Reestablishment Of Spontaneous Circulation Research Articles

Abstract 358: Coronary Features in Different Subsets of Out-of-Hospital Cardiac Arrest

Introduction: Coronary artery disease (CAD) is the leading cause of out-of-hospital cardiac arrest (OHCA) which is usually triggered by acute coronary event. Hypothesis: CAD is more complex if acute coronary event is associated with OHCA. CAD complexity progressively increases from patients with reestablishment of spontaneous circulation (ROSC) to patients with refractory OHCA. Aims: To investigate CAD features in different subgroups of OHCA and compare them to patients with acute coronary syndrome without OHCA. Methods: Consecutive conscious and comatose OHCA with ST-elevation myocardial infarction (STEMI) after ROSC and patients with refractory OHCA undergoing veno-arterial extracorporeal membrane oxygenation (E-CPR OHCA) were compared to STEMI without OHCA (STEMI no OHCA). Results: Between 2016 and 2022, 71 conscious OHCA, 157 comatose OHCA, 50 E-CPR OHCA and 101 randomly selected STEMI no OHCA underwent immediate coronary angiography. Acute culprit lesion was documented less often in OHCA subsets (88.1% vs 97%; p=0.009) but complete occlusion was more prevalent (68.8% vs 58.4%; p=0.038) (Figure A) . Incidence of multivessel disease, > 50% unprotected left main stenosis, and presence of > 1 chronic total occlusion progressively increased from STEMI no OHCA to E-CPR OHCA. This was reflected in baseline SYNTAX score which was 5.6 in STEMI no OHCA,10.2 in conscious OHCA, 13.4 in comatose OHCA and 26.8 in E-CPR OHCA (p<0.001) (Figure B) . There was a linear correlation between SYNTAX score and delay to ROSC (r 2 =0.61; p<0.001) (Figure C) . Baseline and residual SYNTAX scores were among independent predictors of 5-year survival which was significantly decreased in comatose (56.1%) and E-CPR (36.0%) OHCA (Figure D) . Conclusion: OHCA is associated with increased incidence of acute coronary occlusion and progressive complexity of CAD from conscious OHCA to E-CPR OHCA. Severity of CAD is associated with increased delays to ROSC and decreased long-term survival.

Coronary features across the spectrum of out-of-hospital cardiac arrest with ST-elevation myocardial infarction (CAD-OHCA study)

AimWe hypothesized that adult patients with out-of-hospital cardiac arrest (OHCA) and ST-elevation myocardial infarction (STEMI) requiring prolonged resuscitation have more severe coronary artery disease (CAD) than those responding rapidly, and more severe CAD than patients with STEMI without OHCA. MethodsConsecutive conscious and comatose OHCA patients with STEMI after reestablishment of spontaneous circulation (ROSC), and patients with refractory OHCA undergoing veno-arterial extracorporeal membrane oxygenation (E-CPR OHCA) were compared to STEMI without OHCA (STEMI no OHCA). CAD severity was assessed by a single physician blinded to the resuscitation method, time to ROSC and level of consciousness. ResultsBetween 2016 and 2022, 71 conscious OHCA, 157 comatose OHCA, 50 E-CPR OHCA and 101 STEMI no OHCA underwent immediate coronary angiography. Acute culprit lesion was documented less often in OHCA (88.1% vs 97%; p = 0.009) but complete occlusion was more frequent (68.8% vs 58.4%; p = 0.038) than in STEMI no OHCA. SYNTAX score was 5.6 in STEMI no OHCA, 10.2 in conscious OHCA, 13.4 in comatose OHCA and 26.8 in E-CPR OHCA (p < 0.001). There was a linear correlation between SYNTAX score and delay to ROSC/ECMO initiation (r2 = 0.61; p < 0.001). Post PCI culprit TIMI 3 flow was comparable between the groups (≥86%). SYNTAX score was among independent predictors of 5-year survival which was significantly decreased in comatose OHCA (56.1%) and E-CPR OHCA (36.0%) compared to conscious OHCA (83.1%) and STEMI no OHCA (88.1%). ConclusionCompared to STEMI no OHCA, OHCA was associated with increased incidence of acute coronary occlusion and more complex non culprit CAD which progressively increased from conscious OHCA to E-CPR OHCA. Severity of CAD was associated with increased delays to ROSC/ECMO initiation and decreased long term survival.

