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evoked In the rst 24 to 48 h, death may terminate this state in a setting of rising temperature, deepening coma, and circulatory collapse, or the syndrome of brain death intervenes, as discussed below Most patients who have suffered severe but lesser degrees of hypoxia will have stabilized their breathing and cardiac activity by the time they are rst examined; yet they may be comatose, with the eyes slightly divergent and motionless but with reactive pupils, the limbs inert and accid or intensely rigid, and the tendon re exes diminished Within a few minutes after cardiac action and breathing have been restored, generalized convulsions and isolated or grouped myoclonic twitches of muscles may supervene The seizures, if severe and recurrent, double or treble the oxygen need of cerebral tissues With severe degrees of injury, the cerebral and cerebellar cortices and parts of the thalami are partly or completely destroyed but the brainstem-spinal structures survive Tragically, the individual may survive for an inde nite period in a state that is variously referred to as cortical death, irreversible coma, or persistent vegetative state (see page 304) Some patients remain mute, unresponsive, and unaware of their environment for weeks, months, or years Long survival is usually attended by some degree of improvement, but the patient appears to know nothing of his present situation and to have lost all past memories, power of reasoning, and capacity for meaningful social interaction and independent existence (a so-called minimally responsive state, actually a severe dementia, page 305) One has only to observe such patients and their families to appreciate the gravity of the problem, the family s anguish, and the tremendous expense of medical care The only person who does not appear to suffer is the patient With lesser degrees of anoxic-ischemic injury, the patient improves after a period of coma lasting hours or less Some of these patients quickly pass through this acute posthypoxic phase and proceed to make a full recovery; others are left with varying degrees of permanent disability The ndings on imaging studies vary The most common early change in cases of severe injury is a loss of the distinction between the cerebral gray and white matter (Fig 40-1); both ischemia and hypoxia are usually involved Patient with this nding are invariably comatose and few awaken with a good neurologic outcome With less severe and predominantly hypotensive-ischemic events such as cardiac arrest, watershed infarctions become evident in the border zones between the anterior, middle, and posterior cerebral arteries (Fig 40-2) The clinical syndromes associated with watershed infarction are discussed below Brain Death Syndrome (See Chap 17) This represents the most severe degree of oxygen lack, usually caused by circulatory arrest; it is manifest by a state of complete unawareness and unresponsiveness with abolition of all brainstem re exes Natural respiration cannot be sustained; only cardiac action and blood pressure are maintained No electrical activity is seen in the EEG (it is isoelectric) At autopsy one nds that most if not all the gray matter of cerebral, cerebellar, and brainstem structures and in some instances even the upper cervical spinal cord has been severely damaged One must always exercise caution in concluding that a patient has this form of irreversible brain damage, because anesthesia, intoxication with certain drugs, and hypothermia may also cause deep coma and an isoelectric EEG but permit recovery Therefore it is often advisable to repeat the clinical and laboratory tests after an interval of a day or so, during which time the results of toxic screen-.

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CertCam AVI clips provide detailed examples of key certification objectives These clips walk you step-by-step through various hardware and operating system configurations You can access the clips directly from the CertCam table of contents (shown in Figure A-3) The CertCam AVI clips are recorded and produced using TechSmith s Camtasia Producer Since AVI clips can be very large, ExamSim uses TechSmith s special AVI Codec to compress the clips The file named tsccviddll is copied to your Windows\ System folder when you install CertTrainer If the AVI clip runs with audio but no video, you may need to re-install the file from the CD-ROM Browse to the bin folder, and run TSCCEXE

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nied by hip weakness (referred to as a man in the barrel syndrome), re ecting infarction in the territory between the middle and anterior cerebral arteries These patients are able to walk, but their arms dangle and their hips may be weak The two watershed syndromes rarely coexist The interested reader may consult the appropriate chapter in the text on neurologic intensive care by Ropper and associates for further details Seizures may or may not be a problem, and they are often resistant to treatment Well-formed motor convulsions are infrequent Myoclonus is more common and may be intermixed with fragmentary convulsions Myoclonus is a grave sign in most cases, but it generally recedes after several hours or a few days These movements are also dif cult to suppress, as noted further on Delayed Postanoxic Encephalopathy This is a relatively uncommon and unexplained phenomenon Initial improvement, which appears to be complete, is followed after a variable period of time (1 to 4 weeks in most instances) by a relapse, characterized by apathy, confusion, irritability, and occasionally agitation or mania Most patients survive this second episode, but some are left with serious mental and motor disturbances (Choi; Plum et al) In still other cases, there appears to be progression of the initial neurologic syndrome with additional weakness, shuf ing gait, diffuse rigidity and spasticity, sphincteric incontinence, coma, and death after 1 to 2 weeks Exceptionally, there is yet another syndrome in which an episode of hypoxia is followed by slow deterioration, which progresses for weeks to months until the patient is mute, rigid, and helpless In such cases the basal ganglia are affected more than the cerebral cortex and white matter as in the case studied by our colleagues Dooling and Richardson Instances have followed cardiac arrest, drowning, asphyxiation, and carbon monoxide poisoning.

Figure 40-1 CT scan without contrast infusion after cardiac arrest demonstrating the loss of distinction between gray and white matter throughout the cerebral hemispheres The patient remained comatose and became vegetative

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