101
|
Peskine A, Cariou A, Hajage D, Deye N, Guérot E, Dres M, Sonneville R, Lafourcade A, Navarro V, Robert H, Azouvi P, Sharshar T, Bayen E, Luyt CE. Long-Term Disabilities of Survivors of Out-of-Hospital Cardiac Arrest: The Hanox Study. Chest 2020; 159:699-711. [PMID: 32702410 DOI: 10.1016/j.chest.2020.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 07/03/2020] [Accepted: 07/10/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Long-term outcomes of awakened survivors of out-of-hospital cardiac arrest (OHCA) are poorly known. RESEARCH QUESTION What are the month (M) 18 outcomes of survivors of out-of-hospital cardiac arrest (OHCA) who awakened during the first 2 weeks' post-OHCA and their poor-outcome risk factors? STUDY DESIGN AND METHODS All OHCA survivors with a Glasgow Coma Scale score ≥12 during the first 2 weeks' post-OHCA were enrolled in six ICUs and followed up at M3, M6, M12, and M18. The primary outcome measure was Glasgow Outcome Scale-Extended (GOS-E) score at M18. Secondary outcome measures included evaluation at M18 of neurologic, behavioral, and cognitive disabilities; health-related quality of life (HR-QOL), anxiety and depression; and poor-outcome risk factors (GOS-E score ≤ 6). RESULTS Among the 139 included patients, 98 were assessable for the primary outcome measure. At M18, 64 (65%) had full recovery or minor disabilities (GOS-E score > 6), 18 (18%) had moderate disabilities but were autonomous for daily-life activities (GOS-E score = 6), 12 (12%) had poor autonomy (GOS-E score < 6 but > 1), and four had died. Percentages of patients with GOS-E scores > 6 increased significantly over the 18-month study period. At M18, no patients had major neurologic disabilities, 20% had cognitive disabilities, 32% had anxiety symptoms, 25% had depression symptoms, and their HR-QOL was impaired compared with a sex- and age-matched population. Low-flow time, Sequential Organ Failure Assessment score at admission, coma duration > 3 days after cardiac arrest, and mechanical ventilation on days 3 and 7 were associated with poor functional outcome. INTERPRETATION Among patients who awoke (Glasgow Coma Scale score ≥12) in the 14 days following OHCA, 35% had moderate to severe disabilities or had died at M18. Interestingly, patients improved until M18 post-OHCA. Risk factors associated with poor functional outcome were low-flow time, clinical severity at ICU admission, prolonged coma duration, and mechanical ventilation. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT02292147; URL: www.clinicaltrials.gov.
Collapse
Affiliation(s)
- Anne Peskine
- Service de Médecine Physique et Réadaptation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Alain Cariou
- Service de Médecine Intensive Réanimation, Hôpital Cochin, APHP, Paris et Université de Paris, Faculté de Médecine, Paris, France
| | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre-Louis d'Epidémiologie et de Santé Publique, APHP, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Nicolas Deye
- Service de Médecine Intensive Réanimation, Hôpital Lariboisière, APHP, Paris, France
| | - Emmanuel Guérot
- Service de Médecine Intensive Réanimation, Hôpital Européen Georges-Pompidou, APHP, Paris, France
| | - Martin Dres
- Service de Pneumologie et Médecine Intensive Réanimation (département R3S), Groupe Hospitalier Pitié-Salpêtrière, APHP, Paris, France
| | - Romain Sonneville
- Service de Médecine Intensive Réanimation, Hôpital Bichat-Claude-Bernard, APHP, Paris, France
| | - Alexandre Lafourcade
- Sorbonne Université, INSERM, Institut Pierre-Louis d'Epidémiologie et de Santé Publique, APHP, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Vincent Navarro
- Sorbonne Université, ICM (Institut du Cerveau et de la Moelle Epinière), INSERM, CNRS, and Unité d'Épilepsie et d'EEG, Groupe Hospitalier Pitié-Salpêtrière, APHP, Paris, France
| | - Hélène Robert
- Service de Médecine Physique et Réadaptation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Philippe Azouvi
- Service de Médecine Physique et Réadaptation, Hôpital Raymond-Poincaré, APHP, Garches, France
| | - Tarek Sharshar
- Service de Réanimation Neurochirurgicale, Hôpital Sainte-Anne, Paris, France
| | - Eleonore Bayen
- Service de Médecine Physique et Réadaptation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Charles-Edouard Luyt
- Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, and Service de Médecine Intensive Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, APHP, Paris, France.
| | | |
Collapse
|
102
|
Minami Y, Mishima S, Oda J. Prediction of the level of consciousness using pupillometer measurements in patients with impaired consciousness brought to the emergency and critical care center. Acute Med Surg 2020; 7:e537. [PMID: 32685175 PMCID: PMC7358821 DOI: 10.1002/ams2.537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/26/2020] [Accepted: 06/04/2020] [Indexed: 11/13/2022] Open
Abstract
Aim We investigated whether the level of consciousness can be predicted using pupillometer measurements in patients with severe disturbance of consciousness. Methods Patients with a Glasgow Coma Scale (GCS) of 3–8, except for those after cardiac arrest, were included. Pupillary contraction rate and contraction velocity were each measured using a pupillometer. Results Thirty‐five patients were analyzed. At the time of discharge or changing hospitals, 16 patients had a GCS score of 3–13 and 19 patients had a GCS score of 14–15. In the non‐sedative group at about the time of arrival at our hospital, average pupillary contraction rates were 18.36% in the GCS 3–13 group and 19.67% in the GCS 14–15 group (P = 0.739), and average pupillary contraction velocities were 1.02 and 1.48, respectively (P = 0.182). Approximately 48 h after arrival, average pupillary contraction rates were 21.18% and 29.27%, respectively (P = 0.058), and average pupillary contraction velocities were 1.37 and 1.91, respectively (P = 0.172). Among the sedative group, at about the time of arrival, average pupillary contraction rates were 8.75% in the GCS 3–13 group and 19.75% in the GCS 14–15 group (P = 0.032). Average pupillary contraction velocities were 0.34 and 1.48, respectively (P = 0.001). Approximately 48 h after arrival, average pupillary contraction rates were 13.50% and 13.50%, respectively (P = 1.00), and average pupillary contraction velocities were 0.80 and 0.82, respectively (P = 0.93). Conclusions Pupillometer measurements could predict level of consciousness of patients with severe consciousness disorder.
Collapse
Affiliation(s)
- Yosuke Minami
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Shiro Mishima
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Jun Oda
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| |
Collapse
|
103
|
Admiraal MM, Horn J, Hofmeijer J, Hoedemaekers CW, van Kaam C, Keijzer HM, van Putten MJ, Schultz MJ, van Rootselaar AF. EEG reactivity testing for prediction of good outcome in patients after cardiac arrest. Neurology 2020; 95:e653-e661. [DOI: 10.1212/wnl.0000000000009991] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 01/17/2020] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo determine the additional value of EEG reactivity (EEG-R) testing to EEG background pattern for prediction of good outcome in adult patients after cardiac arrest (CA).MethodsIn this post hoc analysis of a prospective cohort study, EEG-R was tested twice a day, using a strict protocol. Good outcome was defined as a Cerebral Performance Category score of 1–2 within 6 months. The additional value of EEG-R per EEG background pattern was evaluated using the diagnostic odds ratio (DOR). Prognostic value (sensitivity and specificity) of EEG-R was investigated in relation to time after CA, sedative medication, different stimuli, and repeated testing.ResultsBetween 12 and 24 hours after CA, data of 108 patients were available. Patients with a continuous (n = 64) or discontinuous (n = 19) normal voltage background pattern with reactivity were 3 and 8 times more likely to have a good outcome than without reactivity (continuous: DOR, 3.4; 95% confidence interval [CI], 0.97–12.0; p = 0.06; discontinuous: DOR, 8.0; 95% CI, 1.0–63.97; p = 0.0499). EEG-R was not observed in other background patterns within 24 hours after CA. In 119 patients with a normal voltage EEG background pattern, continuous or discontinuous, any time after CA, prognostic value was highest in sedated patients (sensitivity 81.3%, specificity 59.5%), irrespective of time after CA. EEG-R induced by handclapping and sternal rubbing, especially when combined, had highest prognostic value. Repeated EEG-R testing increased prognostic value.ConclusionEEG-R has additional value for prediction of good outcome in patients with discontinuous normal voltage EEG background pattern and possibly with continuous normal voltage. The best stimuli were clapping and sternal rubbing.
Collapse
|
104
|
Hannawi Y, Muschelli J, Mulder M, Sharrock M, Storm C, Leithner C, Crainiceanu CM, Stevens RD. Postcardiac arrest neurological prognostication with quantitative regional cerebral densitometry. Resuscitation 2020; 154:101-109. [PMID: 32629092 DOI: 10.1016/j.resuscitation.2020.06.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/14/2020] [Accepted: 06/16/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To quantitatively assess the severity of anoxic-ischemic brain injury early after cardiac arrest (CA) using a novel automated method applied to head computed tomography (HCT). METHODS Adult patients who were comatose and underwent HCT < 24 h after arrest were included in a retrospective analysis. Principal endpoint was unfavorable outcome (UO) defined as Cerebral Performance Category (CPC) of 3-5 at hospital discharge. We developed an automated processing algorithm for HCT images to be registered, atlas-segmented in 181 regions, and region-specific radiologic densities determined in Hounsfield Units. This approach was compared with an established manual method evaluating grey-white matter ratios (GWR). We tested univariable and multivariable prognostic models which integrated clinical and HCT features including densities in lobes and in nodes of cerebral networks linked to CA recovery. RESULTS Ninety-one patients were enrolled among whom 66 (73%) had an UO. HCTs were interpreted as normal or without acute abnormality by a neuroradiologist in 77 cases (85%). Compared to the favorable outcome group, UO patients had significantly lower densities in all lobes and in nodes of cerebral networks. A model combining clinical variables with the automated method applied to cerebral network nodes had the highest prognostic performance although not significantly different than the combined clinical-GWR method (AUC [95% CI] 0.94 [0.86-1.00] and 0.92 [0.83-1.00] respectively). CONCLUSION In comatose survivors of CA, automated quantitative analysis of HCT revealed very early multifocal changes in brain tissue density which are mostly overlooked on conventional neuroradiologic interpretation and are associated with neurological outcome.
Collapse
Affiliation(s)
- Yousef Hannawi
- Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - John Muschelli
- Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Maximilian Mulder
- Department of Critical Care, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Matthew Sharrock
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA; Neurology, The Johns Hopkins University, Baltimore, MD, USA
| | - Christian Storm
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA; Department of Nephrology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Germany
| | | | | | - Robert D Stevens
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA; Neurology, The Johns Hopkins University, Baltimore, MD, USA; Neurosurgery, The Johns Hopkins University, Baltimore, MD, USA; Radiology, The Johns Hopkins University, Baltimore, MD, USA.
| |
Collapse
|
105
|
Yang S, Wang X, Gu H, Wang D, Guan T, Liao W, Peng X. Prognostic value of magnetic resonance imaging performed during the subacute phase in adult patients with hypoxic-ischemic encephalopathy for long-term neurological outcomes. J Stroke Cerebrovasc Dis 2020; 29:104950. [PMID: 32689616 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104950] [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: 01/19/2020] [Revised: 04/20/2020] [Accepted: 05/06/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To investigate the value of a model based on brain magnetic resonance imaging (MRI) performed in the subacute phase (between the 1st and 30th day) in predicting long-term neurological outcomes of adult hypoxic-ischemic encephalopathy (HIE) patients. METHODS Ninety-six adult HIE patients who underwent conventional MRI and diffusion-weighted imaging (DWI) during the subacute phase were retrospectively analyzed. Favorable (Cerebral Performance Categories (CPC) 1-2) and unfavorable outcome (CPC 3-5) groups were created based on patient neurological status approximately three months after the onset of hypoxic-ischemic events. A multivariate stepwise regression model was applied after univariate analysis of MRI findings, and then the overall MRI score, Alberta Stroke Program Early Computed Tomography Score (ASPECTS), Bilateral ASPECTS (Bi-ASPECTS), modified ASPECTS (mASPECTS) and Bi-ASPECTS combined with posterior circulation ASPECTS (PC-ASPECTS) were calculated based on MRI findings. Receiver operating characteristic (ROC) curves were used to assess prognostic accuracy. RESULTS Both univariate and multivariate analyses showed the cerebral cortex and cerebellum, neostriatum, hippocampus, brainstem and postanoxic leukoencephalopathy were independent prognostic factors for unfavorable outcomes. The multivariate regression analysis resulted in an overall classification accuracy of 84.4%, a sensitivity of 84.2% (95% CI, 71.6-92.1%), and a specificity of 92.3% (95% CI, 78.0-98.0%) for unfavorable outcomes. The model had an areas under the ROC curves (AUC) of 0.944 (95% CI, 0.901-0.987); the MRI overall scores were 0.918 (95% CI, 0.866, 0.971), ASPECTS 0.839 (95% CI, 0.755, 0.923), Bi-ASPECTS 0.837 (95% CI, 0.753, 0.922), mASPECTS 0.851(95% CI, 0.771, 0.931) and Bi-ASPECTS+PC-ASPECTS 0.876 (95% CI, 0.806, 0.946). CONCLUSIONS The multivariate model based on conventional MRI combined with DWI performed in the subacute phase could help predict the prognosis of adult HIE with high performance.
