Can fifth nerve mapping guide rhizotomy for recurrent trigeminal neuralgia? Case report.

INTRODUCTION: Microvascular decompression (MVD) is usually considered the first-line treatment for trigeminal neuralgia (TN) when medical treatments fail. Recurrence is rare and best treatment option is controversial. MVD was proposed as a feasible and effective technique for recurrent TN by many authors. Nevertheless, in a substantial number of cases, not any impingement or deterioration are found intraoperatively and partial selective rhizotomy is then advised. The rhizotomy site is mostly guided by anatomical landmarks, but variations due to scarring and adhesions are common pitfalls in these second surgeries. Intraoperative monitoring is infrequently used during MVD for trigeminal neuralgia. We describe the use of nerve mapping in a case of recurrence, revealing an unexpected rootlet distribution and thus safely guiding partial rhizotomy. CLINICAL PRESENTATION: A 53-year-old woman had suffered from bilateral trigeminal neuralgia for 10 years. Symptoms began on the right side. MVD resolved her symptoms but, after a few months, she developed left TN which persisted after left MVD, radiofrequency and radiosurgery. She was referred to our center for a second MVD on the left side. Intraoperative inspection detected no relevant findings, and nerve mapping followed by partial selective rhizotomy was performed. Complete pain relief was achieved. There were no complications. CONCLUSION: Rhizotomy is seldom employed for refractory trigeminal neuralgia. The effects of previous treatments can jeopardize anatomical landmarks. Nerve mapping seems a promising tool to improve results.

The Italian technical/administrative recommendations for telemedicine in clinical neurophysiology.

Recent advances in technology, information technology, Internet networks, and, more recently, fiber optics in industrialized countries allow the exchange of a huge amount of data, in real time, across the globe. The acquisition of increasingly sophisticated technologies has made it possible to develop telemedicine, by which the specialist's evaluation can be carried out on the patient even remotely. In Italy, this very useful tool, although possible from a technological and information technology point of view, has not been developed because of the lack of clear and univocal rules and of major administrative obstacles related to the Italian Public Health System. To promote telemedicine implementation in Italy, the Italian Society of Clinical Neurophysiology and the Italian Society of Telemedicine together with the National Centre for Telemedicine and New Assistive Technologies of the Italian Higher Institute of Health prepared these inter-society recommendations. Because of potential forensic value of these recommendations, they were prepared considering the current regulations and the General Data Protection Regulation and will provide the basis for a Consensus Conference planned to discuss and prepare National Telemedicine Guidelines.

Neurophysiological prediction of neurological good and poor outcome in post-anoxic coma.

OBJECTIVE: Investigation of the utility of association between electroencephalogram (EEG) and somatosensory-evoked potentials (SEPs) for the prediction of neurological outcome in comatose patients resuscitated after cardiac arrest (CA) treated with therapeutic hypothermia, according to different recording times after CA. METHODS: Glasgow Coma Scale, EEG and SEPs performed at 12, 24 and 48-72 h after CA were assessed in 200 patients. Outcome was evaluated by Cerebral Performance Category 6 months after CA. RESULTS: Within 12 h after CA, grade 1 EEG predicted good outcome and bilaterally absent (BA) SEPs predicted poor outcome. Because grade 1 EEG and BA-SEPs were never found in the same patient, the recording of both EEG and SEPs allows us to correctly prognosticate a greater number of patients with respect to the use of a single test within 12 h after CA. At 48-72 h after CA, both grade 2 EEG and BA-SEPs predicted poor outcome with FPR=0.0%. When these neurophysiological patterns are both present in the same patient, they confirm and strengthen their prognostic value, but because they also occurred independently in eight patients, poor outcome is predictable in a greater number of patients. SIGNIFICANCE: The combination of EEG/SEP findings allows prediction of good and poor outcome (within 12 h after CA) and of poor outcome (after 48-72 h). Recording of EEG and SEPs in the same patients allows always an increase in the number of cases correctly classified, and an increase of the reliability of prognostication in a single patient due to concordance of patterns.

Single electroencephalographic patterns as specific and time-dependent indicators of good and poor outcome after cardiac arrest.

