Good Neurological Condition Research Articles

Spontaneous spinal epidural hematoma

Spontaneous spinal epidural hematoma (SSEH) is a rare emergent condition. It may result in paraplegia, quadriplegia and even death. Prompt diagnosis and emergent decompressive surgical management have been recommended to prevent mortality and morbidity. Although several factors have been associated with prognosis, controversy remains, partly due to its rarity. Thus, the history, clinical presentation, physical examination findings, radiological images, and surgical and pathological records of 30 patients with SSEH (21 male, nine female [sex ratio of 2.3:1], average age of 35 years) treated between January 2002 and September 2010 have been reviewed. The association of age, sex, hypertension, vascular malformation, vertebral level, position and extension of the hematoma, progression interval, operative interval, spinal cord edema, and preoperative neurological condition with the prognosis is discussed. The outcome was better for patients with incomplete neurological deficit ( p = 0.001), lesions extending <4 vertebral segments ( p = 0.026), and lesions in the thoracolumbar and lumbar region. A shorter progression interval often led to a less favorable prognosis ( p = 0.017). Patients with spinal cord edema experienced a worse preoperative neurological deficit ( p = 0.005) and a worse outcome ( p = 0.000). Patients with a progression interval ⩽12 hours presented with a worse preoperative neurological deficit ( p = 0.026). Early surgical intervention to evacuate the hematoma remains the main treatment for most symptomatic patients. Conservative treatment may be used only for those in a good preoperative neurological condition. Prognosis is associated with the preoperative neurological condition, progression internal, spinal cord edema, and extension and vertebral level of the SSEH. Patients with SSEH in the cervical or cervicothoracic region with a complete preoperative motor deficit have a higher mortality rate.

Association of mechanical chest compression and prehospital thrombolysis

Pulmonary embolism (PE) is a common cause of sudden death; the use of prehospital thrombolysis is currently a last-resort option and requires a prolonged cardiopulmonary resuscitation (CPR). Novel mechanical devices have recently been introduced that provides automatic mechanical chest compression (AMCC) according to the guidelines and continually without decrease efficiency throughout prolonged resuscitation. A 54 year-old woman with a history of breast cancer experienced sudden chest pain and severe dyspnea. A mobile intensive care unit was dispatched to her home. During physical examination, she suddenly collapsed with pulseless electrical activity as the initial rhythm. Prehospital thrombolysis during CPR combined with use of AMCC was performed based on a strongly suspected diagnosis of massive PE. After 75 minutes of effective CPR, return of spontaneous circulation was attained. After admission to an intensive care unit, computed tomographic scan confirmed bilateral PE. The patient was discharged 3 weeks after CPR in good neurologic condition. To our knowledge, this is the first case describing combined use of thrombolysis and AMCC in out-ofhospital cardiac arrest. However, for the time being, prehospital thrombolysis in CPR continues to be a measure that should only be performed on a case-by-case basis based on informed decision. Further studies are needed to evaluate the efficacy and safety of AMCC with thrombolysis and thus prolonged CPR.

Cervical extramedullary lymphomatoid granulomatosis

Lymphomatoid granulomatosis (LYG) is a rare multisystem disease involving most frequently the lung, kidney and skin. LYG is characterized by an infiltration of atypical lymphocytoid and plasmocytoid cells, with granulomatous inflammation in an angiocentric and angiodestructive pattern. There have been only a few reports of spinal involvement of LYG. To our knowledge, we report the first patient with cervical extramedullary LYG undergoing surgical removal of a lesion causing spinal cord compression, and review the pertinent literature. The patient underwent C5-partial T1 laminectomy with partial removal of the lesion and decompression of the spinal cord. A diagnosis of a grade III LYG was made and chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) was administered. The patient was in good neurological condition at the 6-month follow-up but died 5 months later because of systemic progression of the disease. Although prognosis of LYG remains poor, surgery can be considered to improve pain relief and neurological morbidity of spinal LYG.

