Rossetti AO, Oddo M, Logroscino G, Kaplan PW. Prognostication after cardiac arrest and hypothermia: a prospective study
ABSTRACT Current American Academy of Neurology (AAN) guidelines for outcome prediction in comatose survivors of cardiac arrest (CA) have been validated before the therapeutic hypothermia era (TH). We undertook this study to verify the prognostic value of clinical and electrophysiological variables in the TH setting.
A total of 111 consecutive comatose survivors of CA treated with TH were prospectively studied over a 3-year period. Neurological examination, electroencephalography (EEG), and somatosensory evoked potentials (SSEP) were performed immediately after TH, at normothermia and off sedation. Neurological recovery was assessed at 3 to 6 months, using Cerebral Performance Categories (CPC).
Three clinical variables, assessed within 72 hours after CA, showed higher false-positive mortality predictions as compared with the AAN guidelines: incomplete brainstem reflexes recovery (4% vs 0%), myoclonus (7% vs 0%), and absent motor response to pain (24% vs 0%). Furthermore, unreactive EEG background was incompatible with good long-term neurological recovery (CPC 1-2) and strongly associated with in-hospital mortality (adjusted odds ratio for death, 15.4; 95% confidence interval, 3.3-71.9). The presence of at least 2 independent predictors out of 4 (incomplete brainstem reflexes, myoclonus, unreactive EEG, and absent cortical SSEP) accurately predicted poor long-term neurological recovery (positive predictive value = 1.00); EEG reactivity significantly improved the prognostication.
Our data show that TH may modify outcome prediction after CA, implying that some clinical features should be interpreted with more caution in this setting as compared with the AAN guidelines. EEG background reactivity is useful in determining the prognosis after CA treated with TH.
- SourceAvailable from: Lawrence James Hirsch
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- "S1–S3). Since recent studies have identified the absence of background reactivity as a predictor of poor outcome after cardiac arrest (Rossetti et al., 2010; Crepeau et al., 2013), there may be a common pathophysiology linking the absence of variability or reactivity to poor outcome regardless of the primary neurological insult. Although the term ''triphasic " only achieved fair IRA, we designed the study to compare individual rater perceptions with actual clinical outcomes rather than using a 'gold standard' in Table 1 Survey questions and inter-rater agreement. "
ABSTRACT: Generalized periodic discharges (GPDs) are associated with nonconvulsive seizures. Triphasic waves (TWs), a subtype of GPDs, have been described in relation to metabolic encephalopathy and not felt to be associated with seizures. We sought to establish the consistency of use of this descriptive term and its association with seizures. 11 experts in continuous EEG monitoring scored 20 cEEG samples containing GPDs using Standardized Critical Care EEG Terminology. In the absence of patient information, the inter-rater agreement (IRA) for EEG descriptors including TWs was assessed along with raters' clinical EEG interpretation and compared with actual patient information. The IRA for 'generalized' and 'periodic' was near-perfect (kappa=0.81), but fair for 'triphasic' (kappa=0.33). Patients with TWs were as likely to develop seizures as those without (25% vs 26%, N.S.) and surprisingly, patients with TWs were less likely to have toxic-metabolic encephalopathy than those without TWs (55% vs 79%, p<0.01). While IRA for the terms "generalized" and "periodic" is high, it is only fair for TWs. EEG interpreted as TWs presents similar risk for seizures as GPDs without triphasic appearance. GPDs are commonly associated with metabolic encephalopathy, but 'triphasic' appearance is not predictive. Conventional association of 'triphasic waves' with specific clinical conditions may lead to inaccurate EEG interpretation. Copyright © 2015 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.Clinical neurophysiology: official journal of the International Federation of Clinical Neurophysiology 08/2015; DOI:10.1016/j.clinph.2015.07.018 · 3.10 Impact Factor
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- "Our patient survived only because her parents insisted on continued intensive care treatment despite the firm conviction of her neurologists that she would remain unconscious because of absent cortical SEP responses. This “accurate” predictor of poor outcome has an estimated false positive ratio of 0.7% (95% confidence interval 0.1 to 3.7) , even after therapeutic hypothermia . The MRI shows why the SEP had been misleading in our patient: the primary sensory cortex, the generator of the N20-component of the SEP, was one of the few cortical areas with altered DWI signals. "
ABSTRACT: Bilaterally absent N20 components of the sensory evoked potentials (SEP) from the median nerve are regarded as accurately predicting poor outcome after cardiac arrest. We are reporting on a patient, who regained consciousness despite this ominous finding. Early after cardiac arrest, MRI showed signal alterations in diffusion weighted imaging (DWI) bilaterally in the primary visual and sensorimotor cortex and in the basal ganglia. SEP were repeatedly absent. The patient survived shut out form sensory and visual experience and locked in for voluntary movements, but kept her verbal competence in several languages. SEP inform about integrity only of a narrow cortical strip. It is unguarded, but common practice, to conclude from absent SEP, that a patient has suffered diffuse cortical damage after cardiac arrest. Cerebral MRI with DWI helps to avoid this prognostic error and furthers understanding of the sometimes very peculiar state of mind after cardiac arrest.BMC Neurology 04/2014; 14(1):82. DOI:10.1186/1471-2377-14-82 · 2.04 Impact Factor
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- "Early prognostication of neurological outcome after successful cardiopulmonary resuscitation using clinical examination alone is difficult and has become more complicated with the introduction of therapeutic hypothermia as a treatment strategy for comatose cardiac arrest patients. Hypothermia affects the metabolism of sedative drugs, and lingering sedation has been found to be an important reason for the decreased reliability of a clinical neurological examination to predict poor outcome after cardiac arrest, as reported by several authors [2,3]. Hence, there is a need for novel methods to estimate the extent of brain injury and predict outcome. "
ABSTRACT: Early prognostication after successful cardiopulmonary resuscitation is difficult and there is a need for novel methods to estimate the extent of brain injury and predict outcome. In this study, we evaluate the impact of the cardiac arrest syndrome on the plasma levels of selected tissue-specific microRNAs (miRNAs) and assess their ability to prognosticate death and neurological disability. We included 65 patients treated with hypothermia after cardiac arrest in the study. Blood samples were obtained at 24 hours and at 48 hours. For miRNA-screening purposes, custom quantitative polymerase chain reaction (qPCR)-panels were first used. Thereafter, individual miRNAs were assessed at 48 hours with qPCR. miRNAs successful at predicting prognosis at 48 hours were further analyzed at 24 hours. Outcome was measured according to the Cerebral Performance Categories scale (CPC) at 6 months after cardiac arrest and stratified into good (CPC 1-2) or poor (CPC 3-5). At 48 hours, miR-146a, miR-122, miR-208b, miR-21, miR-9 and miR-128 did not differ between the good and poor neurological outcome groups. In contrast, miR-124 was significantly elevated in patients with poor outcome compared to those with a favorable outcome (P <0.0001) at 24 hours and 48 hours after cardiac arrest. Analysis of receiver operating curves showed an area under the curve of 0.87 (95% confidence interval (CI) 0.79 to 0.96) at 24 hours and of 0.89 (95% CI 0.80 to 0.97) at 48 hours after cardiac arrest. The brain-enriched miRNA miR-124 is a promising novel biomarker for prediction of neurological prognosis following cardiac arrest.Critical care (London, England) 03/2014; 18(2):R40. DOI:10.1186/cc13753 · 4.48 Impact Factor