Abstract
IntroductionPatients may remain comatose after the resumption of spontaneous circulation with cardiopulmonary resuscitation. A primary neurologic event may precede a cardiac standstill.Case reportWe present a 33-year-old patient with successful resuscitation for pulseless electrical activity and a “normal computed tomography (CT) scan.” Further scrutiny showed a hyperdense basilar artery sign (‘big white dot’) that led to a CT angiogram confirming an embolus to the proximal basilar artery. His examination showed fixed and dilated midsize (mesencephalic) pupils and extensor posturing. Endovascular retrieval of the clot was successful, but there was a devastating ischemic injury to the brainstem.ConclusionThis case reminds us to consider neurologic causes of cardiac arrest.
Highlights
Patients may remain comatose after the resumption of spontaneous circulation with cardiopulmonary resuscitation
Ischemic stroke and intracranial hemorrhage are known, but rare, causes of out-of-hospital cardiac arrest leading to the development of non-shockable rhythms such as asystole or pulseless electrical activity
Basilar artery occlusion suggested on non-contrast computed tomography (CT) scan should be confirmed by a CT angiogram of the head and neck, followed by emergent mechanical thrombectomy
Summary
1. A non-shockable rhythm in the setting of a sudden cardiac arrest should raise alarms for a primary non-cardiac ethology, and the absence of brainstem reflexes increases the likelihood of an intracranial process. 2. Ischemic stroke and intracranial hemorrhage are known, but rare, causes of out-of-hospital cardiac arrest leading to the development of non-shockable rhythms such as asystole or pulseless electrical activity. 3. Basilar artery occlusion suggested on non-contrast CT scan should be confirmed by a CT angiogram of the head and neck, followed by emergent mechanical thrombectomy. 4. In patients presenting with posterior circulation stroke-like symptoms, a hyperdense basilar artery sign on a non-contrast head CT is a strong predictor of basilar artery thrombosis
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