The Prognostic Value of EEG in Coma Survivors after Cardiac Arrest

EEG was recorded in 64 patients while they were in a state of moderate coma after cardiac arrest. The clinical course of the patients was followed, and the prognosis was compared with the EEG findings.
A total of 59 patients died within periods ranging from 1 to 287 days, 57 without having regained consciousness. Five patients survived, all with cerebral sequelae. The immediate causes of death were brain death in 18, pneumonia in 24, and cardiovascular complications in 17 cases. Autopsy was performed in 54 patients.
The EEGs were visually graded and classified into five groups, in order of increasing abnormalities (H ockaday et al. 1965). Of the records, 17% were unclassifiable. An extremely abnormal EEG (grade V) was indicative of death after a few days, while other grades of EEG changes did not give any prognostic indications. Good correlation was disclosed by multiple regression analysis between the length of the survival time and the EEG changes estimated on the basis of 12 variables.
A method is described by which it is possible to estimate the probable length of survival of a patient from his EEG records. There was a fair correlation between the estimated and observed survival times, except in the patients who died from cardiovascular complications after a few days. In these cases the prediction from the EEG was too optimistic.
It is concluded that EEG is a useful supplement to the clinical evaluation of patients in coma after cardiac arrest. The EEG must be assessed in a special way, as simple visual grading is of only limited prognostic value.     

EEG and the linear skull fractures.

The EEGs of 111 children under the age of 16, and 21 adults after a head injury with a linear skull fracture were reviewed. From our results it can be concluded that linear skull fractures do not add any significant abnormality or any variation to what is stated for EEGs of minimal to mild concussions.     

The value of routine electroencephalographic recordings in predicting postoperative seizures associated with meningioma surgery

We analyzed the incidence of postoperative seizures in patients undergoing craniotomy for meningioma removal in order to determine whether EEG recordings are able to predict the incidence of postoperative seizures. We included 102 patients who had undergone surgery on intracranial meningiomas. Pre- and postoperative EEG images were divided into groups showing epileptiform activity including spikes or sharp waves, focal slowing, and normal activity. Follow-up was carried out using a standardized telephone questionnaire by an independent investigator after a mean of 889 days. Seizure outcome was determined by patient reports to the interviewer. Preoperatively obtained, abnormal EEGs correlated significantly to preoperative seizures (P<0.0005), but neither preoperative nor postoperative EEGs correlated to the incidence of postoperative seizures. It would seem that, while evaluation of some clinical parameters revealed a statistically significant correlation, pre- and early postoperative EEGs after meningioma surgery are not useful in determining the risk of postoperative seizures.     

Indications for computed tomographic brain scanning in psychiatric inpatients.

This study examined the rate of use of computed tomographic (CT) scanning as well as clinical parameters pertaining to that used in psychiatric patients. These patients were compared with a randomly selected control group of psychiatric patients who were not scanned. In addition, scan abnormalities were examined and correlated with clinical and electro-encephalographic (EEG) data. CT scanning was used on 13.5% of admissions. On axis 1 of the DSM III-R, the CT scan group had a significantly higher incidence of delirium and dementia (P < 0.05) and a much higher rate of medical illness (P < 0.01) on axis 3. The rate of CT abnormality was fairly high at 45.2%. An abnormal CT scan was associated with the diagnosis of dementia, the presence of organic mental status abnormality and of abnormality on neurological examination. Focally abnormal CT scans were associated with focally abnormal EEGs in a significant number of patients (P < 0.05).     

Reversible electrocardiographic changes in severe acute asthma.

Previous reports have documented the occurrence of reversible electrocardiographic changes including right axis deviation, P pulmonale, right bundle-branch block, and ST-segment and T-wave abnormalities in patients with acute attacks of asthma. In a further systematic study, the electrocardiographs of 63 patients admitted with severe acute asthma have been evaluated. The most consistent change was an abnormally vertical P-wave axis in 78% of the patients. P pulmonale was present in 22% and right ventricular enlargement in only one patient. Right axis deviation, right bundle-branch block, and rhythm abnormality were not present in any patient. In 11%, ST-segment or T-wave abnormalities suggesting myocardial ischaemia were noted. These abnormalities persisted for up to nine days and were unexplained. Other ECG abnormalities in acute asthma may reflec positional changes of the heart due to overdistension of the lungs. All ECG changes resolved after clinical improvement.     

Stauffer's syndrome--diagnostic help in hypernephroma.

