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Portell Penadés E, Alvarez V. A Comprehensive Review and Practical Guide of the Applications of Evoked Potentials in Neuroprognostication After Cardiac Arrest. Cureus 2024; 16:e57014. [PMID: 38681279 PMCID: PMC11046378 DOI: 10.7759/cureus.57014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 05/01/2024] Open
Abstract
Cardiorespiratory arrest is a very common cause of morbidity and mortality nowadays, and many therapeutic strategies, such as induced coma or targeted temperature management, are used to reduce patient sequelae. However, these procedures can alter a patient's neurological status, making it difficult to obtain useful clinical information for the reliable estimation of neurological prognosis. Therefore, complementary investigations are conducted in the early stages after a cardiac arrest to clarify functional prognosis in comatose cardiac arrest survivors in the first few hours or days. Current practice relies on a multimodal approach, which shows its greatest potential in predicting poor functional prognosis, whereas the data and tools to identify patients with good functional prognosis remain relatively limited in comparison. Therefore, there is considerable interest in investigating alternative biological parameters and advanced imaging technique studies. Among these, somatosensory evoked potentials (SSEPs) remain one of the simplest and most reliable tools. In this article, we discuss the technical principles, advantages, limitations, and prognostic implications of SSEPs in detail. We will also review other types of evoked potentials that can provide useful information but are less commonly used in clinical practice (e.g., visual evoked potentials; short-, medium-, and long-latency auditory evoked potentials; and event-related evoked potentials, such as mismatch negativity or P300).
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Wahlster S, Danielson K, Craft L, Matin N, Town JA, Srinivasan V, Schubert G, Carlbom D, Kim F, Johnson NJ, Tirschwell D. Factors Associated with Early Withdrawal of Life-Sustaining Treatments After Out-of-Hospital Cardiac Arrest: A Subanalysis of a Randomized Trial of Prehospital Therapeutic Hypothermia. Neurocrit Care 2023; 38:676-687. [PMID: 36380126 DOI: 10.1007/s12028-022-01636-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The objective of this study is to describe incidence and factors associated with early withdrawal of life-sustaining therapies based on presumed poor neurologic prognosis (WLST-N) and practices around multimodal prognostication after out-of-hospital cardiac arrest (OHCA). METHODS We performed a subanalysis of a randomized controlled trial assessing prehospital therapeutic hypothermia in adult patients admitted to nine hospitals in King County with nontraumatic OHCA between 2007 and 2012. Patients who underwent tracheal intubation and were unconscious following return of spontaneous circulation were included. Our outcomes were (1) incidence of early WLST-N (WLST-N within < 72 h from return of spontaneous circulation), (2) factors associated with early WLST-N compared with patients who remained comatose at 72 h without WLST-N, (3) institutional variation in early WLST-N, (4) use of multimodal prognostication, and (5) use of sedative medications in patients with early WLST-N. Analysis included descriptive statistics and multivariable logistic regression. RESULTS We included 1,040 patients (mean age was 65 years, 37% were female, 41% were White, and 44% presented with arrest due to ventricular fibrillation) admitted to nine hospitals. Early WLST-N accounted for 24% (n = 154) of patient deaths and occurred in half (51%) of patients with WLST-N. Factors associated with early WLST-N in multivariate regressions were older age (odds ratio [OR] 1.02, 95% confidence interval [CI]: 1.01-1.03), preexisting do-not-attempt-resuscitation orders (OR 4.67, 95% CI: 1.55-14.01), bilateral absent pupillary reflexes (OR 2.4, 95% CI: 1.42-4.10), and lack of neurological consultation (OR 2.60, 95% CI: 1.52-4.46). The proportion of patients with early WLST-N among all OHCA admissions ranged from 19-60% between institutions. A head computed tomography scan was obtained in 54% (n = 84) of patients with early WLST-N; 22% (n = 34) and 5% (n = 8) underwent ≥ 1 and ≥ 2 additional prognostic tests, respectively. Prognostic tests were more frequently performed when neurological consultation occurred. Most patients received sedating medications (90%) within 24 h before early WLST-N; the median time from last sedation to early WLST-N was 4.2 h (interquartile range 0.4-15). CONCLUSIONS Nearly one quarter of deaths after OHCA were due to early WLST-N. The presence of concerning neurological examination findings appeared to impact early WLST-N decisions, even though these are not fully reliable in this time frame. Lack of neurological consultation was associated with early WLST-N and resulted in underuse of guideline-concordant multimodal prognostication. Sedating medications were often coadministered prior to early WLST-N and may have further confounded the neurological examination. Standardizing prognostication, restricting early WLST-N, and a multidisciplinary approach including neurological consultation might improve outcomes after OHCA.
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Affiliation(s)
- Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA.
- Department of Anesthesiology, University of Washington, Seattle, WA, USA.
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
| | - Kyle Danielson
- Airlift Northwest, University of Washington Medicine, Seattle, WA, USA
| | - Lindy Craft
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Nassim Matin
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
| | - James A Town
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Glenn Schubert
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
| | - David Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Francis Kim
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicholas J Johnson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - David Tirschwell
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
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Nawfal O, El Halabi T, Dib G, Dirani M, Beydoun A. Bilateral Reappearance of the N20 Potential in a Normothermic Young Woman Post-Anoxic Brain Injury. J Clin Neurophysiol 2022; 39:e21-e25. [PMID: 35239554 DOI: 10.1097/wnp.0000000000000928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Hypoxic-ischemic brain injury is a well-known consequence of cardiac arrest and providing an accurate prognostication remains a challenge, especially in decisions related to withdrawal of care. Bilateral absence of the cortical response (N20 potential) on median somatosensory evoked potentials, on days 1 to 3 after the return of spontaneous circulation, is widely considered as the most reliable predictor of poor outcome with a high specificity and a low false-positive rate. The authors describe the case of a young comatose woman after hypoxic injury because of cardiac arrest whose initial median somatosensory evoked potentials revealed bilateral absence of the N20 response associated with evidence of selective injury to both perirolandic cortices and basal ganglia on brain MRI. This patient made a substantial recovery associated with bilateral reappearance of the N20 potential and resolution of the neuroimaging abnormalities.This case revealed that an acute selective and reversible hypoxic injury to both perirolandic cortices may lead to a temporary loss of the N20 responses and an inaccurate prediction of poor outcome after cardiac arrest. It emphasizes on the importance of adopting a multimodal approach in the prognostic assessment of survivors of cardiac arrest.
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Affiliation(s)
- Omar Nawfal
- American University of Beirut Medical Center, Beirut, Lebanon
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Scarpino M, Lanzo G, Bonizzoli M, Troiano S, Baldanzi F, Lolli F, Grippo A. Bilateral reappearance of the cortical SEP in a comatose patient after cardiac arrest: pitfall or reality? Clin Neurophysiol 2022; 136:58-61. [DOI: 10.1016/j.clinph.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/28/2022]
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Delval A, Girard B, Lacan L, Chaton L, Flamein F, Storme L, Derambure P, The Tich SN, Lamblin MD, Betrouni N. Neurophysiological recordings improve the accuracy of the evaluation of the outcome in perinatal hypoxic ischemic encephalopathy. Eur J Paediatr Neurol 2022; 36:51-56. [PMID: 34890946 DOI: 10.1016/j.ejpn.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 09/20/2021] [Accepted: 11/16/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Our objective was to evaluate the potential additional value of electroencephalogram (EEG) and evoked potentials in neonates with hypoxic-ischemic encephalopathy to predict their disability at 1 and 2 years old. METHODS 30 full-term infants after perinatal asphyxia who underwent therapeutic hypothermia were evaluated at 1 year and 2 years for disability using International Classification of Functioning, Disability and Health classification. Scores for EEG, sensory evoked potentials and brainstem auditory evoked potentials were evaluated after withdrawal of therapeutic hypothermia that lasted 72 h. A regression approach was investigated to build models allowing to distinguish neonates according to their disability at 1 and 2 years. Two models were built, the first by considering the clinical data and EEG before and after therapeutic hypothermia and the second by incorporating evoked potentials recording. RESULTS Adding EEG and evoked potentials data after rewarming improved dramatically the accuracy of the model considering outcome at 1 and 2 years. INTERPRETATION We propose to record systematically EEG and evoked potentials following rewarming to predict the outcome of neonates with hypoxic ischemic encephalopathy. Combination of altered evoked potentials with no improvement of EEG after rewarming appeared to be a robust criterion for a poor outcome.
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Affiliation(s)
- Arnaud Delval
- Univ. Lille, Inserm, U1172 - Lille, Neuroscience Cognition, F-59000, Lille, France; Clinical Neurophysiology Department, Lille University Medical Center, F-59000, Lille, France.
