Cardiac arrest is the common cause of anoxic brain injury. Other reasons to have brain anoxia include severe hypotension, hypotension with limited CNS blood flow like high ICP, carbon monoxide poisoning, and strangulation. Lance et.al1 published in 1963 the first presentation of post anoxic recovery myoclonus. The presence of myoclonus in post-cardiac arrest patients is frequently seen, though the syndrome is named after the original paper; Lance-Adams syndrome is the residual presence of myoclonus after the patient survives. The literature review was done and there is no mention of second cardiac arrest in Lance- Adams syndrome patients with the disappearance of myoclonus.
45 year old male with a preadmission history significant for hypertension, diabetes, diabetic neuropathy, necrotizing fasciitis secondary to a boating accident, and bipolar disorder admitted to the hospital a year before his present admission with shortness of breath. He was admitted with bilateral pneumonia. During this first hospitalization, he underwent surgery for left below-the-knee amputations. The day after his surgery, he was found to have difficulty breathing after which he suffered asystole cardiopulmonary arrest with ROSC being achieved after 12 minutes of resuscitation. He underwent a targeted temperature management protocol. Post hypothermia, he woke up and started following commands. He stayed on the ventilator for 12 days followed by successful extubation. In subsequent days, he suffered myoclonic jerking of his upper and lower extremities. Electroencephlaogray did not show any seizures. CT head was negative for findings consistent with anoxic brain injury. MRI brain was not possible at that stage due to concern for hardware for a history of cervical spine surgery. He was able to follow commands, and move his extremities independently with intermittent myoclonic jerking, track movement, and garbled, incoherent speech. He was discharged to rehab and eventually home but required total care from his mother. A clinical diagnosis of Lance-Adams syndrome was made and symptomatic treatment was initiated.
He was brought to the emergency department after the second asystole cardiac arrest followed by pulseless electrical activity at home. ROSC was achieved on arrival to ED after 5 rounds of CPR following ACLS protocol. Per his mother, his baseline mental status prior to arrest was intermittently following commands and ability to express himself. He was intubated and subsequently underwent targeted temperature management protocol in the intensive care unit.
After completion of hypothermia, he stayed in a coma without any sedation. The myoclous due to Lance-Adams syndrome was not present. His eyes opened up and was able to track but not able to follow commands or move extremities. CT head did not show any active process. Brain MRI was able to be done showing minimal small vessels with subtle ischemic changes. EEG was negative for any seizures with marked encephalopathic changes. Over the next many days, there was no change and the family proceeded to terminal extubation and terminal care.e
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