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Kim JH, Kim MJ, You JS, Lee HS, Park YS, Park I, Chung SP. Multimodal approach for neurologic prognostication of out-of-hospital cardiac arrest patients undergoing targeted temperature management. Resuscitation 2018; 134:33-40. [PMID: 30562594 DOI: 10.1016/j.resuscitation.2018.11.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/22/2018] [Accepted: 11/05/2018] [Indexed: 11/16/2022]
Abstract
AIM Since the introduction of targeted temperature management (TTM), the accuracy and timing of prognostic tests for post-cardiac arrest patients have changed. Although previous studies have demonstrated the effectiveness of a multimodal approach in assessing the prognosis of TTM patients, few studies have investigated an optimised strategy that sequentially combines different prognostic modalities. This study identified an optimal sequential combination of prognostic modalities to predict poor neurologic outcomes in patients undergoing TTM. METHODS We performed a retrospective analysis using TTM management registry data. All patients underwent an identical sequence of prognostic tests at fixed timings. The sequence included brain computed tomography (CT), serum neuron-specific enolase (NSE), electrophysiological examination, neurologic examination, and diffusion-weighted imaging. We used hierarchical classification and regression tree analysis to find the optimal prognostic model. The primary measure was a poor neurologic outcome at one month after cardiac arrest. RESULTS A total of 192 patients were included and 103 patients (53.6%) had poor neurologic outcomes. The final model consisted of brain CT, serum NSE, electroencephalogram, somatosensory-evoked potentials, and pupil light reflex. Our model predicted poor outcomes with a 0% false positive rate. Moreover, our model had an area under the receiver operating characteristic curve value of 0.911 (95% confidence interval, 0.872-0.950), which was significantly higher than that of each prognostic modality alone. CONCLUSIONS Our stepwise model showed excellent prognostic ability to predict poor outcomes at one month after cardiac arrest and may be used to minimise the risk of false pessimistic predictions in patients undergoing TTM.
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Affiliation(s)
- Ji Hoon Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Incheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
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152
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Nagaraj SB, Tjepkema-Cloostermans MC, Ruijter BJ, Hofmeijer J, van Putten MJ. The revised Cerebral Recovery Index improves predictions of neurological outcome after cardiac arrest. Clin Neurophysiol 2018; 129:2557-2566. [DOI: 10.1016/j.clinph.2018.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/28/2018] [Accepted: 10/14/2018] [Indexed: 01/27/2023]
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153
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Oddo M, Sandroni C, Citerio G, Miroz JP, Horn J, Rundgren M, Cariou A, Payen JF, Storm C, Stammet P, Taccone FS. Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study. Intensive Care Med 2018; 44:2102-2111. [PMID: 30478620 PMCID: PMC6280828 DOI: 10.1007/s00134-018-5448-6] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 11/02/2018] [Indexed: 11/04/2022]
Abstract
Purpose To assess the ability of quantitative pupillometry [using the Neurological Pupil index (NPi)] to predict an unfavorable neurological outcome after cardiac arrest (CA). Methods We performed a prospective international multicenter study (10 centers) in adult comatose CA patients. Quantitative NPi and standard manual pupillary light reflex (sPLR)—blinded to clinicians and outcome assessors—were recorded in parallel from day 1 to 3 after CA. Primary study endpoint was to compare the value of NPi versus sPLR to predict 3-month Cerebral Performance Category (CPC), dichotomized as favorable (CPC 1–2: full recovery or moderate disability) versus unfavorable outcome (CPC 3–5: severe disability, vegetative state, or death). Results At any time between day 1 and 3, an NPi ≤ 2 (n = 456 patients) had a 51% (95% CI 49–53) negative predictive value and a 100% positive predictive value [PPV; 0% (0–2) false-positive rate], with a 100% (98–100) specificity and 32% (27–38) sensitivity for the prediction of unfavorable outcome. Compared with NPi, sPLR had significantly lower PPV and significantly lower specificity (p < 0.001 at day 1 and 2; p = 0.06 at day 3). The combination of NPi ≤ 2 with bilaterally absent somatosensory evoked potentials (SSEP; n = 188 patients) provided higher sensitivity [58% (49–67) vs. 48% (39–57) for SSEP alone], with comparable specificity [100% (94–100)]. Conclusions Quantitative NPi had excellent ability to predict an unfavorable outcome from day 1 after CA, with no false positives, and significantly higher specificity than standard manual pupillary examination. The addition of NPi to SSEP increased sensitivity of outcome prediction, while maintaining 100% specificity. Electronic supplementary material The online version of this article (10.1007/s00134-018-5448-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mauro Oddo
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, CH-1011, Lausanne, Switzerland.
