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Chou CC, Hou JY, Chou IJ, Lan SY, Kong SS, Huang MH, Weng YC, Lin YY, Kuo CY, Hsieh MY, Chou ML, Hung PC, Wang HS, Lin KL, Wang YS, Lin JJ. Electroencephalogram pattern predicting neurological outcomes of children with seizures secondary to abusive head trauma. Pediatr Neonatol 2024; 65:249-254. [PMID: 38012896 DOI: 10.1016/j.pedneo.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 04/22/2023] [Accepted: 05/19/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND The clinical presentations of abusive head trauma can abruptly worsen, so the occurrence of seizures and changes of EEG can be variable according to patients' conditions. Since the changes of EEG background waves reflect the cortical function of children, we aimed to find out whether the timing of EEG background, epileptiform discharges and seizure patterns were associated with the outcomes of patients with AHT. MATERIAL AND METHODS Using seizure type and acute stage electroencephalographic (EEG) characteristics to assess adverse neurological outcomes in children with seizures secondary to abusive head trauma (AHT). Children who were hospitalized with AHT at a tertiary referral hospital from October 2000 to April 2010 were evaluated retrospectively. A total of 50 children below 6 years of age admitted due to AHT were included. KOSCHI outcome scale was used to evaluate the primary outcome and neurological impairment was used as secondary outcome after 6 months discharge. RESULTS Children with apnea, cardiac arrest, reverse blood flow and skull fracture in clinic had a higher mortality rate even in the no-seizure group (3/5 [60%] vs. 3/45 [6.7%], odds ratio [OR] = 11; 95% CI = 2.3-52; p = 0.025). Seizure occurrence reduced mostly at the second day after admission in seizure groups; but children with persistent seizures for 1 week showed poor neurological outcomes. The occurrence of initial seizure was frequency associated with younger age; focal seizure, diffuse cortical dysfunction in acute-stage EEG, and low Glasgow Coma Scale (GCS) score were significantly related to poor outcomes after 6 months. Diffuse cortical dysfunction was also associated with motor, speech, and cognitive dysfunction. CONCLUSIONS Diffuse cortical dysfunction in acute-stage EEG combined with low GCS score and focal seizure may related to poor outcomes and neurological dysfunctions in children with AHT.
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Affiliation(s)
- Cheng-Che Chou
- Division of Pediatric Neurology, Department of Pediatrics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Ph.D. Program in Medical Neuroscience, College of Medical Science and Technology, Taipei Medical University, Taiwan
| | - Ju-Yin Hou
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - I-Jun Chou
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Shih-Yun Lan
- Division of Pediatric Neurology, Department of Pediatrics, New Taipei City Hospital, New Taipei City, Taiwan
| | - Shu-Sing Kong
- Division of Pediatric Neurology, Department of Pediatrics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
| | - Man-Hsu Huang
- Department of Pathology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
| | - Yu-Chieh Weng
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Yu Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Yen Kuo
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Meng-Ying Hsieh
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Min-Liang Chou
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Po-Cheng Hung
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Yi-Shan Wang
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [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: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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Park JS, Kim EY, You Y, Min JH, Jeong W, Ahn HJ, In YN, Lee IH, Kim JM, Kang C. Combination strategy for prognostication in patients undergoing post-resuscitation care after cardiac arrest. Sci Rep 2023; 13:21880. [PMID: 38072906 PMCID: PMC10711008 DOI: 10.1038/s41598-023-49345-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 12/07/2023] [Indexed: 12/18/2023] Open
Abstract
This study investigated the prognostic performance of combination strategies using a multimodal approach in patients treated after cardiac arrest. Prospectively collected registry data were used for this retrospective analysis. Poor outcome was defined as a cerebral performance category of 3-5 at 6 months. Predictors of poor outcome were absence of ocular reflexes (PR/CR) without confounding factors, a highly malignant pattern on the most recent electroencephalography, defined as suppressed background with or without periodic discharges and burst-suppression, high neuron-specific enolase (NSE) after 48 h, and diffuse injury on imaging studies (computed tomography or diffusion-weighted imaging [DWI]) at 72-96 h. The prognostic performances for poor outcomes were analyzed for sensitivity and specificity. A total of 130 patients were included in the analysis. Of these, 68 (52.3%) patients had poor outcomes. The best prognostic performance was observed with the combination of absent PR/CR, high NSE, and diffuse injury on DWI [91.2%, 95% confidence interval (CI) 80.7-97.1], whereas the combination strategy of all available predictors did not improve prognostic performance (87.8%, 95% CI 73.8-95.9). Combining three of the predictors may improve prognostic performance and be more efficient than adding all tests indiscriminately, given limited medical resources.