OBJECTIVE: To evaluate the prognostic value of single EEG patterns recorded at various time-frames in postanoxic comatose patients. METHODS: This retrospective study included 30-min EEGs, classified according to the definitions of continuity of background activity given by the American Clinical Neurophysiology Society. Isoelectric pattern was distinguished from other suppressed activities. Epileptiform patterns were considered separately. Outcome was dichotomised based on recovery of consciousness as good (Glasgow Outcome Scale [GOS] 3-5) or poor (GOS 1-2). RESULTS: We analysed 211 EEGs, categorised according to time since cardiac arrest (within 12h and around 24, 48 and 72h). In each time-frame we observed at least one EEG pattern which was 100% specific to poor or good outcome: at 12h continuous and nearly continuous patterns predicted good outcome and isoelectric pattern poor outcome; at 24h isoelectric and burst-suppression predicted poor outcome; at 48 and 72h isoelectric, burst-suppression and suppression (2-10µV) patterns predicted poor outcome. CONCLUSIONS: The prognostic value of single EEG patterns, defined according to continuity and voltage of background activity, changes until 48-72h after cardiac arrest and in each time-frame there is at least one pattern which accurately predicts good or poor outcome. SIGNIFICANCE: Standard EEG can provide time-dependent reliable indicators of good and poor outcome throughout the first 48-72h after cardiac arrest.

Consumption of a high n-3 polyunsaturated fatty acid diet during gradual mild physiological stress in rats.

n-3 Polyunsaturated fatty acids (n-3PUFAs) may be beneficial for anxiety and depression under stressful conditions. Studies however, typically utilise physical or sudden physiological stress, while gradual physiological stress is also relevant to human conditions. Using deoxycorticosterone acetate (DOCA) administration to induce gradual physiological stress, this study investigated the impact of n-3PUFAs under gradual physiological stress in rats. Animals (aged 2 months) (N=8-12/group) received daily injections of DOCA or vehicle and were concurrently fed a high n-3PUFA or control diet for eight weeks. Behavioural measures were taken throughout. Behavioural tests and physiological measures were conducted after six and eight weeks respectively. DOCA administration decreased plasma renin, plasma proteins and relative adrenal weight, and increased water intake, relative kidney weight, and anxiety in the open field. These findings demonstrate disruptions to the renin-angiotensin-aldosterone system, a result of mild physiological stress, that also impact on anxiety behaviours. No effects of n-3PUFAs were found.

Absent SEP during therapeutic hypothermia did not reappear after re-warming in comatose patients following cardiac arrest.

BACKGROUND: Early prediction of neurological outcome for patients resuscitated from cardiac arrest (CA) is a challenging task. Therapeutic hypothermia (TH) has been shown to improve neurological outcome after CA. Two recent studies indicated that somatosensory evoked potentials (SEP) recorded during TH retains high prediction value for poor neurological outcome. It remains unclear whether TH can influence the recovery of bilaterally absent (BA) N20 after re-warming. The primary endpoint of the present study was to evaluate if patients with BA SEPs during TH can recover cortical responses after re-warming. The secondary endpoint was to evaluate whether BA SEPs recorded during TH retains its prediction value for poor neurological outcome as in normothermic patients. METHODS: A single centre prospective cohort study including comatose adults resuscitated from in/out-of-hospital CA treated with TH. SEPs were recorded during TH (6-24 hours after CA) and after re-warming in those patients who remained comatose. Neurological outcome was assessed 6 months after CA using the Glasgow Outcome Scale. RESULTS: Sixty patients were included. In patients with preserved SEP, no significant differences were found between N20 mean amplitude during TH and after re-warming. During TH, 24 patients showed bilaterally absent N20 but none of these recovered cortical responses after re-warming. All patients with absent SEPs during TH did not recover consciousness. CONCLUSIONS: In a single centre cohort of comatose CA patients, our results showed that all patients with absent SEPs during early recording (6-24 hours) during TH showed bilaterally absent SEPs after re-warming. As a secondary result we confirmed previous data that BA SEPs during TH retains its prognostic value for poor neurological outcome, as in normothermic patients.

Neurophysiological monitoring in adult and pediatric intensive care.

Clinical neurophysiology is both an extension of clinical examination and an integration of neuroimaging. It plays a role in diagnosis, prognosis and monitoring in the Intensive Care Unit (ICU). Electroencephalography (EEG) and somatosensory evoked potentials (SEPs) are the most informative neurophysiological tests. Both have a major prognostic role in the hypoxic-ischemic encephalopathy and traumatic brain injury (TBI). In the former the absence of bilateral cortical SEPs has an unfavorable prognostic significance of 100%, whereas bilateral normal SEPs has uncertain prognostic value. In TBI these SEP patterns have high early prognostic value for both bad and good outcome. Continuous EEG monitoring is indicated for diagnosis and treatment of non convulsive seizures and status epilepticus (NCSE), whereas SEPs are more able to indicate the occurrence of neurological deterioration. In our opinion EEG-SEP monitoring is also valuable for interpretation and management of ICP trends, contributing to optimise treatment in a single patient. The EEG seems to have the same prognostic utility in pediatric as in adult ICU. Recent reviews supported the use of SEPs in the integrated process of outcome prediction after acute brain injury in children. However differences in interpretation are needed and the issue is whether it is possible to establish an age limit over which the prediction of SEPs is similar to that in adults. There are only a few studies of seizure prevalence in pediatric ICU. The variability of frequency of NCSE in comatose children is high as in adults and, similar to the adult, remains unclear the impact on outcome.