| | - Claudio Sandroni
- Department of Anesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neurointensive Care, San Gerardo Hospital, Monza, Italy
| | - John-Paul Miroz
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, CH-1011, Lausanne, Switzerland
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Malin Rundgren
- Department of Clinical Sciences, Anesthesiology and Intensive Care Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | - Alain Cariou
- Réanimation Médicale-Hôpital Cochin, Paris, France.,Université Paris Descartes, Paris, France
| | - Jean-François Payen
- Department of Anesthesia and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-University, Berlin, Germany
| | - Pascal Stammet
- Medical and Health Department, National Fire and Rescue Corps, Luxembourg, Luxembourg
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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154
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Eertmans W, Tran TMP, Genbrugge C, Peene L, Mesotten D, Dens J, Jans F, De Deyne C. A prediction model for good neurological outcome in successfully resuscitated out-of-hospital cardiac arrest patients. Scand J Trauma Resusc Emerg Med 2018; 26:93. [PMID: 30413210 PMCID: PMC6230284 DOI: 10.1186/s13049-018-0558-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 10/10/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In the initial hours after out-of-hospital cardiac arrest (OHCA), it remains difficult to estimate whether the degree of post-ischemic brain damage will be compatible with long-term good neurological outcome. We aimed to construct prognostic models able to predict good neurological outcome of OHCA patients within 48 h after CCU admission using variables that are bedside available. METHODS Based on prospectively gathered data, a retrospective data analysis was performed on 107 successfully resuscitated OHCA patients with a presumed cardiac cause of arrest. Targeted temperature management at 33 °C was initiated at CCU admission. Prediction models for good neurological outcome (CPC1-2) at 180 days post-CA were constructed at hour 1, 12, 24 and 48 after CCU admission. Following multiple imputation, variables were selected using the elastic-net method. Each imputed dataset was divided into training and validation sets (80% and 20% of patients, respectively). Logistic regression was fitted on training sets and prediction performance was evaluated on validation sets using misclassification rates. RESULTS The prediction model at hour 24 predicted good neurological outcome with the lowest misclassification rate (21.5%), using a cut-off probability of 0.55 (sensitivity = 75%; specificity = 82%). This model contained sex, age, diabetes status, initial rhythm, percutaneous coronary intervention, presence of a BIS 0 value, mean BIS value and lactate as predictive variables for good neurological outcome. DISCUSSION This study shows that good neurological outcome after OHCA can be reasonably predicted as early as 24 h following ICU admission using parameters that are bedside available. These prediction models could identify patients who would benefit the most from intensive care.