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Affiliation(s)
- Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Eun Young Kim
- Department of Neurology, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong, Republic of Korea
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - In Ho Lee
- Department of Radiology, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Radiology, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jae Moon Kim
- Department of Neurology, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea.
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea.
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Guo Y, Gharibani P, Agarwal P, Cho S, Thakor NV, Geocadin RG. Hyperacute autonomic and cortical function recovery following cardiac arrest resuscitation in a rodent model. Ann Clin Transl Neurol 2023; 10:2223-2237. [PMID: 37776065 PMCID: PMC10723251 DOI: 10.1002/acn3.51907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/29/2023] [Accepted: 09/11/2023] [Indexed: 10/01/2023] Open
Abstract
OBJECTIVE There is a complex interaction between nervous and cardiovascular systems, but sparse data exist on brain-heart electrophysiological responses to cardiac arrest resuscitation. Our aim was to investigate dynamic changes in autonomic and cortical function during hyperacute stage post-resuscitation. METHODS Ten rats were resuscitated from 7-min cardiac arrest, as indicators of autonomic response, heart rate (HR), and its variability (HRV) were measured. HR was monitored through continuous electrocardiography, while HRV was assessed via spectral analysis, whereby the ratio of low-/high-frequency (LF/HF) power indicates the balance between sympathetic/parasympathetic activities. Cortical response was evaluated by continuous electroencephalography and quantitative analysis. Parameters were quantified at 5-min intervals over the first-hour post-resuscitation. Neurological outcome was assessed by Neurological Deficit Score (NDS, range 0-80, higher = better outcomes) at 4-h post-resuscitation. RESULTS A significant increase in HR was noted over 15-30 min post-resuscitation (p < 0.01 vs.15-min, respectively) and correlated with higher NDS (rs = 0.56, p < 0.01). LF/HF ratio over 15-20 min was positively correlated with NDS (rs = 0.75, p < 0.05). Gamma band power surged over 15-30 min post-resuscitation (p < 0.05 vs. 0-15 min, respectively), and gamma band fraction during this period was associated with NDS (rs ≥0.70, p < 0.05, respectively). Significant correlations were identified between increased HR and gamma band power during 15-30 min (rs ≥0.83, p < 0.01, respectively) and between gamma band fraction and LF/HF ratio over 15-20 min post-resuscitation (rs = 0.85, p < 0.01). INTERPRETATIONS Hyperacute recovery of autonomic and cortical function is associated with favorable functional outcomes. While this observation needs further validation, it presents a translational opportunity for better autonomic and neurologic monitoring during early periods post-resuscitation to develop novel interventions.