Dysfunctions of the liver known as Stauffer's syndrome have been observed in various cases of renal cell carcinoma. In a case history of renal cell carcinoma the most common clinical symptoms and laboratory findings of early presentation are displayed. During the first clinical investigations the evidence of typical laboratory values indicating unusual hepatic dysfunction, did not lead to the true diagnosis until symptoms became clearer two year later. Intensified renal diagnosis are asked for in any case of unexplained abnormalities of liver function in order to exclude a renal cell carcinoma or to force its early diagnosis.     

Routine Radiographs After Total Joint Arthroplasty: Is There Clinical Value?

BackgroundRoutine radiographs have historically been obtained during routine care after total joint arthroplasty (TJA). However, substantial improvements in surgical technique, biomaterials, and changes in payment models placing greater emphasis on value have occurred. Recently, there has been interest in a transition to performing follow-up visits virtually. The purpose of this study was to assess how frequently patients attend postoperative appointments and the clinical utility of routine radiographs after TJA.MethodsPatients undergoing primary total hip arthroplasty and total knee arthroplasty at a single tertiary institution in 2018 were included. Patients attending scheduled follow-up at 6 to 12 weeks and 1 year were assessed. Retrospective chart review was conducted to determine whether abnormalities were noted on routine radiographic surveillance by the orthopedic surgeons or radiologist and if any radiographic findings altered clinical management.ResultsA total of 938 TJAs were performed, and 885 met inclusion criteria, with 423 (47.8%) total hip arthroplasties and 462 (52.2%) total knee arthroplasties. Eight hundred sixty-five (97.7%) patients attended a follow-up visit at 6 or 12 weeks and 589 (66.6%) attended at 1 year postoperatively. A single radiographic abnormality was detected, occurring at the 6- to 12-week period by the radiologist and interpreted as being an artifact by the surgeon. No additional radiographic abnormalities were detected at 1 year. Information from radiographs did not change clinical management for any patients.ConclusionIn a large cohort of patients, routine radiographic surveillance did not detect any true abnormalities during the first year after primary TJA. For patients without symptoms attributable to the TJA prosthesis, conducting virtual care visits without routine radiographs may be considered.     

Spontaneous spinal cerebrospinal fluid leaks and minor skeletal features of Marfan syndrome: a microfibrillopathy.

OBJECT: Spontaneous spinal cerebrospinal fluid (CSF) leaks are increasingly recognized as a cause of postural headaches. The authors examined a group of patients suffering from spontaneous spinal CSF leaks who also had minor skeletal features of Marfan syndrome for abnormalities of fibrillin-containing microfibrils. METHODS: Patients with spontaneous CSF leaks were evaluated for the clinical characteristics of connective tissue disorders. Skin biopsies were obtained in three patients with skeletal manifestations that constitute part of the Marfan syndrome phenotype. Cultured fibroblasts were studied for fibrillin-1 synthesis and incorporation into the extracellular matrix (ECM) by performing quantitative metabolic labeling and immunohistochemical analysis. Among 20 consecutive patients found to have spinal CSF leaks, four (20%) exhibited minor skeletal features of Marfan syndrome, but lacked any ocular or cardiovascular abnormalities. The mean age of these patients (30 years) was lower than that of the 16 patients without skeletal abnormalities (44 years; p = 0.01). Abnormalities in fibrillin-1 metabolism and immunostaining were detected in all three patients with the skeletal abnormalities who underwent examination, but not in a control patient without these skeletal manifestations. CONCLUSIONS: Twenty percent of patients who experience spontaneous spinal CSF leaks have minor skeletal features of Marfan syndrome. The authors demonstrated abnormalities in fibrillin-1 protein deposition in all patients examined, but only one person was found to have a fibrillin-1 abnormality typically found in classic Marfan syndrome. The results indicate that there is a heterogeneous involvement of other components of ECM microfibrils at the basis of this cerebrospinal manifestation. In addition, the authors identified a connective-tissue etiological factor in a group of disorders not previously classified as such.     

Influence of systematic echodoppler arterial survey on hepatic artery thrombosis after liver transplantation in adults