| | - Barbara Girard
- Children Department of Physical Medicine and Rehabilitation, Institut Régional de Réadaptation, Flavigny sur Moselle, France
| | - Laure Lacan
- EA4489, Environnement Périnatal et Santé, Faculté de Médecine, Université de Lille, France; Pediatric Neurology Department, Lille University Medical Center, F-59000, Lille, France
| | - Laurence Chaton
- Clinical Neurophysiology Department, Lille University Medical Center, F-59000, Lille, France
| | - Florence Flamein
- EA4489, Environnement Périnatal et Santé, Faculté de Médecine, Université de Lille, France
| | - Laurent Storme
- Pediatric Neurology Department, Lille University Medical Center, F-59000, Lille, France
| | - Philippe Derambure
- Univ. Lille, Inserm, U1172 - Lille, Neuroscience Cognition, F-59000, Lille, France; Clinical Neurophysiology Department, Lille University Medical Center, F-59000, Lille, France
| | - Sylvie Nguyen The Tich
- EA4489, Environnement Périnatal et Santé, Faculté de Médecine, Université de Lille, France; Pediatric Neurology Department, Lille University Medical Center, F-59000, Lille, France
| | - Marie-Dominique Lamblin
- Clinical Neurophysiology Department, Lille University Medical Center, F-59000, Lille, France
| | - Nacim Betrouni
- Univ. Lille, Inserm, U1172 - Lille, Neuroscience Cognition, F-59000, Lille, France
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Lilja L, Thuccani M, Joelsson S, Nilsson J, Redfors P, Lundgren P, Rylander C. The capacity of neurological pupil index to predict absence of somatosensory evoked potentials after cardiac arrest-A study protocol. Acta Anaesthesiol Scand 2021; 65:852-858. [PMID: 33735459 DOI: 10.1111/aas.13822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anoxic-ischemic brain injury is the most common cause of death after cardiac arrest (CA). Robust methods to detect severe injury with a low false positive rate (FPR) for poor neurological outcome include the pupillary light reflex (PLR) and somatosensory evoked potentials (SSEP). The PLR can be assessed manually or with automated pupillometry which provides the neurological pupil index (NPi). We aim to describe the interrelation between NPi values and the absence of SSEP cortical response and to evaluate the capacity of NPi to predict the absence of cortical SSEP response in comatose patients after CA. METHODS A total of 50 patients will be included in an explorative, prospective, observational study of adult (>18 years) comatose survivors of CA admitted to intensive care in a university hospital. NPi assessed with a hand-held pupillometer will be compared to SSEP signals recorded >48 hours after CA. Primary outcomes are sensitivity, specificity, and odds ratio for NPi to predict bilateral absence of the SSEP N20 signal, with NPi values corresponding to <5% FPRs of SSEP absence. Secondary outcomes are the PLR and SSEP sensitivity, specificity, and odds ratio for poor neurological outcome at hospital discharge and death at 30 days. DISCUSSION The PLR and SSEP may have a systematic interrelation, and a certain NPi threshold could potentially predict the absence of cortical SSEP response. If this can be concluded from the present study, SSEP testing could be excluded in certain patients to save resources in the multimodal prognostication after CA. Editorial comment The interrelation between loss of the pupillary light reflex (PLR) and the loss of cortical response to a somatosensory evoked potential (SSEP) in comatose cardiac arrest patients is not known. This exploratory prospective study is designed to evaluate whether a specific degree of attenuated PLR, as measured by semiautomated pupillometry, can predict the bilateral loss of cortical SSEP response in severe anoxic/ischemic brain injury. Such an interrelation between the two methods would enable the use of pupillometry rather than the more resource demanding SSEP for neurologic prognostication in post cardiac arrest patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT04720482, Registered 21 January 2021, retrospectively registered.
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Affiliation(s)
- Linus Lilja
- Department of Anaesthesiology and Intensive Care Medicine Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Meena Thuccani
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Sara Joelsson
- Department of Clinical Neurophysiology Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Josefin Nilsson
- Department of Clinical Neurophysiology Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Peter Lundgren
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Prehospen—Centre for Prehospital Research University of Borås Borås Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
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Endisch C, Westhall E, Kenda M, Streitberger KJ, Kirkegaard H, Stenzel W, Storm C, Ploner CJ, Cronberg T, Friberg H, Englund E, Leithner C. Hypoxic-Ischemic Encephalopathy Evaluated by Brain Autopsy and Neuroprognostication After Cardiac Arrest. JAMA Neurol 2021; 77:1430-1439. [PMID: 32687592 DOI: 10.1001/jamaneurol.2020.2340] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance Neuroprognostication studies are potentially susceptible to a self-fulfilling prophecy as investigated prognostic parameters may affect withdrawal of life-sustaining therapy. Objective To compare the results of prognostic parameters after cardiac arrest (CA) with the histopathologically determined severity of hypoxic-ischemic encephalopathy (HIE) obtained from autopsy results. Design, Setting, and Participants In a retrospective, 3-center cohort study of all patients who died following cardiac arrest during their intensive care unit stay and underwent autopsy between 2003 and 2015, postmortem brain histopathologic findings were compared with post-CA brain computed tomographic imaging, electroencephalographic (EEG) findings, somatosensory-evoked potentials, and serum neuron-specific enolase levels obtained during the intensive care unit stay. Data analysis was conducted from 2015 to 2020. Main Outcomes and Measures The severity of HIE was evaluated according to the selective eosinophilic neuronal death (SEND) classification and patients were dichotomized into categories of histopathologically severe and no/mild HIE. Results Of 187 included patients, 117 were men (63%) and median age was 65 (interquartile range, 58-74) years. Severe HIE was found in 114 patients (61%) and no/mild HIE was identified in 73 patients (39%). Severe HIE was found in all 21 patients with bilaterally absent somatosensory-evoked potentials, all 15 patients with gray-white matter ratio less than 1.10 on brain computed tomographic imaging, all 9 patients with suppressed EEG, 15 of 16 patients with burst-suppression EEG, and all 29 patients with neuron-specific enolase levels greater than 67 μg/L more than 48 hours after CA without confounders. Three of 7 patients with generalized periodic discharges on suppressed background and 1 patient with burst-suppression EEG had a SEND 1 score (<30% dead neurons) in the cerebral cortex, but higher SEND scores (>30% dead neurons) in other oxygen-sensitive brain regions. Conclusions and Relevance In this study, histopathologic findings suggested severe HIE after cardiac arrest in patients with bilaterally absent cortical somatosensory-evoked potentials, gray-white matter ratio less than 1.10, highly malignant EEG, and serum neuron-specific enolase concentration greater than 67 μg/L.
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Affiliation(s)
- Christian Endisch
- AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Erik Westhall
- Clinical Neurophysiology, Skane University Hospital, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Martin Kenda
- AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kaspar J Streitberger
- AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Werner Stenzel
- Charité Campus Mitte, Department of Neuropathology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Storm
- Cardiac Arrest Center of Excellence Berlin, Campus Virchow Klinikum, Department of Nephrology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph J Ploner
- AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Cronberg
- Neurology, Skane University Hospital, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Hans Friberg
- Intensive and Perioperative Care, Skane University Hospital, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Elisabet Englund
- Oncology and Pathology, Skane University Hospital, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Christoph Leithner
- AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Abstract
Improved understanding of post-cardiac arrest syndrome and clinical practices such as targeted temperature management have led to improved mortality in this cohort. Attention has now been placed on development of tools to aid in predicting functional outcome in comatose cardiac arrest survivors. Current practice uses a multimodal approach including physical examination, neuroimaging, and electrophysiologic data, with a primary utility in predicting poor functional outcome. These modalities remain confounded by self-fulfilling prophecy and the withdrawal of life-sustaining therapies. To date, a reliable measure to predict good functional outcome has not been established or validated, but the use of quantitative somatosensory evoked potential (SSEP) shows potential for this use. MEDLINE and EMBASE search using words "Cardiac Arrest" and "SSEP," "Somato sensory evoked potentials," "qSSEP," "quantitative SSEP," "targeted temperature management in cardiac arrest" was conducted. Relevant recent studies on targeted temperature management in cardiac arrest, plus studies on SSEP in cardiac arrest in the setting of hypothermia and without hypothermia, were included. In addition, animal studies evaluating the role of different components of SSEP in cardiac arrest were reviewed. SSEP is a specific indicator of poor outcomes in post-cardiac arrest patients but lacks sensitivity and has not clinically been established to foresee good outcomes. Novel methods of analyzing quantitative SSEP (qSSEP) signals have shown potential to predict good outcomes in animal and human studies. In addition, qSSEP has potential to track cerebral recovery and guide treatment strategy in post-cardiac arrest patients. Lying beyond the current clinical practice of dichotomized absent/present N20 peaks, qSSEP has the potential to emerge as one of the earliest predictors of good outcome in comatose post-cardiac arrest patients. Validation of qSSEP markers in prospective studies to predict good and poor outcomes in the cardiac arrest population in the setting of hypothermia could advance care in cardiac arrest. It has the prospect to guide allocation of health care resources and reduce self-fulfilling prophecy.
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Roman-Pognuz E, Elmer J, Guyette FX, Poillucci G, Lucangelo U, Berlot G, Manganotti P, Peratoner A, Pellis T, Taccone F, Callaway C. Multimodal Long-Term Predictors of Outcome in Out of Hospital Cardiac Arrest Patients Treated with Targeted Temperature Management at 36 °C. J Clin Med 2021; 10:jcm10061331. [PMID: 33807041 PMCID: PMC8005130 DOI: 10.3390/jcm10061331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/05/2021] [Accepted: 03/17/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction: Early prediction of long-term outcomes in patients resuscitated after cardiac arrest (CA) is still challenging. Guidelines suggested a multimodal approach combining multiple predictors. We evaluated whether the combination of the electroencephalography (EEG) reactivity, somatosensory evoked potentials (SSEPs) cortical complex and Gray to White matter ratio (GWR) on brain computed tomography (CT) at different temperatures could predict survival and good outcome at hospital discharge and six months after the event. Methods: We performed a retrospective cohort study including consecutive adult, non-traumatic patients resuscitated from out-of-hospital CA who remained comatose on admission to our intensive care unit from 2013 to 2017. We acquired SSEPs and EEGs during the treatment at 36 °C and after rewarming at 37 °C, Gray to white matter ratio (GWR) was calculated on the brain computed tomography scan performed within six hours of the hospital admission. We primarily hypothesized that SSEP was associated with favor-able functional outcome at distance and secondarily that SSEP provides independent information from EEG and CT. Outcomes were evaluated using the Cerebral Performance Category (CPC) scale at six months from discharge. Results: Of 171 resuscitated patients, 75 were excluded due to missing data or uninterpretable neurophysiological findings. EEG reactivity at 37 °C has been shown the best single predictor of good out-come (AUC 0.803) while N20P25 was the best single predictor for survival at each time point. (AUC 0.775 at discharge and AUC 0.747 at six months follow up). The predictive value of a model including EEG reactivity, average GWR, and SSEP N20P25 amplitude was superior (AUC 0.841 for survival and 0.920 for good out-come) to any combination of two tests or any single test. Conclusions: Our study, in which life-sustaining treatments were never suspended, suggests SSEP cortical complex N20P25, after normothermia and off sedation, is a reliable predictor for survival at any time. When SSEP cortical complex N20P25 is added into a model with GWR average and EEG reactivity, the predictivity for good outcome and survival at distance is superior than each single test alone.
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Affiliation(s)
- Erik Roman-Pognuz
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Strada di Fiume 447, 34100 Trieste, Italy; (U.L.); (G.B.); (A.P.)