Collapse
Affiliation(s)
- Shuai Yang
- Department of Radiology, Xiangya Hospital, Central South University; 87 Xiangya Road, Changsha 410008, China
| | - Xiaoyi Wang
- Department of Radiology, Xiangya Hospital, Central South University; 87 Xiangya Road, Changsha 410008, China
| | - Huimin Gu
- Department of Infectious Diseases, Xiangya Hospital, Central South University; 87 Xiangya Road, Changsha 410008, China
| | - Dongcui Wang
- Department of Radiology, Xiangya Hospital, Central South University; 87 Xiangya Road, Changsha 410008, China
| | - Tingting Guan
- Department of Radiology, Xiangya Hospital, Central South University; 87 Xiangya Road, Changsha 410008, China
| | - Weihua Liao
- Department of Radiology, Xiangya Hospital, Central South University; 87 Xiangya Road, Changsha 410008, China
| | - Xianjing Peng
- Department of Radiology, Xiangya Hospital, Central South University; 87 Xiangya Road, Changsha 410008, China.
| |
Collapse
|
106
|
Qualitative and quantitative analysis of diffusion-weighted brain MR imaging in comatose survivors after cardiac arrest. Neuroradiology 2020; 62:1361-1369. [PMID: 32500276 DOI: 10.1007/s00234-020-02460-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/13/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study is to compare a qualitative and a quantitative assessment of brain diffusion-weighted imaging (DWI) in predicting outcome of comatose patients after cardiac arrest (CA). METHODS Two observers used a scoring template to analyze the DWI of 75 patients. A total of 13 regions were scored from 0 to 3 (0 = normal, 1 = probably normal, 2 = probably abnormal, 3 = definitely abnormal). The total cerebral cortex (TCC), the total deep grey nuclei (TDGN), the total brain stem, the total cerebellum, and the total brain score were calculated. Intra- and inter-observer variability were tested. The mean whole brain apparent diffusion coefficient (ADC) values and percentage of voxels below a specific ADC value cut-off were calculated. The data were correlated with clinical outcome (cerebral performance category score after 180 days, dichotomized in a score 1-2 with favorable outcome and score 3-5 with unfavorable outcome) using ROC analysis. RESULTS Intra-observer variability was excellent for the TCC score (ICC 0.95 and 0.86) and the TDGN score (ICC 0.89 and 0.75). Inter-observer variability was good to excellent for total cerebral cortex score and total deep grey nuclei score in both the first (ICC 0.78 and 0.69) and third (ICC 0.86 and 0.83) image assessment. TCC and TDGN score show the best correlation with clinical outcome (highest AUC values 0.87 and 0.87). Quantitative parameters did not show good correlation with clinical outcome (AUC values 0.57 and 0.60). CONCLUSION A qualitative assessment of brain DWI using a scoring template provides useful data regarding patient outcome while quantitative data appeared less reliable.
Collapse
|
107
|
Beuchat I, Sivaraju A, Amorim E, Gilmore EJ, Dunet V, Rossetti AO, Westover MB, Hsu L, Scirica BM, Silva D, Tang K, Lee JW. MRI-EEG correlation for outcome prediction in postanoxic myoclonus: A multicenter study. Neurology 2020; 95:e335-e341. [PMID: 32482841 DOI: 10.1212/wnl.0000000000009610] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 01/27/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the prognostic ability of the combination of EEG and MRI in identifying patients with good outcome in postanoxic myoclonus (PAM) after cardiac arrest (CA). METHODS Adults with PAM who had an MRI within 20 days after CA were identified in 4 prospective CA registries. The primary outcome measure was coma recovery to command following by hospital discharge. Clinical examination included brainstem reflexes and motor activity. EEG was assessed for best background continuity, reactivity, presence of epileptiform activity, and burst suppression with identical bursts (BSIB). MRI was examined for presence of diffusion restriction or fluid-attenuated inversion recovery changes consistent with anoxic brain injury. A prediction model was developed using optimal combination of variables. RESULTS Among 78 patients, 11 (14.1%) recovered at discharge and 6 (7.7%) had good outcome (Cerebral Performance Category < 3) at 3 months. Patients who followed commands were more likely to have pupillary and corneal reflexes, flexion or better motor response, EEG continuity and reactivity, no BSIB, and no anoxic injury on MRI. The combined EEG/MRI variable of continuous background and no anoxic changes on MRI was associated with coma recovery at hospital discharge with sensitivity 91% (95% confidence interval [CI], 0.59-1.00), specificity 99% (95% CI, 0.92-1.00), positive predictive value 91% (95% CI, 0.59-1.00), and negative predictive value 99% (95% CI, 0.92-1.00). CONCLUSIONS EEG and MRI are complementary and identify both good and poor outcome in patients with PAM with high accuracy. An MRI should be considered in patients with myoclonus showing continuous or reactive EEGs.
Collapse
Affiliation(s)
- Isabelle Beuchat
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Adithya Sivaraju
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Edilberto Amorim
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Emily J Gilmore
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Vincent Dunet
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrea O Rossetti
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - M Brandon Westover
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Liangge Hsu
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin M Scirica
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Danuzia Silva
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kathleen Tang
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jong Woo Lee
- From the Department of Clinical Neuroscience, Neurology Service (I.B., A.O.R.), and Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital and University of Lausanne, Switzerland; Division of Clinical Neurophysiology and Comprehensive Epilepsy Center (A.S., E.J.G.), Department of Neurology, Yale School of Medicine, New Haven, CT; Department of Neurology (E.A., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology (L.H.), Medicine/Cardiology (B.S., D.S.), and Neurology (I.B., K.T., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
108
|
Kustermann T, Ata Nguepnjo Nguissi N, Pfeiffer C, Haenggi M, Kurmann R, Zubler F, Oddo M, Rossetti AO, De Lucia M. Brain functional connectivity during the first day of coma reflects long-term outcome. NEUROIMAGE-CLINICAL 2020; 27:102295. [PMID: 32563037 PMCID: PMC7305428 DOI: 10.1016/j.nicl.2020.102295] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 01/02/2023]
Abstract
Coma patients show different connectivity patterns depending on long-term outcome. Time-variance of functional connectivity is an early prognostic marker for coma patients. Connectivity patterns observed in chronic patients may develop early after coma onset.
Objective In patients with disorders of consciousness (DOC), properties of functional brain networks at rest are informative of the degree of consciousness impairment and of long-term outcome. Here we investigate whether connectivity differences between patients with favorable and unfavorable outcome are already present within 24 h of coma onset. Methods We prospectively recorded 63-channel electroencephalography (EEG) at rest during the first day of coma after cardiac arrest. We analyzed 98 adults, of whom 57 survived beyond unresponsive wakefulness. Functional connectivity was estimated by computing the ‘debiased weighted phase lag index’ over epochs of five seconds duration. We evaluated the network’s topological features, including clustering coefficient, path length, modularity and participation coefficient and computed their variance over time. Finally, we estimated the predictive value of these topological features for patients’ outcomes by splitting the patient sample in training and test datasets. Results Group-level analysis revealed lower clustering coefficient, higher modularity and path length variance in patients with favorable compared to those with unfavorable outcomes (p < 0.01). Within all features, the path length variance in the network provided the best positive predictive value (PPV) for favorable outcome and specificity for unfavorable outcome in the test dataset (PPV: 0.83, p < 0.01; specificity: 0.86, p < 0.01) with above-chance negative predictive value and accuracy. Of note, the exclusion of patients with epileptiform activity (20 in total) eliminates all false positive predictions (n = 6) for path length variance. Interpretation Topological features of functional connectivity differ as a function of long-term outcome in patients on the first day of coma. These differences are not interpretable in terms of consciousness levels as all patients were in a deep unconscious state. The time variance of path length is informative of comatose patients’ outcome, as patients with favorable outcome exhibit a richer repertoire of path length than those with unfavorable outcomes.
Collapse
Affiliation(s)
- Thomas Kustermann
- Laboratoire de Recherche en Neuroimagerie (LREN), University Hospital (CHUV) & University of Lausanne, Switzerland.
| | | | | | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Rebekka Kurmann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Frédéric Zubler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Mauro Oddo
- Department of Intensive Care Medicine, University Hospital (CHUV) & University of Lausanne, Switzerland
| | - Andrea O Rossetti
- Department of Neurology, University Hospital (CHUV) & University of Lausanne, Switzerland
| | - Marzia De Lucia
- Laboratoire de Recherche en Neuroimagerie (LREN), University Hospital (CHUV) & University of Lausanne, Switzerland
| |
Collapse
|
109
|
Byron-Alhassan A, Tulloch HE, Collins B, Quinlan B, Fang Z, Chakraborty S, Le May M, Duchesne L, Smith AM. Exploratory Analyses of Cerebral Gray Matter Volumes After Out-of-Hospital Cardiac Arrest in Good Outcome Survivors. Front Psychol 2020; 11:856. [PMID: 32435222 PMCID: PMC7218079 DOI: 10.3389/fpsyg.2020.00856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 04/06/2020] [Indexed: 01/15/2023] Open
Abstract
Background Survival rates of cardiac arrest have increased over recent years, however, survivors may still be left with significant morbidity and functional impairment. A primary concern in cardiac arrest survivors is the effect of prolonged hypoxia/ischemia on the brain. The objectives of the present study were threefold: (1) to explore the effect of cardiac arrest on brain gray matter volumes (GMV) in “good outcome” survivors of out-of-hospital cardiac arrest (OHCA), (2) to examine the relationship between GMV, cognitive functioning and arrest factors, and (3) to explore whether OHCA patients differ from a group of patients with myocardial infarction (MI) uncomplicated by cardiac arrest and a group of healthy controls in terms of GMV. Methods Medically stable OHCA survivors with preserved neurological function and who were eligible for magnetic resonance imaging scanning (MRI; n = 9), were compared to: (1) patients who had experienced a MI (n = 19) and (2) healthy controls (n = 12). Participants underwent brain MRI on a 3T Siemens Trio MRI scanner and GMV was measured by voxel-based morphometry. A comprehensive neuropsychological assessment was also conducted. Global GMV was compared in the three samples using analyses of variance. The relationships between cognition and GMV were examined within group using correlations. Results The OHCA and MI groups showed a similar pattern of differences compared to the healthy control group. Both groups had decreased GMV in the anterior cingulate cortex, bilateral hippocampus, right dorsolateral prefrontal cortex, right putamen, and bilateral cerebellum. There were no significant differences in global or regional GMV between the OHCA and MI groups. Cognitive functioning was correlated with global GMV in the OHCA group; no such correlation was observed in the MI group. Conclusion Regional atrophy was observed in OHCA and MI survivors, compared to a healthy control group, suggesting a common mechanism, presumably preexisting cardiovascular disease. Although similar regional volume differences were observed between the MI and OHCA groups, the relationship between GMV and cognition was only observed in OHCA survivors. We suggest the acute hypoxia/ischemia ensuing from the arrest may interact with diminished neural reserve in select brain areas to expose occult cognitive dysfunction.
Collapse
Affiliation(s)
- Aziza Byron-Alhassan
- Department of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada.,School of Psychology, University of Ottawa, Ottawa, ON, Canada
| | - Heather E Tulloch
- Department of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada.,School of Psychology, University of Ottawa, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Barbara Collins
- Department of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada.,School of Psychology, University of Ottawa, Ottawa, ON, Canada
| | - Bonnie Quinlan
- Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Zhuo Fang
- School of Psychology, University of Ottawa, Ottawa, ON, Canada
| | - Santanu Chakraborty
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Medical Imaging, The Ottawa Hospital, Ottawa, ON, Canada
| | - Michel Le May
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Lloyd Duchesne
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Andra M Smith
- School of Psychology, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
110
|
Late awakening, prognostic factors and long-term outcome in out-of-hospital cardiac arrest – results of the prospective Norwegian Cardio-Respiratory Arrest Study (NORCAST). Resuscitation 2020; 149:170-179. [DOI: 10.1016/j.resuscitation.2019.12.031] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/24/2019] [Accepted: 12/04/2019] [Indexed: 02/02/2023]
|
111
|
Forgacs PB, Devinsky O, Schiff ND. Independent Functional Outcomes after Prolonged Coma following Cardiac Arrest: A Mechanistic Hypothesis. Ann Neurol 2020; 87:618-632. [PMID: 31994749 PMCID: PMC7393600 DOI: 10.1002/ana.25690] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 01/23/2020] [Accepted: 01/23/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Survivors of prolonged (>2 weeks) post-cardiac arrest (CA) coma are expected to remain permanently disabled. We aimed to investigate 3 outlier patients who ultimately achieved independent functional outcomes after prolonged post-CA coma to identify electroencephalographic (EEG) markers of their recovery potential. For validation purposes, we also aimed to evaluate these markers in an independent cohort of post-CA patients. METHODS We identified 3 patients with late recovery from coma (17-37 days) following CA who recovered to functionally independent behavioral levels. We performed spectral power analyses of available EEGs during prominent burst suppression patterns (BSP) present in all 3 patients. Using identical methods, we also assessed the relationship of intraburst spectral power and outcomes in a prospectively enrolled cohort of post-CA patients. We performed chart reviews of common clinical, imaging, and EEG prognostic variables and clinical outcomes for all patients. RESULTS All 3 patients with late recovery from coma lacked evidence of overwhelming cortical injury but demonstrated prominent BSP on EEG. Spectral analyses revealed a prominent theta (~4-7Hz) feature dominating the bursts during BSP in these patients. In the prospective cohort, similar intraburst theta spectral features were evident in patients with favorable outcomes; patients with BSP and unfavorable outcomes showed either no features, transient burst features, or decreasing intraburst frequencies with time. INTERPRETATION BSP with theta (~4-7Hz) peak intraburst spectral power after CA may index a recovery potential. We discuss our results in the context of optimizing metabolic substrate availability and stimulating the corticothalamic system during recovery from prolonged post-CA coma. ANN NEUROL 2020;87:618-632.