Abstract Hepatic artery thrombosis after liver transplantation remains a major problem which may lead to graft loss and retransplantation. Hepatic artery diseases were compared in two matched groups of liver grafted patients. In Group I (67 patients), echodoppler examinations of the graft hepatic artery were carried out after clinical or biological abnormalities became evident. In Group II (85 patients), echodoppler examinations were systematically made during the follow-up at 2 weeks, 1, 3, 6, and 12 months after liver transplantation. In cases of an abnormal echodoppler examination, arteriography was carried out in order to confirm hepatic artery stenosis and to perform endoluminal angioplasty. In Group I, echodoppler examinations revealed no arterial blood flow in three cases and reduction of hepatic blood flow in two cases. Hepatic artery thromboses were always confirmed by angiography, in the latter two cases, a collateral arterial revascularization of the graft was developed. In this group, two retransplantations, one choledocojejunostomy, and four percutaneous radiological biliary drainages were necessary. In Group II, echodoppler results showing a resistive index below 0.5 and a systolic acceleration time above 0.08 s involved 13 arteriographies. Ten stenoses were diagnosed without any biological abnormalities. Nine endoluminal angioplasties were made without any complication. There was no recurrence of stenosis. One pseudoaneurysm of the femoral artery was cured by compression. The early and non-aggressive detection of hepatic artery stenoses after liver transplantation by echodoppler allows treatment by angioplasty in order to prevent hepatic artery thrombosis and reduce retransplantation.     

Personality correlates of chronic,unstable epilepsy

The present study included 60 males with unstable epilepsy despite therapeutic levels of anticopulsants. They were middle age or older (x = 45.6 years; s.d. = 11.1), with chronic documented seizures (X = 17.1 years; s.d. = 13.2). When type of EEG abnormality was considered, significant differences were found on two individual MMPI scales. Scale L was significantly higher in patients with right temporal lobe abnormalities compared to left temporal foci. The group with generalized EEG findings also scored higher on L compared to those with left temporal, extratemporal and normal EEG patterns. In addition, those with right temporal lobe EEG abnormalities and the group with extratemporal foci scored significantly higher on scale Pd than those with generalized, left temporal or normal EEGs. No differences were found on the MMPI when chronicity, trauma or age at onset were considered. Thus, subtle personality differences as measured by the MMPI were found only when type and laterality of the EEG abnormalities were controlled.     

T and B lymphocytes in sarcoidosis: a clinical correlation.

Immunological abnormalities in sarcoidosis have been previously described. Cutaneous anergy to a wide variety of antigens first prompted the suggestion that the underlying defect may be of importance in the aetiology or pathogenesis of the disorder. The thymus derived lymphocytes appear to be particularly affected, and both quantitative and qualitative in vitro defects have been described in these cells in sarcoidosis patients. We have quantitatively investigated T and B cells in a series of 52 sarcoidosis patients, and our results indicate that, as a group, sarcoidosis patients have lower mean total lymphocyte counts and lower T cell counts than the control series in agreement and with other reports. We found no difference between B cells in the sarcoidosis and control groups. The quantitative abnormalities detected did not correlate with any of the clinical parameters which were investigated--stage of disease, duration of the disease, treatment regime, and activity of disease--and there was a considerable overlap between the results obtained in sarcoidosis patients and the controls. Our results indicate that these investigations are of little value in the management of sarcoidosis patients.     

Can anaesthetists be taught to interpret the effects of general anaesthesia on the electroencephalogram? Comparison of performance with the BIS and spectral entropy

Background: Unlike the other physiological waveforms monitored in anaesthesia,the EEG lacks a regularly repeating pattern, implying that itwould be very difficult for an anaesthetist to obtain any usefulinformation from the raw EEG. There are, however, clear changesin the EEG caused by GABA-ergic anaesthetic agents. The anaesthetizedEEG still looks like a random waveform, but clearly a differentrandom waveform from that seen when conscious. Methods: The aim of this study was to assess how 40 anaesthetists wouldperform at interpreting intra-operative EEGs compared with twoprocessed EEG (pEEG) monitors, BIS and entropy, after a shorteducational presentation. Short segments of EEGs were used fromthe pre-induction phase, the intra-operative phase with adequatesurgical anaesthesia, and the transition phase between thesetwo states. Results: While anaesthetists’ performance varied widely, most couldreliably differentiate an anaesthetized from a conscious EEG.Further, both humans (41% wrong) and machines (30% wrong) mademistakes. Unlike the anaesthetists, the pEEG monitors did notmake a major error (i.e. producing a number in the consciousrange (>85) when analysing an anaesthetized EEG or the converseerror). Conclusion: A brief PowerPoint presentation enables anaesthetists to recognizethe effects on the EEG of GABA-ergic anaesthetic agents. Inthe clinical context, it remains likely that the combinationof a pEEG monitor that clearly presents the EEG and a clinicianwho has a good, basic understanding of, and a willingness tolook at, the raw EEG will result in more accurate interpretationof the intra-operative EEG.     

Surgical management of penetrating injuries to the coronary arteries.

