Ch 28 (s28.9, s28.16); Ch 23; Ch 24; Ch 74; Ch 75
Persistent coma off sedation with an unreactive delta electroencephalogram was not explained by structural brain injury in half of these patients. Absent electroencephalographic reactivity on a circuit is a prognostic variable, not a diagnosis. Prognosticate slowly, multidisciplinarily, after rewarming, and having excluded sedation, electrolyte and haemolysis confounders.
Clinical and electrophysiological impression versus neuropathology
DOI 10.1177/0391398820901829
Post-mortem brain examination compared against ante-mortem clinical and electroencephalographic findings
Four patients, one centre, all of whom died — the design cannot estimate how often this occurs. The smallest study cited in Chapter 28.
Case 1 showed small cortical infarcts; Case 2 cortical microhaemorrhages and chronic basal ganglia microinfarcts; Cases 3 and 4 diffuse hypoxic-ischaemic brain injury. The authors conclude that the clinical presentation was consistent with widespread neuropathologic injury in two cases but not in the other two, and that while 'poor neurological status' was provided in the end-of-life discussion in all four, only two had significant brain injuries.
Four adult patients (median age 56) who underwent brain autopsy at a single centre between November 2017 and December 2018. All four had venoarterial cannulation, none had a known acute neurological injury before ECMO, all were persistently comatose off sedation on support, and all four had continuous electroencephalography showing delta frequency with absent reactivity.