Collapse
Affiliation(s)
- Peter B. Forgacs
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY 10065, USA
- Department of Neurology, Weill Cornell Medical College, New York, NY 10065, USA
- The Rockefeller University, New York, NY 10065, USA
| | | | - Nicholas D. Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY 10065, USA
- Department of Neurology, Weill Cornell Medical College, New York, NY 10065, USA
- The Rockefeller University, New York, NY 10065, USA
| |
Collapse
|
112
|
Hosseini M, Wilson RH, Crouzet C, Amirhekmat A, Wei KS, Akbari Y. Resuscitating the Globally Ischemic Brain: TTM and Beyond. Neurotherapeutics 2020; 17:539-562. [PMID: 32367476 PMCID: PMC7283450 DOI: 10.1007/s13311-020-00856-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cardiac arrest (CA) afflicts ~ 550,000 people each year in the USA. A small fraction of CA sufferers survive with a majority of these survivors emerging in a comatose state. Many CA survivors suffer devastating global brain injury with some remaining indefinitely in a comatose state. The pathogenesis of global brain injury secondary to CA is complex. Mechanisms of CA-induced brain injury include ischemia, hypoxia, cytotoxicity, inflammation, and ultimately, irreversible neuronal damage. Due to this complexity, it is critical for clinicians to have access as early as possible to quantitative metrics for diagnosing injury severity, accurately predicting outcome, and informing patient care. Current recommendations involve using multiple modalities including clinical exam, electrophysiology, brain imaging, and molecular biomarkers. This multi-faceted approach is designed to improve prognostication to avoid "self-fulfilling" prophecy and early withdrawal of life-sustaining treatments. Incorporation of emerging dynamic monitoring tools such as diffuse optical technologies may provide improved diagnosis and early prognostication to better inform treatment. Currently, targeted temperature management (TTM) is the leading treatment, with the number of patients needed to treat being ~ 6 in order to improve outcome for one patient. Future avenues of treatment, which may potentially be combined with TTM, include pharmacotherapy, perfusion/oxygenation targets, and pre/postconditioning. In this review, we provide a bench to bedside approach to delineate the pathophysiology, prognostication methods, current targeted therapies, and future directions of research surrounding hypoxic-ischemic brain injury (HIBI) secondary to CA.
Collapse
Affiliation(s)
- Melika Hosseini
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Robert H Wilson
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Christian Crouzet
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Arya Amirhekmat
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Kevin S Wei
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Yama Akbari
- Department of Neurology, School of Medicine, University of California, Irvine, USA.
- Beckman Laser Institute, University of California, Irvine, USA.
| |
Collapse
|
113
|
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]
|
114
|
Barbella G, Lee JW, Alvarez V, Novy J, Oddo M, Beers L, Rossetti AO. Prediction of regaining consciousness despite an early epileptiform EEG after cardiac arrest. Neurology 2020; 94:e1675-e1683. [DOI: 10.1212/wnl.0000000000009283] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 11/16/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveAfter cardiac arrest (CA), epileptiform EEG, occurring in about 1/3 of patients, often but not invariably heralds poor prognosis. We tested the hypothesis that a combination of specific EEG features identifies patients who may regain consciousness despite early epileptiform patterns.MethodsWe retrospectively analyzed a registry of comatose patients post-CA (2 Swiss centers), including those with epileptiform EEG. Background and epileptiform features in EEGs 12–36 hours or 36–72 hours from CA were scored according to the American Clinical Neurophysiology Society nomenclature. Best Cerebral Performance Category (CPC) score within 3 months (CPC 1–3 vs 4–5) was the primary outcome. Significant EEG variables were combined in a score assessed with receiver operating characteristic curves, and independently validated in a US cohort; its correlation with serum neuron-specific enolase (NSE) was also tested.ResultsOf 488 patients, 107 (21.9%) had epileptiform EEG <72 hours; 18 (17%) reached CPC 1–3. EEG 12–36 hours background continuity ≥50%, absence of epileptiform abnormalities (p< 0.00001 each), 12–36 and 36–72 hours reactivity (p< 0.0001 each), 36–72 hours normal background amplitude (p= 0.0004), and stimulus-induced discharges (p= 0.0001) correlated with favorable outcome. The combined 6-point score cutoff ≥2 was 100% sensitive (95% confidence interval [CI], 78%–100%) and 70% specific (95% CI, 59%–80%) for CPC 1–3 (area under the curve [AUC], 0.98; 95% CI, 0.94–1.00). Increasing score correlated with NSE (ρ = −0.46,p= 0.0001). In the validation cohort (41 patients), the score was 100% sensitive (95% CI, 60%–100%) and 88% specific (95% CI, 73%–97%) for CPC 1–3 (AUC, 0.96; 95% CI, 0.91–1.00).ConclusionPrognostic value of early epileptiform EEG after CA can be estimated combining timing, continuity, reactivity, and amplitude features in a score that correlates with neuronal damage.
Collapse
|
115
|
Rasulo FA, Togni T, Romagnoli S. Essential Noninvasive Multimodality Neuromonitoring for the Critically Ill Patient. Crit Care 2020; 24:100. [PMID: 32204723 PMCID: PMC7092614 DOI: 10.1186/s13054-020-2781-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
Collapse
Affiliation(s)
- Frank A Rasulo
- Division of Anesthesiology, Intensive Care & Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy.
| | - Tommaso Togni
- Division of Anesthesiology, Intensive Care & Emergency Medicine, University of Brescia at Spedali Civili Hospital, Brescia, Italy
| | - Stefano Romagnoli
- Department of Health Science, University of Florence, Florence, Italy
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| |
Collapse
|
116
|
Kim TJ, Kim JM, Lee JS, Park SH, Jeong HB, Choi JK, Kim K, Bae HM, Ko SB. Prognostication of neurological outcome after cardiac arrest using wavelet phase coherence analysis of cerebral oxygen. Resuscitation 2020; 150:41-49. [PMID: 32194164 DOI: 10.1016/j.resuscitation.2020.02.031] [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: 11/11/2019] [Revised: 02/20/2020] [Accepted: 02/24/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND The prognosis for cardiac arrest (CA) is associated with the degree of cerebral ischemia. We investigated the relationship between the wavelet coherence of cerebral oxyhemoglobin (HbO2) among different channels and outcomes after CA. Moreover, we aimed to develop a prognostication method after CA. METHODS Eighty-three post-resuscitation patients were included. The HbO2 data were collected during the post-resuscitation period (median day, 1) using functional near-infrared spectroscopy. The coherence between sections of prefrontal HbO2 oscillations in five frequency intervals (I, 0.6-2 Hz; II, 0.15-0.6 Hz; III, 0.05-0.15 Hz; IV, 0.02-0.05 Hz; and V, 0.0095-0.02 Hz) were analyzed. We evaluated the outcomes using cerebral performance category (CPC) scores (good outcome, CPC ≤ 2 and poor outcome, CPC ≥ 3) at 3 months after CA. Additionally, the predictive method was developed using the biomarker and coherence value after CA. RESULTS Among the included patients, 19 patients (22.9%) had a good outcome. Poor outcome group had significantly lower phase coherence in the myogenic frequency interval III compared to good outcome group (0.36 ± 0.14 vs. 0.54 ± 0.18, P < 0.001). The predictive method using neuron-specific enolase (NSE) and interval III value demonstrated good discrimination (area under the curve 0.919; 95% confidence interval, 0.850-0.989). CONCLUSIONS The predictive method using NSE and phase coherence of HbO2 in the interval III from the vascular smooth muscle cells could be a useful tool for prognosticating after CA. This suggests that evaluating cerebral ischemia using phase coherence of HbO2 might be a helpful outcome predictor following CA.
Collapse
Affiliation(s)
- Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea; Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae-Myoung Kim
- Department of Electrical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea
| | - Soo-Hyun Park
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hae-Bong Jeong
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jong-Kwan Choi
- Department of Electrical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyeon-Min Bae
- Department of Electrical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea; Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
| |
Collapse
|
117
|
Mayà-Casalprim G, Ortiz J, Tercero A, Reyes D, Iranzo Á, Santamaria J, Bosch X, Gaig C. Cervical spinal cord injury by a low-impact trauma as an unnoticed cause of cardiorespiratory arrest. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-6. [PMID: 32352051 PMCID: PMC7180526 DOI: 10.1093/ehjcr/ytaa044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/02/2019] [Accepted: 02/05/2020] [Indexed: 11/12/2022]
Abstract
Background Cardiorespiratory arrest (CA) secondary to traumatic cervical spinal cord injury can occur in minor accidents with low-impact trauma and may be overlooked as the cause of CA in patients admitted in the coronary care unit. Case summary We present two patients admitted to the coronary care unit because of suspected CA of cardiac origin. Both patients were found in CA with asystole, one after collapsing in a shopping mall and falling down a few steps and the other in the street next to his bicycle. They underwent early pharmacologically induced coma and hypothermia precluding neurological examination. Both patients remained in coma after rewarming, with preserved brainstem reflexes but absent motor response to pain. One patient had post-anoxic myoclonus in the face without limb involvement. In both patients, median nerve somatosensory evoked potentials demonstrated bilateral absence of thalamocortical N19 responses and abnormal cervicomedullary junction potentials (N13 wave). Extensive diagnostic work-up did not find a cardiac cause of the CA, pulmonary thromboembolism, or intracranial haemorrhage. In both patients, cervical spinal cord injury was diagnosed incidentally 5 and 6 days after CA, when a brain magnetic resonance imaging performed to assess post-anoxic brain injuries detected spinal cord hyperintensities with fracture and luxation of the odontoid. Both patients died 11 and 8 days after CA. Discussion Low-impact traumatic cervical spinal cord injury should be considered in the diagnostic work-up of patients with CA of unknown cause.
Collapse
Affiliation(s)
- Gerard Mayà-Casalprim
- Neurology Department, Hospital Clínic de Barcelona, Centros de Investigación Biomédica en Red de enfermedades neurodegenerativas (CIBERNED), C/Villarroel 170, Barcelona 0008036, Spain
| | - Jose Ortiz
- Cardiology Department, Coronary Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Ana Tercero
- Neurology Department, Hospital Clínic de Barcelona, Centros de Investigación Biomédica en Red de enfermedades neurodegenerativas (CIBERNED), C/Villarroel 170, Barcelona 0008036, Spain
| | - David Reyes
- Neurology Department, Hospital Clínic de Barcelona, Centros de Investigación Biomédica en Red de enfermedades neurodegenerativas (CIBERNED), C/Villarroel 170, Barcelona 0008036, Spain
| | - Álex Iranzo
- Neurology Department, Hospital Clínic de Barcelona, Centros de Investigación Biomédica en Red de enfermedades neurodegenerativas (CIBERNED), C/Villarroel 170, Barcelona 0008036, Spain
| | - Joan Santamaria
- Neurology Department, Hospital Clínic de Barcelona, Centros de Investigación Biomédica en Red de enfermedades neurodegenerativas (CIBERNED), C/Villarroel 170, Barcelona 0008036, Spain
| | - Xavier Bosch
- Cardiology Department, Coronary Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carles Gaig
- Neurology Department, Hospital Clínic de Barcelona, Centros de Investigación Biomédica en Red de enfermedades neurodegenerativas (CIBERNED), C/Villarroel 170, Barcelona 0008036, Spain
| |
Collapse
|
118
|
Bongiovanni F, Romagnosi F, Barbella G, Di Rocco A, Rossetti AO, Taccone FS, Sandroni C, Oddo M. Standardized EEG analysis to reduce the uncertainty of outcome prognostication after cardiac arrest. Intensive Care Med 2020; 46:963-972. [PMID: 32016534 DOI: 10.1007/s00134-019-05921-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/28/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE Post-resuscitation guidelines recommend a multimodal algorithm for outcome prediction after cardiac arrest (CA). We aimed at evaluating the prevalence of indeterminate prognosis after application of this algorithm and providing a strategy for improving prognostication in this population. METHODS We examined a prospective cohort of comatose CA patients (n = 485) in whom the ERC/ESICM algorithm was applied. In patients with an indeterminate outcome, prognostication was investigated using standardized EEG classification (benign, malignant, highly malignant) and serum neuron-specific enolase (NSE). Neurological recovery at 3 months was dichotomized as good (Cerebral Performance Categories [CPC] 1-2) vs. poor (CPC 3-5). RESULTS Using the ERC/ESICM algorithm, 155 (32%) patients were prognosticated with poor outcome; all died at 3 months. Among the remaining 330 (68%) patients with an indeterminate outcome, the majority (212/330; 64%) showed good recovery. In this patient subgroup, absence of a highly malignant EEG by day 3 had 99.5 [97.4-99.9] % sensitivity for good recovery, which was superior to NSE < 33 μg/L (84.9 [79.3-89.4] % when used alone; 84.4 [78.8-89] % when combined with EEG, both p < 0.001). Highly malignant EEG had equal specificity (99.5 [97.4-99.9] %) but higher sensitivity than NSE for poor recovery. Further analysis of the discriminative power of outcome predictors revealed limited value of NSE over EEG. CONCLUSIONS In the majority of comatose CA patients, the outcome remains indeterminate after application of ERC/ESICM prognostication algorithm. Standardized EEG background analysis enables accurate prediction of both good and poor recovery, thereby greatly reducing uncertainty about coma prognostication in this patient population.