Spontaneous cerebellar hemorrhage—experience with 57 surgically treated patients and review of the literature

The treatment of spontaneous cerebellar hemorrhage is still discussed controversially. We analyzed a series of 57 patients who underwent surgical evacuation of a cerebellar hematoma at our department. Preoperative clinical and radiological parameters were assessed and correlated with the clinical outcome in order to identify factors with impact on outcome. The overall clinical outcome according to the Glasgow Outcome Scale at the last follow-up was good (GOS 4-5) in 27 patients (47%) and poor (GOS 2-3) in 16 patients (28%). Fourteen patients (25%) died. The initial neurological condition and the level of consciousness proved to be significant factors determining clinical outcome (p = 0.0032 and p = 0.0001, respectively). Among radiological parameters, brain stem compression and a tight posterior fossa solely showed to be predictive for clinical outcome (p = 0.0113 and p = 0.0167, respectively). Overall, our results emphasize the predictive impact of the initial neurological condition on clinical outcome confirming the grave outcome of patients in initially poor state as reported in previous studies. The hematoma size solely, in contrast to previous observations, showed not to be predictive for clinical outcome. Especially for the still disputed treatment of patients in good initial neurological condition, a suggestion can be derived from the present study. Based on the excellent outcome of patients with good initial clinical condition undergoing surgery due to secondary deterioration, we do not recommend preventive evacuation of a cerebellar hematoma in these patients.

Clinical Analysis of 21 Cases of Spinal Cord Ependymoma : Positive Clinical Results of Gross Total Resection

To evaluate the clinical results of gross total resection in the surgical approach to spinal ependymoma. Between June 1995 and May 2009, 13 males and 8 females (mean age 34) diagnosed with intramedullary or extramedullary spinal ependymoma were surgically treated at our centre. The neurological and functional state of each patient were evaluated according to the modified McCormick scale. The average follow-up duration was 54 months (ranging from 12 to 168 months). The locations of the lesions were: thoracic region (4, 19%), lumbar region (7, 34%), cervical region (4, 19%), cervicothoracic region (3, 14%) and conus medullaris (3, 14%). Four patients (19%) had deterioration of neurological function in the early postoperative period. The neurological function of three patients was completely recovered at the 6th postoperative month, while that of another patient was recovered at the 14th month. In the last assessment of neurological function, 20 patients (95%) were assessed as McCormick grade 1. No perioperative complications developed in any of our patients. In one patient's 24-month assessment, tumour recurrence was observed. Re-operation was not performed and the patient was taken under observation. Two determinants of good clinical results after spinal ependymoma surgery are a gross total resection of the tumour and a good neurological condition before the operation. Although neurological deficits in the early postoperative period can develop as a result of gross total tumour resection, significant improvement is observed six months after the operation.

Cardiac arrest in the catheterisation laboratory: A 5-year experience of using mechanical chest compressions to facilitate PCI during prolonged resuscitation efforts

Purpose Lengthy resuscitations in the catheterisation laboratory carry extremely high rates of mortality because it is essentially impossible to perform effective chest compressions during percutaneous coronary intervention (PCI). The purpose of this study was to evaluate the use of a mechanical chest compression device, LUCAS™, in the catheterisation laboratory, in patients who suffered circulatory arrest requiring prolonged resuscitation. Materials and methods The study population was comprised of patients who arrived alive to the catheterisation laboratory and then required mechanical chest compression at some time during the angiogram, PCI or pericardiocentesis between 2004 and 2008 at the Lund University Hospital. This is a retrospective registry analysis. Results During the study period, a total of 3058 patients were treated with PCI for ST-elevation myocardial infarction (STEMI) of whom 118 were in cardiogenic shock and 81 required defibrillations. LUCAS™ was used in 43 patients (33 STEMI, 7 non-ST-elevation myocardial infarction (NSTEMI), 2 elective PCIs and 1 patient with tamponade). Five patients had tamponade due to myocardial rupture prior to PCI that was revealed at the start of the PCI, and all five died. Of the remaining 38 patients, 1 patient underwent a successful pericardiocentesis and 36 were treated with PCI. Eleven of these patients were discharged alive in good neurological condition. Conclusion The use of mechanical chest compressions in the catheterisation laboratory allows for continued PCI or pericardiocentesis despite ongoing cardiac or circulatory arrest with artificially sustained circulation. It is unlikely that few, if any, of the patients would have survived without the use of mechanical chest compressions in the catheterisation laboratory.