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Affiliation(s)
- Yu Guo
- Department of Biomedical EngineeringJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Payam Gharibani
- Division of Neuroimmunology, Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Prachi Agarwal
- Department of Electrical and Computer EngineeringJohns Hopkins Whiting School of EngineeringBaltimoreMarylandUSA
| | - Sung‐Min Cho
- Departments of Neurology, Anesthesiology‐Critical Care Medicine and NeurosurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Nitish V. Thakor
- Department of Biomedical EngineeringJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Romergryko G. Geocadin
- Departments of Neurology, Anesthesiology‐Critical Care Medicine and NeurosurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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Appavu BL, Temkit MH, Foldes ST, Burrows BT, Jacobson AM, Mangum TK, Boerwinkle VL, Marku I, Abruzzo TA, Adelson PD. Quantitative Electroencephalography After Pediatric Anterior Circulation Stroke. J Clin Neurophysiol 2022; 39:610-615. [PMID: 33417384 PMCID: PMC9624379 DOI: 10.1097/wnp.0000000000000813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Regional differences were investigated in quantitative EEG (QEEG) characteristics and associations of QEEG to hemodynamics after pediatric acute stroke. METHODS Quantitative EEG was analyzed, including power in delta, theta, alpha, and beta bands, alpha-delta power ratio, total power, and spectral edge frequency from 11 children with unilateral, anterior circulation strokes during the first 24 hours of continuous EEG recording. Differences between injured and uninjured hemispheres were assessed using multivariate dynamic structural equations modeling. Dynamic structural equations modeling was applied to six children with hemorrhagic stroke undergoing arterial blood pressure, heart rate, and cerebral oximetry monitoring to investigate associations between hemodynamics with QEEG adjacent to anterior circulation regions. RESULTS All patients with acute ischemic stroke ( n = 5) had lower alpha and beta power and spectral edge frequency on injured compared with uninjured regions. This was not consistent after hemorrhagic stroke ( n = 6). All hemorrhagic stroke patients demonstrated negative association of total power with arterial blood pressure within injured regions. No consistency was observed for direction or strength of association in other QEEG measures to arterial blood pressure nor were such consistent relationships observed for any QEEG measure studied in relation to heart rate or cerebral oximetry. CONCLUSIONS After pediatric anterior circulation acute ischemic stroke, reduced spectral edge frequency and alpha and beta power can be observed on injured as compared with noninjured regions. After pediatric anterior circulation hemorrhagic stroke, total power can be negatively associated with arterial blood pressure within injured regions. Larger studies are needed to understand conditions in which QEEG patterns manifest and relate to hemodynamics and brain penumbra.
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Affiliation(s)
- Brian L. Appavu
- Department of Neurosciences, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A.; and
- Department of Child Health, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona, U.S.A
| | - M'hamed H. Temkit
- Department of Neurosciences, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A.; and
| | - Stephen T. Foldes
- Department of Neurosciences, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A.; and
- Department of Child Health, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona, U.S.A
| | - Brian T. Burrows
- Department of Neurosciences, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A.; and
| | - Austin M. Jacobson
- Department of Neurosciences, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A.; and
| | - Tara K. Mangum
- Department of Neurosciences, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A.; and
- Department of Child Health, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona, U.S.A
| | - Varina L. Boerwinkle
- Department of Neurosciences, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A.; and
- Department of Child Health, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona, U.S.A
| | - Iris Marku
- Department of Neurosciences, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A.; and
| | - Todd A. Abruzzo
- Department of Neurosciences, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A.; and
- Department of Child Health, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona, U.S.A
| | - Phillip D. Adelson
- Department of Neurosciences, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A.; and
- Department of Child Health, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona, U.S.A
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Prognosis After Cardiac Arrest: The Additional Value of DWI and FLAIR to EEG. Neurocrit Care 2022; 37:302-313. [DOI: 10.1007/s12028-022-01498-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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Keijzer HM, Hoedemaekers CWE. Timing is everything: Combining EEG and MRI to predict neurological recovery after cardiac arrest. Resuscitation 2020; 149:240-242. [PMID: 32084570 DOI: 10.1016/j.resuscitation.2020.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/12/2020] [Indexed: 10/25/2022]
Affiliation(s)
- H M Keijzer
- Department of Neurology, Rijnstate Hospital, Arnhem and Department of Intensive Care Medicine and Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, P.O. Box 9555, 6800 TA Arnhem, The Netherlands.
| | - C W E Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, P.O. Box 9101, 6500HB Nijmegen, The Netherlands.