Collapse
Affiliation(s)
- Filippo Bongiovanni
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Federico Romagnosi
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,Section of Anaesthesiology and Intensive Care, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University Hospital Integrated Trust of Verona, Verona, Italy
| | - Giuseppina Barbella
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,Neurology Unit, San Gerardo Hospital, School of Medicine and Surgery and Milan-Center for Neuroscience (NeuroMI), University of Milano-Bicocca, Milan, Italy
| | - Arianna Di Rocco
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Erasme University Hospital, Brussels, Belgium
| | - Claudio Sandroni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Mauro Oddo
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.
| |
Collapse
|
119
|
Martínez-Losas P, López de Sá E, Armada E, Rosillo S, Monedero MC, Rey JR, Caro-Codón J, Buño Soto A, López Sendón JL. Cinética de la enolasa neuroespecífica: una herramienta adicional para el pronóstico neurológico después de una parada cardiaca. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.01.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
120
|
Barbella G, Novy J, Marques-Vidal P, Oddo M, Rossetti AO. Prognostic role of EEG identical bursts in patients after cardiac arrest: Multimodal correlation. Resuscitation 2020; 148:140-144. [PMID: 32004660 DOI: 10.1016/j.resuscitation.2020.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/13/2020] [Accepted: 01/18/2020] [Indexed: 12/19/2022]
Abstract
AIMS EEG burst-suppression (BS) heralds poor outcome after cardiac arrest (CA). Within this pattern, identical bursts (IB) have been suggested to be absolutely specific, in isolation. We assessed IB prevalence and their added predictive value for poor outcome in a multimodal prognostic approach. METHODS We retrospectively analyzed a registry of comatose adults with CA (April 2011-February 2019), undergoing EEG at 5-36 h and 36-72 h. SB and IB were visually assessed. Cerebral Performance Categories (CPC) at 3 months were dichotomized as "good" (CPC 1-2), or "poor" (CPC 3-5). Sensitivity, specificity, positive, negative predictive values of BS and IB for poor outcome were calculated. A multimodal prognostic score was created assigning one point each to unreactive and epileptiform EEG, pupillary light reflex and SSEPs absence, NSE > 75 μg/l. In a second score, IB were added; predictive performances were compared using Receiver Operating Characteristic (ROC) curves. RESULTS Of 522 patients, 147 (28%) had BS in any EEG (10 [7%] had good outcome and 129 [88%] died). Of them, 53/147 (36%, 10% of total) showed IB, 47/53 (89%) of which within 36 h. IB were 100% specific for poor outcome, and associated with higher serum NSE than BS. However, there was no significant difference between the scores with and without IB for CPC 3-5 (p = 0.116). CONCLUSION IB occur in 10% of patients after CA. In our multimodal context, IB, albeit being very specific for poor outcome, seem redundant with other predictors.
Collapse
Affiliation(s)
- Giuseppina Barbella
- Neurology Unit, San Gerardo Hospital, Monza, Italy; School of Medicine and Surgery and Milan-Center for Neuroscience (NeuroMI), University of Milano-Bicocca, Milan, Italy; Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland
| | - Jan Novy
- Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland
| | - Pedro Marques-Vidal
- Department of Medicine, Internal Medicine, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland
| | - Mauro Oddo
- Department of Adult Intensive Care, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland
| | - Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland.
| |
Collapse
|
121
|
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: 11] [Impact Index Per Article: 2.8] [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").
Collapse
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
| |
Collapse
|
122
|
Maciel CB, Youn TS, Barden MM, Dhakar MB, Zhou SE, Pontes-Neto OM, Silva GS, Theriot JJ, Greer DM. Corneal Reflex Testing in the Evaluation of a Comatose Patient: An Ode to Precise Semiology and Examination Skills. Neurocrit Care 2020; 33:399-404. [PMID: 31919808 DOI: 10.1007/s12028-019-00896-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVE The corneal reflex assesses the integrity of the trigeminal and facial cranial nerves. This brainstem reflex is fundamental in neuroprognostication after cardiac arrest and in brain death determination. We sought to investigate corneal reflex testing methods among neurologists and general critical care providers in the context of neuroprognostication following cardiac arrest. METHODS This is an international cross-sectional study disseminated to members of the Neurocritical Care Society, Society of Critical Care Medicine, and American Academy of Neurology. We utilized an open Web-based survey (Qualtrics®, Provo, UT, USA) to disseminate 26 questions regarding neuroprognostication practices following cardiac arrest, in which 3 questions pertained to corneal reflex testing. Descriptive statistical measures were used, and subgroup analyses performed between neurologists and non-neurologists. Questions were not mandatory; therefore, the percentages were relative to the number of respondents for each question. RESULTS There were 959 respondents in total. Physicians comprised 85.1% of practitioners (762 out of 895), of which 55% (419) identified themselves as non-neurologists and 45% (343) as neurologists. Among physicians, 85.9% (608 out of 708) deemed corneal reflex relevant for prognostication following cardiac arrest (neurologists 84.4% versus non-neurologists 87.0%). A variety of techniques were employed for corneal reflex testing, the most common being "light cotton touch" (59.2%), followed by "cotton-tipped applicator with pressure" (23.9%), "saline or water squirt" (15.9%), and "puff of air" (1.0%). There were no significant differences in the methods for testing between neurologists and non-neurologists (p = 0.52). The location of stimulus application was variable, and 26.1% of physicians (148/567) apply the stimulus on the temporal conjunctiva rather than on the cornea itself. CONCLUSIONS Corneal reflex testing remains a cornerstone of the coma exam and is commonly used in neuroprognostication of unconscious cardiac arrest survivors and in brain death determination. A wide variability of techniques is noted among practitioners, including some that may provide suboptimal stimulation of corneal nerve endings. Imprecise testing in this setting may lead to inaccuracies in critical settings, which carries significant consequences such as guiding decisions of care limitations, misdiagnosis of brain death, and loss of public trust.
Collapse
Affiliation(s)
- Carolina B Maciel
- Department of Neurology, UF Health, Shands Hospital, McKnight Brain Institute, University of Florida College of Medicine, University of Florida, Room L3-185, 1149 Newell Drive, Gainesville, FL, 32611, USA. .,Department of Neurology, Yale University School of Medicine, New Haven, CT, USA. .,Department of Neurology, University of Utah, Salt Lake City, UT, 84108, USA.
| | - Teddy S Youn
- Department of Neurology, UF Health, Shands Hospital, McKnight Brain Institute, University of Florida College of Medicine, University of Florida, Room L3-185, 1149 Newell Drive, Gainesville, FL, 32611, USA
| | - Mary M Barden
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Monica B Dhakar
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.,Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30303, USA
| | - Sonya E Zhou
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Octavio M Pontes-Neto
- Stroke Service, Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo and Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Jeremy J Theriot
- Department of Neurology, University of Utah, Salt Lake City, UT, 84108, USA
| | - David M Greer
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.,Department of Neurology, Boston University School of Medicine, Boston, MA, 02118, USA
| |
Collapse
|
123
|
Prognostic Abilities of Serial Neuron-Specific Enolase and Lactate and their Combination in Cardiac Arrest Survivors During Targeted Temperature Management. J Clin Med 2020; 9:jcm9010159. [PMID: 31936049 PMCID: PMC7019578 DOI: 10.3390/jcm9010159] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/27/2019] [Accepted: 01/05/2020] [Indexed: 12/26/2022] Open
Abstract
This study aimed to determine the prognostic ability of serial neuron-specific enolase (NSE) and lactate in cardiac arrest survivors treated with targeted temperature management (TTM) and to investigate whether a combination of NSE and lactate could increase prognostic information. This observational, retrospective, cohort study was conducted between January 2013 and December 2018; data were extracted from an out-of-hospital cardiac arrest registry. We collected serial serum NSE and lactate levels during TTM. The primary endpoint was poor neurological outcome at 28 days from cardiac arrest. Of all 160 included patients, 98 (61.3%) had poor neurological outcomes. Areas under the curves (AUCs) for NSE were 0.797, 0.871, and 0.843 at 24, 48, and 72 h, respectively (all p < 0.05). AUCs for lactate were 0.669, 0.578, 0.634, and 0.620 at 0, 24, 48, and 72 h, respectively (all p < 0.05). Although the combination of initial lactate and NSE at 48 h yielded the highest discovered AUC (0.877) it was not statistically different from that for the 48 h NSE alone (p = 0.692). During the TTM, NSE at 48 h from cardiac arrest was the most robust prognostic marker in comatose cardiac arrest survivors. However, a combination of the 48 h NSE with lactate did not increase the prognostic information.
Collapse
|
124
|
Benghanem S, Mazeraud A, Azabou E, Chhor V, Shinotsuka CR, Claassen J, Rohaut B, Sharshar T. Brainstem dysfunction in critically ill patients. Crit Care 2020; 24:5. [PMID: 31907011 PMCID: PMC6945639 DOI: 10.1186/s13054-019-2718-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 12/23/2019] [Indexed: 02/06/2023] Open
Abstract
The brainstem conveys sensory and motor inputs between the spinal cord and the brain, and contains nuclei of the cranial nerves. It controls the sleep-wake cycle and vital functions via the ascending reticular activating system and the autonomic nuclei, respectively. Brainstem dysfunction may lead to sensory and motor deficits, cranial nerve palsies, impairment of consciousness, dysautonomia, and respiratory failure. The brainstem is prone to various primary and secondary insults, resulting in acute or chronic dysfunction. Of particular importance for characterizing brainstem dysfunction and identifying the underlying etiology are a detailed clinical examination, MRI, neurophysiologic tests such as brainstem auditory evoked potentials, and an analysis of the cerebrospinal fluid. Detection of brainstem dysfunction is challenging but of utmost importance in comatose and deeply sedated patients both to guide therapy and to support outcome prediction. In the present review, we summarize the neuroanatomy, clinical syndromes, and diagnostic techniques of critical illness-associated brainstem dysfunction for the critical care setting.
Collapse
Affiliation(s)
- Sarah Benghanem
- Department of Neurology, Neuro-ICU, Sorbonne University, APHP Pitié-Salpêtrière Hospital, Paris, France
- Medical ICU, Cochin Hospital, AP-HP, Paris, France
| | - Aurélien Mazeraud
- Department of Neuro-ICU, GHU-Paris, Paris-Descartes University, Paris, France
- Laboratory of Experimental Neuropathology, Pastuer Institute, Paris, France
| | - Eric Azabou
- Department of Physiology, Clinical Neurophysiology Unit, APHP, Raymond Poincaré Hospital, University of Versailles Saint Quentin en Yvelines, Garches, France
| | - Vibol Chhor
- Department of Intensive Care Medicine, Saint-Joseph Hospital, Paris, France
| | - Cassia Righy Shinotsuka
- Intensive Care Unit and Postgraduate Program, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
- D'Or Institute for Research and Education, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jan Claassen
- Department of Neurology, Neuro-ICU, Columbia University, New York, NY, USA
| | - Benjamin Rohaut
- Department of Neurology, Neuro-ICU, Sorbonne University, APHP Pitié-Salpêtrière Hospital, Paris, France
- Department of Neurology, Neuro-ICU, Columbia University, New York, NY, USA
- Institut du Cerveau et de la Moelle épinière, ICM, INSERM UMRS 1127, CNRS UMR 7225, Pitié- Salpêtrière Hospital, Paris, F-75013, France
| | - Tarek Sharshar
- Department of Neuro-ICU, GHU-Paris, Paris-Descartes University, Paris, France.