Coronary disease in refractory cardiac arrest undergoing resuscitation with extracorporeal membrane oxygenation.

Because re-establishment of spontaneous circulation (ROSC) in patients with cardiac arrest is frequently not achieved by conventional cardiopulmonary resuscitation (C-CPR), selected patients may undergo resuscitation with extracorporeal membrane oxygenation (E-CPR). We compared angiographic features and percutaneous coronary intervention (PCI) between patients undergoing E-CPR and those with ROSC after C-CPR. Forty-nine consecutive E-CPR patients undergoing immediate coronary angiography admitted between August 2013 and August 2022 were matched to 49 patients with ROSC after C-CPR. Multivessel disease (69.4% vs. 34.7%; P = 0.001), ≥ 50% unprotected left main (ULM) stenosis (18.4% vs. 4.1%; P = 0.025), and ≥1 chronic total occlusion (CTO) (28.6% vs. 10.2%; P = 0.021) were more often documented in E-CPR group. There was no significant differences in the incidence, features, and distribution of acute culprit lesion which was present in >90%. Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) (27.6 vs. 13.4; P = 0.002) and GENSINI (86.2 vs. 46.0; P = 0.001) scores were increased in E-CPR group. Optimal cut-off predicting E-CPR was 19.75 for SYNTAX (sensitivity 74%, specificity 87%) and 60.50 (sensitivity 69%, specificity 75%) for GENSINI score. More lesions were treated (1.3 vs. 1.1 lesions/patient; P = 0.002) and stents implanted (2.0 vs. 1.3/patient; P < 0.001) in E-CPR group. Final TIMI three flow was comparable (88.6% vs. 95.7%; P = 0.196) but residual SYNTAX (13.6 vs. 3.1; P < 0.001) and GENSINI (36.7 vs. 10.9; P < 0.001) scores remained increased in E-CPR group. Extracorporeal membrane oxygenation patients have more multivessel disease, ULM stenosis, and CTO but similar incidence, features, and distribution of acute culprit lesion. Despite more complex PCI, revascularization is less complete.

Abstract 269: Comparison Of Coronary Anatomy And Percutaneous Coronary Intervention Between Patients Undergoing Conventional And Extracorporeal Membrane Oxygenation Resuscitation

Introduction: Because reestablishment of spontaneous circulation (ROSC) is frequently not achieved by conventional cardiopulmonary resuscitation (C-CPR), selected patients undergo resuscitation with extracorporeal membrane oxygenation (E-CPR). If coronary cause is suspected, coronary angiography (CAG) and percutaneous coronary intervention (PCI) are performed. Hypothesis: Coronary anatomy in E-CPR patients is more complex. Despite decreased and retrograde aortic blood flow, PCI is feasible and successful. Methods: Forty-three consecutive E-CPR patients undergoing immediate CAG admitted between August 2013 to May 2022 were matched by sex and age with 43 patients with ROSC after C-CPR. Results: Except for increased body mass index (28.9 ± 4.6 vs 26.3 ± 2.7; p=0.002) and more smoking (79% vs 58%; p=0.021) in E-CPR group , there was no significant differences in patient characteristics. Arrest was witnessed in 100% in E-CPR and 93% in C-CPR (p=0.078), basic life support was performed in 100% and 84% (p=0.006) and initial shockable rhythm was present in 63% and 82% (p=0.054), respectively. Multivessel disease (60.4% vs 32.5%) and chronic total occlusion (27.9% vs 9.3%) were more prevalent in E-CPR group (Table). There was no difference in the incidence and distribution of the acute culprit lesion present in &gt;90%. Syntax score was significantly increased in E-CPR group. E-CPR patients received more stents (2.08 vs 1.38/patient) with increased total length (49.3 vs 27.7 mm). There was no significant difference in final TIMI 3 (88.9% vs 97.4%). Residual Syntax score remained increased in E-CPR group. Conclusion E-CPR patients have more extensive chronic coronary disease without significant difference in acute culprit lesion. More complex anatomy may be, in the setting of comparable initial resuscitation, responsible for C-CPR failure. PCI in E-CPR is successful but more complex with increased residual disease burden.