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Lopez Soto C, Dragoi L, Heyn CC, Kramer A, Pinto R, Adhikari NKJ, Scales DC. Imaging for Neuroprognostication After Cardiac Arrest: Systematic Review and Meta-analysis. Neurocrit Care 2020; 32:206-216. [PMID: 31549351 DOI: 10.1007/s12028-019-00842-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Predicting neurological outcome in comatose survivors of cardiac arrest relies on clinical findings, radiological and neurophysiological test results. To evaluate the predictive accuracy of brain computed tomography (CT) and magnetic resonance imaging (MRI) for prognostication of neurological outcomes after cardiac arrest. METHODS We searched MEDLINE (database inception to August 2018) and included all observational cohort studies or randomized controlled trials including adult (16 years or older) survivors of cardiac arrest which evaluated the diagnostic accuracy of CT or MRI for predicting neurologic outcome or mortality. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. All review stages were conducted independently by 2 reviewers, and where possible data were pooled using bivariate meta-analysis. The main outcome was to evaluate the of accuracy of CT and MRI in neuroprognostication of patients after cardiac arrest. RESULTS We included 44 studies that examined brain CT (n = 24) or MRI (n = 21) in 4008 (n per study, 9-398) patients. Decreased grey to white matter ratio on CT (20 studies) was useful for predicting poor neurological outcome (sensitivity 0.44, 95% CI 0.29-0.60; specificity 0.97, 95% CI 0.93-0.99; positive likelihood ratio [LR+] 13.8, 95% CI 6.9-27.7). Similarly, diffusion-weighted imaging (DWI) on MRI (16 studies; sensitivity 0.77, 95% CI 0.65-0.85; specificity 0.92, 95% CI 0.85-0.96; LR+ 9.2, 95% CI 5.2-16.4) and DWI and fluid-attenuated inversion recovery (FLAIR) MRI (4 studies, sensitivity 0.70, 95% CI 0.43-0.88; specificity 0.95, 95% CI 0.79-0.99; LR+ 13.4, 95% CI 3.5-51.2) were useful for predicting poor neurological outcomes. We found marked heterogeneity in timing of radiological examinations and neurological assessments relative to the cardiac arrest. CONCLUSION Decreased grey to white matter ratio on CT and DWI or DWI and FLAIR on MRI are useful adjuncts for predicting poor early neurological outcome after cardiac arrest.
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Affiliation(s)
- Carmen Lopez Soto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Laura Dragoi
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Chinthaka C Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Andreas Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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9
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Barth R, Zubler F, Weck A, Haenggi M, Schindler K, Wiest R, Wagner F. Topography of MR lesions correlates with standardized EEG pattern in early comatose survivors after cardiac arrest. Resuscitation 2020; 149:217-224. [PMID: 31982504 DOI: 10.1016/j.resuscitation.2020.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 01/01/2020] [Accepted: 01/16/2020] [Indexed: 12/01/2022]
Abstract
AIM Multimodal prognostication in comatose patients after cardiac arrest (CA) is complicated by the fact that different modalities are usually not independent. Here we set out to systematically correlate early EEG and MRI findings. METHODS 89 adult patients from a prospective register who underwent at least one EEG and one MRI in the acute phase after CA were included. The EEGs were characterized using pre-existent standardized categories (highly malignant, malignant, benign). For MRIs, the apparent diffusion coefficient (ADC) was computed in pre-defined regions. We then introduced a novel classification based on the topography of ADC reduction (MR-lesion pattern (MLP) 1: no lesion; MLP 2: purely cortical lesions; MLP 3: involvement of the basal ganglia; MLP 4 involvement of other deep grey matter regions). RESULTS EEG background reactivity and EEG background continuity were strongly associated with a lower MLP value (p < 0.001 and p = 0.003 respectively). The EEG categories highly malignant, malignant and benign were strongly correlated with the MLP values (rho = 0.46, p < 0.001). CONCLUSION The MRI lesions are highly correlated with the EEG pattern. Our results suggest that performing MRI in comatose patients after CA with either highly malignant or with a benign EEG pattern is unlikely to yield additional useful information for prognostication, and should therefore be performed in priority in patients with intermediate EEG patterns ("malignant pattern").