- Correspondence: ; Tel.: +39-3394879119
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; (J.E.); (F.X.G.); (C.C.)
| | - Frank X. Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; (J.E.); (F.X.G.); (C.C.)
| | - Gabriele Poillucci
- Department of Radiology, Azienda Sanitaria Universitaria Giuliano Isontina, 34128 Trieste, Italy;
| | - Umberto Lucangelo
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Strada di Fiume 447, 34100 Trieste, Italy; (U.L.); (G.B.); (A.P.)
| | - Giorgio Berlot
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Strada di Fiume 447, 34100 Trieste, Italy; (U.L.); (G.B.); (A.P.)
| | - Paolo Manganotti
- Department of Neurology, University of Trieste, 34100 Trieste, Italy;
| | - Alberto Peratoner
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Strada di Fiume 447, 34100 Trieste, Italy; (U.L.); (G.B.); (A.P.)
| | - Tommaso Pellis
- Department of Intensive Care, Azienda Sanitaria Friuli Occidentale Tommaso, 33170 Pordenone, Italy;
| | - Fabio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Bruxelles, Belgium;
| | - Clifton Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; (J.E.); (F.X.G.); (C.C.)
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10
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McDevitt WM, Quinn L, Bill PR, Morris KP, Scholefield BR, Seri S. Reliability in the assessment of paediatric somatosensory evoked potentials post cardiac arrest. Clin Neurophysiol 2021; 132:765-769. [PMID: 33571884 DOI: 10.1016/j.clinph.2020.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 11/15/2020] [Accepted: 12/06/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To measure inter- and intra-rater agreement in the interpretation of cortical somatosensory evoked potential (SSEP) components following paediatric cardiac arrest (CA) in multi-professional neurophysiology teams. METHODS Thirteen professionals blinded to patient outcome interpreted 96 SSEPs in paediatric patients 24-/48-/72-hours following CA. Of these, 34 were duplicates used to assess intra-rater agreement. Consistent interpretations (absent/present/indeterminate) between scientists (who record/identify SSEP components) and neurophysiologists (who provide prognostic SSEP interpretation) were expressed as percentages. Rates of agreement were calculated using Fleiss' kappa coefficient (K). RESULTS Unanimous agreement between professionals was present in 40% (95%CI: 28-54%) of the interpreted SSEPs, with a K value of 0.62 (95%CI: 0.55-0.70) based on average agreement. Agreement was similar between neurophysiologists (K = 0.67; 95%CI: 0.57-0.77) and scientists (K = 0.62; 95%CI: 0.54-0.70) but lower in patients < 2 years old (K = 0.23; 95%CI: 0.14-0.33) and in those with poor outcome (K = 0.21; 95%CI: 0.07-0.35). No SSEP was unanimously interpreted as absent and 92% (95%CI: 89-95%) of duplicate SSEPs were interpreted consistently. CONCLUSION Despite substantial agreement when interpreting prognostic SSEPs, this was significantly lower in children with poor outcome and of younger age. SIGNIFICANCE Clinicians using SSEPs in the intensive care unit should be aware of the inter-rater variability when interpreting SSEPs as absent.
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Affiliation(s)
- William M McDevitt
- Department of Neurophysiology, Birmingham Women's and Children's NHS Foundation Trust, UK.
| | - Laura Quinn
- Institute of Applied Health Research, University of Birmingham, UK; Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, UK
| | - Peter R Bill
- Department of Neurophysiology, Birmingham Women's and Children's NHS Foundation Trust, UK
| | - Kevin P Morris
- Institute of Applied Health Research, University of Birmingham, UK; Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, UK
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, UK; Birmingham Acute Care Research Group, University of Birmingham, UK
| | - Stefano Seri
- Department of Neurophysiology, Birmingham Women's and Children's NHS Foundation Trust, UK; Aston Brain Centre, College of Health and Life Sciences, Aston University, UK
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11
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McDevitt WM, Rowberry TA, Davies P, Bill PR, Notghi LM, Morris KP, Scholefield BR. The Prognostic Value of Somatosensory Evoked Potentials in Children After Cardiac Arrest: The SEPIA Study. J Clin Neurophysiol 2021; 38:30-35. [PMID: 31702709 DOI: 10.1097/wnp.0000000000000649] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Absent cortical somatosensory evoked potentials (SSEPs) reliably predict poor neurologic outcome in adults after cardiac arrest (CA). However, there is less evidence to support this in children. In addition, targeted temperature management, test timing, and a lack of blinding may affect test accuracy. METHODS A single-center, prospective cohort study of pediatric (aged 24 hours to 15 years) patients in which prognostic value of SSEPs were assessed 24, 48, and 72 hours after CA. Targeted temperature management (33-34°C for 24 hours) followed by gradual rewarming to 37°C was used. Somatosensory evoked potentials were graded as present, absent, or indeterminate, and results were blinded to clinicians. Neurologic outcome was graded as "good" (score 1-3) or "poor" (4-6) using the Pediatric Cerebral Performance Category scale 30 days after CA and blinded to SSEP interpreter. RESULTS Twelve patients (median age, 12 months; interquartile range, 2-150; 92% male) had SSEPs interpreted as absent (6/12) or present (6/12) <72 hours after CA. Outcome was good in 7 of 12 patients (58%) and poor in 5 of 12 patients (42%). Absent SSEPs predicted poor outcome with 88% specificity (95% confidence interval, 53% to 98%). One patient with an absent SSEP had good outcome (Pediatric Cerebral Performance Category 3), and all patients with present SSEPs had good outcome (specificity 100%; 95% confidence interval, 51% to 100%). Absence or presence of SSEP was consistent across 24-hour (temperature = 34°C), 48-hour (t = 36°C), and 72-hour (t = 36°C) recordings after CA. CONCLUSIONS Results support SSEP utility when predicting favorable outcome; however, predictions resulting in withdrawal of life support should be made with caution and never in isolation because in this very small sample there was a false prediction of unfavorable outcome. Further prospective, blinded studies are needed and encouraged.
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Affiliation(s)
- William M McDevitt
- Department of Neurophysiology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Tracey A Rowberry
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Paul Davies
- Institute of Child Health, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Peter R Bill
- Department of Neurophysiology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Lesley M Notghi
- Department of Neurophysiology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Kevin P Morris
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom ; and
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
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12
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Good outcome despite absence of cortical somatosensory evoked potentials after cardiac arrest: Fact or artifact? Case report and literature review. Clin Neurophysiol 2020; 131:2537-2539. [DOI: 10.1016/j.clinph.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 11/21/2022]
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13
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Determining Prognosis After a Cardiac Arrest: Role of Somatosensory Evoked Potentials*. Crit Care Med 2020; 48:1391-1392. [DOI: 10.1097/ccm.0000000000004480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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14
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Comanducci A, Boly M, Claassen J, De Lucia M, Gibson RM, Juan E, Laureys S, Naccache L, Owen AM, Rosanova M, Rossetti AO, Schnakers C, Sitt JD, Schiff ND, Massimini M. Clinical and advanced neurophysiology in the prognostic and diagnostic evaluation of disorders of consciousness: review of an IFCN-endorsed expert group. Clin Neurophysiol 2020; 131:2736-2765. [PMID: 32917521 DOI: 10.1016/j.clinph.2020.07.015] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 07/06/2020] [Accepted: 07/26/2020] [Indexed: 12/13/2022]
Abstract
The analysis of spontaneous EEG activity and evoked potentialsis a cornerstone of the instrumental evaluation of patients with disorders of consciousness (DoC). Thepast few years have witnessed an unprecedented surge in EEG-related research applied to the prediction and detection of recovery of consciousness after severe brain injury,opening up the prospect that new concepts and tools may be available at the bedside. This paper provides a comprehensive, critical overview of bothconsolidated and investigational electrophysiological techniquesfor the prognostic and diagnostic assessment of DoC.We describe conventional clinical EEG approaches, then focus on evoked and event-related potentials, and finally we analyze the potential of novel research findings. In doing so, we (i) draw a distinction between acute, prolonged and chronic phases of DoC, (ii) attempt to relate both clinical and research findings to the underlying neuronal processes and (iii) discuss technical and conceptual caveats.The primary aim of this narrative review is to bridge the gap between standard and emerging electrophysiological measures for the detection and prediction of recovery of consciousness. The ultimate scope is to provide a reference and common ground for academic researchers active in the field of neurophysiology and clinicians engaged in intensive care unit and rehabilitation.
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Affiliation(s)
- A Comanducci
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - M Boly
- Department of Neurology and Department of Psychiatry, University of Wisconsin, Madison, USA; Wisconsin Institute for Sleep and Consciousness, Department of Psychiatry, University of Wisconsin-Madison, Madison, USA
| | - J Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - M De Lucia
- Laboratoire de Recherche en Neuroimagerie, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - R M Gibson
- The Brain and Mind Institute and the Department of Physiology and Pharmacology, Western Interdisciplinary Research Building, N6A 5B7 University of Western Ontario, London, Ontario, Canada
| | - E Juan
- Wisconsin Institute for Sleep and Consciousness, Department of Psychiatry, University of Wisconsin-Madison, Madison, USA; Amsterdam Brain and Cognition, Department of Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - S Laureys
- Coma Science Group, Centre du Cerveau, GIGA-Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; Fondazione Europea per la Ricerca Biomedica Onlus, Milan 20063, Italy
| | - L Naccache
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; Sorbonne Université, UPMC Université Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - A M Owen
- The Brain and Mind Institute and the Department of Physiology and Pharmacology, Western Interdisciplinary Research Building, N6A 5B7 University of Western Ontario, London, Ontario, Canada
| | - M Rosanova
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy; Fondazione Europea per la Ricerca Biomedica Onlus, Milan 20063, Italy
| | - A O Rossetti
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - C Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA
| | - J D Sitt
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - N D Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| | - M Massimini
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy; Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
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15
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Scarpino M, Lanzo G, Amantini A, Grippo A. What is new about somatosensory evoked potentials as neurological predictors of comatose survivors after cardiac arrest? FUTURE NEUROLOGY 2020. [DOI: 10.2217/fnl-2020-0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Maenia Scarpino
- Servizio di Neurofisiopatologia, IRCCS Fondazione Don Carlo Gnocchi, Firenze, Italy
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
| | - Giovanni Lanzo
- Servizio di Neurofisiopatologia, IRCCS Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Aldo Amantini
- Servizio di Neurofisiopatologia, IRCCS Fondazione Don Carlo Gnocchi, Firenze, Italy
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
| | - Antonello Grippo
- Servizio di Neurofisiopatologia, IRCCS Fondazione Don Carlo Gnocchi, Firenze, Italy
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
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16
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Glimmerveen AB, Keijzer HM, Ruijter BJ, Tjepkema-Cloostermans MC, van Putten MJAM, Hofmeijer J. Relevance of Somatosensory Evoked Potential Amplitude After Cardiac Arrest. Front Neurol 2020; 11:335. [PMID: 32425878 PMCID: PMC7212397 DOI: 10.3389/fneur.2020.00335] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/07/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: We present relations of SSEP amplitude with neurological outcome and of SSEP amplitude with EEG amplitude in comatose patients after cardiac arrest. Methods: This is a post hoc analysis of a prospective cohort study in comatose patients after cardiac arrest. Amplitude of SSEP recordings obtained within 48-72 h, and EEG patterns obtained at 12 and 24h after cardiac arrest were related to good (CPC 1-2) or poor (CPC 3-5) outcome at 6 months. In 39% of the study population multiple SSEP measurements were performed. Additionally, SSEP amplitude was related to mean EEG amplitude. Results: We included 138 patients (77% poor outcome). Absent SSEP responses, a N20 amplitude <0.4 μV within 48-72 h, and suppressed or synchronous EEG with suppressed background at 12 or 24 h after cardiac arrest were invariably associated with a poor outcome. Combined, these tests reached a sensitivity for prediction of poor outcome up to 58 at 100% specificity. N20 amplitude increased with a mean of 0.55 μV per day in patients with a poor outcome, and remained stable with a good outcome. There was no statistically significant correlation between SSEP and EEG amplitudes in 182 combined SSEP and EEG measurements (R 2 < 0.01). Conclusions: N20 amplitude <0.4 μV is invariably associated with poor outcome. There is no correlation between SSEP and EEG amplitude. Significance: SSEP amplitude analysis may contribute to outcome prediction after cardiac arrest.
