No abstract

BACKGROUNDWhether the treatment of rhythmic and periodic electroencephalographic (EEG) patterns in comatose survivors of cardiac arrest improves outcomes is uncertain. METHODSWe conducted an open-label trial of suppressing rhythmic and periodic EEG patterns detected on continuous EEG monitoring in comatose survivors of cardiac arrest. Patients were randomly assigned in a 1:1 ratio to a stepwise strategy of antiseizure medications to suppress this activity for at least 48 consecutive hours plus standard care (antiseizure-treatment group) or to standard care alone (control group); standard care included targeted temperature management in both groups. The primary outcome was neurologic outcome according to the score on the Cerebral Performance Category (CPC) scale at 3 months, dichotomized as a good outcome (CPC score indicating no, mild, or moderate disability) or a poor outcome (CPC score indicating severe disability, coma, or death). Secondary outcomes were mortality, length of stay in the intensive care unit (ICU), and duration of mechanical ventilation. RESULTSWe enrolled 172 patients, with 88 assigned to the antiseizure-treatment group and 84 to the control group. Rhythmic or periodic EEG activity was detected a median of 35 hours after cardiac arrest; 98 of 157 patients (62%) with available data had myoclonus. Complete suppression of rhythmic and periodic EEG activity for 48 consecutive hours occurred in 49 of 88 patients (56%) in the antiseizure-treatment group and in 2 of 83 patients (2%) in the control group. At 3 months, 79 of 88 patients (90%) in the antiseizure-treatment group and 77 of 84 patients (92%) in the control group had a poor outcome (difference, 2 percentage points; 95% confidence interval, −7 to 11; P = 0.68). Mortality at 3 months was 80% in the antiseizure-treatment group and 82% in the control group. The mean length of stay in the ICU and mean duration of mechanical ventilation were slightly longer in the antiseizure-treatment group than in the control group. CONCLUSIONSIn comatose survivors of cardiac arrest, the incidence of a poor neurologic outcome at 3 months did not differ significantly between a strategy of suppressing rhythmic and periodic EEG activity with the use of antiseizure medication for at least 48 hours plus standard care and standard care alone. (Funded by the Dutch Epilepsy Foundation; TELSTAR ClinicalTrials.gov number, NCT02056236.

Although global CBF was unaffected in patients with mild HF, significant changes in basilar inflow volume, cerebral autoregulation and vasomotor reactivity were observed. We describe a model of dynamic cerebral mechanisms required to compensate for the impaired haemodynamics in early-stage HF.

We describe a previously not recognized nonsense mutation in exon 10 of the ALS2 gene in two sibs with infantile-onset ascending spastic paralysis. The mutation predicts chain termination at amino-acid position 715 of the gene product ALSIN (p.Gln715X). The sibs' parents are descendants of a common ancestor who lived in the northern Netherlands during the eighteenth century. This is the first ALS2 mutation detected in northwestern Europeans. The findings emphasize that mutations in ALS2 also need to be considered in patients from northwestern Europe with early-onset spastic paralysis and amyotrophic or primary lateral sclerosis. In ALS2 both upper and lower motor neurons are affected, whereas neurodegeneration only involves upper motor neurons in JPLS and IAHSP. 5,6 Despite this difference in neuropathology, there is considerable clinical overlap of the major signs and symptoms in the three conditions, including spasticity of the limbs and dysarthria. The age of onset is during early childhood (first or second year), in the three disorders but appears to be somewhat later in ALS2 than in JPLS and IAHSP. The ALS2 gene is located on the long arm of chromosome 2 (2q33) and is composed of 34 exons.1,2 It can be transcribed into two alternative transcripts of 6.5 and 2.6 kb. The large transcript encodes ALSIN, a protein of 184 kD. ALSIN contains three putative guanine nucleotide exchange factor (GEF) domains, the N-terminal regulator of chromatin condensation (RCC1) domain, the central Db1 and pleckstrin homology (DH/PH) domains, and the C-terminal vacuolar protein sorting 9 (VPS9) domain. European Journal of Human Genetics (2008) 16, 1407-1411 & 2008 Macmillan Publishers Limited All rights reserved 1018-4813/08 $32.00 www.nature.com/ejhgIt is not known whether the short transcript is physiologically translated into a functional polypeptide as well.To date, a total of 12 different mutations have been described in the ALS2 gene. All had occurred in people from Mediterranean countries and from Asia. Here we describe the first mutation in ALS2 in sibs from northwestern Europe. They are the children of consanguineous parents, who are descendants of a common ancestor who lived in the eighteenth century (around 1750) in the province of Friesland, in the northern part of the Netherlands. The findings are discussed in the context of published ALS2 mutations. Materials and methodsDNA extraction and sequencing of the 34 exons of ALS2 were performed according to standard procedures. Case reportsPatient 1, the proband, is the first child of healthy parents of Dutch descent. She was born at term after an uncomplicated pregnancy and delivery. At the age of 8 months she developed distal spasticity in her legs and axial hypotonia. She was never able to sit or stand without support. During the following 3 years, spastic diplegia slowly progressed to the upper extremities. Starting at age 5, she developed tetraplegia; with the lower extremities being more severely affected than the upper extremities, soft pseudobulbar speech, and dysp...