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In addition to developing mouth-to-mouth resuscitation, Dr. Peter
Safar introduced the concept of cardiopulmonary cerebral resuscitation
to save lives and promote research that focused on therapies to
treat brains that “were too good to die.”1 The
concept of brain-directed therapy has since expanded to include
all causes of acute brain injury and led to the field of reanimatology,
commonly referred to as cerebral resuscitation.
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Acute brain injury is a leading cause of morbidity and mortality
in both adults and children. Hundreds of thousands of patients worldwide
suffer permanent neurologic deficits and death every year after
acute brain injuries from cardiac arrest, stroke, near drowning,
anesthesia mishaps, traumatic brain injury, and other acute injuries.2 In
addition to personal tragedy and impaired functional capacity to
individuals, the financial strain on the health care system is enormous.
Estimates indicate that >3% of every health care dollar
is spent on care for patients who sustain acute brain injury, totaling
over $60 billion dollars a year.3 Cerebral
resuscitation research provides hope for patients with acute brain
injuries.
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Although there is minimal pathologic evidence of irreversible
brain injury after nearly 2 hours of complete disruption of blood
flow to the brain,4 as little as 5 minutes of transient
ischemia prime the brain for a cascade of vascular, cellular, biochemical,
and molecular events that result in irreversible brain damage during reperfusion.
This cascade of events are collectively referred to as reperfusion
disease or the postresuscitation syndrome.5
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Postresuscitation syndrome occurs after both focal and global
cerebral ischemia. Stroke and traumatic brain injury cause disruption
of local blood brain flow (focal ischemia), whereas cardiac arrest
and severe asphyxia result in global brain ischemia. The chapters
on stroke (see Chapter 161, Stroke, Transient Ischemic
Attack, and Cervical Artery Dissection) and traumatic brain injury
(see Chapter 254, Head Trauma in Adults and Children)
provide information on the pathophysiology of focal cerebral ischemia.
This chapter provides information on the pathophysiology of the
postresuscitation syndrome specific to transient global brain ischemia.
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Primary cardiac arrest from ventricular fibrillation/tachycardia
is the most common cause of global brain ischemia in adults, whereas
asphyxia is the leading cause of global brain ischemia in children.6 The
differences in postresuscitation syndrome from primary cardiac versus
asphyxial cardiac arrest are not well studied. There is likely overlap
in the mechanisms that lead to irreversible brain injury, as brain
injury occurs in the same selectively vulnerable regions of the
hippocampus, thalamus, and cerebellum independent of the etiology
of the cardiac arrest.7 In addition, brain injury
occurs in a similar “delayed neuronal death pattern” of hours
after the transient global brain ischemia, suggesting that there
is a window of opportunity to treat all forms of acute brain injury.8
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After cardiac arrest, there is an initial period of no cerebral
blood flow even if normal blood pressure is restored. This no reflow
phenomenon is ...