A rare bone–leptomeningeal metastasis from an adrenal cortical carcinoma

We report a rare bone–leptomeningeal metastasis from an adrenal cortical carcinoma (ACC). ACC is a rare malignancy and represents one of the most unusual sources of intracranial metastases (0–0.2%); the localization to the skull bone and meninges is uncommon. A 45-year-old man underwent surgery for a non-functioning ACC; 4 months later he developed a soft left frontal mass. The CT scans and MRI showed a large tumor with bone and leptomeningeal involvement. Despite chemotherapy, the lesion increased in volume, which led to local pain and right hemiparesis. Thus, the patient underwent excision of the mass; histopathological diagnosis confirmed that it was an ACC metastasis. The patient underwent standard radiation therapy after surgery. At post-operative follow-up, the patient was in a good neurological condition with no radiological evidence of a cranial recurrence; however, there was a voluminous abdominal regrowth of the primary tumor. To our knowledge, this is the second case of bone and leptomeningeal metastasis arising from an ACC. This patient report confirms the effectiveness of aggressive surgery for management of large intracranial metastases, particularly those that arise from primary tumors that are resistant to radiotherapy and chemotherapy. In our opinion, surgery represents the most appropriate treatment for voluminous intracranial metastasis – even when there are no neurological signs.

Intractable blood loss during brain tumour surgery in a child: effect of recombinant activated factor VII

Editor, In neurosurgery, resection of richly vascularized brain tumours may be accompanied by excessive blood loss. In such cases, extensive transfusions of blood and blood products combined with application of local haemostatic agents and administration of antifibrinolytics may not halt blood loss sufficiently to end the procedure and may result in volume overload and brain swelling. Only two reports have been described in which the pro-haemostatic agent recombinant activated factor VII (rFVIIa) was administered for massive blood loss in children operated on for brain tumour resection [1,2].

ELSEVIER AND COMPLEMENTARY THERAPIES IN CLINICAL PRACTICE BEST DISSERTATION AWARD

In terms of treatment options, the underlying cause of out-of-hospital cardiac arrest (OHCA) has an impact on survival. This study aimed to examine the frequencies of different causes of OHCA and their outcomes using data from a national resuscitation registry.All pre-hospital cardiopulmonary resuscitations (CPR) documented in the German Resuscitation Registry between 2007 and 2017 were retrospectively investigated with regard to cause of cardiac arrest, return of spontaneous circulation (ROSC), and hospital discharge rate with good neurological outcome. To avoid selection bias, only rescue services with a return rate in the form ‘further clinical treatment’ of >30% were included, this resulted in a total return rate of 84% of the included data.In total, 33,772 patients were included. The most common causes of OHCA were cardiac events (62.2%), hypoxia (11.1%) and trauma (3.2%), in 17.2% no or unknown cause were documented. Overall, 44.8% of patients achieved ROSC, 13.1% of patients were discharged alive from hospital and 68.3% of these were in good neurological condition (9.0% of all patients). ROSC rates differed between 8.9% (sudden infant death syndrome) and 64.4% (intracranial bleeding), while discharge rates with good neurological outcome ranged between 0.9% (sepsis) and 14.0% (intoxication).The most common causes of OHCA are cardiac events and hypoxia. Depending on the underlying cause, outcome after pre-hospital CPR varies widely with a survival rate with good neurological outcome ranging from 0.9 to 14%.