Among 76 patients with heart wounds treated over a 4 year period, nine had penetrating injuries to the coronary arteries with clinical presentations of pericardial tamponade, electrocardiographic abnormalities of bundle branch block or ST and T wave changes, and hemothorax. The right coronary artery was injured in two patients, the left anterior descending coronary artery in six patients, and the left circumflex coronary artery in one patient. All but one of these injured coronary arteries were treated by ligation. One patient with a proximal left anterior descending coronary artery transection presented with cardiac arrest and was managed successfully by emergency cardiopulmonary support and saphenous vein bypass with ligation of the transected ends of the artery. The only death occurred six days postoperatively in a patient with a right coronary artery laceration and was not related to the heart injury. No late symptomatic or hemodynamic sequelae have been noted among any of these patients. Principles of elective cardiac surgery are readily adaptable to the patient with a coronary artery injury.     

Congenital abnormalities of the urogenital tract in association with congenital vertebral malformations

There is a close link between the embryological development of the musculoskeletal system and all other main organ systems. We report a prospective series of 202 patients with congenital vertebral abnormalities and document the associated abnormalities in other systems. There were 100 boys and 102 girls. In 153 there were 460 associated abnormalities, a mean of 2.27 abnormalities for each patient. Intravenous pyelography was carried out on 173 patients (85.6%) and ultrasonography on the remaining 29 (14.4%). Patients with genitourinary anomalies were more likely to have musculoskeletal (p = 0.002), gastrointestinal (p = 0.02) and cardiac abnormalities (p = 0.008) than those without genitourinary involvement. A total of 54 (26.7%) had at least one genitourinary abnormality, the most frequent being unilateral renal agenesis. There was urinary obstruction in six (3%). There was no association between genitourinary abnormality and the place of birth, parental age, birth order, level of spinal curvature, or the number, type and side of spinal anomaly. There was, however, a statistically significant association (p = 0.04) between costal and genitourinary abnormalities. The incidence of genitourinary abnormalities (26.7%) was similar to that of previously reported series. The diagnosis of a congenital vertebral abnormality should alert the clinician to a wide spectrum of possible associated anomalies most of which are of clinical importance.     

Ultrastructural changes in IgA nephropathy in relation to histologic and clinical data

In order to evaluate the ultrastructural changes in IgA nephropathy (IgAN) and their relationship with light microscopic and clinical features, renal biopsy material from 239 Korean patients with IgAN was studied by light, electron and immunofluorescence microscopy. Forty-one were children and 198 were adults. Modified classification of Meadow et al (1972) for Henoch-Sch?nlein nephritis was used for the histologic grading of glomerular lesions. Forty-three adults (18%) exhibited histologic grades IV and V lesions in association with more severe clinical findings, when compared to the remaining 196 patients with histologic grades I to III. A significant difference was noted between children and adults in the severity of the glomerular lesions (P less than 0.01). Mesangial deposits were observed in all (100%), subendothelial deposits in 37%, subepithelial deposits in 18%, abnormalities in glomerular basement membrane (GBM) in 20%, mesangiolysis in 44%, and mesangial interposition in 25%. The frequency of GBM abnormalities and subepithelial deposits in children was significantly higher than that seen in adults (P less than 0.01). The abnormalities of GBM were not related to more severe clinical manifestations when our analysis was restricted to grade III histologic lesions. All of the above ultrastructural changes except for mesangial deposits were associated with more severe histologic grading in adults (P less than 0.025 or P less than 0.01). Yet a correlation between these ultrastructural changes and histologic grading could not be studied in children due to confinement of their histology within a more benign group. These results suggest that the five ultrastructural parameters described here appear to bear important prognostic value in adults with IgAN.(ABSTRACT TRUNCATED AT 250 WORDS)     

Kolff's Credo: New Ways of Thinking!

Dr. Willem J. Kolff's imaginative venturesomeness in adopting "new ways of thinking" has served as an encouraging model for this author's research career. In appreciation of his leadership and beginning with the favorable results that attended the initial use of the Brigham-Kolff artificial kidney at a renal center in the Korean war, this presentation summarizes four experiences to illustrate how "new ways of thinking" produced new results and new research, namely, the concept and use of prophylactic daily hemodialysis; the use of a model of acute renal failure in rats to examine mechanisms of pathogenesis and means of prevention; the recognition of patients' uremic illness as an encephalopathy that can be quantified by appropriate measures; and the use of daily peritoneal dialysis and quantified EEGs in rats to explore relationships between dialysis-induced concentrations of potentially toxic solutes, quantified indices of symptomatic uremic encephalopathy, and concurrent, localized metabolic abnormalities in the brain. The results of these "new ways of thinking" suggest that we may ultimately come to understand the clinical uremic illness and its response to dialysis.     