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Affiliation(s)
| | - Hanneke M Keijzer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands.,Department of Intensive Care Medicine and Neurology, Donders Institute for Brain Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - Barry J Ruijter
- Clinical Neurophysiology, Technical Medical Centre, University of Twente, Enschede, Netherlands
| | - Marleen C Tjepkema-Cloostermans
- Clinical Neurophysiology, Technical Medical Centre, University of Twente, Enschede, Netherlands.,Department of Neurology and Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Michel J A M van Putten
- Clinical Neurophysiology, Technical Medical Centre, University of Twente, Enschede, Netherlands.,Department of Neurology and Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands.,Clinical Neurophysiology, Technical Medical Centre, University of Twente, Enschede, Netherlands
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17
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Added value of somato-sensory evoked potentials amplitude for prognostication after cardiac arrest. Resuscitation 2020; 149:17-23. [DOI: 10.1016/j.resuscitation.2020.01.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 12/31/2019] [Accepted: 01/22/2020] [Indexed: 12/13/2022]
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18
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Nobile L, Pognuz ER, Rossetti AO, Franchi F, Verginella F, Mavroudakis N, Creteur J, Berlot G, Oddo M, Taccone FS. The characteristics of patients with bilateral absent evoked potentials after post-anoxic brain damage: A multicentric cohort study. Resuscitation 2020; 149:134-140. [PMID: 32114066 DOI: 10.1016/j.resuscitation.2020.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/18/2020] [Accepted: 02/21/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Patients with bilateral absence of cortical response (N20ABS) to somatosensory evoked potentials (SSEPs) have poor neurological outcome after cardiac arrest (CA). However, SSEPs are not available in all centers. The aim of this study was to identify predictors of N20ABS. METHODS Retrospective analysis of institutional databases (2008-2015) in three ICUs including all adult admitted comatose patients undergoing SSEPs between 48 and 72 h after CA. We collected clinical (i.e. absence of pupillary reflexes, PLR, myoclonus and absent or posturing motor response and myoclonus on day 2-3), electroencephalographic (EEG; i.e. unreactive to painful stimuli; presence of a highly malignant patterns, such as burst-suppression or flat tracings) findings during the first 48 h, and the highest NSE levels on the first 3 days after CA. Unfavorable neurological outcome (UO) was assessed at 3 months using the Cerebral Performance Categories of 3-5. RESULTS We studied 532 patients with SSEPs, including 143 (27%) without N20ABS; UO was observed in 334 (63%) patients. Median time to SSEPs was 72 [48-72] h after CA. No patient with absent PLR and myoclonus during the ICU stay had N20 present; similar results were observed with the combination of absent PLR, myoclonus and any EEG pattern (i.e. unreactive or highly malignant). Similar results were observed in the subgroup of patients where NSE was available (n = 303). In a multivariate logistic regression, non-cardiac etiology of arrest, unreactive EEG to painful stimuli, absence of pupillary reflexes and posturing motor response, were independent predictors of N20ABS. When available, the highest NSE was also an independent predictor of N20ABS. CONCLUSIONS Clinical and EEG findings predicting patients with N20ABS, confirm that N20ABS reflects a severe and permanent cerebral damage after CA.
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Affiliation(s)
- Leda Nobile
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Erik Roman Pognuz
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITs), Italy
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Federico Franchi
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Francesca Verginella
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITs), Italy
| | - Nicolas Mavroudakis
- Department of Neurology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Giorgio Berlot
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITs), Italy
| | - Mauro Oddo
- Department of Intensive Care Medicine, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
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19
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Agarwal S, Morris N, Der-Nigoghossian C, May T, Brodie D. The Influence of Therapeutics on Prognostication After Cardiac Arrest. Curr Treat Options Neurol 2019; 21:60. [PMID: 31768661 DOI: 10.1007/s11940-019-0602-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to highlight the influence of therapeutic maneuvers on neuro-prognostication measures administered to comatose survivors of cardiac arrest. We focus on the effect of sedation regimens in the setting of targeted temperature management (TTM), one of the principle interventions known to improve neurological recovery after cardiac arrest. Further, we discuss the critical need for novel markers, as well as refinement of existing markers, among patients receiving extracorporeal membrane oxygenation (ECMO) in the setting of failed conventional resuscitation, known as extracorporeal cardiopulmonary resuscitation (ECPR). RECENT FINDINGS Automated pupillometry may have some advantage over standard pupillary examination for prognostication following TTM, sedation, or the use of ECMO after cardiac arrest. New serum biomarkers such as Neurofilament light chain have shown good predictive abilities and need further validation in these populations. There is a high-level uncertainty in brain death declaration protocols particularly related to apnea testing and appropriate ancillary tests in patients receiving ECMO. Both sedation and TTM alone and in combination have been shown to affect prognostic markers to varying degrees. The optimal approach to analog-sedation is unknown, and requires further study. Moreover, validation of known prognostic markers, as well as brain death declaration processes in patients receiving ECMO is warranted. Data on the effects of TTM, sedation, and ECMO on biomarkers (e.g., neuron-specific enolase) and electrophysiology measures (e.g., somatosensory-evoked potentials) is sparse. The best approach may be one customized to the individual patient, a precision-medicine approach.
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Affiliation(s)
- Sachin Agarwal
- Division of Neurocritical Care and Hospitalist Neurology, Department of Neurology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.
| | - Nicholas Morris
- Department of Neurology, Program in Trauma, University of Maryland Medical Center, Baltimore, MD, USA
| | - Caroline Der-Nigoghossian
- Clinical Pharmacy, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Teresa May
- Division of Pulmonary and Critical Care Medicine, Maine Medical Center, Portland, ME, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
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20
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Rothstein TL. SSEP retains its value as predictor of poor outcome following cardiac arrest in the era of therapeutic hypothermia. Crit Care 2019; 23:327. [PMID: 31647028 PMCID: PMC6813072 DOI: 10.1186/s13054-019-2576-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/19/2019] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES To re-evaluate the role of median nerve somatosensory evoked potentials (SSEPs) and bilateral loss of the N20 cortical wave as a predictor of unfavorable outcome in comatose patients following cardiac arrest (CA) in the therapeutic hypothermia (TH) era. METHODS Review the results and conclusions drawn from isolated case reports and small series of comatose patients following CA in which the bilateral absence of N20 response has been associated with recovery, and evaluate the proposal that SSEP can no longer be considered a reliable and accurate predictor of unfavorable neurologic outcome. RESULTS There are many methodological limitations in those patients reported in the literature with severe post anoxic encephalopathy who recover despite having lost their N20 cortical potential. These limitations include lack of sufficient clinical and neurologic data, severe core body hypothermia, specifics of electrophysiologic testing, technical issues such as background noise artifacts, flawed interpretations sometimes related to interobserver inconsistency, and the extreme variability in interpretation and quality of SSEP analysis among different clinicians and hospitals. CONCLUSIONS The absence of the SSEP N20 cortical wave remains one of the most reliable early prognostic tools for identifying unfavorable neurologic outcome in the evaluation of patients with severe anoxic-ischemic encephalopathy whether or not they have been treated with TH. When confounding factors are eliminated the false positive rate (FPR) approaches zero.
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Affiliation(s)
- Ted L Rothstein
- Department of Neurology, George Washington University, Washington, DC, USA.
