Patient 3, a 78-year-old woman, showed large bifrontal ICH in addition to aSAH. She had 12 SDs on days 2 and 3, and 1 on day 10. One SD was a spreading convulsion. The others were classified as spreading depressions. The PTDDD was 144.1 minutes and occurred on day 2. Her past medical history was significant for liver cirrhosis of unknown etiology. During her clinical course, she developed a hepatorenal syndrome with progressive failure of liver, kidneys, lungs, and circulation. A family discussion was held and a DNR-CC order was activated followed by terminal extubation on day 11. As shown in Figure A, the ECoG showed a deviation from the 2 previous cases because the terminal SD started in electrode 3 at 7 minutes before the circulatory arrest. In this moment, spontaneous brain activity was still present. Accordingly, the terminal SD induced spreading depression at electrode 3. From electrode 3, the SD spread to the other electrodes. Finally, nonspreading depression rendered the remaining spontaneous brain activity isoelectric while the terminal SD was still propagating. Presumably, the last SD originated from the rim of the previous ICH. The circulatory arrest then converted this SD into a terminal one.
Patient 5 was a 47-year-old male occupant of a car struck by a train with reported field Glasgow Coma Scale (GCS) = 3. The patient was intubated for airway protection and arrived at the trauma center with presentation GCS = 3T. Bilateral chest tubes were placed for traumatic pneumothoraces. Once stabilized, the patient had a postresuscitation GCS = 1T3. CT of the head demonstrated skull vault fractures, diffuse traumatic SAH, subdural hematoma, and diffuse petechial shear injuries. He was admitted to neurocritical care, and an ICP monitor was placed with elevated ICP noted. A family discussion was held on day 2, a DNR-CC order was activated, and the patient was terminally extubated. Similar to Patients 2 and 4, nonspreading depression occurred while ptiO2 showed the final drop. The terminal SD started 73 seconds after nonspreading depression had rendered the ECoG isoelectric (Fig A, B).