- Laboratory of Experimental Neuropathology, Pastuer Institute, Paris, France.
| |
Collapse
|
125
|
Caraganis A, Mulder M, Kempainen RR, Brown RZ, Oswood M, Hoffman B, Prekker ME. Interobserver Variability in the Recognition of Hypoxic-Ischemic Brain Injury on Computed Tomography Soon After Out-of-Hospital Cardiac Arrest. Neurocrit Care 2020; 33:414-421. [PMID: 31898176 DOI: 10.1007/s12028-019-00900-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cerebral edema and loss of gray-white matter differentiation on head computed tomography (CT) after cardiac arrest generally portend a poor prognosis. The interobserver variability in physician recognition of hypoxic-ischemic brain injury (HIBI) on early CT after out-of-hospital cardiac arrest has not been studied. METHODS In this survey study, participating physicians and a neuroradiologist reviewed 20 randomly selected head CTs obtained within 2 h of out-of-hospital cardiac arrest and decided if HIBI was present. All participants were blinded to clinical details. Interobserver agreement on the presence of HIBI (primary outcome) and pairwise agreement between participants and the neuroradiologist (secondary outcome) were determined using multi- and dual-rater kappa statistics with 95% confidence intervals (CIs). RESULTS Agreement among physicians regarding the presence of HIBI on head CT was fair (kappa 0.34; 95% CI 0.19-0.49). Individual physician agreement with the neuroradiologist varied from poor to moderate (kappa 0.0-0.48), with 8 of 10 physicians having no more than fair agreement. Regarding the perceived severity of HIBI on head CT, physician agreement was moderate (ICC = 0.56; 95% CI 0.38-0.77). CONCLUSION Physicians, including radiologists, demonstrated substantial interobserver variability when identifying HIBI on head CT soon after out-of-hospital cardiac arrest.
Collapse
Affiliation(s)
- Andrew Caraganis
- Division of Pulmonary, Allergy, Critical Care and Sleep, University of Minnesota, MMC #276, 420 Delaware St SE, Minneapolis, MN, USA.
| | - Maximilian Mulder
- Division of Neurocritical Care, Department of Critical Care, Abbott Northwestern Hospital, 800 E 28th St., Minneapolis, MN, USA
| | - Robert R Kempainen
- Division of Pulmonary and Critical Care, Hennepin County Medical Center, 701 Park Ave S, Minneapolis, MN, USA
| | - Roland Z Brown
- Department of Biostatistics, School of Public Health, University of Minnesota, 516 Delaware St SE, Minneapolis, MN, USA
| | - Mark Oswood
- Department of Radiology, Hennepin County Medical Center, 701 Park Ave S, Minneapolis, MN, USA
| | - Benjamin Hoffman
- Department of Radiology, Hennepin County Medical Center, 701 Park Ave S, Minneapolis, MN, USA
| | - Matthew E Prekker
- Division of Pulmonary and Critical Care, Hennepin County Medical Center, 701 Park Ave S, Minneapolis, MN, USA.,Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Ave S, Minneapolis, MN, USA
| |
Collapse
|
126
|
Clifford-Mobley O, Palmer F, Rooney K, Skorko A, Bayly G. Serum neuron-specific enolase measurement for neuro-prognostication post out-of-hospital cardiac arrest: Determination of the optimum testing strategy in routine clinical use. Ann Clin Biochem 2020; 57:69-76. [DOI: 10.1177/0004563219886326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Measurement of serum neuron-specific enolase (NSE) for neuro-prognostication post out-of-hospital cardiac arrest (OHCA) is recommended by international guidelines. There is, however, a lack of consensus regarding the cut-offs and time points to use. In addition, NSE is particularly susceptible to haemolysis interference. This study aimed to define the optimum NSE testing strategy to support the intensive care unit (ICU). Methods Patients admitted to ICU post-OHCA over 16 months had NSE measured. The outcome was survival to ICU discharge. NSE at 0 h, 24 h, 48 h, 72 h and change in NSE (ΔNSE) were assessed for prognostic accuracy using receiver operator characteristic curve analysis. The magnitude of haemolysis interference was quantified by spiking haemolysate into paired serum. Results There is a consistent linear increase in NSE with increasing haemolysis, independent of baseline NSE concentration. A haemolysis index acceptance threshold was defined as 20. There were 142 patients, and 82 survived to ICU discharge. The NSE parameter with best predictive performance was ΔNSE at 48 h, which had an area under the receiver operator characteristic curve of 0.91. A cut-off of >0 μg/L at this time point had sensitivity of 80% and specificity of 97% for predicting death on ICU. When patients who died of non-neurological causes were removed, the sensitivity increased to 91%. Conclusions Application of a stringent haemolysis interference threshold and measurement of NSE at two time points enabled us to achieve excellent discrimination. Increasing NSE over the first 48 h, suggestive of an ongoing reperfusion injury to the brain, is a strong predictor of poor outcome.
Collapse
Affiliation(s)
- Oliver Clifford-Mobley
- Department of Clinical Biochemistry, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Frances Palmer
- Department of Clinical Biochemistry, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Kieron Rooney
- Department of Intensive Care Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Agnieszka Skorko
- Department of Intensive Care Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Graham Bayly
- Department of Clinical Biochemistry, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| |
Collapse
|
127
|
Miroz JP, Ben-Hamouda N, Bernini A, Romagnosi F, Bongiovanni F, Roumy A, Kirsch M, Liaudet L, Eckert P, Oddo M. Neurological Pupil index for Early Prognostication After Venoarterial Extracorporeal Membrane Oxygenation. Chest 2019; 157:1167-1174. [PMID: 31870911 DOI: 10.1016/j.chest.2019.11.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/19/2019] [Accepted: 11/30/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation therapy (VA-ECMO) after refractory cardiogenic shock or cardiac arrest has significant morbidity and mortality. Early outcome prediction is crucial in this setting, but data on neuroprognostication are limited. We examined the prognostic value of clinical neurologic examination, using an automated device for the quantitative measurement of pupillary light reactivity. METHODS An observational cohort of sedated, mechanically ventilated VA-ECMO patients was analyzed during the early phase after ECMO insertion (first 72 h). Using the NPi-200 automated infrared pupillometer, pupillary light reactivity was assessed repeatedly (every 12 h) by calculating the Neurological Pupil index (NPi). Trends of NPi over time were correlated to 90-day mortality, and the prognostic performance of the NPi, alone and in combination with the 12-h PREDICT VA-ECMO score, was evaluated. RESULTS One hundred consecutive patients were studied (51 with refractory cardiogenic shock and 49 with refractory cardiac arrest; 12-h PREDICT VA-ECMO, 40%; observed 90-day survival, 43%). Nonsurvivors (n = 57) had significantly lower NPi than did survivors at all time points (all P < .01). Abnormal NPi (< 3, at any time from 24 to 72 h) was 100% specific for 90-day mortality, with 0% false positives. Adding the 12-h PREDICT VA-ECMO score to the NPi provided the best prognostic performance (specificity, 100% [95% CI, 92%-100%]; sensitivity, 60% [95% CI, 46%-72%]; area under the receiver operating characteristic curve, 0.82). CONCLUSIONS Quantitative NPi alone had excellent ability to predict a poor outcome from day 1 after VA-ECMO insertion, with no false positives. Combining NPi and 12-h PREDICT-VA ECMO score increased the sensitivity of outcome prediction, while maintaining 100% specificity.
Collapse
Affiliation(s)
- John-Paul Miroz
- Department of Adult Intensive Care Medicine, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland; Neuroscience Critical Care Research Group, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Adult Intensive Care Medicine, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Adriano Bernini
- Neuroscience Critical Care Research Group, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Federico Romagnosi
- Neuroscience Critical Care Research Group, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Filippo Bongiovanni
- Neuroscience Critical Care Research Group, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Aurélien Roumy
- Department of Heart and Vessels, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Matthias Kirsch
- Department of Heart and Vessels, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Lucas Liaudet
- Department of Adult Intensive Care Medicine, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Philippe Eckert
- Department of Adult Intensive Care Medicine, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Mauro Oddo
- Department of Adult Intensive Care Medicine, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland; Neuroscience Critical Care Research Group, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland.
| |
Collapse
|
128
|
Identifying neuronal correlates of dying and resuscitation in a model of reversible brain anoxia. Prog Neurobiol 2019; 185:101733. [PMID: 31836416 DOI: 10.1016/j.pneurobio.2019.101733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/29/2019] [Accepted: 12/06/2019] [Indexed: 11/20/2022]
Abstract
We developed a new rodent model of reversible brain anoxia and performed continuous electrocorticographic (ECoG) and intracellular recordings of neocortical neurons to identify in real-time the cellular and network dynamics that successively emerge throughout the dying-to-recovery process. Along with a global decrease in ECoG amplitude, deprivation of oxygen supply resulted in an early surge of beta-gamma activities, accompanied by rhythmic membrane depolarizations and regular firing in pyramidal neurons. ECoG and intracellular signals were then dominated by low-frequency activities which progressively declined towards isoelectric levels. Cortical neurons during the isoelectric state underwent a massive membrane potential depolarizing shift, captured in the ECoG as a large amplitude triphasic wave known as the "wave-of-death" (WoD). This neuronal anoxic depolarization, associated with a block of action potentials and a loss of cell integrative properties, could however be reversed if brain re-oxygenation was rapidly restored (within 2-3.5 min). The subsequent slow repolarization of neocortical neurons resulted in a second identifiable ECoG wave we termed "wave-of-resuscitation" since it inaugurated the progressive regaining of pre-anoxic synaptic and firing activities. These results demonstrate that the WoD is not a biomarker of an irremediable death and unveil the cellular correlates of a novel ECoG wave that may be predictive of a successful recovery. The identification of real-time biomarkers of onset and termination of cell anoxic insult could benefit research on interventional strategies to optimize resuscitation procedures.
Collapse
|
129
|
Disanto G, Prosperetti C, Gobbi C, Barro C, Michalak Z, Cassina T, Kuhle J, Casso G, Agazzi P. Serum neurofilament light chain as a prognostic marker in postanoxic encephalopathy. Epilepsy Behav 2019; 101:106432. [PMID: 31375414 DOI: 10.1016/j.yebeh.2019.07.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/08/2019] [Accepted: 07/08/2019] [Indexed: 11/25/2022]
Abstract
Functional outcome in patients with postanoxic encephalopathy after cardiac arrest (CA) often remains unclear, and there is a strong need of new prognostication measures. We aimed at investigating serum neurofilament light (NfL) chain concentration in patients with a postanoxic encephalopathy after CA and its prognostic potential. Serum samples were prospectively collected at different time points after CA in consecutive patients admitted to the intensive care unit (ICU) of Ticino Cardiocentre (Lugano, Switzerland) between June 2017 and March 2018. Serum NfL concentration was measured using a single molecule array (SIMOA) assay. The association of NfL levels with time to return of spontaneous circulation (ROSC), serum neuronal specific enolase (NSE) concentration, time between CA and sample collection, electroencephalogram (EEG) pattern and clinical outcome (death status at one month) were explored. Fourteen patients experiencing 15 CAs were included in the study (median age = 58 (57-68) years, 8 males). Median serum NfL concentration was 1027.0 (25.5-6033.7) pg/ml. There were positive associations between serum NfL and time to ROSC (rho = 0.60, p < 0.0001), NSE concentration (rho = 0.76, p < 0.0001), and severity of brain damage as estimated by EEG, with the highest concentrations measured in patients with suppressed electrical activity (14,954.0 [9006.0-25,364.0] pg/ml). Neurofilament light concentration remained high in samples collected up to 17 days after CA. Median NfL levels were higher among dead than alive patients at one month (6401.7 [3768.5-15,573.3] vs 25.5 [25.2-75.4] pg/ml). High NfL levels performed better than NSE in predicting death status at one month (NfL area under the curve (AUC) = 0.98, 95% confidence interval (CI) = 0.94-1.00; NSE AUC = 0.80, 95% CI = 0.67-0.94). These results support the potential inclusion of serum NfL in the battery of prognostication measures to be used in patients with postanoxic encephalopathy in ICU settings. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
Collapse
Affiliation(s)
- Giulio Disanto
- Neurocenter of Southern Switzerland, Civic Hospital, Lugano, Switzerland
| | - Chiara Prosperetti
- Neurocenter of Southern Switzerland, Civic Hospital, Lugano, Switzerland
| | - Claudio Gobbi
- Neurocenter of Southern Switzerland, Civic Hospital, Lugano, Switzerland
| | - Christian Barro
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Zuzanna Michalak
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Pamela Agazzi
- Neurocenter of Southern Switzerland, Civic Hospital, Lugano, Switzerland.