Social defeat and isolation induce clear signs of a depression-like state, but modest cardiac alterations in wild-type rats.

Adverse social environments play a relevant role in the onset and progression of mood disorders. On the other hand, depression is an independent risk factor for cardiovascular morbidity. This study was aimed at (i) corroborating the validity of a rat model of depression based on a negative social episode followed by social isolation and (ii) verifying its impact on cardiac function and structure. Pair housed, wild-type Groningen rats (Rattus norvegicus) were implanted with radiotransmitters for ECG, temperature and activity recordings. They were either exposed to a social defeat episode followed by 4-week isolation or left undisturbed with their female partners. The social challenge induced a series of biological changes that are commonly taken as markers of depression in rats, including decreased body weight gain and reduced preference for sucrose consumption, functional and structural changes of the hypothalamic-pituitary-adrenocortical axis, increased anxiety in the elevated plus maze test. The cardiovascular alterations consisted in (i) transitory heart rate circadian rhythm alterations, (ii) lack of habituation of cardiac autonomic responsivity (tachycardia and vagal withdrawal) to an acute stressor, and (iii) moderate hypertrophy affecting the right ventricle of the heart. These results indicate that a depression-like state induced via this model of social challenge was associated with a few modest cardiovascular changes. Further studies are required to confirm the validity of this rat model of depression as a valid preclinical approach to the comprehension of the biological substrates underlying depression-cardiovascular comorbidity.

Biomechanical and electromyographic assessment of spastic hypertonus in motor complete traumatic spinal cord-injured individuals.

STUDY DESIGN: Between-groups design with repeated measures. OBJECTIVE: To quantify spastic hypertonia in spinal cord-injured (SCI) individuals. SETTING: Rehabilitative Center, Italy. SUBJECTS: 29 individuals with a motor complete SCI (American Spinal Injury Association impairment scale grade A or B) and 22 controls. METHODS: According to the modified Ashworth scale (MAS), patients were subgrouped as SCI-1 (MAS=1, 1+) and SCI-2 (MAS=2, 3). Passive flexo-extensions of the knee were applied using an isokinetic device (LIDO Active) at 30°, 60°, 90° and 120° s(-1). We measured the peak torque, mean torque (MT) and work. Simultaneous electromyography (EMG) was recorded from leg muscles. RESULTS: At the speed of 120° s(-1) all SCI-2 patients presented EMG reflex activities in the hamstring muscle. All biomechanical parameter values increased significantly according to speed, but analysis of variance revealed a significant interaction between the angular velocity and group (F(d.f. 6, 138) = 8.89, P < 0.0001); post hoc analysis showed significantly greater torque parameter values in the SCI-2 group compared with the SCI-1 group and the control group at 90° and 120° s(-1). Receiver operating characteristic curves showed that using peak torque values the probability of correctly classifying a patient into SCI-1 and SCI-2 was 95%, compared with 70% for MT and 68% for work. CONCLUSIONS: The isokinetic device is useful for distinguishing individuals with a high level of spastic hypertonus. Examination of EMG activity may help ascertain whether increased muscle tone is caused by reflex hyper excitability and to determine whether muscle spasm is present. Peak torque and simultaneous EMG assessment should be considered for the evaluation of individuals with SCI in the rehabilitative context, that is, in measuring therapeutic interventions.

Continuous EEG-SEP monitoring in severe brain injury.