Relationship between changes in power spectra of electroencephalograms and arterial halothane concentration in infants

A power spectral analysis of electroencephalograms (EEGs) was performed in 30 infants who underwent plastic surgery for cleft lip or cleft palate. The study was conducted to investigate whether there was a significant correlation between EEG changes and arterial halothane concentration in infants. The power spectral analysis of EEGs was performed by the fast Fourier transform (FFT). Arterial halothane concentration was measured with gas chromatography. The relationship between the changes in the power spectra of EEGs and the arterial halothane concentration was examined by means of a multivariate analysis. Prior to administration of halothane, two kinds of EEG patterns were discernible. In one pattern the peak of the EEG power spectra was seen in the slow wave band (slow wave group); in the other the peak of the power spectra was present in the fast wave band (fast wave group). In the occipital lead the multiple correlation coefficient and the index of determination of the slow wave group were 0.71 and 0.50, respectively, and those of the fast wave group were 0.78 and 0.61, respectively. A significant correlation was proved to be present between the normalized values of the EEG power spectra and arterial halothane concentration in the occipital lead. Therefore, the results of the present study suggest that the relationship between changes in the power spectra of EEGs in the occipital lead and arterial halothane concentration in infants can be expressed by means of multiple regression formulas.     

Chromosomal anomalies in cryptorchidism and hypospadias.

We have studied peripheral blood samples for chromosomal anomalies in 110 consecutive patients who had cryptorchidism and/or hypospadias. Of the patients 7 (6.4%) were found to have chromosomal anomalies. The incidence of chromosomal anomalies in patients with cryptorchidism only was 4/83 (4.8%), in patients with hypospadias only the incidence was 1/18 (5.6%) and in concomitant cases the incidence was 2/9 (22.2%). Of 69 patients with cryptorchidism and/or hypospadias who did not have any other congenital abnormalities, 3 patients (4.3%) were found to have sex chromosomal anomalies. However, of 41 patients associated with generalized congenital abnormalities including mental and growth retardation, we found 4 patients (9.8%) with autosomal anomalies. We conclude that most children with multiple associated abnormalities other than cryptorchidism and/or hypospadias should have chromosome analysis. Moreover, attention should be paid to sex chromosomal anomalies, even when patients with cryptorchidism and/or hypospadias do not have any associated generalized physical abnormalities.     

Estimated Incidence of Cardiac Contusion Using Transthoracic Echocardiography in Patients Suffering from Severe Blunt Trauma to the Chest

Background : Cardiac contusion (CC) is a known complication of blunt trauma to the chest. There have been debates about its true incidence and there are different reports which claim that it occurs in less than 10% to more than 70% of patients. The goal of this study is to estimate the incidence of CC in patients with severe blunt chest trauma (SBCT) using transthoracic echocardiography (TTE).

Methods : After defining inclusion and exclusion criteria, all cases with clinical evidences of SBCT from February 2010 until October 1011 were included in this study. Patients were assessed using electrocardiography (ECG) and transthoracic echocardiography (TTE). Transient echocardiography changes, including wall motion abnormalities, valvular or papillary muscle dysfunction, pericardial effusion or tamponade, free wall rupture and interatrial/interventricular septum defects, were considered to be abnormal and trauma-related.

Results : A total of 110 patients were assessed for CC. Fifty-two trauma-related echocardiography changes in 47 patients were observed, in which 34 cases had simultaneous transient ECG changes. The estimated incidence of CC in these subjects was calculated to be 23.38% and 16.19%, respectively. There was a statistically significant relationship between the presence of both echocardiography changes and ECG abnormalities, and those subjects without ECG changes (P = 0.03). As we evaluated stable patients without any cardiac-related clinical manifestations and TTE was chosen as our diagnostic modality, we claim that the true incidence must be higher.

Conclusions : We believe that a comparison of our findings with those presented in the literature shows that the actual incidence of CC in blunt chest trauma is underestimated.     

The EEG in normal pressure hydrocephalus

Summary Fourteen patients with NPH were studied with special reference to associated EEG changes, one case being reported in detail. In 13 cases the EEG was abnormal, the abnormality most frequently observed being a of the rhythmic slow wave type, consisting of bursts of monorhythmic theta or delta waves seen in both hemispheres. This type of abnormality was present in 7 cases. In 4 of the 5 cases with serial EEGs the abnormality became more accentuated with the advance of the illness. In 4 of 5 cases in whom postoperative EEGs were obtained there was significant improvement of the EEG after the shunting procedure.There were strong correlations between the EEG abnormality described, demonstrable ventricular reflux on cisternography, and the effectiveness of the shunt operation.It was considered that serial EEGs are a useful diagnostic procedure in following up patients at risk of developing NPH.