| |
Collapse
|
130
|
Beretta S, Coppo A, Bianchi E, Zanchi C, Carone D, Stabile A, Padovano G, Sulmina E, Grassi A, Bogliun G, Foti G, Ferrarese C, Pesenti A, Beghi E, Avalli L. Neurological outcome of postanoxic refractory status epilepticus after aggressive treatment. Epilepsy Behav 2019; 101:106374. [PMID: 31300383 DOI: 10.1016/j.yebeh.2019.06.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
Refractory status epilepticus (RSE) occurs in up to 30% of patients following resuscitation after cardiac arrest. The impact of aggressive treatment of postanoxic RSE on long-term neurological outcome remains uncertain. We investigated neurological outcome of cardiac arrest patients with RSE treated with a standardized aggressive protocol with antiepileptic drugs and anesthetics, compared with patients with other electroencephalographic (EEG) patterns. A prospective cohort of 166 consecutive patients with cardiac arrest in coma was stratified according to four independent EEG patterns (benign; RSE; generalized periodic discharges (GPDs); malignant nonepileptiform) and multimodal prognostic indicators. Primary outcomes were survival and cerebral performance category (CPC) at 6 months. Refractory status epilepticus occurred in 36 patients (21.7%) and was treated with an aggressive standardized protocol as long as multimodal prognostic indicators were not unfavorable. Refractory status epilepticus started after 3 ± 2.3 days after cardiac arrest and lasted 4.7 ± 4.3 days. A benign electroencephalographic patterns was recorded in 76 patients (45.8%), a periodic pattern (GPDs) in 13 patients (7.8%), and a malignant nonepileptiform EEG pattern in 41 patients (24.7%). The four EEG patterns were highly associated with different prognostic indicators (low flow time, clinical motor seizures, N20 responses, neuron-specific enolase (NSE), neuroimaging). Survival and good neurological outcome (CPC 1 or 2) at 6 months were 72.4% and 71.1% for benign EEG pattern, 54.3% and 44.4% for RSE, 15.4% and 0% for GPDs, and 2.4% and 0% for malignant nonepileptiform EEG pattern, respectively. Aggressive and prolonged treatment of RSE may be justified in cardiac arrest patients with favorable multimodal prognostic indicators. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
Collapse
Affiliation(s)
- Simone Beretta
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy.
| | - Anna Coppo
- Department of Intensive Care, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Elisa Bianchi
- Department of Neuroscience, IRCCS Mario Negri Institute for Pharmacological Research, Milano, Italy
| | - Clara Zanchi
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Davide Carone
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Andrea Stabile
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Giada Padovano
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Endrit Sulmina
- Department of Intensive Care, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Alice Grassi
- Department of Intensive Care, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Graziella Bogliun
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Giuseppe Foti
- Department of Intensive Care, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Carlo Ferrarese
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Ettore Beghi
- Department of Neuroscience, IRCCS Mario Negri Institute for Pharmacological Research, Milano, Italy
| | - Leonello Avalli
- Department of Intensive Care, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| |
Collapse
|
131
|
Moseby-Knappe M, Mattsson N, Nielsen N, Zetterberg H, Blennow K, Dankiewicz J, Dragancea I, Friberg H, Lilja G, Insel PS, Rylander C, Westhall E, Kjaergaard J, Wise MP, Hassager C, Kuiper MA, Stammet P, Wanscher MCJ, Wetterslev J, Erlinge D, Horn J, Pellis T, Cronberg T. Serum Neurofilament Light Chain for Prognosis of Outcome After Cardiac Arrest. JAMA Neurol 2019; 76:64-71. [PMID: 30383090 DOI: 10.1001/jamaneurol.2018.3223] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Prognostication of neurologic outcome after cardiac arrest is an important but challenging aspect of patient therapy management in critical care units. Objective To determine whether serum neurofilament light chain (NFL) levels can be used for prognostication of neurologic outcome after cardiac arrest. Design, Setting and Participants Prospective clinical biobank study of data from the randomized Target Temperature Management After Cardiac Arrest trial, an international, multicenter study with 29 participating sites. Patients were included between November 11, 2010, and January 10, 2013. Serum NFL levels were analyzed between August 1 and August 23, 2017, after trial completion. A total of 782 unconscious patients with out-of-hospital cardiac arrest of presumed cardiac origin were eligible. Exposures Serum NFL concentrations analyzed at 24, 48, and 72 hours after cardiac arrest with an ultrasensitive immunoassay. Main Outcomes and Measures Poor neurologic outcome at 6-month follow-up, defined according to the Cerebral Performance Category Scale as cerebral performance category 3 (severe cerebral disability), 4 (coma), or 5 (brain death). Results Of 782 eligible patients, 65 patients (8.3%) were excluded because of issues with aliquoting, missing sampling, missing outcome, or transport problems of samples. Of the 717 patients included (91.7%), 580 were men (80.9%) and median (interquartile range [IQR]) age was 65 (56-73) years. A total of 360 patients (50.2%) had poor neurologic outcome at 6 months. Median (IQR) serum NFL level was significantly increased in the patients with poor outcome vs good outcome at 24 hours (1426 [299-3577] vs 37 [20-70] pg/mL), 48 hours (3240 [623-8271] vs 46 [26-101] pg/mL), and 72 hours (3344 [845-7838] vs 54 [30-122] pg/mL) (P < .001 at all time points), with high overall performance (area under the curve, 0.94-0.95) and high sensitivities at high specificities (eg, 69% sensitivity with 98% specificity at 24 hours). Serum NFL levels had significantly greater performance than the other biochemical serum markers (ie, tau, neuron-specific enolase, and S100). At comparable specificities, serum NFL levels had greater sensitivity for poor outcome compared with routine electroencephalogram, somatosensory-evoked potentials, head computed tomography, and both pupillary and corneal reflexes (ranging from 29.2% to 49.0% greater for serum NFL level). Conclusions and Relevance Findings from this study suggest that the serum NFL level is a highly predictive marker of long-term poor neurologic outcome at 24 hours after cardiac arrest and may be a useful complement to currently available neurologic prognostication methods.
Collapse
Affiliation(s)
- Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Niklas Mattsson
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden.,Clinical Memory Research Unit, Faculty of Medicine, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Lund, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Molecular Neuroscience, University College of London Institute of Neurology, London, United Kingdom.,United Kingdom Dementia Research Institute, London, United Kingdom
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Irina Dragancea
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Skåne University Hospital, Lund, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Philip S Insel
- Clinical Memory Research Unit, Faculty of Medicine, Lund University, Lund, Sweden
| | - Christian Rylander
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Westhall
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Skåne University Hospital, Lund, Sweden
| | - Jesper Kjaergaard
- Departments of Cardiology, Rigshospitalet and Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, United Kingdom
| | - Christian Hassager
- Departments of Cardiology, Rigshospitalet and Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael A Kuiper
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | | | - Michael C Jaeger Wanscher
- Department of Cardiothoracic Anaesthesia, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research Department, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - David Erlinge
- Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
| | - Tommaso Pellis
- Anesthesia and Intensive Care, Card. G. Panico Hospital Agency, Tricase, Italy
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
132
|
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.
Collapse
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
| |
Collapse
|
133
|
Gugger JJ, Geocadin RG, Kaplan PW. A multimodal approach using somatosensory evoked potentials for prognostication in hypoglycemic encephalopathy. Clin Neurophysiol Pract 2019; 4:194-197. [PMID: 31886445 PMCID: PMC6921239 DOI: 10.1016/j.cnp.2019.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022] Open
Abstract
Hypoglycemic encephalopathy may be associated with poor neurological prognosis. Little data exists to guide prognostication in hypoglycemic encephalopathy. We describe a multimodal approach to prognostication in hypoglycemia. MRI, EEG, and SSEPs estimate severity of brain injury in hypoglycemic coma.
Objectives We present a case of a patient with hypoglycemic encephalopathy with loss of median nerve N20 somatosensory evoked potentials (SSEPs) and describe our multimodal approach to prognostication in hypoglycemic encephalopathy. Case The patient was a 67-year-old woman with type 2 diabetes and stage 5 chronic kidney disease hospitalized for hypoglycemic encephalopathy. SSEPs showed bilateral absence of the median nerve N20 response. She ultimately suffered a poor outcome. Discussion There are no high-quality evidence-based clinical, neurophysiologic, or imaging studies available to aid in neurologic outcome prediction in hypoglycemic encephalopathy. In our practice we use a multimodal approach to neurologic prognostication, similar to that used in coma after cardiac arrest that includes SSEPs, EEG, and brain MRI, which enables an estimate of the severity of brain injury. As the literature is largely based on small studies or case reports, and is extrapolated from the cardiac arrest literature, we caution against early prognostication and disposition including the withdrawal of care, to avoid a self-fulfilling prophecy.
Collapse
Affiliation(s)
- James J Gugger
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter W Kaplan
- Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
134
|
|
135
|
Morelli P, Oddo M, Ben-Hamouda N. Role of automated pupillometry in critically ill patients. Minerva Anestesiol 2019; 85:995-1002. [DOI: 10.23736/s0375-9393.19.13437-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
136
|
Rossetti AO, Hirsch LJ, Drislane FW. Nonconvulsive seizures and nonconvulsive status epilepticus in the neuro ICU should or should not be treated aggressively: A debate. Clin Neurophysiol Pract 2019; 4:170-177. [PMID: 31886441 PMCID: PMC6921236 DOI: 10.1016/j.cnp.2019.07.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/01/2019] [Accepted: 07/07/2019] [Indexed: 12/29/2022] Open
Abstract
This article presents a "debate" about the appropriate level of aggressiveness of treatment for nonconvulsive status epilepticus (NCSE), held at the International Congress of Clinical Neurophysiology in Washington D.C. on 4 May 2018. The proposition for discussion was "Nonconvulsive seizures and status epilepticus in the intensive care unit should be treated aggressively." Dr. Andrea O. Rossetti from Lausanne, Switzerland, spoke in support of the proposition and Dr. Lawrence J. Hirsch from New Haven, Connecticut, discussed reasons for rejecting the proposal. Dr. Frank W. Drislane from Boston, Massachusetts, was asked by the conference organizers to add comments and perspective.
Collapse
Affiliation(s)
- Andrea O Rossetti
- Département des neurosciences cliniques, University Hospital and Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Lawrence J Hirsch
- Division of Epilepsy and EEG Yale University School of Medicine, PO Box 208018, New Haven Conn. 06520-8018, USA
| | - Frank W Drislane
- KS 479, Neurology Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02460, USA
| |
Collapse
|
137
|
Lee JH, Park I, You JS, Kim MJ, Lee HS, Park YS, Park HC, Chung SP. Predictive performance of plasma neutrophil gelatinase-associated lipocalin for neurologic outcomes in out-of-hospital cardiac arrest patients treated with targeted temperature management: A prospective observational study. Medicine (Baltimore) 2019; 98:e16930. [PMID: 31441881 PMCID: PMC6716698 DOI: 10.1097/md.0000000000016930] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Few studies have demonstrated the prognostic potential of neutrophil gelatinase-associated lipocalin (NGAL) in post-cardiac arrest patients. This study evaluated the usefulness of plasma NGAL in predicting neurologic outcome and mortality in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM). A prospective observational study was conducted between October 2013 and April 2016 at a single tertiary hospital. We enrolled 75 patients treated with TTM and collected their demographic data, cardiopulmonary resuscitation-related information, data on plasma NGAL concentration, and prognostic test results. Plasma NGAL was measured at 4 hours after return of spontaneous circulation (ROSC). The primary endpoint was the neurologic outcome at discharge and the secondary outcome was 28-day mortality. Neurologic outcomes were analyzed using a stepwise multivariate logistic regression while 28-day mortality was analyzed using a stepwise Cox regression. The predictive performance of plasma NGAL for neurologic outcome was measured by the area under the receiver operating characteristic curve and the predictability of 28-day mortality was measured using Harrell C-index. We also compared the predictive performance of plasma NGAL to that of other traditional prognostic modalities for outcome variables. Thirty patients (40%) had good neurologic outcomes and 53 (70.7%) survived for more than 28 days. Plasma NGAL in patients with good neurologic outcomes was 122.7 ± 146.7 ng/ml, which was significantly lower than that in the poor neurologic outcome group (307.5 ± 269.6 ng/ml; P < .001). The probability of a poor neurologic outcome was more than 3.3-fold in the NGAL >124.3 ng/ml group (odds ratio, 3.321; 95% confidence interval [CI], 1.265-8.721]). Plasma NGAL in the survived group was significantly lower than that in the non-survived group (172.7 ± 191.6 vs 379.9 ± 297.8 ng/ml; P = .005). Plasma NGAL was significantly correlated with 28-day mortality (hazard ratio 1.003, 95% CI 1.001-1.004; P < .001). The predictive performance of plasma NGAL was not inferior to that of other prognostic modalities except electroencephalography. Plasma NGAL is valuable for predicting the neurologic outcome and 28-day mortality of patients with OHCA at an early stage after ROSC.This study was registered at ClinicalTrials.gov on November 19, 2013 (Identifier: NCT01987466).