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21
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Estimating the False Positive Rate of Absent Somatosensory Evoked Potentials in Cardiac Arrest Prognostication. Crit Care Med 2019; 46:e1213-e1221. [PMID: 30247243 DOI: 10.1097/ccm.0000000000003436] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Absence of somatosensory evoked potentials is considered a nearly perfect predictor of poor outcome after cardiac arrest. However, reports of good outcomes despite absent somatosensory evoked potentials and high rates of withdrawal of life-sustaining therapies have raised concerns that estimates of the prognostic value of absent somatosensory evoked potentials may be biased by self-fulfilling prophecies. We aimed to develop an unbiased estimate of the false positive rate of absent somatosensory evoked potentials as a predictor of poor outcome after cardiac arrest. DATA SOURCES PubMed. STUDY SELECTION We selected 35 studies in cardiac arrest prognostication that reported somatosensory evoked potentials. DATA EXTRACTION In each study, we identified rates of withdrawal of life-sustaining therapies and good outcomes despite absent somatosensory evoked potentials. We appraised studies for potential biases using the Quality in Prognosis Studies tool. Using these data, we developed a statistical model to estimate the false positive rate of absent somatosensory evoked potentials adjusted for withdrawal of life-sustaining therapies rate. DATA SYNTHESIS Two-thousand one-hundred thirty-three subjects underwent somatosensory evoked potential testing. Five-hundred ninety-four had absent somatosensory evoked potentials; of these, 14 had good functional outcomes. The rate of withdrawal of life-sustaining therapies for subjects with absent somatosensory evoked potential could be estimated in 14 of the 35 studies (mean 80%, median 100%). The false positive rate for absent somatosensory evoked potential in predicting poor neurologic outcome, adjusted for a withdrawal of life-sustaining therapies rate of 80%, is 7.7% (95% CI, 4-13%). CONCLUSIONS Absent cortical somatosensory evoked potentials do not infallibly predict poor outcome in patients with coma following cardiac arrest. The chances of survival in subjects with absent somatosensory evoked potentials, though low, may be substantially higher than generally believed.
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Hypoxic Encephalopathy in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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23
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Oh SH, Park KN, Choi SP, Oh JS, Kim HJ, Youn CS, Kim SH, Chang K, Kim SH. Beyond dichotomy: patterns and amplitudes of SSEPs and neurological outcomes after cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:224. [PMID: 31215475 PMCID: PMC6582536 DOI: 10.1186/s13054-019-2510-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/10/2019] [Indexed: 01/06/2023]
Abstract
Background We hypothesized that the absence of P25 and the N20–P25 amplitude in somatosensory evoked potentials (SSEPs) have higher sensitivity than the absence of N20 for poor neurological outcomes, and we evaluated the ability of SSEPs to predict long-term outcomes using pattern and amplitude analyses. Methods Using prospectively collected therapeutic hypothermia registry data, we evaluated whether cortical SSEPs contained a negative or positive short-latency wave (N20 or P25). The N20–P25 amplitude was defined as the largest difference in amplitude between the N20 and P25 peaks. A good or poor outcome was defined as a Glasgow-Pittsburgh Cerebral Performance Category (CPC) score of 1–2 or 3–5, respectively, 6 months after cardiac arrest. Results A total of 192 SSEP recordings were included. In all patients with a good outcome (n = 51), both N20 and P25 were present. Compared to the absence of N20, the absence of N20–P25 component improved the sensitivity for predicting a poor outcome from 30.5% (95% confidence interval [CI], 23.0–38.8%) to 71.6% (95% CI, 63.4–78.9%), while maintaining a specificity of 100% (93.0–100.0%). Using an amplitude < 0.64 μV, i.e., the lowest N20–P25 amplitude in the good outcome group, as the threshold, the sensitivity for predicting a poor neurological outcome was 74.5% (95% CI, 66.5–81.4%). Using the highest N20–P25 amplitude in the CPC 4 group (2.31 μV) as the threshold for predicting a good outcome, the sensitivity and specificity were 52.9% (95% CI, 38.5–67.1%) and 96.5% (95% CI, 91.9–98.8%), respectively. The predictive performance of the N20–P25 amplitude was good, with an area under the receiver operating characteristic curve (AUC) of 0.94 (95% CI, 0.90–0.97). The absence of N20 was statistically inferior regarding outcome prediction (p < 0.05), and amplitude analysis yielded significantly higher AUC values than did the pattern analysis (p < 0.05). Conclusions The simple pattern analysis of whether the N20–P25 component was present had a sensitivity comparable to that of the N20–P25 amplitude for predicting a poor outcome. Amplitude analysis was also capable of predicting a good outcome. Electronic supplementary material The online version of this article (10.1186/s13054-019-2510-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
| | - Seung Pill Choi
- Department of Emergency Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Joon Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Soo Hyun Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seong Hoon Kim
- Department of Neurology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Kavi T, Desai M, Yilmaz FM, Kakadia B, Burakgazi-Dalkilic E, Shrestha GS. Inter-predictability of Neuroprognostic Modalities After Cardiac Arrest. Cureus 2019; 11:e4489. [PMID: 31259107 PMCID: PMC6581415 DOI: 10.7759/cureus.4489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Introduction At present, there is an emphasis on a multi-modal approach to neuro-prognostication after cardiac arrest using clinical examination, neurophysiologic testing, laboratory biomarkers, and radiological studies. However, this necessitates significant resource utilization and can be challenging in under-resourced clinical settings. Hence, we sought to determine the inter-predictability and correlation of prognostic tests performed in patients after cardiac arrest. Methods Fifty patients were included through neurophysiology laboratory data for this retrospective study. Clinical, radiological and neurophysiological data were collected. Neurophysiological data were re-evaluated by a board-certified neurophysiologist for the purpose of the study. Chi-square testing was used to evaluate the correlation between different diagnostic modalities. Results We found that a non-reactive electroencephalogram (EEG) had a predictive value of 79% for absent bilateral cortical responses (N20) with somatosensory evoked potentials (SSEP). On the other hand, absent bilateral cortical responses N20 had 87% predictive value for a non-reactive EEG. Also, absent cortical responses and non-reactive EEG had predictive values of 78% and 72% for anoxic injury on magnetic resonance imaging (MRI) brain respectively with a non-significant difference on chi-square testing. Individually, absent bilateral N20 SSEP, a non-reactive EEG and anoxic brain injury on MRI studies were highly predictive of poor outcome [modified Rankin scale (mRS) > 4] at hospital discharge. Conclusion Neuroprognostication in a post-cardiac arrest setting is often limited by self-fulfilling prophecy. Given the lack of absolute correlation between different modalities used in post-cardiac arrest patients, the value of the multi-modal approach to neuro-prognostication is highlighted by this study.
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Affiliation(s)
- Tapan Kavi
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Masoom Desai
- Neurology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Furkan M Yilmaz
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Bhavika Kakadia
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | | | - Gentle S Shrestha
- Critical Care, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, NPL
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Carrai R, Scarpino M, Lolli F, Spalletti M, Lanzo G, Peris A, Lazzeri C, Amantini A, Grippo A. Early-SEPs' amplitude reduction is reliable for poor-outcome prediction after cardiac arrest? Acta Neurol Scand 2019; 139:158-165. [PMID: 30230524 DOI: 10.1111/ane.13030] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The bilateral absence of cortical Somatosensory Evoked Potentials (SEPs), after cardiac arrest (CA), is a high reliable predictor of poor outcome but it is present in no more than 40% of patients. An amplitude reduction of cortical SEPs was found in about 30% of subjects, but few papers analysed its prognostic significance. The aim of our study is to identify a value of SEP amplitude reduction below which all the CA patients had poor outcome and the relationship between SEP and Electroencephalogram (EEG) patterns. MATERIAL AND METHODS We analysed comatose patients in whom SEPs and EEG were recorded at 6-12 hours after CA. We evaluated the sensitivity at specificity of 100% of SEP amplitude in predicting the non-recovery of consciousness by plotting Receiver Operating Characteristic (ROC) curves. We also analysed the relationship between SEP amplitude and EEG patterns. Outcome was evaluated at 6 months by Glasgow Outcome Scale. RESULTS We analysed 119 subjects. According to the ROC analysis (area under the curve = 0.95/CI 0.91-0.99), all patients with a cortical SEP amplitude <0.65 μV did not recover consciousness (GOS 1-2), with a sensitivity of 71.8%. Severe EEG abnormalities (suppression and burst-suppression patterns) were also observed in all these patients. CONCLUSION Not only the absence but also a bilateral amplitude reduction of cortical SEPs (<0.65 μV) is associated with ominous prognosis (death or non-recovery of consciousness) with a very high predictive value. However, we emphasize that great caution should be applied before adopting amplitude reduction as a criterion for the poor prognosis of CA patients.
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Affiliation(s)
- Riccardo Carrai
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica, Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
| | - Maenia Scarpino
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica, Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
| | - Francesco Lolli
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - Maddalena Spalletti
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - Giovanni Lanzo
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - Adriano Peris
- SODc Cure intensive per il trauma e i supporti extracorporei, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - Chiara Lazzeri
- SODc Cure intensive per il trauma e i supporti extracorporei, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - Aldo Amantini
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica, Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
| | - Antonello Grippo
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica, Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
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Shahaf G, Kuperman P, Bloch Y, Yariv S, Granovsky Y. Monitoring Migraine Cycle Dynamics with an Easy-to-Use Electrophysiological Marker-A Pilot Study. SENSORS 2018; 18:s18113918. [PMID: 30441751 PMCID: PMC6263618 DOI: 10.3390/s18113918] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/01/2018] [Accepted: 11/11/2018] [Indexed: 11/22/2022]
Abstract
Migraine attacks can cause significant discomfort and reduced functioning for days at a time, including the pre-ictal and post-ictal periods. During the inter-ictsal period, however, migraineurs seem to function normally. It is puzzling, therefore, that event-related potentials of migraine patients often differ in the asymptomatic and inter-ictal period. Part of the electrophysiological dynamics demonstrated in the migraine cycle are attention related. In this pilot study we evaluated an easy-to-use new marker, the Brain Engagement Index (BEI), for attention monitoring during the migraine cycle. We sampled 12 migraine patients for 20 days within one calendar month. Each session consisted of subjects’ reports of stress level and migraine-related symptoms, and a 5 min EEG recording, with a 2-electrode EEG device, during an auditory oddball task. The first minute of the EEG sample was analyzed. Repetitive samples were also obtained from 10 healthy controls. The brain engagement index increased significantly during the pre-ictal (p ≈ 0.001) and the ictal (p ≈ 0.020) periods compared with the inter-ictal period. No difference was observed between the pre-ictal and ictal periods. Control subjects demonstrated intermediate Brain Engagement Index values, that is, higher than inter-ictal, yet lower than pre-ictal. Our preliminary results demonstrate the potential advantage of the use of a simple EEG system for improved prediction of migraine attacks. Further study is required to evaluate the efficacy of the Brain Engagement Index in monitoring the migraine cycle and the possible effects of interventions.
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Affiliation(s)
| | - Pora Kuperman
- The Laboratory of Clinical Neurophysiology, The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 31096, Israel.
| | - Yuval Bloch
- The Emotion-Cognition Research Center, Shalvata Mental Health Care Center, Hod-Hasharon 45100, Israel.