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Affiliation(s)
- Ward Eertmans
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium. .,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Thao Mai Phuong Tran
- Interuniversity Institute for Biostatistics and Statistical Bio-informatics, Hasselt University, Agoralaan Gebouw D, 3590, Diepenbeek, Belgium
| | - Cornelia Genbrugge
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Laurens Peene
- Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Dieter Mesotten
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Jo Dens
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Frank Jans
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Cathy De Deyne
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
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155
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Winther‐Jensen M, Hassager C, Lassen JF, Køber L, Torp‐Pedersen C, Hansen SM, Lippert F, Kragholm K, Christensen EF, Kjaergaard J. Neurological prognostication tools in out-of-hospital cardiac arrest patients in Danish intensive care units from 2005 to 2013. Acta Anaesthesiol Scand 2018; 62:1412-1420. [PMID: 29947076 DOI: 10.1111/aas.13177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neurological prognostication is an essential part of post-resuscitation care in out-of-hospital cardiac arrest (OHCA). This study aims to assess the use of computed tomography (CT) and magnetic resonance imaging (MR) of the head, electroencephalography (EEG), and somatosensory evoked potentials (SSEP) in neurological prognostication in resuscitated OHCA patients and factors associated with their use in Danish tertiary and non-tertiary centers from 2005 to 2013 and associations with outcome. METHODS We used the Danish Cardiac Arrest Registry to identify patients ≥18 years of age admitted to intensive care units due to OHCA of presumed cardiac etiology. CT 0-20 days and MR, SSEP, and EEG ≥2-20 days post OHCA were considered related to prognostication. Incidence and factors associated with procedures were assessed by multiple Cox regression with death as competing risk. RESULTS Use of CT, MR, EEG, and SSEP increased during the study period (CT: 51%-67%, HRCT : 1.06, CI: 1.03-1.08, MR: 2%-5%, P = .08, EEG: 6%-33%, HREEG : 1.25, CI: 1.19-1.30, SSEP: 4%-15%, HRSSEP : 1.23, CI: 1.15-1.32). EEG and SSEP were more used in tertiary centers than non-tertiary (HREEG : 1.86, CI: 1.51-2.29, HRSSEP : 4.44, CI: 2.86-6.89). Use of CT, SSEP, and EEG were associated with higher 30-day mortality, and MR was associated with lower (HRCT : 1.15, CI: 1.01-1.30, HRMR : 0.53, CI: 0.37-0.77, HRSSEP : 1.90, CI: 1.57-2.32, HREEG : 1.75, CI: 1.49-2.05). CONCLUSION Use of neurological prognostication procedures increased during the study period. EEG and SSEP were more used in tertiary centers. CT, EEG and SSEP were associated with increased mortality.
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Affiliation(s)
- M. Winther‐Jensen
- Department of Cardiology The Heart Centre Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - C. Hassager
- Department of Cardiology The Heart Centre Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - J. F. Lassen
- Department of Cardiology The Heart Centre Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - L. Køber
- Department of Cardiology The Heart Centre Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - C. Torp‐Pedersen
- Unit of Epidemiology and Biostatistics Aalborg University Hospital Forskningens Hus Aalborg Denmark
| | - S. M. Hansen
- Unit of Epidemiology and Biostatistics Aalborg University Hospital Forskningens Hus Aalborg Denmark
| | - F. Lippert
- Emergency Medical Services Copenhagen University of Copenhagen Copenhagen Denmark
| | - K. Kragholm
- Department of Anesthesiology and Intensive Care Medicine Cardiovascular Research Centre Aalborg Denmark
| | - E. F. Christensen
- Department of Cardiology Aalborg University Hospital Aalborg Denmark
| | - J. Kjaergaard
- Department of Cardiology The Heart Centre Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
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156
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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. Neurologic outcome of postanoxic refractory status epilepticus after aggressive treatment. Neurology 2018; 91:e2153-e2162. [PMID: 30381366 DOI: 10.1212/wnl.0000000000006615] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 08/23/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate neurologic outcome of patients with cardiac arrest with refractory status epilepticus (RSE) treated with a standardized aggressive protocol with antiepileptic drugs and anesthetics compared to patients with other EEG patterns. METHODS In the prospective cohort study, 166 consecutive patients with cardiac arrest in coma were stratified according to 4 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. RESULTS RSE occurred in 36 patients (21.7%) and was treated with an aggressive standardized protocol as long as multimodal prognostic indicators were not unfavorable. RSE started after 3 ± 2.3 days after cardiac arrest and lasted 4.7 ± 4.3 days. A benign EEG pattern was recorded in 76 patients (45.8%); a periodic pattern (GPDs) was seen in 13 patients (7.8%); and a malignant nonepileptiform EEG pattern was recorded in 41 patients (24.7%). The 4 EEG patterns were highly associated with different prognostic indicators (low-flow time, clinical motor seizures, N20 responses, neuron-specific enolase, neuroimaging). Survival and good neurologic 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. CONCLUSIONS Aggressive and prolonged treatment of RSE may be justified in patients with cardiac arrest with favorable multimodal prognostic indicators.