Abstract 225: Late Awakening In Comatose Survivors Of Out-of-hospital Cardiac Arrest

Background: Despite advanced neuroprognostication using neuron-specific enolase, electroencephalogram and brain imaging, prediction of neurological outcome in comatose survivors of out-of-hospital cardiac arrest (OHCA) remain challenging and early discontinuation of postresuscitation treatment may be harmful for patients with delayed awakening. Hypothesis: Significant proportion of comatose survivors of OHCA may regain consciousness only after discharge from intensive care unit (ICU). Methods: Consecutive comatose survivors of OHCA admitted to our ICU between January 1, 2003 and December 31, 2021 were investigated. Cerebral performance category (CPC) was used for evaluation of neurological recovery. CPC 1 indicated complete recovery, CPC 2 mild neurological impairment, CPC 3 severe neurological impairment and CPC 4 vegetative state. Results: A total of 1098 patients (63 + 14 years, 79% (864 of 1098) men) were enrolled. OHCA was witnessed in 88% (966 of 1098), basic life support was performed in 57% 630 of 1098), delay to emergency team arrival was 7.5 + 5.3 minutes and initial shockable rhythm was present in 77%. (851 of 1098). Reestablishment of spontaneous circulation (ROSC) was obtained after 12.9 + 11.8 minutes of advanced life support. Coronary angiography was performed in 74% (822 of 1098) and percutaneous coronary intervention in 52% (567 of 1098). Mechanical circulatory support was used in 16% (175 of 1098) and hypothermia (32-34 C) in 85% (940 of 1098). Among 740 patients who survived to ICU discharge on day 7 (median), 272 patients (36.8%) of patients remained in CPC 3-4 ( Figure). Among these 272 patients, CPC 1-2 at hospital discharge was documented in 19.9%. (54 patients). Conclusion: Almost 20% of comatose survivors of OHCA without neurological recovery at ICU discharge may ultimately regain consciousness. This argues against premature withdrawal of care in step down units and normal wards.

15-year survival of comatose OHCA patients according to initial rhythm

Abstract Introduction Long-term outcome of comatose survivors of out-of-hospital cardiac arrest (OHCA) is largely unknown. We therefore investigated 15-year survival of consecutive patients who were admitted to our hospital after reestablishment of spontaneous circulation (ROSC) on the field. Methods and results Between January 2003 and January 2022, 851 patients with shockable and 247 patients with non-shockable rhythms were admitted. Patients with shockable rhythm were significantly younger (61.5±13,3 versus 66.8±14.8 years), had more often bystander life support (64% versus 35%), shorter delay to emergency team arrival (7.3±5.1 versus 8.3±5.9 minutes), shorter time from advanced life support to ROSC (16.6±15.27 versus 18.5±14.3) and more aggressive hospital treatment including hypothermia (89% versus 74%), coronary angiography/PCI strategy (81% versus 52%) and more IABP/ECMO support (18% versus 10%). Survival with good neurological outcome in patients with shockable rhythm decreased from 51% at hospital discharge to 35% at 15 years (Figure 1). In patients with non-shockable rhythm, survival decreased from 14% at hospital discharge to 8% at 15 years. Conclusion If comatose OHCA patient survives to hospital discharge, annual death rate during the following 15 years is 1.07% for shockable and 0.40 for non-shockable rhythms indicating good long-term outcome. Funding Acknowledgement Type of funding sources: None.