Results from Austria's nationwide public access defibrillation (ANPAD) programme collected over 2 years

To analyse 2 years of experience after introducing automated external defibrillators (AED) all over Austria. This observational study evaluated the number of privately purchased devices and the rate of local bystander-triggered AED deployments from November 2002 to December 2004. As outcome measurements, the hospital discharge rate and neurological condition were recorded. Arrival times of the emergency medical service (EMS) on scene and the time intervals until shock decisions were made were calculated. Shock decisions were verified according to ECG downloads. Results were compared with historical data if applicable. During the study period, 1865 devices were installed. Seventy-three AED deployments were recorded. Eleven cases were excluded from the study because bystanders were part of the local EMS. Seventeen out of the remaining 62 (27%) compared to a historical 27 out of 623 (4.3%) individuals were discharged alive from hospital. Fourteen out of 26 (54%) patients who were found with a shockable rhythm survived to hospital discharge. Fifteen of our patients survived in good neurological condition (CPC I and II), two suffered from severe neurological deficit (CPC III and IV) and 45 people died. The median "call-to-AED advice interval" was 3.5 min (IQR 2-6 min; N=24). In two cases, the AED made inappropriate decisions because of artefacts. Compared to historical data, short 'intervals to shock' delivery and the frequent start of basic life support resulted in an increased hospital discharge rate in good neurological condition. Despite the relatively high number of installed devices, the number of patients reached remained small.

Cardiopulmonary resuscitation-associated major liver injury

To evaluate the frequency, presentation, treatment and outcome of cardiopulmonary resuscitation-associated major liver injury in patients after non-traumatic in- or out-of-hospital cardiac arrest. Retrospective analysis of a cardiac arrest registry in a tertiary care hospital emergency department. We reviewed patients charts, laboratory data, diagnostic imaging studies and autoptic findings. Within 14.5 years, major liver injury (rupture/laceration, haemorrhage/haematoma) was found in 15 of 2558 cardiac arrest victims (0.6%). Eleven were male (73%), median age was 58 (IQR 53-67). In seven, resuscitation was started out-of-hospital. In 9 of the 15 patients, liver injury was correctly diagnosed intra vitam. In 5, haematocrit level was low on admission, in 8 haematocrit dropped significantly during observation; haemostasis was compromised in 13 patients, 4 of them receiving thrombolytic therapy. Bedside abdominal sonography showed free intra-peritoneal fluid in 8 of 9 cases examined. In 11 patients, we found liver rupture/laceration, in 4 liver haemorrhage/haematoma. The site of injury was the left liver lobe in 11, six underwent emergent surgery. Two of 15 patients survived to 6 months in good neurological condition, 1 after emergency surgery. No patient died from bleeding due to liver injury. Our single centre observation confirms that resuscitation-associated major liver injury is infrequent and shows that most patients had compromised haemostasis. Low or dropping haematocrit should trigger suspicion. Bedside sonography reveals intra-peritoneal fluid or liver injury. A conservative therapeutic approach or emergency surgery may be warranted. Major liver injury alone scarcely appears to influence overall outcome.

Recurrent and metastatic clivus chordoma: systemic palliative therapy retards disease progression

We report on a male patient with progressive and metastatic clivus chordoma treated over a period of 9 years by a multidisciplinary approach. Within the first 4 years, the patient underwent surgery four times. Thereafter, he received radiotherapy and subsequent chemotherapy. Stabilization of disease was achieved repeatedly for variable periods under local radiotherapy, systemic chemotherapy, immunomodulatory and anti-angiogenic therapy with isotretinoin and interferon-alpha, followed by thalidomide. Due to the occurrence of brain and lung metastases 8 years after initial diagnosis, liposomal doxorubicin was added to thalidomide. At the last follow-up control the patient had stable disease, with no progression of the intracranial tumor and regression of pulmonary metastases. He is in a good physical, psychological and neurological condition with a Karnofsky score of 80. Our observations show that multimodal therapy including a systemic palliative approach is associated with long quiescent intervals in recurrent chordoma and with regression of its metastases. Use of substances with high efficacy on tumor tissue and low toxicity, allowing long-term administration, seems promising in similar situations.