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Affiliation(s)
- Simone Beretta
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy.
| | - Anna Coppo
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Elisa Bianchi
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Clara Zanchi
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Davide Carone
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Andrea Stabile
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Giada Padovano
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Endrit Sulmina
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Alice Grassi
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Graziella Bogliun
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Giuseppe Foti
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Carlo Ferrarese
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Antonio Pesenti
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Ettore Beghi
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Leonello Avalli
- From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
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Prediction of neurological outcomes following the return of spontaneous circulation in patients with out-of-hospital cardiac arrest: Retrospective fast-and-frugal tree analysis. Resuscitation 2018; 133:65-70. [PMID: 30292802 DOI: 10.1016/j.resuscitation.2018.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 09/27/2018] [Accepted: 10/02/2018] [Indexed: 11/21/2022]
Abstract
AIM Although various quantitative methods have been developed for predicting neurological prognosis in patients with out-of-hospital cardiac arrest (OHCA), they are too complex for use in clinical practice. We aimed to develop a simple decision rule for predicting neurological outcomes following the return of spontaneous circulation (ROSC) in patients with OHCA using fast-and-frugal tree (FFT) analysis. METHODS We performed a retrospective analysis of prospectively collected data archived in a multi-centre registry. Good neurological outcomes were defined as cerebral performance category (CPC) values of 1 or 2 at 28-day. Variables used for FFT analysis included age, sex, witnessed cardiac arrest, bystander cardiopulmonary resuscitation, initial shockable rhythm, prehospital defibrillation, prehospital ROSC, no flow time, low flow time, cause of arrest (cardiac or non-cardiac), pupillary light reflex, and Glasgow Coma Scale score after ROSC. RESULTS Among the 456 patients enrolled, 86 (18.9%) experienced good neurological outcomes. Prehospital ROSC (true = good), prompt or sluggish light reflex response after ROSC (true = good), and presumed cardiac cause (true = good, false = poor) were selected as nodes for the decision tree. Sensitivity, specificity, positive predictive value, and negative predictive value of the decision tree for predicting good neurological outcomes were 100% (42/42), 64.0% (119/186), 38.5% (42/109), and 100% (119/119) in the training set and 95.5% (42/44), 57.6% (106/184), 35.0% (42/120), and 98.1% (106/108) in the test set, respectively. CONCLUSION A simple decision rule developed via FFT analysis can aid clinicians in predicting neurological outcomes following ROSC in patients with OHCA.
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158
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Admiraal M, van Rootselaar A, Horn J. International consensus on EEG reactivity testing after cardiac arrest: Towards standardization. Resuscitation 2018; 131:36-41. [DOI: 10.1016/j.resuscitation.2018.07.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 07/20/2018] [Accepted: 07/25/2018] [Indexed: 10/28/2022]
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159
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Keijzer HM, Hoedemaekers CWE, Meijer FJA, Tonino BAR, Klijn CJM, Hofmeijer J. Brain imaging in comatose survivors of cardiac arrest: Pathophysiological correlates and prognostic properties. Resuscitation 2018; 133:124-136. [PMID: 30244045 DOI: 10.1016/j.resuscitation.2018.09.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 09/12/2018] [Accepted: 09/14/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Hypoxic-ischemic brain injury is the main cause of death and disability of comatose patients after cardiac arrest. Early and reliable prognostication is challenging. Common prognostic tools include clinical neurological examination and electrophysiological measures. Brain imaging is well established for diagnosis of focal cerebral ischemia but has so far not found worldwide application in this patient group. OBJECTIVE To review the value of Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET) for early prediction of neurological outcome of comatose survivors of cardiac arrest. METHODS A literature search was performed to identify publications on CT, MRI or PET in comatose patients after cardiac arrest. RESULTS We included evidence from 51 articles, 21 on CT, 27 on MRI, 1 on CT and MRI, and 2 on PET imaging. Studies varied regarding timing of measurements, choice of determinants, and cut-off values predicting poor outcome. Most studies were small (n = 6-398) and retrospective (60%). In general, cytotoxic oedema, defined by a grey-white matter ratio <1.10, derived from CT, or MRI-diffusion weighted imaging <650 × 10-6 mm2/s in >10% of the brain could differentiate between patients with favourable and unfavourable outcomes on a group level within 1-3 days after cardiac arrest. Advanced imaging techniques such as functional MRI or diffusion tensor imaging show promising results, but need further evaluation. CONCLUSION CT derived grey-white matter ratio and MRI based measures of diffusivity and connectivity hold promise to improve outcome prediction after cardiac arrest. Prospective validation studies in a multivariable approach are needed to determine the additional value for the individual patient.