EURECA Serbia ONE 2014: Out of hospital cardiac arrest: Venue of accident

Introduction: Data on the success of advanced support measures đivoru indicate that in well organised systems more than 35% of people in cardiac arrest experience re-establishment of spontaneous circulation (ROSC). Percentage of established ROSC according to the data published by the Eureca program in 2014 in Serbia is around 5%. In Serbia, there is no reliable system of collecting data that is linked to the place of the event and the presence of a witness to what we call Out hospital cardiac arrest. (OHCA), whether it is sudden cardiac arrest or heart failure. The EURECA study should shed light on the epidemiological picture in the Republic of Serbia and provide an objective overview of the cite of events of sudden cardiac arrest in Serbia as very important information for the development of a strategy for treating this disease. OBJECTIVE: To determine the place of event in sudden cardiac arrest in accordance with the Utstain protocol. The aim of the protocol is to determine whether the presence of a witness in sudden cardiac arrest affects the number of attempts of resuscitation by the system of Emergency Medical Assistance in Serbia. METHOD: A prospective study that includes data collected through questionnaires, established within the framework of the adopted methodology for collecting data in Clinical Trials ID: NCT02236819 - ONE Eureca 2014. Data from the program defined by the research centers was entered into a database uniquely formed on the Internet at www.eureca.rs Results: In the framework of Eureca in 2014 in Serbia data was collected for around 1828 cardiac arrests that occurred outside the hospital. 789/1828 or 48.46 cardiac arrests took place in the presence of a witness, others were unwitnessed or 839 people had suffered cardiac arrest in a remote area. Resuscitation measures were initiated by the Emergency medical unit at 171/839 or 20.42% of patients have experienced cardiac arrest without the presence of relatives or bystanders. The largest number of cardiac arrests take place in a house or an apartment of a patient 1448/1828 79.21% and with a witness present 629/1448 or in 43.41% of cases. The data collected is related to the recorded heart failures in retirement homes, workplaces, public buildings, street sports facilities. Cardiac arrest in a public place - the street is next in frequency 133/1828 or 7.27% of all cardiac arrests outside of hospitals. Conclusion: A large number of cardiac arrests occur in the home, often without a witness or a person that could activate the emergency service. Further studies of the structure of age, education, number of people in households can provide an answer about the activities that should be taken. Future studies should be designed to shed light on this phenomenon.

Usefulness of cardiac arrest centers - extending lifesaving post-resuscitation therapies: the Arizona experience - .

The post-cardiac arrest syndrome is a complex, multisystems response to the global ischemia and reperfusion injury that occurs with the onset of cardiac arrest, its treatment (cardiopulmonary resuscitation) and the re-establishment of spontaneous circulation. Regionalization of post-cardiac arrest care, utilizing specified cardiac arrest centers (CACs), has been proposed as the best solution to providing optimal care for those successfully resuscitated after out-of-hospital cardiac arrest. A multidisciplinary team of intensive care specialists, including critical care/pulmonologists, cardiologists (general, interventional, and electrophysiology), neurologists, and physical medicine/rehabilitation experts, is crucial for such centers. Particular attention to the timely initiation of targeted temperature management and early coronary angiography/percutaneous coronary intervention is best provided by such CACs. A State-wide program of CACs was started in Arizona in 2007. This is a voluntary program, whereby medical centers agree to provide all resuscitated cardiac arrest patients brought to their facility with state-of-the-art post-resuscitation care, including targeted temperature management for comatose patients and strong consideration for emergent coronary angiography for all patients with a likely cardiac etiology for their cardiac arrest. Survival improved by more than 50% at facilities that became CACs with a commitment to provide aggressive post-resuscitation care to all such patients. Providing aggressive, post-resuscitation care is the next real opportunity to increase long-term survival for cardiac arrest patients.

Urgent invasive coronary strategy and mild induced hypothermia in patients with resuscitated sudden cardiac arrest

Copyright © Polskie Towarzystwo Kardiologiczne INTRODUCTION Sudden cardiac arrest (SCA) remains the leading cause of death in developed countries, with an annual incidence ranging from 36 to 81 events per 100,000 inhabitants. According to the findings of post mortems and immediate coronary angiography, significant coronary artery disease may be documented in more than 70% of patients suffering from SCA [1, 2]. Following initial cardiocerebral resuscitation in the field, the re-establishment of spontaneous circulation (ROSC) is achieved in 40% to 60% of patients who are subsequently transferred to the emergency department. Because of typical delays in the ‘chain of survival’, up to 80% of patients remain comatose despite ROSC which pinpoints post-resuscitation brain injury. Its severity may ultimately vary from mild disability to permanent vegetative state and cannot be accurately prognosticated on hospital admission. Only a minority of ‘lucky losers’ with prompt initiation of chest compression and defibrillation, which is usually the case if emergency medical personnel are already present when cardiac arrest occurs, regain consciousness immediately after ROSC.

