Excellent neurologic recovery after prolonged coma in a cardiac arrest patient with multiple poor prognostic indicators

Independent Functional Outcomes after Prolonged Coma following Cardiac Arrest: A Mechanistic Hypothesis

“…8 Nevertheless, reports of late recoveries from prolonged postcardiac arrest coma suggest that recovery of neuronal function can extend over much longer time periods. [11][12][13][14][15][16] The 3 patients with late recovery presented here all remained in coma for more than 2 weeks following cardiac arrest (17, 37, 30 days, respectively; see Fig 1 and Table 1) and yet achieved independent functional outcomes. In 2 patients (Patients 2 and 3), nonmedical reasons (ie, family wishes and logistical limitations of obtaining a legally authorized decision-maker) prohibited withdrawal of lifesustaining therapy; in the third patient (Patient 1), knowledge of the outcomes and clinical profiles of these first 2 patients provided the basis for the prolonged wait period to allow late emergence from coma (see Table 1).…”

“…However, a general rule of thumb that guides current clinical practice is that longer durations of elapsed time are probative of worsening outcomes . Nevertheless, reports of late recoveries from prolonged post–cardiac arrest coma suggest that recovery of neuronal function can extend over much longer time periods . The 3 patients with late recovery presented here all remained in coma for more than 2 weeks following cardiac arrest (17, 37, 30 days, respectively; see Fig and Table ) and yet achieved independent functional outcomes.…”

“…However, following the widespread use of TTM, an increasing number of reports describe unexpected recoveries despite evidence of poor prognostic markers. [11][12][13][14][15][16] In addition, a lack of imaging-based evidence of anoxic cortical or white matter injuries after cardiac arrest may portend better outcomes, 17 even in patients remaining in coma for more than 7 days. 18 The poorly characterized physiological protective factors related to TTM 19 suggest the possibility that in comatose post-cardiac arrest patients with wide preservation of cerebral structure, some negative predictive markers may only indicate a sustained abnormal state of global neuronal functions without permanent loss of potential to recover integrative cerebral functions.…”

“…In this context, many studies have identified physiological markers that remain associated with poor prognosis to guide management (eg, loss of brainstem reflexes on exam, burst suppression pattern [BSP] or refractory status epilepticus on electroencephalogram [EEG]). However, following the widespread use of TTM, an increasing number of reports describe unexpected recoveries despite evidence of poor prognostic markers . In addition, a lack of imaging‐based evidence of anoxic cortical or white matter injuries after cardiac arrest may portend better outcomes, even in patients remaining in coma for more than 7 days .…”

Reply to: Accurate neuroprognostication in cardiac arrest survivors: Details matter!

“…We appreciate Maciel et al's interest [1] in our recently published letter [2]. We fully agree that both the technical details of test results, as well as the clinical details of a case, are of utmost importance when identifying whether a seemingly extraordinary recovery is truly an outlier that merits reporting or simply the result of unidentified confounders.…”