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 6997801, Israel.
| | - Shahak Yariv
- Department of Psychiatry, Emek Medical Center, Afula 1834111, Israel.
| | - Yelena Granovsky
- The Laboratory of Clinical Neurophysiology, The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 31096, Israel.
- Department of Neurology, Rambam Medical Center, Haifa 3655306, Israel.
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Nguyen PL, Alreshaid L, Poblete RA, Konye G, Marehbian J, Sung G. Targeted Temperature Management and Multimodality Monitoring of Comatose Patients After Cardiac Arrest. Front Neurol 2018; 9:768. [PMID: 30254606 PMCID: PMC6141756 DOI: 10.3389/fneur.2018.00768] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/24/2018] [Indexed: 01/14/2023] Open
Abstract
Out-of-hospital cardiac arrest (CA) remains a leading cause of sudden morbidity and mortality; however, outcomes have continued to improve in the era of targeted temperature management (TTM). In this review, we highlight the clinical use of TTM, and provide an updated summary of multimodality monitoring possible in a modern ICU. TTM is neuroprotective for survivors of CA by inhibiting multiple pathophysiologic processes caused by anoxic brain injury, with a final common pathway of neuronal death. Current guidelines recommend the use of TTM for out-of-hospital CA survivors who present with a shockable rhythm. Further studies are being completed to determine the optimal timing, depth and duration of hypothermia to optimize patient outcomes. Although a multidisciplinary approach is necessary in the CA population, neurologists and neurointensivists are central in selecting TTM candidates and guiding patient care and prognostic evaluation. Established prognostic tools include clinal exam, SSEP, EEG and MR imaging, while functional MRI and invasive monitoring is not validated to improve outcomes in CA or aid in prognosis. We recommend that an evidence-based TTM and prognostication algorithm be locally implemented, based on each institution's resources and limitations. Given the high incidence of CA and difficulty in predicting outcomes, further study is urgently needed to determine the utility of more recent multimodality devices and studies.
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Affiliation(s)
- Peggy L Nguyen
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Laith Alreshaid
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Roy A Poblete
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Geoffrey Konye
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jonathan Marehbian
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Gene Sung
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Abstract
PURPOSE The reliability of somatosensory evoked potentials (SSEPs) in predicting outcome in comatose survivors of cardiac arrest treated with therapeutic hypothermia (TH) has been questioned. We investigated whether the absence of cortical (N20) responses was a reliable predictor of a nonawakening in the setting of TH. METHODS A retrospective review was conducted in cardiac arrest survivors treated with TH admitted to a single tertiary care hospital from April, 2010 to March, 2013 who underwent SSEP testing at various time points after cardiac arrest. N20 responses were categorized as normal, present but abnormal, bilaterally absent, or inadequate for interpretation. Neurologic outcome was assessed at discharge by the Cerebral Performance Category Scale (CPC). RESULTS Ninety-three SSEP studies were performed in 73 patients. Fourteen patients had absent N20 responses; all had poor outcome (CPC 4-5). Eleven patients had absent N20 s during hypothermia, three of whom had follow-up SSEPs after rewarming and cortical responses remained absent. Fifty-seven patients had N20 peaks identified and had variable outcomes. Evaluation of 1 or more N20 peaks was limited or inadequate in 11.4% of SSEPs performed during the cooling because of artifact. CONCLUSIONS Somatosensory evoked potentials remain a reliable prognostic indicator in patients undergoing TH. The limited sample size of patients who had SSEP performed during TH and repeated after normothermia added to the effect of self-fulfilling prophecy limit the interpretation of the reliability of this testing when performed during cooling. Further prospective, multicenter, large scale studies correlating cortical responses in SSEPs during and after TH are warranted. Technical challenges are commonplace during TH and caution is advised in the interpretation of suboptimal recordings.
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Ertl M, Weber S, Hammel G, Schroeder C, Krogias C. Transorbital Sonography for Early Prognostication of Hypoxic-Ischemic Encephalopathy After Cardiac Arrest. J Neuroimaging 2018; 28:542-548. [PMID: 29883008 DOI: 10.1111/jon.12528] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 05/19/2018] [Accepted: 05/21/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Early prognostication of the outcome in resuscitated post cardiac arrest (CA) patients remains challenging especially if treated with therapeutic hypothermia. Brain edema caused by hypoxic-ischemic encephalopathy (HIE) can indirectly be estimated by transorbital sonography (TOS) taking in account the optic nerve sheath diameter (ONSD). The prognostic value of this easy, safe, and reproducible technique was investigated in this study. METHODS A total of 49 patients, initially unconscious (Glasgow Coma Scale ≤6) after successful resuscitation, were enrolled into this prospective observational study. Sonographic ONSD measurements were performed twice on day of admission (day 0) and once on days 1 and 2 after CA. Beyond ONSD, established prognostic parameters like neuron specific enolase and gray-white matter ratios were assessed. Cerebral Performance Category (CPC) score served as outcome parameter. RESULTS A total of 15 (31.3%) patients had a good outcome (CPC-score 1-2), 8 patients (14.6%) had severe disability (CPC-score 3-4), and 26 (54.2%) had a fatal outcome (CPC-score 5). Already in the first measurement on day 0, nonsurvivors showed significantly higher ONSD values (P < .001). For predicting mortality, a threshold of 5.75 mm was calculated with a specificity of 100%. ONSD did not differ significantly depending on hypothermia (P = .7009). CONCLUSION Early and reliable prognostication of outcomes in patients with HIE can be simplified by ONSD values gathered with the use of TOS. Main advantages compared to other established markers are prognostication within the first 24 hours and independence from therapy with hypothermia. A higher level of accuracy can be reached by combining computed tomography (gray-to-white matter ratio values) and ONSD values.
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Affiliation(s)
- Michael Ertl
- Clinic for Neurology and Neurophysiology, Klinikum Augsburg, Augsburg, Germany
| | - Sarah Weber
- Clinic for Neurology and Neurophysiology, Klinikum Augsburg, Augsburg, Germany
| | - Gertrud Hammel
- Chair and Institute of Environmental Medicine, UNIKA-T, Technical University of Munich and Helmholtz Zentrum München, Augsburg, Germany.,CK-CARE, Christine Kühne - Center for Allergy and Research and Education, Davos, Switzerland
| | - Christoph Schroeder
- Department of Neurology, Medical Faculty, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Christos Krogias
- Clinic for Neurology and Neurophysiology, Klinikum Augsburg, Augsburg, Germany
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André-Obadia N, Zyss J, Gavaret M, Lefaucheur JP, Azabou E, Boulogne S, Guérit JM, McGonigal A, Merle P, Mutschler V, Naccache L, Sabourdy C, Trébuchon A, Tyvaert L, Vercueil L, Rohaut B, Delval A. Recommendations for the use of electroencephalography and evoked potentials in comatose patients. Neurophysiol Clin 2018; 48:143-169. [DOI: 10.1016/j.neucli.2018.05.038] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/07/2018] [Indexed: 12/21/2022] Open
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Li F, Liu G, Tian X, Quan F, Li B, Feng G, Wang X, Hu Y. A novel scoring system to predict the outcomes of adult patients with hypoxic-ischemic encephalopathy. Expert Rev Neurother 2018; 18:343-350. [PMID: 29495903 DOI: 10.1080/14737175.2018.1447925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Adult patients with hypoxic-ischemic encephalopathy (HIE) often incur large costs, but their outcomes are poor. Currently, there is lack of a comprehensive quantitative approach to predict patient prognoses. METHODS A total of 73 adult patients with HIE participated in this prospective, observational study. Clinical assessments, laboratory tests, and electrophysiological examinations were conducted within 3 days after HIE occurred. Logistic regression model was used to identify independent factors associated with patient outcomes. RESULTS After a 6-month follow-up, 44 (61.1%) patients survived, 28 (38.9%) patients died, and one patient was lost to follow-up. The level of blood calcium and lactate, the presence of electroencephalography reactivity, and Glasgow Coma Scale (GCS) score were significantly associated with the patient's outcome. Based on the regression coefficients from logistic regression analysis, we constructed a scoring system (CEGL; C: calcium, E: EEG reactivity, G: GCS, L: lactate) to predict the possibility of a patient's death. The area under the receiver operating characteristic curve was 0.91 (P < 0.001, 95% CI [0.87-0.95]) with a specificity of 97.7% and a positive predictive value of 97.4%. CONCLUSION CEGL score can provide clinicians useful information for assessment of patient prognosis within 6 months after HIE.
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Affiliation(s)
- Feng Li
- a Department of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , People's Republic of China
| | - Guangwei Liu
- a Department of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , People's Republic of China
| | - Xin Tian
- a Department of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , People's Republic of China
| | - Fengying Quan
- a Department of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , People's Republic of China
| | - Bosong Li
- b Department of communicable disease control , Center for Disease Control and Prevention , Chongqing , People's Republic of China
| | - Guibo Feng
- c Department of Neurology , Yongchuan Hospital of Chongqing Medical University , Chongqing , People's Republic of China
| | - Xuefeng Wang
- a Department of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , People's Republic of China
| | - Yida Hu
- a Department of Neurology , The First Affiliated Hospital of Chongqing Medical University , Chongqing , People's Republic of China
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Can somatosensory and visual evoked potentials predict neurological outcome during targeted temperature management in post cardiac arrest patients? Resuscitation 2017. [PMID: 28648810 DOI: 10.1016/j.resuscitation.2017.06.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSES In cardiac arrest patients treated with targeted temperature management (TTM), it is not certain if somatosensory evoked potentials (SEPs) and visual evoked potentials (VEPs) can predict neurological outcomes during TTM. The aim of this study was to investigate the prognostic value of SEPs and VEPs during TTM and after rewarming. METHODS This retrospective cohort study included comatose patients resuscitated from cardiac arrest and treated with TTM between March 2007 and July 2015. SEPs and VEPs were recorded during TTM and after rewarming in these patients. Neurological outcome was assessed at discharge by the Cerebral Performance Category (CPC) Scale. RESULTS In total, 115 patients were included. A total of 175 SEPs and 150 VEPs were performed. Five SEPs during treated with TTM and nine SEPs after rewarming were excluded from outcome prediction by SEPs due to an indeterminable N20 response because of technical error. Using 80 SEPs and 85 VEPs during treated with TTM, absent SEPs yielded a sensitivity of 58% and a specificity of 100% for poor outcome (CPC 3-5), and absent VEPs predicted poor neurological outcome with a sensitivity of 44% and a specificity of 96%. The AUC of combination of SEPs and VEPs was superior to either test alone (0.788 for absent SEPs and 0.713 for absent VEPs compared with 0.838 for the combination). After rewarming, absent SEPs and absent VEPs predicted poor neurological outcome with a specificity of 100%. When SEPs and VEPs were combined, VEPs slightly increased the prognostic accuracy of SEPs alone. Although one patient with absent VEP during treated with TTM had a good neurological outcome, none of the patients with good neurological outcome had an absent VEP after rewarming. CONCLUSION Absent SEPs could predict poor neurological outcome during TTM as well as after rewarming. Absent VEPs may predict poor neurological outcome in both periods and VEPs may provide additional prognostic value in outcome prediction.