Low cerebrovascular reserve capacity in long-term follow-up after subarachnoid hemorrhage

Background Intradural arteries formerly in vasospasm after subarachnoid hemorrhage (SAH) show structural changes that result in arterial wall thickening and luminal narrowing. To evaluate if these changes lead to maldistribution of cerebral perfusion and reduced cerebrovascular reserve capacity (CVRC) in surviving patients, a long-term follow-up study of 18 adult patients after SAH was performed. Methods Eighteen patients were selected for the study, all had shown vasospasm after an early operation on a ruptured aneurysm, were in good neurological condition (GOS [Glasgow Outcome Score] 4 or 5 ), and had no residual infarcts. A technetium-99m-hexamethyl-propylenamine oxime (HMPAO) single-photon emission computed tomography was performed 15 to 73 months after SAH. To study CVRC, a second investigation after application of acetazolamide was performed 1 week later. Results Single-photon emission computed tomography showed areas of focally reduced HMPAO uptake predominantly in the hemisphere ipsilateral to the vessels more affected by posthemorrhagic vasospasm. The thalamus and the basal ganglia, the frontal lobe, and the temporal lobe were the regions most frequently showing reduced uptake. The individual change of HMPAO uptake after acetazolamide application ranged from −7% to 44% (mean, 17% ± 15%). Conclusions These results show a remarkable reduction of CVRC compared with findings in healthy individuals. Based on these new findings, further investigations focusing on CVRC in routine SAH follow-up are worth being considered.

Timing of aneurysm surgery in subarachnoid haemorrhage – an observational study in The Netherlands

There is still lack of evidence on the optimal timing of surgery in patients with aneurysmal subarachnoid haemorrhage. Only one randomised clinical trial has been done, which showed no difference between early and late surgery. Other studies were observational in nature and most had methodological drawbacks that preclude clinically meaningful conclusions. We performed a retrospective observational study on the timing of aneurysm surgery in The Netherlands over a two-year period. In eight hospitals we identified 1,500 patients with an aneurysmal subarachnoid haemorrhage. They were subjected to predefined inclusion criteria. We included all patients who were admitted and were conscious at any one time between admission and the end of the third day after the haemorrhage. We categorised the clinical condition on admission according the World Federation of Neurological Surgeons (WFNS) grading scale. Early aneurysm surgery was defined as operation performed within three days after onset of subarachnoid haemorrhage; intermediate surgery as performed on days four to seven, and late surgery as performed after day seven. Outcome was classified as the proportion of patients with poor outcome (death or dependent) two to four months after onset of subarachnoid haemorrhage. We calculated crude odds ratios with late surgery as reference. We distinguished between management results (reconstructed intention to treat analysis) and surgical results (on treatment analysis). The results were adjusted for the major prognosticators for outcome after subarachnoid haemorrhage. We included 411 patients. There were 276 patients in the early surgery group, 36 in the intermediate surgery group and 99 in the late surgery group. On admission 78% were in good neurological condition (WFNS I-III). MANAGEMENT RESULTS: Overall, 93 patients (34%) operated on early had a poor outcome, 13 (36%) of those with intermediate surgery and 37 (37%) in the late surgery group had a poor outcome. For patients in good clinical condition on admission and planned for early surgery the adjusted odds ratio (OR) was 1.3 (95% CI 0.5 to 3.0). The adjusted OR for patients admitted in poor neurologicalcondition (WFNS IV-V) and planned for early surgery was 0.1 (95% CI 0.0 to 0.6). SURGICAL RESULTS: For patients in good clinical condition on admission who underwent early operation the adjusted OR was 1.1 (95% CI 0.4 to 3.2); it was 0.2 (95% CI 0.0 to 0.9) for patients admitted in poor clinical condition. In this observational study we found no significant difference in outcome between early and late operation for patients in good clinical condition on admission. For patients in poor clinical condition on admission outcome was significantly better after early surgery. The optimal timing of surgery is not yet settled. Ideally, evidence on this issue should come from a randomised clinical trial. However, such a trial or even a prospective study are unlikely to be ever performed because of the rapid development of endovascular coiling.