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Affiliation(s)
- H M Keijzer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands; Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands; Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - C W E Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - F J A Meijer
- Department of Radiology and Nuclear medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B A R Tonino
- Department of Radiology, Rijnstate Hospital Arnhem, the Netherlands
| | - C J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands; Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
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160
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Does Continuous Video-EEG in Patients With Altered Consciousness Improve Patient Outcome? Current Evidence and Randomized Controlled Trial Design. J Clin Neurophysiol 2018. [DOI: 10.1097/wnp.0000000000000467] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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161
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Beretta S, Padovano G, Stabile A, Coppo A, Bogliun G, Avalli L, Ferrarese C. Efficacy and safety of perampanel oral loading in postanoxic super-refractory status epilepticus: A pilot study. Epilepsia 2018; 59 Suppl 2:243-248. [DOI: 10.1111/epi.14492] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Simone Beretta
- Epilepsy Center; San Gerardo Hospital Monza; University of Milano Bicocca; Monza Italy
| | - Giada Padovano
- Epilepsy Center; San Gerardo Hospital Monza; University of Milano Bicocca; Monza Italy
| | - Andrea Stabile
- Epilepsy Center; San Gerardo Hospital Monza; University of Milano Bicocca; Monza Italy
| | - Anna Coppo
- Department of Intensive Care; San Gerardo Hospital Monza; Monza Italy
| | - Graziella Bogliun
- Epilepsy Center; San Gerardo Hospital Monza; University of Milano Bicocca; Monza Italy
| | - Leonello Avalli
- Department of Intensive Care; San Gerardo Hospital Monza; Monza Italy
| | - Carlo Ferrarese
- Epilepsy Center; San Gerardo Hospital Monza; University of Milano Bicocca; Monza Italy
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162
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Fatuzzo D, Beuchat I, Alvarez V, Novy J, Oddo M, Rossetti AO. Does continuous EEG influence prognosis in patients after cardiac arrest? Resuscitation 2018; 132:29-32. [PMID: 30153468 DOI: 10.1016/j.resuscitation.2018.08.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/17/2018] [Accepted: 08/23/2018] [Indexed: 11/19/2022]
Abstract
AIM Electroencephalography (EEG) is a key modality for assessment of prognosis following cardiac arrest (CA); however, whether continuous EEG (cEEG) is superior to routine intermittent EEG (rEEG) remains debated. We examined the impact of cEEG (>18 h) vs. rEEG (<30 min) on outcome in comatose CA patients as part of multimodal prognostication. METHODS We analysed a large prospective registry of comatose post-CA adults (n = 497; 2009-2018), stratified based on whether they received cEEG (n = 62) or rEEG (n = 435), including standardized reactivity testing at two time-points. The primary endpoint was the impact of cEEG vs. rEEG on Glasgow-Pittsburgh Cerebral Performance Categories (CPC) at three months; we also assessed impact on time to death. RESULTS Main patients' baseline clinical characteristics and CPC scores were comparable between the EEG groups. By multivariable analysis age, non-shockable rhythm, presence of early myoclonus, absent EEG background reactivity, absent somato-sensory evoked potentials, and serum NSE were independently associated with poor neurological outcome (CPC 3-5), while the EEG approach had no impact on patient prognosis and time to death. CONCLUSIONS Our data suggest that cEEG does not confer any advantage over intermittent rEEG regarding outcome in patients with CA, and does not influence the time to death.