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Grippo A, Carrai R, Scarpino M, Spalletti M, Lanzo G, Cossu C, Peris A, Valente S, Amantini A. Neurophysiological prediction of neurological good and poor outcome in post-anoxic coma. Acta Neurol Scand 2017; 135:641-648. [PMID: 27480262 DOI: 10.1111/ane.12659] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2016] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- A. Grippo
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica; Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
| | - R. Carrai
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica; Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
| | - M. Scarpino
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica; Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
| | - M. Spalletti
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - G. Lanzo
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - C. Cossu
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - A. Peris
- Unità di terapia Intensiva; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - S. Valente
- Dipartimento Cardiotoracovascolare; AOU Careggi; Florence Italy
| | - A. Amantini
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica; Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
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Rossetti AO. Clinical neurophysiology for neurological prognostication of comatose patients after cardiac arrest. Clin Neurophysiol Pract 2017; 2:76-80. [PMID: 30214976 PMCID: PMC6123903 DOI: 10.1016/j.cnp.2017.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/13/2017] [Accepted: 03/13/2017] [Indexed: 12/01/2022] Open
Abstract
A multimodal prognostic approach is recommended after cardiac arrest. EEG (background and, reactivity, repetitive epileptiform features) and SSEP are core assessments. Some outlook into long-latency evoked potentials is offered.
Early prognostication of outcome in comatose patients after cardiac arrest represents a daunting task for clinicians, also considering the nowadays commonly used targeted temperature management with sedation in the first 24–48 h. A multimodal approach is currently recommended, in order to minimize the risks of false-positive prediction of poor outcome, including clinical examination off sedation, EEG (background characterization and reactivity, occurrence of repetitive epileptiform features), and early-latency SSEP responses represent the core assessments in this setting; they may be complemented by biochemical markers and neuroimaging. This paper, which relies on a recent comprehensive review, focuses on an updated review of EEG and SSEP, and also offers some outlook into long-latency evoked potentials, which seem promising in clinical use.
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Affiliation(s)
- Andrea O Rossetti
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Université de Lausanne (UNIL), Lausanne, Switzerland
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Excellent neurologic recovery after prolonged coma in a cardiac arrest patient with multiple poor prognostic indicators. Resuscitation 2017; 113:e11-e12. [PMID: 28189599 DOI: 10.1016/j.resuscitation.2017.01.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 01/23/2017] [Accepted: 01/27/2017] [Indexed: 11/24/2022]
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Reis C, Akyol O, Araujo C, Huang L, Enkhjargal B, Malaguit J, Gospodarev V, Zhang JH. Pathophysiology and the Monitoring Methods for Cardiac Arrest Associated Brain Injury. Int J Mol Sci 2017; 18:ijms18010129. [PMID: 28085069 PMCID: PMC5297763 DOI: 10.3390/ijms18010129] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 12/31/2016] [Accepted: 01/04/2017] [Indexed: 12/23/2022] Open
Abstract
Cardiac arrest (CA) is a well-known cause of global brain ischemia. After CA and subsequent loss of consciousness, oxygen tension starts to decline and leads to a series of cellular changes that will lead to cellular death, if not reversed immediately, with brain edema as a result. The electroencephalographic activity starts to change as well. Although increased intracranial pressure (ICP) is not a direct result of cardiac arrest, it can still occur due to hypoxic-ischemic encephalopathy induced changes in brain tissue, and is a measure of brain edema after CA and ischemic brain injury. In this review, we will discuss the pathophysiology of brain edema after CA, some available techniques, and methods to monitor brain oxygen, electroencephalography (EEG), ICP (intracranial pressure), and microdialysis on its measurement of cerebral metabolism and its usefulness both in clinical practice and possible basic science research in development. With this review, we hope to gain knowledge of the more personalized information about patient status and specifics of their brain injury, and thus facilitating the physicians’ decision making in terms of which treatments to pursue.
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Affiliation(s)
- Cesar Reis
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Onat Akyol
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Camila Araujo
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Lei Huang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Budbazar Enkhjargal
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Jay Malaguit
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Vadim Gospodarev
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
- Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA.
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Mulder M, Geocadin RG. Neurology of cardiopulmonary resuscitation. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:593-617. [PMID: 28190437 DOI: 10.1016/b978-0-444-63599-0.00032-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This chapter aims to provide an up-to-date review of the science and clinical practice pertaining to neurologic injury after successful cardiopulmonary resuscitation. The past two decades have seen a major shift in the science and practice of cardiopulmonary resuscitation, with a major emphasis on postresuscitation neurologic care. This chapter provides a nuanced and thoughtful historic and bench-to-bedside overview of the neurologic aspects of cardiopulmonary resuscitation. A particular emphasis is made on the anatomy and pathophysiology of hypoxic-ischemic encephalopathy, up-to-date management of survivors of cardiopulmonary resuscitation, and a careful discussion on neurologic outcome prediction. Guidance to practice evidence-based clinical care when able and thoughtful, pragmatic suggestions for care where evidence is lacking are also provided. This chapter serves as both a useful clinical guide and an updated, thorough, and state-of-the-art reference on the topic for advanced students and experienced practitioners in the field.
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Affiliation(s)
- M Mulder
- Department of Critical Care and the John Nasseff Neuroscience Institute, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN, USA
| | - R G Geocadin
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine and Departments of Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Leão RN, Ávila P, Cavaco R, Germano N, Bento L. Therapeutic hypothermia after cardiac arrest: outcome predictors. Rev Bras Ter Intensiva 2016; 27:322-32. [PMID: 26761469 PMCID: PMC4738817 DOI: 10.5935/0103-507x.20150056] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/06/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The determination of coma patient prognosis after cardiac arrest has clinical, ethical and social implications. Neurological examination, imaging and biochemical markers are helpful tools accepted as reliable in predicting recovery. With the advent of therapeutic hypothermia, these data need to be reconfirmed. In this study, we attempted to determine the validity of different markers, which can be used in the detection of patients with poor prognosis under hypothermia. METHODS Data from adult patients admitted to our intensive care unit for a hypothermia protocol after cardiac arrest were recorded prospectively to generate a descriptive and analytical study analyzing the relationship between clinical, neurophysiological, imaging and biochemical parameters with 6-month outcomes defined according to the Cerebral Performance Categories scale (good 1-2, poor 3-5). Neuron-specific enolase was collected at 72 hours. Imaging and neurophysiologic exams were carried out in the 24 hours after the rewarming period. RESULTS Sixty-seven patients were included in the study, of which 12 had good neurological outcomes. Ventricular fibrillation and electroencephalographic theta activity were associated with increased likelihood of survival and improved neurological outcomes. Patients who had more rapid cooling (mean time of 163 versus 312 minutes), hypoxic-ischemic brain injury on magnetic resonance imaging or neuron-specific enolase > 58ng/mL had poor neurological outcomes (p < 0.05). CONCLUSION Hypoxic-ischemic brain injury on magnetic resonance imaging and neuron-specific enolase were strong predictors of poor neurological outcomes. Although there is the belief that early achievement of target temperature improves neurological prognoses, in our study, there were increased mortality and worse neurological outcomes with earlier target-temperature achievement.
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Affiliation(s)
- Rodrigo Nazário Leão
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Paulo Ávila
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Raquel Cavaco
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Nuno Germano
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Luís Bento
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
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Abstract
PURPOSE OF REVIEW Neuroprognostication following cardiac arrest is a common and challenging dilemma for neurologists and intensivists, complicated by the use of therapeutic hypothermia and targeted temperature management. Great advances have been made in understanding the mechanisms of disorders of consciousness in hypoxic-ischemic brain injury, and new diagnostic and therapeutic avenues are arising. RECENT FINDINGS In the era of therapeutic hypothermia and targeted temperature management, traditional clinical signs, electrophysiologic findings, and chemical biomarkers have now become questionable or variable, and the proper time for diagnostic and prognostic testing has become murky. Although the value of absent pupillary and corneal reflexes remains fairly robust, the presence of myoclonic status epilepticus and a motor response of extensor posturing or worse no longer appear to have acceptable false-positive rates. Somatosensory evoked potentials (SSEPs), thought to be the most reliable ancillary test for predicting prognosis, have recently been the subject of several reports showing unexpectedly good outcome in the face of absent cortical responses. The presence or absence of reactivity on EEG appears to be a promising prognostic sign, and aggressive treatment of seizures (and even status epilepticus) may lead to better than expected outcomes. Serum biomarkers that were previously felt to be valid, such as elevated neuron-specific enolase, have been drawn into question owing to multiple reports of patient survival with good outcome despite highly elevated levels. Advanced EEG and neuroimaging techniques, particularly looking at functional connectivity and underlying neuronal pathways, are giving great insights to the underlying mechanisms of disease and potential therapeutic targets. SUMMARY Predicting neurologic prognosis following cardiac arrest is an evolving field, with new prognostic methods and reevaluation of older techniques holding great promise for advancing our ability to predict outcome and improve patient care.