AIMS: To monitor acute brain injury in the neurological intensive care unit (NICU), we used EEG and somatosensory evoked potentials (SEP) in combination to achieve more accuracy in detecting brain function deterioration. METHODS: Sixty-eight patients (head trauma and intracranial hemorrhage; GCS<9) were monitored with continuous EEG-SEP and intracranial pressure monitoring (ICP). RESULTS: Fifty-five patients were considered "stable" or improving, considering the GCS and CT scan: in this group, SEP didn't show significant changes. Thirteen patients showed neurological deteriorations and, in all patients, cortical SEP showed significant alterations (amplitude decrease>50% often till complete disappearance). SEP deterioration anticipated ICP increase in 30%, was contemporary in 38%, and followed ICP increase in 23%. Considering SEP and ICP in relation to clinical course, all patients but one with ICP less than 20 mmHg were stable, while the three patients with ICP greater than 40 mmHg all died. Among the 26 patients with ICP of 20-40 mmHg, 17 were stable, while nine showed clinical and neurophysiological deterioration. Thus, there is a range of ICP values (20-40 mmHg) were ICP is scarcely indicative of clinical deterioration, rather it is the SEP changes that identify brain function deterioration. Therefore, SEP have a twofold interest with respect to ICP: their changes can precede an ICP increase and they can constitute a complementary tool to interpret ICP trends. It has been very important to associate SEP and EEG: about 60% of our patients were deeply sedated and, because of their relative insensitivity to anesthetics, only SEP allowed us to monitor brain damage evolution when EEG was scarcely valuable. CONCLUSIONS: We observed 3% of nonconvulsive status epilepticus compared to 18% of neurological deterioration. If the aim of neurophysiological monitoring is to "detect and protect", it may not be limited to detecting seizures, rather it should be able to identify brain deterioration, so we propose the combined monitoring of EEG with SEP.

Transient post-traumatic locked-in syndrome: a case report and a literature review.

INTRODUCTION: Post-traumatic locked-in syndrome may be particularly difficult to recognize, especially when it follows a state of coma and presents the clinical feature of a "total" locked-in syndrome. PATIENT AND METHODS: A 56-year-old male with a closed head injury was admitted in intensive care unit (ICU) with GCS=4 (V1, M2, E1). Computed tomography (CT) scan disclosed a limited subarachnoid haemorrhage in the sylvian region without any brain oedema or ventricular shift. The GCS did not change until day 6. At the same time EEG showed a reactivity to acoustic stimuli consisting in the paradoxical appearance of a posterior rhythm in alpha range (10-12c/s), blocked by passive eye opening. Early cortical components (N20-P25) of somatosensory evoked potentials were normal on both hemispheres; middle components were also clearly evident. Magnetic resonance imaging of the brain showed both diffuse and midbrain axonal injuries, particularly in a strategic lesion involving both cerebral peduncles. Event related potentials showed N2 and P3 components to stimulation by rare tones. CONCLUSIONS: A comprehensive multimodal neurophysiological approach, using the more informative tests and the proper time of recording, should be included in protocols for patients with severe head trauma, in order to establish the actual patient's clinical state and to avoid that a locked-in syndrome state be mistaken for prolonged coma, vegetative state, minimally conscious state or akinetic mutism. Neurophysiological evaluation before discharge from ICU can be a baseline evaluation useful for the follow-up of low-responsive patients in the neuro-rehabilitation unit.

Carpal tunnel syndrome and ulnar neuropathy at the elbow in floor cleaners.

OBJECTIVE: To determine the occurrence of carpal tunnel syndrome (CTS) and ulnar neuropathy at the elbow (UNE) in a cohort of floor cleaners and to check differences between workers with and without CTS. METHODS: All female floor cleaners of three major hospitals in Tuscany (Italy) were contacted. Clinical and electrophysiological severity of CTS and UNE were evaluated with standardized scales and symptoms were assessed with the self-administered Boston Questionnaire (BQ); demographic and non-occupational factors and durations of current and previous occupations were recorded. Univariate analysis of risk factors was performed in workers with and without CTS. Logistic regression was used to evaluate the capacity of independent variables to predict CTS. RESULTS: Out of a total of 179 cleaners, 145 (81%)-mean age 39.6 years (20-64 years)-were enrolled in the study; 70 (48%) had CTS (diagnosis based on clinical and electrophysiological findings). BQ symptom and hand function scores were anomalous in 108 (74%) and 84 (58%) subjects, respectively. UNE was detected in 7/103 women. Univariate analysis showed that cleaners with CTS were older, had greater BMI and longer exposure to cleaning with previous employers than those without CTS. In the logistic regression, the only predictor of CTS was cleaning with previous employers (O.R. 12.1, 95% CI 3-49.9). CONCLUSIONS: These results indicate a high occurrence of CTS in floor cleaners; UNE is less frequent than CTS, presumably due to repetitive movements that stress wrists more than elbows. The only predictive factor of CTS was cleaning as an occupation with previous employers. Therefore, the actual risk factor for CTS could not be cleaning per se, but how this job is performed.

