Patient 6 was a 71-year-old male pedestrian struck by a vehicle with reported field GCS = 14. The patient was intubated for airway compromise, and arrived at the trauma center with presentation GCS = 3T5. His primary survey revealed polytrauma with gross limb deformities and signs of craniofacial injury. A Focused Assessment with Sonography for Trauma examination was negative; CT of the head revealed diffuse traumatic SAH and a small falcine subdural hematoma. He was found to have coagulopathy by admission laboratory evaluation. After resuscitation and correction of coagulopathy, the patient was admitted to neurocritical care and an ICP monitor was placed. Repeat cranial imaging demonstrated worsening bifrontal contusions and an enlarging left temporal contusion. The patient's neurologic examination declined to GCS = 3T despite aggressive medical management for refractory ICP. A family discussion was held on day 2, at which time a DNR-CC order was activated. The patient was terminally extubated. The end-of-life recordings are shown in Figure C.
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.