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Affiliation(s)
- Rike Barth
- Sleep-Wake-Epilepsy Center, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Frederic Zubler
- Sleep-Wake-Epilepsy Center, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Anja Weck
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Intensive Care Medicine, Central Hospital Region Biel/Bienne, Biel/Bienne, Switzerland
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Kaspar Schindler
- Sleep-Wake-Epilepsy Center, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Roland Wiest
- Department of Diagnostic and Interventional Neuroradiology, Support Center for Advanced Neuroimaging (SCAN), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Franca Wagner
- Department of Diagnostic and Interventional Neuroradiology, Support Center for Advanced Neuroimaging (SCAN), Inselspital, Bern University Hospital, University of Bern, Switzerland
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10
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Wei R, Wang C, He F, Hong L, Zhang J, Bao W, Meng F, Luo B. Prediction of poor outcome after hypoxic-ischemic brain injury by diffusion-weighted imaging: A systematic review and meta-analysis. PLoS One 2019; 14:e0226295. [PMID: 31881032 PMCID: PMC6934311 DOI: 10.1371/journal.pone.0226295] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 11/24/2019] [Indexed: 01/16/2023] Open
Abstract
Accurate prediction of the neurological outcome following hypoxic–ischemic brain injury (HIBI) remains difficult. Diffusion-weighted imaging (DWI) can detect acute and subacute brain abnormalities following global cerebral hypoxia. Therefore, DWI can be used to predict the outcomes of HIBI. To this end, we searched the PubMed, EMBASE, and Cochrane Library databases for studies that examine the diagnostic accuracy of DWI in predicting HIBI outcomes in adult patients between January1995 and September 2019. Next, we conducted a comprehensive meta-analysis using the Meta-DiSc and several complementary techniques. Following the application of inclusion and exclusion criteria, a total of 28 studies were included with 98 data subsets. The overall sensitivity and specificity, with 95% confidence interval, were 0.613(0.599–0.628) and 0.958(0.947–0.967), respectively, and the area under the curve was 0.9090. Significant heterogeneity among the included studies and a threshold effect were observed (p<0.001). Different positive indices were the major sources for the heterogeneity, followed by the anatomical region examined, both of which significantly affected the prognostic accuracy. In conclusion, we demonstrated that DWI can be an instrumental modality in predicting the outcome of HIBI with good prognostic accuracy. However, the lack of clear and generally accepted positive indices limits its clinical application. Therefore, using more reliable positive indices and combining DWI with other clinical predictors may improve the diagnostic accuracy of HIBI.
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Affiliation(s)
- Ruili Wei
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chaonan Wang
- Department of Geriatrics, Shulan (Hangzhou) Hospital, Hangzhou, China
| | - Fangping He
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lirong Hong
- Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Jie Zhang
- Department of Rehabilitation, Hangzhou Hospital of Zhejiang CAPR, Hangzhou, China
| | - Wangxiao Bao
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fangxia Meng
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Benyan Luo
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- * E-mail:
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11
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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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12
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Chang JJ, Tsivgoulis G, Goyal N, Alsherbini K, Schuring C, Shrestha R, Yankovich A, Metter JE, Sareen S, Elijovich L, Malkoff MD, Murillo L, Kadaria D, Alexandrov AV, Sodhi A. Prognostication via early computed tomography head in patients treated with targeted temperature management after cardiac arrest. J Neurol Sci 2019; 406:116437. [PMID: 31521958 DOI: 10.1016/j.jns.2019.116437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/10/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND We evaluated computed tomography head (CTH) imaging obtained prior to targeted temperature management (TTM) in patients after cardiac arrest, and its role in prognostication. METHODS In this retrospective cohort study in a tertiary-care hospital, 341 adults presenting with out-of-hospital cardiac arrest received a CTH prior to TTM. Associations between outcomes and neuroimaging variables were evaluated with Chi-square analysis for significant associations that yielded a composite neuroimaging score-Tennessee Early Neuroimaging Score (TENS). Univariable and multivariable logistic regression analysis including TENS as an independent variable and the four outcome dependent variables were analyzed. RESULTS Four of the neuroimaging variables-sulcal effacement, partial gray-white matter effacement, total gray-white matter effacement, deep nuclei effacement-had significant associations with each of the four outcome variables and yielded TENS. In multivariable logistic regression models adjusted for potential confounders, TENS was associated with poor discharge CPC (OR 2.15, 95%CI 1.16-3.98, p = .015), poor disposition (OR 2.62, 95%CI 1.37-5.02, p = .004), in-hospital mortality (OR 1.99, 95%CI 1.09-3.62, p = .024), and ICU mortality (OR 1.89, 95%CI 1.12-3.20, p = .018). CONCLUSION Imaging prior to TTM may help identify post-cardiac arrest patients with severe anoxic brain injury and poor outcomes.
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Affiliation(s)
- Jason J Chang
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA.