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Affiliation(s)
- Daniela Fatuzzo
- Department of Neurology, CHUV and Université de Lausanne, Lausanne, Switzerland; Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Catania, Italy
| | - Isabelle Beuchat
- Department of Neurology, CHUV and Université de Lausanne, Lausanne, Switzerland
| | - Vincent Alvarez
- Department of Neurology, CHUV and Université de Lausanne, Lausanne, Switzerland; Department of Neurology, Hôpital du Valais, Sion, Switzerland
| | - Jan Novy
- Department of Neurology, CHUV and Université de Lausanne, Lausanne, Switzerland
| | - Mauro Oddo
- Department of Intensive Care Medicine, CHUV and Université de Lausanne, Lausanne, Switzerland
| | - Andrea O Rossetti
- Department of Neurology, CHUV and Université de Lausanne, Lausanne, Switzerland.
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163
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Abstract
Status epilepticus (SE) is a medical emergency and presents with either a continuous prolonged seizure or multiple seizures without full recovery of consciousness in between them. The goals of treatment are prompt recognition, early seizure termination, and simultaneous evaluation for any potentially treatable cause. Improved understanding of the pathophysiology has led to a more practical definition. New data have emerged regarding the safety and efficacy of alternative agents, which are increasingly used in the management of these patients. Continuous electroencephalogram monitoring is more widely used and has revealed a higher incidence of subclinical seizures than was previously thought.
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Affiliation(s)
- Sudhir Datar
- Section of Neurocritical Care, Departments of Neurology and Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157, USA.
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164
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EEG Characteristics in Cooled and Rewarmed Periods in Post-cardiac Arrest Therapeutic Hypothermia Patients. J Clin Neurophysiol 2018. [PMID: 28644823 DOI: 10.1097/wnp.0000000000000375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Continuous video EEG is a tool to assess brain function in injuries, including cardiac arrest (CA). In post-CA therapeutic hypothermia (TH) studies, some EEG features are linked to poor prognosis, but the evolvement of EEG characteristics during two temperature phases and its significance is unclear. We systematically analyzed EEG characteristics in cooled and rewarmed phases of post-CA therapeutic hypothermia patients and investigated their correlation to patient outcome. METHODS This is a retrospective study of EEG analyses, from a single academic center, of 20 patients who underwent CA and therapeutic hypothermia. For each patient, three 30-minute EEG segments in cooled and rewarmed phases were analyzed for continuity, frequency, interictal epileptiform discharges, and seizures. Mortality at the time of discharge was used as outcome. RESULTS Rewarming was associated with the emergence of interictal epileptiform discharges, 2.6 times as likely compared with the cooled period (P = 0.03), and was not affected by systemic factors. Continuity, frequency, and discrete seizures were unaffected by temperature and did not show variance within each temperature phase. There was a trend toward the emergence of interictal epileptiform discharges upon rewarming and mortality, but it was not statistically significant. CONCLUSIONS Increased interictal epileptiform discharges with rewarming in post-CA therapeutic hypothermia patients may suggest poor prognosis, but a larger scale prospective study is needed.
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165
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Song M, Yang Y, He J, Yang Z, Yu S, Xie Q, Xia X, Dang Y, Zhang Q, Wu X, Cui Y, Hou B, Yu R, Xu R, Jiang T. Prognostication of chronic disorders of consciousness using brain functional networks and clinical characteristics. eLife 2018; 7:e36173. [PMID: 30106378 PMCID: PMC6145856 DOI: 10.7554/elife.36173] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 08/03/2018] [Indexed: 01/04/2023] Open
Abstract
Disorders of consciousness are a heterogeneous mixture of different diseases or injuries. Although some indicators and models have been proposed for prognostication, any single method when used alone carries a high risk of false prediction. This study aimed to develop a multidomain prognostic model that combines resting state functional MRI with three clinical characteristics to predict one year-outcomes at the single-subject level. The model discriminated between patients who would later recover consciousness and those who would not with an accuracy of around 88% on three datasets from two medical centers. It was also able to identify the prognostic importance of different predictors, including brain functions and clinical characteristics. To our knowledge, this is the first reported implementation of a multidomain prognostic model that is based on resting state functional MRI and clinical characteristics in chronic disorders of consciousness, which we suggest is accurate, robust, and interpretable.