Abstract 42: Cardiac Troponin and Extent of Coronary Artery Disease After Resuscitated Sudden Cardiac Arrest

Interpretation of cardiac troponin after resuscitated sudden cardiac arrest is often difficult because increased values may be caused by cardiac arrest, resuscitation procedures and concomitant myocardial infarction due to obstructive coronary disease. In the present study, we related peak cardiac troponin I (TnI), early postresuscitation electrocardiogram (ECG) and coronary anatomy obtained by urgent coronary angiography following reestablishment of spontaneous circulation (ROSC). Postresuscitation electrocardiogram (ECG) revealed STEMI in 183 patients of whom 179 had at least one obstructive lesion. In 66 patients with ECG patterns other than STEMI, 44 had obstructive coronary disease. As shown in table, peak troponin was much greater in STEMI than in no STEMI groups. Within no STEMI group, greater peak TnI was associated with presence of obstructive coronary artery disease. In conclusion, while great majority of patients with STEMI after ROSC have evidence of at least one obstructive lesion, increased levels of troponin in patients without STEMI indicate presence of at least one obstructive lesion and may thereby facilitate decision for coronary angiography if not performed already on admission.

Hypothermia during percutaneous coronary intervention in comatose survivors of cardiac arrest

Urgent invasive coronary strategy including coronary angiography and percutaneous coronary intervention (PCI) is feasible and safe in combination with mild induced hypothermia and may significantly improve survival with good neurological outcome in comatose patients after reestablishment of spontaneous circulation (ROSC). The starting hypothermia already in the prehospital setting or immediately after arrival to the catheterization laboratory to complement urgent coronary angi-ography and PCI seems to be a logical strategy.

Urgent coronary angiography and percutaneous coronary intervention as a part of postresuscitation management

Because an acute coronary thrombotic event may be viewed as the main trigger of sudden cardiac arrest, urgent coronary angiography followed by percutaneous coronary intervention appeared as a promising tool in the early postresuscitation phase. Unfortunately, large randomized trials, which have unequivocally demonstrated benefits of urgent percutaneous coronary intervention in patients with acute coronary syndromes, systematically excluded patients with preceding cardiac arrest followed by successful reestablishment of spontaneous circulation. There are several nonrandomized trials in patients with electrocardiographic signs of acute ST-elevation myocardial infarction after reestablishment of spontaneous circulation which together accumulated 478 patients. After urgent coronary angiography, percutaneous coronary intervention was performed in 98%. Patency of infarct-related artery was reestablished in 89%. Success of primary percutaneous coronary intervention and hospital survival in patients regaining consciousness soon after reestablishment of spontaneous circulation appeared to be comparable with ST-elevation myocardial infarction population without preceding cardiac arrest. This is in contrast with comatose survivors of cardiac arrest in whom survival to hospital discharge was, despite somewhat smaller patency of infarct-related artery after percutaneous coronary intervention (94% vs. 82%; p = .12), disproportionably decreased to 57% with good neurologic outcome in only 38%. There is evidence that in these patients, urgent coronary angiography and percutaneous coronary intervention can be safely combined with mild induced hypothermia to facilitate neurologic recovery.

Primary percutaneous coronary intervention in comatose survivors of cardiac arrest with ST-elevation acute myocardial infarction: a single-center experience in Florence

Primary percutaneous coronary intervention is currently known as the most effective reperfusion strategy in patients with ST-elevation myocardial infarction. There are no formal recommendations from the American Heart Association/American College of Cardiology and European Society of Cardiology guidelines regarding the treatment of comatose patients with signs of ST-elevation myocardial infarction after reestablishment of spontaneous circulation. We assessed prognosis in 31 consecutive comatose ST-elevation myocardial infarction patients admitted to our intensive cardiac care unit after early percutaneous coronary intervention from 1 January 2005 to 30 June 2006. During intensive cardiac care unit stay, eight patients died (8/23, 34.7%). In comparison between patients who died and those who survived, the former were older (P = 0.049), showed a higher incidence of chronic obstructive pulmonary disease and had a shorter intensive cardiac care unit length of stay (P = 0.001). No differences were detectable in the two subgroups regarding angiographic characteristics. The incidence of thrombolysis in myocardial infarction grade 3 postpercutaneous coronary intervention was higher in patients who survived (P = 0.0437). Patients who died showed higher latency times, both symptoms-to-basic life support and symptoms-emergency-team (P = 0.0171 and 0.0116, respectively). Patients who survived showed a higher ejection fraction than those who died, as well as lower values of peak troponin I, leukocytes and glycemia (P = 0.01, 0.001 and 0.05, respectively). According to our data, comatose survivors undoubtedly present a high-risk subgroup of ST-elevation myocardial infarction population in which percutaneous coronary intervention shows a procedural efficacy similar to conscious ST-elevation myocardial infarction patients and whose prognosis seems to be related both to infarct size and to neurological status. Further studies need to be performed in this high-risk subgroup investigating the effects of mild hypothermia (mainly on the neurological outcome) as well as the feasibility, safety and outcome of assistance device.