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Second Department of Neurology, "Attikon University Hospital", National & Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Khalid Alsherbini
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Craig Schuring
- Division of Pulmonary and Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rabin Shrestha
- Division of Pulmonary and Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrei Yankovich
- Division of Pulmonary and Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeffrey E Metter
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Srishti Sareen
- Division of Pulmonary and Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Marc D Malkoff
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Luis Murillo
- Division of Pulmonary and Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Dipen Kadaria
- Division of Pulmonary and Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Amik Sodhi
- Division of Pulmonary and Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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13
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Geocadin RG, Callaway CW, Fink EL, Golan E, Greer DM, Ko NU, Lang E, Licht DJ, Marino BS, McNair ND, Peberdy MA, Perman SM, Sims DB, Soar J, Sandroni C. Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e517-e542. [DOI: 10.1161/cir.0000000000000702] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Significant improvements have been achieved in cardiac arrest resuscitation and postarrest resuscitation care, but mortality remains high. Most of the poor outcomes and deaths of cardiac arrest survivors have been attributed to widespread brain injury. This brain injury, commonly manifested as a comatose state, is a marker of poor outcome and a major basis for unfavorable neurological prognostication. Accurate prognostication is important to avoid pursuing futile treatments when poor outcome is inevitable but also to avoid an inappropriate withdrawal of life-sustaining treatment in patients who may otherwise have a chance of achieving meaningful neurological recovery. Inaccurate neurological prognostication leading to withdrawal of life-sustaining treatment and deaths may significantly bias clinical studies, leading to failure in detecting the true study outcomes. The American Heart Association Emergency Cardiovascular Care Science Subcommittee organized a writing group composed of adult and pediatric experts from neurology, cardiology, emergency medicine, intensive care medicine, and nursing to review existing neurological prognostication studies, the practice of neurological prognostication, and withdrawal of life-sustaining treatment. The writing group determined that the overall quality of existing neurological prognostication studies is low. As a consequence, the degree of confidence in the predictors and the subsequent outcomes is also low. Therefore, the writing group suggests that neurological prognostication parameters need to be approached as index tests based on relevant neurological functions that are directly related to the functional outcome and contribute to the quality of life of cardiac arrest survivors. Suggestions to improve the quality of adult and pediatric neurological prognostication studies are provided.
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14
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Rittenberger JC. In search of a needle. Resuscitation 2018; 131:A5-A6. [DOI: 10.1016/j.resuscitation.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
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15
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Keijzer HM, Hoedemaekers CWE, Meijer FJA, Tonino BAR, Klijn CJM, Hofmeijer J. Brain imaging in comatose survivors of cardiac arrest: Pathophysiological correlates and prognostic properties. Resuscitation 2018; 133:124-136. [PMID: 30244045 DOI: 10.1016/j.resuscitation.2018.09.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 09/12/2018] [Accepted: 09/14/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Hypoxic-ischemic brain injury is the main cause of death and disability of comatose patients after cardiac arrest. Early and reliable prognostication is challenging. Common prognostic tools include clinical neurological examination and electrophysiological measures. Brain imaging is well established for diagnosis of focal cerebral ischemia but has so far not found worldwide application in this patient group. OBJECTIVE To review the value of Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET) for early prediction of neurological outcome of comatose survivors of cardiac arrest. METHODS A literature search was performed to identify publications on CT, MRI or PET in comatose patients after cardiac arrest. RESULTS We included evidence from 51 articles, 21 on CT, 27 on MRI, 1 on CT and MRI, and 2 on PET imaging. Studies varied regarding timing of measurements, choice of determinants, and cut-off values predicting poor outcome. Most studies were small (n = 6-398) and retrospective (60%). In general, cytotoxic oedema, defined by a grey-white matter ratio <1.10, derived from CT, or MRI-diffusion weighted imaging <650 × 10-6 mm2/s in >10% of the brain could differentiate between patients with favourable and unfavourable outcomes on a group level within 1-3 days after cardiac arrest. Advanced imaging techniques such as functional MRI or diffusion tensor imaging show promising results, but need further evaluation. CONCLUSION CT derived grey-white matter ratio and MRI based measures of diffusivity and connectivity hold promise to improve outcome prediction after cardiac arrest. Prospective validation studies in a multivariable approach are needed to determine the additional value for the individual patient.