Long-term management of patients with multiple brain metastases after shaped beam radiosurgery

✓ The role of radiosurgery in the treatment of patients with advanced-stage metastatic disease is currently under debate. Previous randomized studies have not consistently supported the use of radiosurgery to treat patients with numbers of brain metastases. In negative-results studies, however, intracranial tumor control was high but extracranial disease progressed; thus, patient survival was not greatly affected, although neurocognitive function was generally maintained until death. Because the future promises improved systemic (extracranial) therapy, the successful control of brain disease is that much more crucial. Thus, for selected patients with multiple metastases to the brain who remain in good neurological condition, aggressive lesion-targeting radiosurgery should be very useful. Although a major limitation to success of this therapy is the lack of control of extracranial disease in most patients, it is clear that well-designed, aggressive treatment substantially decreases the progression of brain metastases and also improves neurocognitive survival. The authors present the management and a methodology for rational treatment of a patient with breast cancer who has harbored 24 brain metastases during a 3-year period.

Long-term management of patients with multiple brain metastases after shaped beam radiosurgery

✓ The role of radiosurgery in the treatment of patients with advanced-stage metastatic disease is currently under debate. Previous randomized studies have not consistently supported the use of radiosurgery to treat patients with numbers of brain metastases. In negative-results studies, however, intracranial tumor control was high but extracranial disease progressed; thus, patient survival was not greatly affected, although neurocognitive function was generally maintained until death. Because the future promises improved systemic (extracranial) therapy, the successful control of brain disease is that much more crucial. Thus, for selected patients with multiple metastases to the brain who remain in good neurological condition, aggressive lesion-targeting radiosurgery should be very useful. Although a major limitation to success of this therapy is the lack of control of extracranial disease in most patients, it is clear that well-designed, aggressive treatment substantially decreases the progression of brain metastases and also improves neurocognitive survival. The authors present the management and a methodology for rational treatment of a patient with breast cancer who has harbored 24 brain metastases during a 3-year period.

Cyclosporin A in treatment of refractory patients with chronic inflammatory demyelinating polyradiculoneuropathy

To investigate the therapeutic efficacy of cyclosporin A (CyA) in the treatment of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), a microemulsion form of this drug (Neoral®) was orally given to seven patients with the disease who were unresponsive or resistant to conventional therapies. The daily dose of CyA was carefully controlled in order to keep the plasma trough concentration between 100 and 150 ng/ml. Within 1 month of initiation of CyA, all patients subjectively showed improvement of clinical symptoms, while both modified Rankin and INCAT disability scores were significantly decreased ( p<0.05) and grip strength was significantly increased ( p<0.05) 3 months after initiation compared with before. Total protein in the cerebrospinal fluid was significantly decreased 3 and 6 months after starting CyA ( p<0.05). Although the maximal motor nerve conduction velocity showed a significant improvement in the median nerve 1 to 1.5 years after commencement of CyA ( p<0.05), there were no significant changes in any other neurophysiological parameters. One patient with anti-sulphoglucuronyl paragloboside IgM antibodies gradually became resistant to CyA, but the rest have since been in good neurological condition without complications ascribable to this drug. These results suggest that oral CyA may be effective even for refractory cases with CIDP. CyA should be actively considered as a therapeutic option when patients with CIDP are resistant to conventional treatment.

