Teaching Video NeuroImage: Postanoxic Tonic Eyelid Opening

A 29-year-old man with end-stage renal disease presented with out-of-hospital pulseless electrical activity arrest, requiring multiple rounds of resuscitation. Video-EEG within 24 hours demonstrated a generalized burst suppression pattern (Figure, A). The patient was noted to have repetitive eyelid opening (Video 1) with a duration of 1750.3 +/- 710.9 milliseconds. 68.5% of these eyelid openings were time-locked to bursts with a latency of 434.7 +/- 213.3 milliseconds. Tonic eyelid opening has been described in postanoxic coma time-locked with EEG bursts.1 The presence of EEG bursts preceding the eyelid opening supports a cortical mechanism. However, partial eyelid openings without EEG bursts (Figure, A) support a subcortical mechanism. Brain MRI demonstrated diffuse anoxic injury with relative sparing of the brainstem (Figure, B and C). The patient was declared brain dead on day 5. This clinical sign is associated with poor prognosis, but the data are limited.1 Generalized EEG burst suppression, however, is reliably associated with poor prognosis after cardiac arrest.2