Collapse
Affiliation(s)
- Ji Hwan Lee
- Department of Emergency Medicine, Yonsei University College of Medicine
- Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon
| | - Incheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine
| | - Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine
| | - Hyeong Cheon Park
- Division of Nephrology, Department of Internal Medicine Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine
| |
Collapse
|
138
|
Jonas S, Rossetti AO, Oddo M, Jenni S, Favaro P, Zubler F. EEG-based outcome prediction after cardiac arrest with convolutional neural networks: Performance and visualization of discriminative features. Hum Brain Mapp 2019; 40:4606-4617. [PMID: 31322793 DOI: 10.1002/hbm.24724] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/24/2019] [Accepted: 07/01/2019] [Indexed: 12/11/2022] Open
Abstract
Prognostication for comatose patients after cardiac arrest is a difficult but essential task. Currently, visual interpretation of electroencephalogram (EEG) is one of the main modality used in outcome prediction. There is a growing interest in computer-assisted EEG interpretation, either to overcome the possible subjectivity of visual interpretation, or to identify complex features of the EEG signal. We used a one-dimensional convolutional neural network (CNN) to predict functional outcome based on 19-channel-EEG recorded from 267 adult comatose patients during targeted temperature management after CA. The area under the receiver operating characteristic curve (AUC) on the test set was 0.885. Interestingly, model architecture and fine-tuning only played a marginal role in classification performance. We then used gradient-weighted class activation mapping (Grad-CAM) as visualization technique to identify which EEG features were used by the network to classify an EEG epoch as favorable or unfavorable outcome, and also to understand failures of the network. Grad-CAM showed that the network relied on similar features than classical visual analysis for predicting unfavorable outcome (suppressed background, epileptiform transients). This study confirms that CNNs are promising models for EEG-based prognostication in comatose patients, and that Grad-CAM can provide explanation for the models' decision-making, which is of utmost importance for future use of deep learning models in a clinical setting.
Collapse
Affiliation(s)
- Stefan Jonas
- Computer Vision Group, Department of Computer Science, University of Bern, Bern, Switzerland
| | - Andrea O Rossetti
- Department of Neurology, University Hospital (CHUV) & University of Lausanne, Lausanne, Switzerland
| | - Mauro Oddo
- Department of Intensive Care Medicine, University Hospital (CHUV) & University of Lausanne, Lausanne, Switzerland
| | - Simon Jenni
- Computer Vision Group, Department of Computer Science, University of Bern, Bern, Switzerland
| | - Paolo Favaro
- Computer Vision Group, Department of Computer Science, University of Bern, Bern, Switzerland
| | - Frederic Zubler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
139
|
Seki T, Tamura T, Suzuki M. Outcome prediction of out-of-hospital cardiac arrest with presumed cardiac aetiology using an advanced machine learning technique. Resuscitation 2019; 141:128-135. [PMID: 31220514 DOI: 10.1016/j.resuscitation.2019.06.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Outcome prediction for patients with out-of-hospital cardiac arrest (OHCA) has the possibility to detect patients who could have been potentially saved. Advanced machine learning techniques have recently been developed and employed for clinical studies. In this study, we aimed to establish a prognostication model for OHCA with presumed cardiac aetiology using an advanced machine learning technique. METHODS AND RESULTS Cohort data from a prospective multi-centre cohort study for OHCA patients transported by an ambulance in the Kanto area of Japan between January 2012 and March 2013 (SOS-KANTO 2012 study) were analysed in this study. Of 16,452 patients, data for OHCA patients aged ≥18 years with presumed cardiac aetiology were retrieved, and were divided into two groups (training set: n = 5718, between January 1, 2012 and December 12, 2012; test set: n = 1608, between January 1, 2013 and March 31, 2013). Of 421 variables observed during prehospital and emergency department settings, 35 prehospital variables, or 35 prehospital and 18 in-hospital variables, were used for outcome prediction of 1-year survival using a random forest method. In validation using the test set, prognostication models trained with 35 variables, or 53 variables for 1-year survival showed area under the receiver operating characteristics curve (AUC) values of 0.943 (95% CI [0.930, 0.955]) and 0.958 (95% CI [0.948, 0.969]), respectively. CONCLUSIONS The advanced machine learning technique showed favourable prediction capability for 1-year survival of OHCA with presumed cardiac aetiology. These models can be useful for detecting patients who could have been potentially saved.
Collapse
Affiliation(s)
- Tomohisa Seki
- Department of Healthcare Information Management, The University of Tokyo Hospital, Tokyo, Japan.
| | - Tomoyoshi Tamura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Suzuki
- Department of Emergency Medicine, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan
| | | |
Collapse
|
140
|
Storm C, Behringer W, Wolfrum S, Michels G, Fink K, Kill C, Arrich J, Leithner C, Ploner C, Busch HJ. [Postcardiac arrest treatment guide]. Med Klin Intensivmed Notfmed 2019; 115:573-584. [PMID: 31197420 DOI: 10.1007/s00063-019-0591-6] [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: 01/17/2019] [Revised: 03/28/2019] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Treatment after cardiac arrest has become more complex and interdisciplinary over the last few years. Thus, the clinically active intensive and emergency care physician not only has to carry out the immediate care and acute diagnostics, but also has to prognosticate the neurological outcome. AIM The different, most important steps are presented by leading experts in the area, taking into account the interdisciplinarity and the currently valid guidelines. MATERIALS AND METHODS Attention was paid to a concise, practice-oriented presentation. RESULTS AND DISCUSSION The practical guide contains all important steps from the acute care to the neurological prognosis generation that are relevant for the clinically active intensive care physician.
Collapse
Affiliation(s)
- C Storm
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivmedizin, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - W Behringer
- Zentrum für Notfallmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
| | - S Wolfrum
- Interdisziplinäre Notaufnahme, Universitätsklinikum Lübeck, Lübeck, Deutschland
| | - G Michels
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Köln, Deutschland
| | - K Fink
- Universitäts-Notfallzentrum, Universitätsklinikum Freiburg, Sir-Hans-A.-Krebs-Straße, 79106, Freiburg Breisgau, Deutschland
| | - C Kill
- Zentrum für Notfallmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - J Arrich
- Zentrum für Notfallmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - C Leithner
- Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - C Ploner
- Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - H-J Busch
- Universitäts-Notfallzentrum, Universitätsklinikum Freiburg, Sir-Hans-A.-Krebs-Straße, 79106, Freiburg Breisgau, Deutschland.
| |
Collapse
|
141
|
Spectral Content of Electroencephalographic Burst-Suppression Patterns May Reflect Neuronal Recovery in Comatose Post-Cardiac Arrest Patients. J Clin Neurophysiol 2019; 36:119-126. [PMID: 30422916 DOI: 10.1097/wnp.0000000000000536] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To assess the potential biologic significance of variations in burst-suppression patterns (BSPs) after cardiac arrest in relation to recovery of consciousness. In the context of recent theoretical models of BSP, bursting frequency may be representative of underlying network dynamics; discontinuous activation of membrane potential during impaired cellular energetics may promote neuronal rescue. METHODS We reviewed a database of 73 comatose post-cardiac arrest patients who underwent therapeutic hypothermia to assess for the presence of BSP and clinical outcomes. In a subsample of patients with BSP (n = 14), spectral content of burst and suppression periods were quantified using multitaper method. RESULTS Burst-suppression pattern was seen in 45/73 (61%) patients. Comparable numbers of patients with (31.1%) and without (35.7%) BSP regained consciousness by the time of hospital discharge. In addition, in two unique cases, BSP initially resolved and then spontaneously reemerged after completion of therapeutic hypothermia and cessation of sedative medications. Both patients recovered consciousness. Spectral analysis of bursts in all patients regaining consciousness (n = 6) showed a prominent theta frequency (5-7 Hz) feature, but not in age-matched patients with induced BSP who did not recover consciousness (n = 8). CONCLUSIONS The prognostic implications of BSP after hypoxic brain injury may vary based on the intrinsic properties of the underlying brain state itself. The presence of theta activity within bursts may index potential viability of neuronal networks underlying recovery of consciousness; emergence of spontaneous BSP in some cases may indicate an innate neuroprotective mechanism. This study highlights the need for better characterization of various BSP patterns after cardiac arrest.
Collapse
|
142
|
Admiraal MM, van Rootselaar A, Hofmeijer J, Hoedemaekers CWE, van Kaam CR, Keijzer HM, van Putten MJAM, Schultz MJ, Horn J. Electroencephalographic reactivity as predictor of neurological outcome in postanoxic coma: A multicenter prospective cohort study. Ann Neurol 2019; 86:17-27. [PMID: 31124174 PMCID: PMC6618107 DOI: 10.1002/ana.25507] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 11/30/2022]
Abstract
Objective Outcome prediction in patients after cardiac arrest (CA) is challenging. Electroencephalographic reactivity (EEG‐R) might be a reliable predictor. We aimed to determine the prognostic value of EEG‐R using a standardized assessment. Methods In a prospective cohort study, a strictly defined EEG‐R assessment protocol was executed twice per day in adult patients after CA. EEG‐R was classified as present or absent by 3 EEG readers, blinded to patient characteristics. Uncertain reactivity was classified as present. Primary outcome was best Cerebral Performance Category score (CPC) in 6 months after CA, dichotomized as good (CPC = 1–2) or poor (CPC = 3–5). EEG‐R was considered reliable for predicting poor outcome if specificity was ≥95%. For good outcome prediction, a specificity of ≥80% was used. Added value of EEG‐R was the increase in specificity when combined with EEG background, neurological examination, and somatosensory evoked potentials (SSEPs). Results Of 160 patients enrolled, 149 were available for analyses. Absence of EEG‐R for poor outcome prediction had a specificity of 82% and a sensitivity of 73%. For good outcome prediction, specificity was 73% and sensitivity 82%. Specificity for poor outcome prediction increased from 98% to 99% when EEG‐R was added to a multimodal model. For good outcome prediction, specificity increased from 70% to 89%. Interpretation EEG‐R testing in itself is not sufficiently reliable for outcome prediction in patients after CA. For poor outcome prediction, it has no substantial added value to EEG background, neurological examination, and SSEPs. For prediction of good outcome, EEG‐R seems to have added value. ANN NEUROL 2019
Collapse
Affiliation(s)
- Marjolein M. Admiraal
- Amsterdam University Medical Centers, University of AmsterdamDepartment of Intensive Care, Amsterdam NeuroscienceAmsterdamthe Netherlands
| | - Anne‐Fleur van Rootselaar
- Amsterdam University Medical Centers, University of AmsterdamDepartment of Neurology/Clinical Neurophysiology, Amsterdam NeuroscienceAmsterdamthe Netherlands
| | - Jeannette Hofmeijer
- Rijnstate HospitalDepartment of NeurologyArnhemthe Netherlands
- Clinical NeurophysiologyTechMed Centre, University of TwenteEnschedethe Netherlands
| | | | | | - Hanneke M. Keijzer
- Rijnstate HospitalDepartment of NeurologyArnhemthe Netherlands
- Department of Intensive Care Medicine and NeurologyDonders Institute for Brain, Cognition, and Behavior, Radboud University Medical CenterNijmegenthe Netherlands
| | - Michel J. A. M. van Putten
- Clinical NeurophysiologyTechMed Centre, University of TwenteEnschedethe Netherlands
- Department of Clinical NeurophysiologyMedisch Spectrum TwenteEnschedethe Netherlands
| | - Marcus J. Schultz
- Amsterdam University Medical Centers, University of AmsterdamDepartment of Intensive Care, Amsterdam NeuroscienceAmsterdamthe Netherlands
- Amsterdam University Medical Centers, University of AmsterdamLaboratory for Experimental Intensive Care and AnesthesiologyAmsterdamthe Netherlands
- Mahidol UniversityMahidol Oxford Tropical Medicine Research UnitBangkokThailand
| | - Janneke Horn
- Amsterdam University Medical Centers, University of AmsterdamDepartment of Intensive Care, Amsterdam NeuroscienceAmsterdamthe Netherlands
- Amsterdam University Medical Centers, University of AmsterdamLaboratory for Experimental Intensive Care and AnesthesiologyAmsterdamthe Netherlands
| |
Collapse
|
143
|
Kustermann T, Nguepnjo Nguissi NA, Pfeiffer C, Haenggi M, Kurmann R, Zubler F, Oddo M, Rossetti AO, De Lucia M. Electroencephalography-based power spectra allow coma outcome prediction within 24 h of cardiac arrest. Resuscitation 2019; 142:162-167. [PMID: 31136808 DOI: 10.1016/j.resuscitation.2019.05.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/26/2019] [Accepted: 05/16/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Outcome prediction in comatose patients following cardiac arrest remains challenging. Here, we assess the predictive performance of electroencephalography-based power spectra within 24 h from coma onset. METHODS We acquired electroencephalography (EEG) from comatose patients (n = 138) on the first day of coma in four hospital sites in Switzerland. Outcome was categorised as favourable or unfavourable based on the best state within three months. Data were split in training and test sets. We evaluated the predictive performance of EEG power spectra for long term outcome and its added value to standard clinical tests. RESULTS Out of 138 patients, 80 had a favourable outcome. Power spectra comparison between favourable and unfavourable outcome in the training set yielded significant differences at 5.2-13.2 Hz and above 21 Hz. Outcome prediction based on power at 5.2-13.2 Hz was accurate in training and test sets. Overall, power spectra predicted patients' outcome with maximum specificity and positive predictive value: 1.00 (95% with CI: 0.94-1.00 and 0.89-1.00, respectively). The combination of power spectra and reactivity yielded better accuracy and sensitivity (0.81, 95% CI: 0.71-0.89) than prediction based on power spectra alone. CONCLUSIONS On the first day of coma following cardiac arrest, low power spectra values around 10 Hz, typically linked to impaired cortico-thalamic structural connections, are highly specific of unfavourable outcome. Peaks in this frequency range can predict long-term outcome.
