Prognostic Value of Magnetic Resonance Imaging in Post-Resuscitation Encephalopathy

Department of Neurology, Hacettepe University Hospitals, Ankara, Turkey.
Internal Medicine (Impact Factor: 0.9). 01/2009; 48(18):1635-45. DOI: 10.2169/internalmedicine.48.2091
Source: PubMed


Prediction of the prognosis of comatose survivors after cardiopulmonary arrest (CPA), so-called post-resuscitation encephalopathy (PRE), relies on neurological examination findings. Early laboratory indicators of poor prognosis (vegetative state/death) are not sensitive enough.
We analyzed the results of magnetic resonance (MR) imaging with fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) in 22 consecutive patients with PRE. Clinical details such as arrest place and anoxia time along with neurological examination findings including items of Glasgow coma scale (GCS) and the Full Outline of UnResponsiveness (FOUR) score were determined. Receiver Operator Characteristics (ROC) curves were produced to determine prognostic yield of the parameters studied.
Prognosis was classified as 'poor' (Glasgow-Pittsburg Cerebral Performance -CPC-score 4 or 5) in 16 and 'better' (CPC score 1-3) in 6 patients. The lower limit of confidence interval (CI) of the area under the curve (AUC) of the ROC was higher than 0.5 for visual, motor and total scores of GCS and FOUR score. Presence of a lesion pattern of multilobar, or diffuse, cortical involvement, termed as "extensive cortical lesion pattern" in MR imaging was a very good predictor of poor prognosis with an AUC of ROC of 0,937. Sensitivity of GCS motor part score and MR was 87.5% (95% CI: 61.6%-92.6%). Motor part of the FOUR score has a slightly lower sensitivity (68.7% with 95% CI from 41.4% to 88.9%). Incorporating of MR to the motor scores (either GCS or FOUR score) improved sensitivity to 100 % (95% CI: 79.2%-100%). AUC of the ROC was 1.000 (95%CI: 0.844-1.000) for the combination of MR and GCS motor score.
This study provides the preliminary evidence that MRI, when used in conjunction with a neurological examination, may have potential in terms of predicting outcome in patients with PRE.

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    • "Prognostic assessment after cardiac arrest should include DWI. An extensive cortical MRI lesion pattern was associated with poor outcome in 22 consecutive patients, whereas a regional pattern as in our patient was less ominous [17]. Less than 10% of the brain volume had reduced absolute diffusion coefficients in survivors of post-cardiac arrest, whereas 10 to 40% of the brain was involved in most patients who died Figure four in ref. [18]. "
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    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.
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    • "Most patients need additional but less-proven investigations, the most promising emerging modality being MRI brain.[9] An abnormal MRI with multilobar, or diffuse, cortical involvement, termed as “extensive cortical lesion pattern” or extensive basal ganglia abnormalities, may have a reliable poor prognostic value with the above-mentioned limitation of poor sensitivity.[9–12] "
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