Urgent invasive coronary strategy in patients with sudden cardiac arrest

To review the evidence on urgent coronary angiography and percutaneous coronary intervention after resuscitated cardiac arrest and during ongoing cardiocerebral resuscitation. In almost 450 patients with acute ST-elevation myocardial infarction after reestablishment of spontaneous circulation, success rate of primary percutaneous coronary intervention was 89%. Survival rates in conscious patients after reestablishment of spontaneous circulation were comparable to patients without preceding cardiac arrest while in comatose patients, survival was 57% and survival with acceptable neurological outcome 38%. Nonrandomized trials in 106 comatose survivors of cardiac arrest indicate that urgent invasive coronary strategy can be safely combined with mild induced hypothermia. Percutaneous coronary intervention is also feasible in patients undergoing cardiocerebral resuscitation. In 34 reported patients, the success rate of percutaneous coronary intervention was 88% and survival to hospital discharge 41%. Urgent coronary angiography and percutaneous coronary intervention should be attempted in conscious patients after reestablishment of spontaneous circulation similarly as in patients with acute coronary syndromes without preceding cardiac arrest. In comatose survivors, urgent coronary strategy is reasonable if acute ischemic cause is suspected and if there is realistic hope for neurological recovery that should be facilitated with mild induced hypothermia. Urgent coronary invasive strategy may be successful also during ongoing resuscitation in selected patients without advanced heart diseases and significant comorbidities.

Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fibrillation with ST-elevation acute myocardial infarction

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST-elevation acute myocardial infarction (STEMI). In comatose survivors of cardiac arrest, mild induced hypothermia (MIH) improves neurological recovery. In the present study, we investigated feasibility and safety of combining primary PCI and MIH in comatose survivors of ventricular fibrillation with signs of STEMI after reestablishment of spontaneous circulation. Forty consecutive patients undergoing primary PCI and MIH from November 1, 2003 to December 31, 2005 were compared to 32 consecutive patients who underwent primary PCI but no MIH between January 1, 2000 and November 1, 2003. There were no significant differences between the MIH and no MIH groups in general characteristics, cardiac arrest circumstances and angiographic features. Except for decreases in heart rate during hypothermia interval, there was no difference between the MIH and no MIH groups in arterial pressure, peak arterial lactate (5.1 mmol/l versus 5.7 mmol/l; p = .56), need for vasopressors (65% versus 53%; p = .44), inotropes (48% versus 59%; p = .44), aortic balloon counterpulsation (20% versus 22%; p = .92), repeat cardioversion/defibrillation (30% versus 34%; p=.89) and use of antiarrhythmics (33% versus 53%; p = .13). There was also no difference in inspired oxygen requirements during mechanical ventilation and in renal function. Hospital survival with cerebral performance category 1 and 2 was significantly better in MIH group (55% versus 16%; p=.001). Our preliminary experience indicates that primary PCI and MIH are feasible and may be combined safely in comatose survivors of ventricular fibrillation with signs of STEMI. Such a strategy may improve survival with good neurological recovery.

SURVIVAL AFTER 40 MINUTES' SUBMERSION WITHOUT CEREBRAL SEQUELÆ

Cardiopulmonary resuscitation and rewarming were successful in a 5-year-old boy who had been submerged for 40 minutes in ice-cold fresh water. Severe metabolic acidosis was corrected by intravenous infusion of sodium bicarbonate solution before spontaneous circulation could be re-established. Fulminant pulmonary œdema developed after re-establishment of spontaneous circulation. This was efficiently reversed by positive-end-expiratory-pressure ventilation. During 2 days of treatment on a respirator the patient gradually regained consciousness; the endotracheal tube was then removed and the patient immediately started talking intelligently. The patient went through a period of slow cerebration and motor dysfunction but recovered rapidly, and on examination 13 months after the accident all findings were normal.