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Shahaf G. Migraine as dysfunctional drive reduction: Insight from electrophysiology. Med Hypotheses 2016; 91:62-66. [DOI: 10.1016/j.mehy.2016.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 04/11/2016] [Indexed: 11/24/2022]
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Cortical somatosensory evoked high-frequency (600Hz) oscillations predict absence of severe hypoxic encephalopathy after resuscitation. Clin Neurophysiol 2016; 127:2561-9. [PMID: 27291874 DOI: 10.1016/j.clinph.2016.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/09/2016] [Accepted: 04/14/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Following cardiac arrest (CA), hypoxic encephalopathy (HE) frequently occurs and hence reliable neuroprognostication is crucial to decide on the extent of intensive care. Several investigations predict severe HE leading to persistent unresponsive wakefulness or death, with high specificity. Only few studies attempted to predict absence of severe HE. Cortical somatosensory evoked high-frequency (600Hz) oscillation (HFO) bursts indicate the presence of highly synchronized spiking activity in the primary somatosensory cortex. Since global neuronal damage characterizes severe HE preserved cortical HFOs may early exclude severe HE. METHODS We determined amplitudes of early and late HFO bursts in 302 comatose CA patients after median nerve somatosensory evoked potential (SSEPs) and clinical outcome upon intensive care unit discharge using the cerebral performance category (CPC) scale. RESULTS We detected significant early HFO bursts in 146 patients and late HFO bursts in 95 patients. Only one of 27 unresponsive wakefulness patients had a late HFO burst amplitude above 70nV and all seventeen patients who died despite higher amplitudes died from non-neurological causes. CONCLUSIONS High-frequency SSEP components can reliably be studied in comatose CA patients using standard equipment. SIGNIFICANCE Late HFO burst amplitudes above 70nV largely exclude severe HE incompatible with regaining consciousness.
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Influence of the temperature on the moment of awakening in patients treated with therapeutic hypothermia after cardiac arrest. Resuscitation 2016; 103:32-36. [PMID: 27036662 DOI: 10.1016/j.resuscitation.2016.03.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/07/2016] [Accepted: 03/14/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Target temperature management (TTM) has shown to reduce brain damage after an out-of-hospital cardiac arrest (CA), but the time to neurological recovery is not defined yet. We sought to determine the time these patients need to regain consciousness, as well as factors associated with a late post-arrest awakening. METHODS We performed a retrospective analysis of patients cooled to 32-34°C during 24h after CA, who regained neurological responsiveness after rewarming. We measured the time until awakening, defined as obedience to verbal commands. RESULTS We included 163 CA survivors (84.7% male, 60.2 years) who regained consciousness after TTM: target temperature was either 32°C (36.2%), 33°C (56.4%) or 34°C (6.7%). Mean time of awakening was 3.8 days. Thirty-four patients (20.9%) regained neurological responsiveness after 5 days after CA. All of them had been cooled to either 32°C (18 patients) or 33°C (16), and no patient cooled to 34°C awakened after day 5. A lower target temperature was associated with a later awakening (p<0.001). The time to advanced cardiopulmonary resuscitation (CPR) was shorter among the early awakers (p=0.04), but we found no other predictors of an earlier awakening. CONCLUSIONS A high proportion of CA survivors induced to TTM regained consciousness after 5 days, and cooling to a lower target temperature may influence on a late neurological recovery. Therefore, withdrawal of life supporting treatment should be delayed to more than 5 days in patients cooled to 33°C or less. Time to advanced CPR was found to be a predictor of early awakening.
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Neurological prognostication of outcome in patients in coma after cardiac arrest. Lancet Neurol 2016; 15:597-609. [PMID: 27017468 DOI: 10.1016/s1474-4422(16)00015-6] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/23/2015] [Accepted: 01/12/2016] [Indexed: 11/24/2022]
Abstract
Management of coma after cardiac arrest has improved during the past decade, allowing an increasing proportion of patients to survive, thus prognostication has become an integral part of post-resuscitation care. Neurologists are increasingly confronted with raised expectations of next of kin and the necessity to provide early predictions of long-term prognosis. During the past decade, as technology and clinical evidence have evolved, post-cardiac arrest prognostication has moved towards a multimodal paradigm combining clinical examination with additional methods, consisting of electrophysiology, blood biomarkers, and brain imaging, to optimise prognostic accuracy. Prognostication should never be based on a single indicator; although some variables have very low false positive rates for poor outcome, multimodal assessment provides resassurance about the reliability of a prognostic estimate by offering concordant evidence.
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Callaway CW, Soar J, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O'Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J. Part 4: Advanced Life Support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2016; 132:S84-145. [PMID: 26472860 DOI: 10.1161/cir.0000000000000273] [Citation(s) in RCA: 241] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Karunasekara N, Salib S, MacDuff A. A good outcome after absence of bilateral N20 SSEPs post-cardiac arrest. J Intensive Care Soc 2015; 17:168-170. [PMID: 28979482 DOI: 10.1177/1751143715616137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 51-year-old man suffered a cardiac arrest after an attempted hanging. Post-arrest assessment revealed the bilateral absence of negative 20 somatosensory evoked potentials (N20 SSEPs) which is suggestive of a poor neurological outcome. Current evidence recommends its use in prognostication. Our patient made a good recovery which brings into question the value of negative 20 somatosensory evoked potentials in prognostication with concomitant neck injuries and swelling.
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Affiliation(s)
| | - S Salib
- Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - A MacDuff
- New Cross Hospital, Wolverhampton, UK
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Zanatta P, Linassi F, Mazzarolo AP, Aricò M, Bosco E, Bendini M, Sorbara C, Ori C, Carron M, Scarpa B. Pain-related Somato Sensory Evoked Potentials: a potential new tool to improve the prognostic prediction of coma after cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:403. [PMID: 26573633 PMCID: PMC4647335 DOI: 10.1186/s13054-015-1119-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 10/28/2015] [Indexed: 11/23/2022]
Abstract
Introduction Early prediction of a good outcome in comatose patients after cardiac arrest still remains an unsolved problem. The main aim of the present study was to examine the accuracy of middle-latency SSEP triggered by a painful electrical stimulation on median nerves to predict a favorable outcome. Methods No- and low-flow times, pupillary reflex, Glasgow motor score and biochemical data were evaluated at ICU admission. The following were considered within 72 h of cardiac arrest: highest creatinine value, hyperthermia occurrence, EEG, SSEP at low- (10 mA) and high-intensity (50 mA) stimulation, and blood pressure reactivity to 50 mA. Intensive care treatments were also considered. Data were compared to survival, consciousness recovery and 6-month CPC (Cerebral Performance Category). Results Pupillary reflex and EEG were statistically significant in predicting survival; the absence of blood pressure reactivity seems to predict brain death within 7 days of cardiac arrest. Middle- and short-latency SSEP were statistically significant in predicting consciousness recovery, and middle-latency SSEP was statistically significant in predicting 6-month CPC outcome. The prognostic capability of 50 mA middle-latency-SSEP was demonstrated to occur earlier than that of EEG reactivity. Conclusions Neurophysiological evaluation constitutes the key to early information about the neurological prognostication of postanoxic coma. In particular, the presence of 50 mA middle-latency SSEP seems to be an early and reliable predictor of good neurological outcome, and its absence constitutes a marker of poor prognosis. Moreover, the absence 50 mA blood pressure reactivity seems to identify patients evolving towards the brain death.
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Affiliation(s)
- Paolo Zanatta
- Department of Anaesthesia and Intensive Care, Intraoperative and Critical Care Neurophysiology in Cardiac Surgery, Treviso Regional Hospital, Azienda Ospedaliera Ulss 9, Piazzale Ospedale 1, 31100, Treviso, Italy.
| | - Federico Linassi
- Neuromonitoring Project, Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Anna Paola Mazzarolo
- Neuromonitoring Project, Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Maria Aricò
- Neuromonitoring Project, Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Enrico Bosco
- Department of Anaesthesia and Intensive Care, Intraoperative and Critical Care Neurophysiology in Cardiac Surgery, Treviso Regional Hospital, Azienda Ospedaliera Ulss 9, Piazzale Ospedale 1, 31100, Treviso, Italy.
| | - Matteo Bendini
- Unit of Neuroradiology, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Carlo Sorbara
- Department of Anaesthesia and Intensive Care, Intraoperative and Critical Care Neurophysiology in Cardiac Surgery, Treviso Regional Hospital, Azienda Ospedaliera Ulss 9, Piazzale Ospedale 1, 31100, Treviso, Italy.
| | - Carlo Ori
- Department of Anesthesia and Intensive Care, Padova University Hospital, Via 8 Febbraio 1848, 2, 35122, Padova, PD, Italy.
| | - Michele Carron
- Department of Anesthesia and Intensive Care, Padova University Hospital, Via 8 Febbraio 1848, 2, 35122, Padova, PD, Italy.
| | - Bruno Scarpa
- Department of Statistical Sciences, Padova University, Via 8 Febbraio 1848, 2, 35122, Padova, PD, Italy.
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Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy MA, Thompson TM, Zimmerman JL. Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S465-82. [PMID: 26472996 PMCID: PMC4959439 DOI: 10.1161/cir.0000000000000262] [Citation(s) in RCA: 997] [Impact Index Per Article: 110.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
To determine the optimal use and indications of electroencephalography (EEG) in critical care management of acute brain injury (ABI). An electronic literature search was conducted for articles in English describing electrophysiological monitoring in ABI from January 1990 to August 2013. A total of 165 studies were included. EEG is a useful monitor for seizure and ischemia detection. There is a well-described role for EEG in convulsive status epilepticus and cardiac arrest (CA). Data suggest EEG should be considered in all patients with ABI and unexplained and persistent altered consciousness and in comatose intensive care unit (ICU) patients without an acute primary brain condition who have an unexplained impairment of mental status. There remain uncertainties about certain technical details, e.g., the minimum duration of EEG studies, the montage, and electrodes. Data obtained from both EEG and EP studies may help estimate prognosis in ABI patients, particularly following CA and traumatic brain injury. Data supporting these recommendations is sparse, and high quality studies are needed. EEG is used to monitor and detect seizures and ischemia in ICU patients and indications for EEG are clear for certain disease states, however, uncertainty remains on other applications.
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Endisch C, Storm C, Ploner CJ, Leithner C. Amplitudes of SSEP and outcome in cardiac arrest survivors. Neurology 2015; 85:1752-60. [DOI: 10.1212/wnl.0000000000002123] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/16/2015] [Indexed: 11/15/2022] Open
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