Continuous EEG-SEP monitoring of severely brain injured patients in NICU: methods and feasibility.

AIMS: To evaluate the feasibility of a continuous neurophysiologic monitoring (electroencephalography (EEG)-somatosensory evoked potentials (SEPs)) in the neuro-intensive care unit (NICU), taking into account both the technical and medical aspects that are specific of this environment. METHODS: We used an extension of the recording software that is routinely used in our unit of clinical neurophysiology. It performs cycles of alternate EEG and SEP recordings. Raw traces and trends are simultaneously displayed. Patient head and stimulator box are placed behind the bed and linked to the ICU monitoring terminal through optic fibers. The NICU staff has been trained to note directly clinical events, main artefacts and therapeutic changes. The hospital local area network (LAN) enables remote monitoring survey. RESULTS: Continuous EEG (CEEG)-SEP monitoring was performed in 44 patients. Problems of needle detachment were seldomly encountered, thanks to the use of a sterile plastic dressing, which covers needles. We never had infection or skin lesions due to needles or the electrical stimulator. The frequent administration of sedative at high doses prevented us from having a clinically valuable EEG in several cases but SEPs were always monitorable, independently of the level of EEG suppression. The diagnosis of seizures and non-epileptic status was based on raw EEG, while quantitative EEG (QEEG) was used to quantify ictal activity as a guide to treatment. CONCLUSIONS: EEG and EP waveforms collected in NICU were of comparable quality to routine clinical measurements and contained the same clinical information. A continuous SEP monitoring in a comatose and sedated patient in NICU is not technically more difficult and potentially less useful than in operating room. This monitoring appears to be feasible provided the observance of some requirement regarding setting, electrodes, montages, personnel integration, consulting and software.

Sadness and broken hearts: neurohumoral mechanisms and co-morbidity of ischemic heart disease and psychological depression.

Heart disease and depression are highly co-morbid. Clinical and experimental research over the past 70 years has led to several neurohumoral hypotheses of causative factors present under the conditions of either heart failure or of psychological depression. Some of these hypothesized factors are common to both disorders and are therefore attractive candidates to account for the high incidence of co-occurrence of depression and heart disease. One experimental approach to study the co-morbidity of heart failure and depression has been to study the behavioral, biochemical and physiological changes in a chronic mild stress model of depression and in heart failure induced by experimental myocardial infarction. Our studies have led us to focus on the pro-inflammatory cytokines, in particular tumor necrosis factor (TNF)-alpha, and the renin-angiotensin-aldosterone system. Both of these families of humoral factors are elevated in human heart failure and in depression and the two experimental models we have studied. The demonstrated validity of each of these models will be of great value in elucidating the nature of the actions and interactions of these humoral agents as they contribute to the co-morbid conditions of heart failure and depression.

Anoxic-ischemic alpha coma: prognostic significance of the incomplete variant.

The prognostic significance of post-anoxic-ischemic alpha coma (AC) is controversial. We recorded somatosensory evoked potentials (SEPs) and performed serial electroencephalography (EEG) in a 60-year-old woman in coma after cardiac arrest. The first EEG was recorded after 48 hours (GCS=5; E1-V1-M3); brain-stem reflexes were preserved. The EEG pattern showed monotonous alpha frequencies (10-11 Hz) with posterior predominance; acoustic and noxious stimuli evoked EEG reactivity. Early cortical SEPs (72 h) were normal. On the fifth day (GCS=8; E4-V1-M3), the EEG alpha pattern was replaced by a diffuse delta activity; rhythmic theta changes appeared spontaneously or in response to stimuli. The patient regained consciousness on the tenth day and EEG showed posterior theta activity (6-7 c/s) partially reactive to stimuli. At the 6-month follow-up, cognitive evaluation showed mild dementia. Recent studies identified two forms of AC. Patients with complete AC have an outcome that is almost invariably poor. Conversely, incomplete AC (posteriorly accentuated alpha frequency, reactive and with SEPs mostly normal) reflects a less severe degree of anoxic-ischemic encephalopathy. The case we report should be classified, according to the SEPs and EEG features, as incomplete AC. The fact that the patient has regained consciousness, even if with residual cognitive impairment, confirms the need to distinguish this variant from complete AC.

[Clinical comparison between guided tissue regeneration and induced tissue regeneration]. / Valutazione clinica tra rigenerazione tissutale guidata e rigenerazione tissutale indotta.