The treatment of brain metastases in melanoma patients

The incidence of central nervous system (CNS) metastases in patients with melanoma ranges from 10% to 40% in clinical studies and is even higher in autopsy series with as many as two-thirds of patients with metastatic melanoma having CNS involvement. Treatment options for patients with cerebral metastases are limited and depend largely on the number and the size of the lesions and on the extracranial extension of metastatic disease. This report gives the results of different treatment modalities in patients with melanoma metastases to the brain. As data from prospective randomized studies are lacking, the general recommendations based on clinical series reports are: (i) the combination of surgery and whole-brain radiotherapy (WBRT) is superior to WBRT alone for the treatment of single brain metastasis in patients with limited or absent systemic disease and good neurological condition. (ii) Radio surgery, alone or in conjunction with WBRT, yields results which are comparable to those reported after surgery followed by WBRT, provided that the lesion's diameter does not exceed 3 cm. With the use of WBRT after surgery or radio surgery the local control seems better (with the combined approach), but the overall survival does not improve. (iii) WBRT alone or in combination with chemotherapy is the treatment of choice in patients with single brain metastasis not amenable to surgery or radio surgery, with an active systemic disease, and in patients with multiple brain metastases. Chemotherapy may be also offered to patients with a good performance status, or after recurrence to local therapy.

Frequency and outcome of in-hospital resuscitation outside the ICU-setting.

Guidelines on performing cardiopulmonary resuscitation and its research have been published. Only few data concerning in-hospital resuscitation are available from Switzerland. The aim of our study was to evaluate the frequency and outcome of cardiopulmonary arrests in our hospital and to look for ways of improving our resuscitation management. The prospective study was performed in the Kantonsspital Liestal, a primary care hospital with 360 beds, where about 24'300 in-patients were treated during the 2 year observation period. Only in-hospital resuscitations outside the ICU were included and recorded according to the Utstein criteria. Within a 24 months period, 61 emergency calls were registered. 25 patients needed cardiopulmonary resuscitation. Initial cardiac rhythms were available for all subjects: 8 patients had asystole, 7 ventricular fibrillation and 10 pulseless electrical activity. 12 of 25 resuscitated patients had a return of spontaneous circulation, 7 lived longer than 24 hours and 6 patients (24%) survived to hospital discharge, 4 of them in a very good or good neurological condition. After 12 months 3 patients (12%) were living independently at home, 2 patients had to be treated in a nursing home and 1 patient had died. Our data correspond to survival rates in larger studies from abroad but are limited by the number of patients investigated. Improvements are necessary in documentation of resuscitation efforts. Rapid defibrillation must be further stressed. The implementation of a multicentre study is suggested because quality control and further improvement of in-hospital resuscitation are needed in Switzerland.

Frequency and outcome of in-hospital resuscitation outside the ICU-setting.

Guidelines on performing cardiopulmonary resuscitation and its research have been published. Only few data concerning in-hospital resuscitation are available from Switzerland. The aim of our study was to evaluate the frequency and outcome of cardiopulmonary arrests in our hospital and to look for ways of improving our resuscitation management. The prospective study was performed in the Kantonsspital Liestal, a primary care hospital with 360 beds, where about 24'300 in-patients were treated during the 2 year observation period. Only in-hospital resuscitations outside the ICU were included and recorded according to the Utstein criteria. Within a 24 months period, 61 emergency calls were registered. 25 patients needed cardiopulmonary resuscitation. Initial cardiac rhythms were available for all subjects: 8 patients had asystole, 7 ventricular fibrillation and 10 pulseless electrical activity. 12 of 25 resuscitated patients had a return of spontaneous circulation, 7 lived longer than 24 hours and 6 patients (24%) survived to hospital discharge, 4 of them in a very good or good neurological condition. After 12 months 3 patients (12%) were living independently at home, 2 patients had to be treated in a nursing home and 1 patient had died. Our data correspond to survival rates in larger studies from abroad but are limited by the number of patients investigated. Improvements are necessary in documentation of resuscitation efforts. Rapid defibrillation must be further stressed. The implementation of a multicentre study is suggested because quality control and further improvement of in-hospital resuscitation are needed in Switzerland.