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Affiliation(s)
- Ming Song
- National Laboratory of Pattern Recognition, Institute of AutomationChinese Academy of SciencesBeijingChina
- Brainnetome Center, Institute of AutomationChinese Academy of SciencesBeijingChina
| | - Yi Yang
- Department of NeurosurgeryPLA Army General HospitalBeijingChina
| | - Jianghong He
- Department of NeurosurgeryPLA Army General HospitalBeijingChina
| | - Zhengyi Yang
- National Laboratory of Pattern Recognition, Institute of AutomationChinese Academy of SciencesBeijingChina
- Brainnetome Center, Institute of AutomationChinese Academy of SciencesBeijingChina
| | - Shan Yu
- National Laboratory of Pattern Recognition, Institute of AutomationChinese Academy of SciencesBeijingChina
- Brainnetome Center, Institute of AutomationChinese Academy of SciencesBeijingChina
| | - Qiuyou Xie
- Centre for Hyperbaric Oxygen and NeurorehabilitationGuangzhou General Hospital of Guangzhou Military CommandGuangzhouChina
| | - Xiaoyu Xia
- Department of NeurosurgeryPLA Army General HospitalBeijingChina
| | - Yuanyuan Dang
- Department of NeurosurgeryPLA Army General HospitalBeijingChina
| | - Qiang Zhang
- Department of NeurosurgeryPLA Army General HospitalBeijingChina
| | - Xinhuai Wu
- Department of RadiologyPLA Army General HospitalBeijingChina
| | - Yue Cui
- National Laboratory of Pattern Recognition, Institute of AutomationChinese Academy of SciencesBeijingChina
- Brainnetome Center, Institute of AutomationChinese Academy of SciencesBeijingChina
| | - Bing Hou
- National Laboratory of Pattern Recognition, Institute of AutomationChinese Academy of SciencesBeijingChina
- Brainnetome Center, Institute of AutomationChinese Academy of SciencesBeijingChina
| | - Ronghao Yu
- Centre for Hyperbaric Oxygen and NeurorehabilitationGuangzhou General Hospital of Guangzhou Military CommandGuangzhouChina
| | - Ruxiang Xu
- Department of NeurosurgeryPLA Army General HospitalBeijingChina
| | - Tianzi Jiang
- National Laboratory of Pattern Recognition, Institute of AutomationChinese Academy of SciencesBeijingChina
- Brainnetome Center, Institute of AutomationChinese Academy of SciencesBeijingChina
- CAS Center for Excellence in Brain Science and Intelligence TechnologyChinese Academy of SciencesBeijingChina
- Key Laboratory for Neuroinformation of the Ministry of Education, School of Life Science and TechnologyUniversity of Electronic Science and Technology of ChinaChengduChina
- Queensland Brain InstituteUniversity of QueenslandBrisbaneAustralia
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166
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Wijdicks EFM, Rabinstein AA. Myoclonus Status and Prognostication of Postresuscitation Coma: The Bigger Picture. Ann Neurol 2018; 80:173-4. [PMID: 27438529 DOI: 10.1002/ana.24733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 11/09/2022]
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167
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Preliminary guideline- and pathophysiology-based protocols for neurocritical care. J Intensive Care 2018; 6:45. [PMID: 30094030 PMCID: PMC6081801 DOI: 10.1186/s40560-018-0316-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/27/2018] [Indexed: 12/31/2022] Open
Abstract
Background Because of the complex pathophysiological processes involved, neurocritical care has been driven by anecdotal experience and physician preferences, which has led to care variation worldwide. Standardization of practice has improved outcomes for many of the critical conditions encountered in the intensive care unit. Main body In this review article, we introduce preliminary guideline- and pathophysiology-based protocols for (1) prompt shivering management, (2) traumatic brain injury and intracranial pressure management, (3) neurological prognostication after cardiac arrest, (4) delayed cerebral ischemia after subarachnoid hemorrhage, (5) nonconvulsive status epilepticus, and (6) acute or subacute psychosis and seizure. Conclusion These tentative protocols may be useful tools for bedside clinicians who need to provide consistent, standardized care in a dynamic clinical environment. Because most of the contents of presented protocol are not supported by evidence, they should be validated in a prospective controlled study in future. We suggest that these protocols should be regarded as drafts to be tailored to the systems, environments, and clinician preferences in each institution.