AIM: The aim of the present study was to evaluate, over a period of 1 y, 3 different surgical methods for the treatment of periodontal bone defects. METHODS: Thirty-six infrabone defects, at least 4 mm in depth, in non-smokers were enrolled in the study. Of these, 12 were treated with guided tissue regeneration (GTR) using a resorbable membrane with collagen, 12 with enamel matrix derivative (EMD) gel and 12 with a modified Widman flap (MWF). The pocket depth, attachment loss and gingival recession both before commencement of therapy and after an interval of 1 y are reported. RESULTS: The reduction in pocket depth was 4 mm, 4.4 mm, and 4.5 mm, respectively, for the control group, GTR group and EMD group. The attachment gain for the respective treatments was: MWF, 2 mm; GTR, 2.8 mm; EMD, 2.9 mm. Gingival recession was: MWF, 1.8 mm; GTR, 1.5 mm; EMD, 1.1 mm. CONCLUSION: These findings show the efficacy of the 3 methods in the treatment of bone defects, but none of the 3 emerges as being statistically superior to the others 2.

Respiratory-related evoked potential and upper airway transmural pressure change by using the negative expiratory pressure (NEP) device.

OBJECTIVE: Several studies have previously shown respiratory related evoked potentials (RREP) in humans elicited by mechanical stimuli applied on upper airways (UA). According to us, heterogeneous findings, concerning latencies and amplitudes, have been reported because of the different timing of stimuli application during the respiratory cycle and/or features of pressure stimuli. Therefore we evaluated the cortical response evoked by transmural pressure changes at the mouth induced by a negative expiratory pressure (NEP) device. METHODS: RREP were recorded in 22 healthy non-obese, non-snoring volunteers. The subjects were studied awake in seated position during quiet breathing. Three different pressure levels were applied, in a random order, 200 ms after the beginning of expiration. Cortical electrical responses were recorded from scalp electrodes at Fz, Cz, and Pz scalp location (international 10-20 system) referenced to the linked earlobes. RESULTS: RREP responses consisted of two negative (N45, N120) and two positive (P22, P85) waves. There was no significant effect of pressure or electrode on component latencies. The P22 wave (PRESSURE: F(df 2,42)=6.66, P<0.01), the N45 wave (PRESSURE: F(df 2,42)=16.51, P<0.001), and the P85 wave (PRESSURE: F(df2,42)=15.15, P<0.001) increased significantly theyr amplitude with increasing from pressure stimuli 1 to 10 cmH2O. CONCLUSIONS: The present results suggest that the UA NEP application in humans is a reliable way of evoking cortical responses. The experimental features that we described allow us to minimize the confounding factors in evaluating RREPs. The NEP device appears to be a useful tool for investigation of the neurobiology of UA sensation in humans.

An exceptional case of complete neurologic recovery after more than 5-h cardiac arrest.

We describe a case of more than 5 h cardiac arrest in a 60-year-old patient who underwent general anesthesia for a urologic operation. Before extubation, the patient suddenly developed ventricular fibrillation, pulseless ventricular tachycardia and asystole which was immediately treated by advanced life support (ALS) measures. Thirty minutes later seizures developed and were controlled by 200 mg of thiopentone and 10 mg of diazepam. A pattern of ventricular tachycardia, coarse ventricular fibrillation and asystole lasted for nearly 120 min. Termination of resuscitation maneuvers was considered, but long-term life support was continued for 5 h. After this time, peripheral pulses, with a supraventricular tachycardia-like rhythm and regular spontaneous breathing reappeared. Seven hours later, the patient had a Glasgow Coma Scale (GCS) of 5, dilated unresponsive, absence of pupils, and a systolic arterial pressure of 100 mmHg. He was then transferred to intensive care unit (ICU). The morning after, the patient was awake, responded to simple orders, breathing spontaneously, and free from sensomotor deficit. He was, therefore, extubated. Subsequently, other episodes of transitory ST-line upper wave followed by ventricular fibrillation appeared, suggesting Prinzmetal angina. This was successfully treated by percutaneous coronary angioplasty. The first electroencephalogram recorded the day after cardiac arrest showed a mild widespread background slowing. An electroencephalogram 6 days later showed a return to alpha rhythm with only mild theta-wave abnormalities. Four weeks after the first cardiac arrest the patient was discharged. This is an exceptional experience compared with the others reported. We believe that all the efforts must not be given up when such an event occurs during anesthesia and there are optimal conditions for resuscitation maneuvers.