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Affiliation(s)
- H M Keijzer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands; Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands; Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - C W E Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - F J A Meijer
- Department of Radiology and Nuclear medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B A R Tonino
- Department of Radiology, Rijnstate Hospital Arnhem, the Netherlands
| | - C J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands; Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
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Beretta S, Padovano G, Stabile A, Coppo A, Bogliun G, Avalli L, Ferrarese C. Efficacy and safety of perampanel oral loading in postanoxic super-refractory status epilepticus: A pilot study. Epilepsia 2018; 59 Suppl 2:243-248. [DOI: 10.1111/epi.14492] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Simone Beretta
- Epilepsy Center; San Gerardo Hospital Monza; University of Milano Bicocca; Monza Italy
| | - Giada Padovano
- Epilepsy Center; San Gerardo Hospital Monza; University of Milano Bicocca; Monza Italy
| | - Andrea Stabile
- Epilepsy Center; San Gerardo Hospital Monza; University of Milano Bicocca; Monza Italy
| | - Anna Coppo
- Department of Intensive Care; San Gerardo Hospital Monza; Monza Italy
| | - Graziella Bogliun
- Epilepsy Center; San Gerardo Hospital Monza; University of Milano Bicocca; Monza Italy
| | - Leonello Avalli
- Department of Intensive Care; San Gerardo Hospital Monza; Monza Italy
| | - Carlo Ferrarese
- Epilepsy Center; San Gerardo Hospital Monza; University of Milano Bicocca; Monza Italy
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17
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Lyden P, Rittenberger J, Rincon F. Perspectives on Temperature Management. Ther Hypothermia Temp Manag 2017; 7:188-192. [DOI: 10.1089/ther.2017.29035.pjl] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Patrick Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Fred Rincon
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania
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18
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Rittenberger J, Kurz M, Polderman KH. Therapeutic Hypothermia in Postcardiac Arrest. Ther Hypothermia Temp Manag 2017; 7:184-187. [PMID: 29027885 DOI: 10.1089/ther.2017.29036.jjr] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jon Rittenberger
- 1 Department of Emergency Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Michael Kurz
- 2 Department of Emergency Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Kees H Polderman
- 3 Department of Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
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Youn CS, Callaway CW, Rittenberger JC. Combination of initial neurologic examination, quantitative brain imaging and electroencephalography to predict outcome after cardiac arrest. Resuscitation 2016; 110:120-125. [PMID: 27840004 DOI: 10.1016/j.resuscitation.2016.10.024] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 10/27/2016] [Accepted: 10/30/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prognosticating outcome following cardiac arrest is challenging and requires a multimodal approach. We tested the hypothesis that the combination of initial neurologic examination, quantitative analysis of head computed tomography (CT) and continuous EEG (cEEG) improve outcome prediction after cardiac arrest. METHODS Review of consecutive patients receiving head CT within 24h and cEEG monitoring between April 2010 and May 2013. Initial neurologic examination (Full Outline of UnResponsiveness_Brainstem reflexes (FOUR_B) score and initial Pittsburgh Post-Cardiac Arrest Category (PCAC)), gray matter to white matter attenuation ratio (GWR) on head CT and cEEG patterns were evaluated. The primary outcome was in-hospital mortality. RESULTS Of 240 subjects, 70 (29%) survived and 22 (9%) had a good neurologic outcome at hospital discharge. Combined determination of GW ratio and malignant cEEG had an incremental predictive value (AUC: 0.776 for mortality and 0.792 for poor neurologic outcome), with 0% false positive rate when compared with either test alone (AUC of GW ratio: 0.683 for mortality and 0.726 for poor outcome, AUC of malignant cEEG: 0.650 for mortality and 0.647 for poor outcome). Addition of FOUR_B or PCAC to this model improved prediction of mortality (p=0.014 for FOUR_B and 0.001 for PCAC) but not of poor outcome (p=0.786 for FOUR_B and 0.099 for PCAC). CONCLUSIONS Combining GWR with cEEG was superior to any individual test for predicting mortality and neurologic outcome. Addition of clinical variables further improved prognostication for mortality but not neurologic outcome. These preliminary data support a multi-modal prognostic workup in this population.
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Affiliation(s)
- Chun Song Youn
- Department of Emergency Medicine, The Catholic University of Korea, Republic of Korea
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States.
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