brain Res. 1985;  63 29-37
• 77 Adams J H, Brierley J B, Connor R C, Treip C S. The effects of systemic hypotension upon the human brain: clinical and neuropathological observations in 11 cases.  Brain. 1966;  89 235-268
• 78 Mohr J P. Distal field infarction.  Neurology. 1969;  19 279 (Abstract)
• 79 Sage J I, Van Uitert R L. Man-in-the-barrel syndrome.  Neurology. 1986;  36 1102-1103
• 80 Caronna J J. Diagnosis, prognosis, and treatment of hypoxic coma.  Adv Neurol. 1979;  26 1-15
• 81 Gilles F H, Nag D. Vulnerability of human spinal cord in transient cardiac arrest.  Neurology. 1971;  21 833-839
• 82 Duggal N, Lach B. Selective vulnerability of the lumbosacral spinal cord after cardiac arrest and hypotension.  Stroke. 2002;  33 116-121
• 83 Azzarelli B, Roessmann U. Diffuse “anoxic” myelopathy.  Neurology. 1977;  27 1049-1052
• 84 Roine R O, Kajaste S, Kaste M. Neuropsychological sequelae of cardiac arrest.  JAMA. 1993;  269 237-242
• 85 Grubb N R, O'Carroll R, Cobbe S M, Sirel J, Fox K A. Chronic memory impairment after cardiac arrest outside hospital.  BMJ. 1996;  313 143-146
• 86 van Alem A P, de Vos R, Schmand B, Koster R W. Cognitive impairment in survivors of out-of-hospital cardiac arrest.  Am Heart J. 2004;  148 416-421
• 87 Volpe B T, Hirst W. The characterization of an amnesic syndrome following hypoxic ischemic injury.  Arch Neurol. 1983;  40 436-440
• 88 Volpe B T, Petito C K. Dementia with bilateral medial temporal lobe ischemia.  Neurology. 1985;  35 1793-1797
• 89 Bunch T J, White R D, Gersh B J et al.. Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation.  N Engl J Med. 2003;  348 2626-2633
• 90 Cummings J L, Tomiyasu U, Read S, Benson D F. Amnesia with hippocampal lesions after cardiopulmonary arrest.  Neurology. 1984;  34 679-681
• 91 Muramoto O, Kuru Y, Sugishita M, Toyokura Y. Pure memory loss with hippocampal lesions: a pneumoencephalographic study.  Arch Neurol. 1979;  36 54-56
• 92 Petito C K, Feldmann E, Pulsinelli W A, Plum F. Delayed hippocampal damage in humans following cardiorespiratory arrest.  Neurology. 1987;  37 1281-1286
• 93 Ginsberg M D. Delayed neurological deterioration following hypoxia.  Adv Neurol. 1979;  26 21-44
• 94 Thacker A K, Asthana A B, Sarkari N B. Delayed post-anoxic encephalopathy.  Postgrad Med J. 1995;  71 373-374
• 95 Lee M H. Clinical studies on delayed sequelae of carbon monoxide intoxication.  J Kor Neuropsychiatry Assoc. 1978;  15 374-385
• 96 Choi I S. Delayed neurologic sequelae in carbon monoxide intoxication.  Arch Neurol. 1983;  40 433-435
• 97 Shillito F, Drinker C. The problem of nervous and mental sequelae in carbon monoxide poisoning.  JAMA. 1936;  106 669-674
• 98 Custodio C M, Basford J R. Delayed postanoxic encephalopathy: a case report and literature review.  Arch Phys Med Rehabil. 2004;  85 502-505
• 99 Plum F, Posner J B, Hain R F. Delayed neurological deterioration after anoxia.  Arch Intern Med. 1962;  110 18-25
• 100 Gottfried J A, Mayer S A, Shungu D C, Chang Y, Duyn J H. Delayed posthypoxic demyelination: association with arylsulfatase A deficiency and lactic acidosis on proton MR spectroscopy.  Neurology. 1997;  49 1400-1404
• 101 Ginsberg M D, Hedley-Whyte E T, Richardson Jr E P. Hypoxic-ischemic leukoencephalopathy in man.  Arch Neurol. 1976;  33 5-14
• 102 Heckmann J G, Erbguth F, Neundorfer B. Delayed postanoxic demyelination registry.  Neurology. 1998;  51 1235-1236
• 103 Weinberger L M, Schmidley J W, Schafer I A, Raghavan S. Delayed postanoxic demyelination and arylsulfatase-A pseudodeficiency.  Neurology. 1994;  44 152-154