Collapse
Affiliation(s)
- Thomas Kustermann
- Laboratoire de Recherche en Neuroimagerie (LREN), University Hospital (CHUV) & University of Lausanne, Mont-Paisible 16, Lausanne, CH-1011, Switzerland.
| | - Nathalie Ata Nguepnjo Nguissi
- Laboratoire de Recherche en Neuroimagerie (LREN), University Hospital (CHUV) & University of Lausanne, Mont-Paisible 16, Lausanne, CH-1011, Switzerland
| | - Christian Pfeiffer
- Department of Psychology, University of Zürich, Binzmühlestrasse 14, CH-8050 Zürich, Switzerland
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010 Bern, Switzerland
| | - Rebekka Kurmann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010 Bern, Switzerland
| | - Frédéric Zubler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010 Bern, Switzerland
| | - Mauro Oddo
- Department of Intensive Care Medicine, University Hospital (CHUV) & University of Lausanne, Rue du Bugnon 21, CH-1011, Switzerland
| | - Andrea O Rossetti
- Department of Neurology, University Hospital (CHUV) & University of Lausanne, Rue du Bugnon 21, CH-1011, Switzerland
| | - Marzia De Lucia
- Laboratoire de Recherche en Neuroimagerie (LREN), University Hospital (CHUV) & University of Lausanne, Mont-Paisible 16, Lausanne, CH-1011, Switzerland
| |
Collapse
|
144
|
The author replies. Crit Care Med 2019; 45:e876. [PMID: 28708695 DOI: 10.1097/ccm.0000000000002507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
145
|
Caporro M, Rossetti AO, Seiler A, Kustermann T, Nguepnjo Nguissi NA, Pfeiffer C, Zimmermann R, Haenggi M, Oddo M, De Lucia M, Zubler F. Electromyographic reactivity measured with scalp-EEG contributes to prognostication after cardiac arrest. Resuscitation 2019; 138:146-152. [DOI: 10.1016/j.resuscitation.2019.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 03/03/2019] [Accepted: 03/06/2019] [Indexed: 01/02/2023]
|
146
|
Oddo M, Bracard S, Cariou A, Chanques G, Citerio G, Clerckx B, Godeau B, Godier A, Horn J, Jaber S, Jung B, Kuteifan K, Leone M, Mailles A, Mazighi M, Mégarbane B, Outin H, Puybasset L, Sharshar T, Sandroni C, Sonneville R, Weiss N, Taccone FS. Update in Neurocritical Care: a summary of the 2018 Paris international conference of the French Society of Intensive Care. Ann Intensive Care 2019; 9:47. [PMID: 30993550 PMCID: PMC6468018 DOI: 10.1186/s13613-019-0523-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 04/08/2019] [Indexed: 02/08/2023] Open
Abstract
The 2018 Paris Intensive Care symposium entitled "Update in Neurocritical Care" was organized in Paris, June 21-22, 2018, under the auspices of the French Intensive Care Society. This 2-day post-graduate educational symposium comprised several chapters, aiming first to provide all-board intensivists with current standards for the clinical assessment of altered consciousness states (including coma and delirium) and peripheral nervous system in critically ill patients, monitoring of brain function (specifically, electro-encephalography) and best practices for sedation-analgesia-delirium management. An update on the treatment of specific severe brain pathologies-including ischaemic/haemorrhagic stroke, cerebral venous thrombosis, hypoxic-ischaemic brain injury, immune-mediated and infectious encephalitis and refractory status epilepticus-was also provided. Finally, we discuss how to approach some difficult decisions, namely the role of decompressive craniectomy and prognostication models in patients with head injury. For each chapter, the scope of the present review was to provide important issues and key messages, provide most recent and relevant literature in the field, and briefly describe new developments in the field.
Collapse
Affiliation(s)
- Mauro Oddo
- Department of Intensive Care Medicine, CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University of Lorraine and University Hospital of Nancy, Nancy, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital, Université Paris Descartes, Paris, France
| | - Gérald Chanques
- Department of Anaesthesia and Intensive Care, Montpellier Saint Eloi University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, 34295, Montpellier Cedex 5, France
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Béatrix Clerckx
- Department of Intensive Care Medicine, University Hospitals Leuven, Louvain, Belgium
| | - Bertrand Godeau
- Service de Médecine Interne, Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Hôpital Henri-Mondor, Créteil, France
| | - Anne Godier
- Fondation Adolphe de Rothschild, Department of Anesthesiology and Intensive Care, Paris Descartes University, Paris, France
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Samir Jaber
- Department of Anaesthesia and Intensive Care, Montpellier Saint Eloi University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, 34295, Montpellier Cedex 5, France
| | - Boris Jung
- Medical Intensive Care Unit, Montpellier Teaching Hospital, PhyMedex, University of Montpellier, Montpellier, France
| | | | - Marc Leone
- Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Alexandra Mailles
- ESGIB, ESCMID Study Group for Infectious Diseases of the Brain, Santé Publique France, 12, rue du Val-d'Osne, 94415, Saint-Maurice Cedex, France
| | - Mikael Mazighi
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris, France
| | - Hervé Outin
- Service de Réanimation Médico-Chirurgicale, CHI de Poissy-Saint Germain en Laye, Poissy, France
| | - Louis Puybasset
- Department of Anesthesia and Intensive Care, Pitié-Salpetrière Hospital, Paris, France
| | - Tarek Sharshar
- Medical and Surgical Neurointensive Care Centre, Hospital Sainte Anne, Paris, France
| | - Claudio Sandroni
- Istituto Anestesiologia e Rianimazione Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Romain Sonneville
- Department of Intensive Care Medicine and Infectious Diseases, Hôpital Bichat-Claude, Université Paris Diderot, Paris, France
| | - Nicolas Weiss
- Neurocritical Care Unit, Department of Neurology, Assistance Publique - Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Sorbonne Université, Paris, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
| |
Collapse
|
147
|
Cour M, Turc J, Madelaine T, Argaud L. Risk factors for progression toward brain death after out-of-hospital cardiac arrest. Ann Intensive Care 2019; 9:45. [PMID: 30963296 PMCID: PMC6453982 DOI: 10.1186/s13613-019-0520-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/02/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Successfully resuscitated out-of-hospital cardiac arrest (OHCA) may lead to brain death (BD) and good-quality transplantable organs. We aimed to determine risk factors for evolution toward BD after OHCA. We analyzed adult patients admitted to an intensive care unit (ICU) who survived at least 24 h after an OHCA between 2005 and 2015. BD was defined according to international guidelines. Multivariate logistic regression was used to identify potential risk factors for BD available 24 h after OHCA. RESULTS A total of 214 patients were included (median age 68 years; sex ratio 1.25; non-shockable OHCA: 88%). Among these, 42 (19.6%) developed BD, while 22 (10.3%) were alive at 1 year with a good neurological outcome. Independent risk factors for BD were age (OR per year 0.95; 95% CI [0.92-0.98]), female gender (OR 2.34; 95% CI [1.02-5.35]), neurological cause of OHCA (OR 14.72; 95% CI [3.03-71.37]), duration of the low-flow period > 16 min (OR 2.94, 95% CI [1.21-7.16]) and need of vasoactive drugs at 24 h (OR 6.20, 95% CI [2.41-15.93]). CONCLUSIONS The study identified, in a population of OHCA with predominantly non-shockable initial rhythms, five simple risk factors independently associated with progression toward BD.
Collapse
Affiliation(s)
- Martin Cour
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 5, Place d’Arsonval, 69437 Lyon Cedex 03, France
- Faculté de médecine Lyon-Est, Université Claude Bernard Lyon 1, Université de Lyon, 69373 Lyon, France
- U1060 CarMeN, INSERM, 69373 Lyon, France
| | - Jean Turc
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 5, Place d’Arsonval, 69437 Lyon Cedex 03, France
| | - Thomas Madelaine
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 5, Place d’Arsonval, 69437 Lyon Cedex 03, France
- Faculté de médecine Lyon-Est, Université Claude Bernard Lyon 1, Université de Lyon, 69373 Lyon, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 5, Place d’Arsonval, 69437 Lyon Cedex 03, France
- Faculté de médecine Lyon-Est, Université Claude Bernard Lyon 1, Université de Lyon, 69373 Lyon, France
- U1060 CarMeN, INSERM, 69373 Lyon, France
| |
Collapse
|
148
|
Taccone FS, Horn J, Storm C, Cariou A, Sandroni C, Friberg H, Hoedemaekers CA, Oddo M. Death after awakening from post-anoxic coma: the "Best CPC" project. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:107. [PMID: 30944013 PMCID: PMC6446295 DOI: 10.1186/s13054-019-2405-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 03/22/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND In patients who recover consciousness after cardiac arrest (CA), a subsequent death from non-neurological causes may confound the assessment of long-term neurological outcome. We investigated the prevalence and causes of death after awakening (DAA) in a multicenter cohort of CA patients. METHODS Observational multicenter cohort study on patients resuscitated from CA in eight European intensive care units (ICUs) from January 2007 to December 2014. DAA during the hospital stay was extracted retrospectively from patient medical records. Demographics, comorbidities, initial CA characteristics, concomitant therapies, prognostic tests (clinical examination, electroencephalography (EEG), somatosensory evoked potentials (SSEPs)), and cause of death were identified. RESULTS From a total 4646 CA patients, 2478 (53%) died in-hospital, of whom 196 (4.2%; ranges 0.6-13.0%) had DAA. DAA was less frequent among out-of-hospital than in-hospital CA (82/2997 [2.7%] vs. 114/1649 [6.9%]; p < 0.001). Median times from CA to awakening and from awakening to death were 2 [1-5] and 9 [3-18] days, respectively. The main causes of DAA were multiple organ failure (n = 61), cardiogenic shock (n = 61), and re-arrest (n = 26). At day 3 from admission, results from EEG (n = 56) and SSEPs (n = 60) did not indicate poor outcome. CONCLUSIONS In this large multicenter cohort, DAA was observed in 4.2% of non-survivors. Information on DAA is crucial since it may influence epidemiology and the design of future CA studies evaluating neuroprognostication and neuroprotection.
Collapse
Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium. .,Université Libre de Bruxelles, Brussels, Belgium.
| | - Janneke Horn
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christian Storm
- Medical Department, Division of Nephrology and Internal Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alain Cariou
- Intensive Care Unit, AP-HP, Cochin Hospital, Descartes University, Paris, France
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care - Fondazione Policlinico Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hans Friberg
- Department of Anesthesiology and Intensive Care Medicine, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | | | - Mauro Oddo
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
149
|
Neuron-specific enolase kinetics: an additional tool for neurological prognostication after cardiac arrest. ACTA ACUST UNITED AC 2019; 73:123-130. [PMID: 30857978 DOI: 10.1016/j.rec.2019.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 01/14/2019] [Indexed: 01/25/2023]
Abstract
INTRODUCTION AND OBJECTIVES To analyze neuron-specific enolase (NSE) kinetics as a prognostic biomarker of neurological outcome in cardiac arrest survivors treated with targeted temperature management. METHODS We performed a retrospective analysis of patients resuscitated from in- or out-of-hospital cardiac arrest admitted from September 2006 to May 2018 in a single tertiary care center and cooled to 32°C to 34°C for 24 hours. Blood samples for measurement of NSE values were drawn at hospital admission and at 24, 48, and 72hours after return of spontaneous circulation (ROSC). Neurological outcome was evaluated by means of the Cerebral Performance Category (CPC) score at 3 months and was characterized as good (CPC 1-2) or poor (CPC 3-5). RESULTS Of 451 patients, 320 fulfilled the inclusion criteria and were analyzed (80.3% male, mean age 61±14.1 years). Among these, 174 patients (54.4%) survived with good neurological status. Poor outcome patients had higher median NSE values at hospital admission and at 24, 48 and 72 hours after ROSC. At 48 and 72 hours after ROSC, NSE predicted poor neurological outcome with areas under the receiver-operating characteristic curves of 0.85 (95%CI, 0.81-0.90) and 0.88 (95%CI, 0.83-0.93), respectively. In addition, delta NSE values between 72hours after ROSC and hospital admission predicted poor neurological outcome with an area under the receiver-operating characteristic curve of 0.90 (95%CI, 0.85-0.95) and was an independent predictor of unfavorable outcome on multivariate analysis (P <.001). CONCLUSIONS In cardiac arrest survivors treated with targeted temperature management, delta NSE values between 72 hours after ROSC and hospital admission strongly predicted poor neurological outcome.
Collapse
|
150
|
Neuron-specific-enolase as a predictor of the neurologic outcome after cardiopulmonary resuscitation in patients on ECMO. Resuscitation 2019; 136:14-20. [DOI: 10.1016/j.resuscitation.2019.01.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 12/22/2018] [Accepted: 01/06/2019] [Indexed: 12/13/2022]
|