Extracerebral Complications

The cause of death in the majority of patients after resuscitation is mostly extracerebral in nature. In the BRCT 1 study, 63.6% of patients died due to extracerebral causes, whereas 36.4% died from cerebral causes (15). A similar proportion was observed in BRCT 2, with extracerebral causes noted in 72.2% of patients and cerebral causes of death noted in 27.8% (20). In both BRCT 1 and 2, cardiac death accounted for approximately two-thirds of all extracerebral deaths. It is, therefore, noteworthy that the management of extracerebral or systemic complications in these patients, particularly of cardiac injury, is paramount to patient survival. A review of the percentage of mortality in the placebo-treated patients across clinical trials dedicated to brain injury after CA reveals a trend in a reduction in overall mortality over three decades (Fig. 2). With the exception of the 1990 nimodipine study (23), the controlled clinical trials from 1986 to 1993 had a percentage mortality of 80% or greater. The study by Roine selected patients with lesser injury by limiting the duration of CA time and resuscitation time (23). A declining trend in percentage mortality (< 80%) is noted in studies from 1997 (27) to 2002 (8,9). Due to the wide variability in trial design, it will be very difficult to precisely determine the factors that lead to the reduction in mortality. However, two key factors might have changed in clinical practice over the time these trials were undertaken: (i) the desire of investigators to include patients with higher chances of survival after CA to allow the assessment of functional outcome, and (ii) the continued improvement in the standard of overall critical care in patients treated with placebo. As we evaluate the therapies to improve neurologic function, we must also consider the need for continued development in the critical care therapies. Only adequate critical care support will allow good functional recovery from brain injury post CA.

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