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168
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Periodic leg movements after cardiac arrest. Resuscitation 2018; 129:e15. [DOI: 10.1016/j.resuscitation.2018.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/16/2018] [Accepted: 05/26/2018] [Indexed: 11/23/2022]
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169
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Abstract
With the development of modern international medicine, the subject of disorders of consciousness (DOCs) has begun to be raised in mainland China. Much progress has been made to date in several specialties related to the management of chronic DOC patients in China. In this article, we briefly review the present status of DOC studies in China, specifically concerning diagnosis, prognosis, therapy, and rehabilitation. The development of DOC-related scientific organizations and activities in China are introduced. Some weaknesses that need improvement are also noted. The current program provides a good foundation for future development.
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Affiliation(s)
- Jizong Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.
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170
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Abstract
Improvements in cardiopulmonary resuscitation and intensive care medicine have led to declining mortality rates for patients with out-of-hospital cardiac arrest, but overall it is still a minority that achieves good outcomes. Estimating neurologic prognosis for patients that remain comatose after resuscitation remains a challenge and the need for accurate and early prognostic predictors is crucial. A thoughtful approach is required and should take into account information acquired from multiple tests in association with neurologic examination. No decision should be made based on a single predictor. In addition to clinical examination, somatosensory evoked potentials, electroencephalogram, serum biomarkers, and neuroimaging provide complimentary information to inform prognosis.
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171
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Hsu CH, Haac BE, Drake M, Bernard AC, Aiolfi A, Inaba K, Hinson HE, Agarwal C, Galante J, Tibbits EM, Johnson NJ, Carlbom D, Mirhoseini MF, Patel MB, O’Bosky KR, Chan C, Udekwu PO, Farrell M, Wild JL, Young KA, Cullinane DC, Gojmerac DJ, Weissman A, Callaway C, Perman SM, Guerrero M, Aisiku IP, Seethala RR, Co IN, Madhok DY, Darger B, Kim DY, Spence L, Scalea TM, Stein DM. EAST Multicenter Trial on targeted temperature management for hanging-induced cardiac arrest. J Trauma Acute Care Surg 2018; 85:37-47. [PMID: 29677083 PMCID: PMC6026030 DOI: 10.1097/ta.0000000000001945] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND We sought to determine the outcome of suicidal hanging and the impact of targeted temperature management (TTM) on hanging-induced cardiac arrest (CA) through an Eastern Association for the Surgery of Trauma (EAST) multicenter retrospective study. METHODS We analyzed hanging patient data and TTM variables from January 1992 to December 2015. Cerebral performance category score of 1 or 2 was considered good neurologic outcome, while cerebral performance category score of 3 or 4 was considered poor outcome. Classification and Regression Trees recursive partitioning was used to develop multivariate predictive models for survival and neurologic outcome. RESULTS A total of 692 hanging patients from 17 centers were analyzed for this study. Their overall survival rate was 77%, and the CA survival rate was 28.6%. The CA patients had significantly higher severity of illness and worse outcome than the non-CA patients. Of the 175 CA patients who survived to hospital admission, 81 patients (46.3%) received post-CA TTM. The unadjusted survival of TTM CA patients (24.7% vs 39.4%, p < 0.05) and good neurologic outcome (19.8% vs 37.2%, p < 0.05) were worse than non-TTM CA patients. However, when subgroup analyses were performed between those with an admission Glasgow Coma Scale score of 3 to 8, the differences between TTM and non-TTM CA survival (23.8% vs 30.0%, p = 0.37) and good neurologic outcome (18.8% vs 28.7%, p = 0.14) were not significant. Targeted temperature management implementation and post-CA management varied between the participating centers. Classification and Regression Trees models identified variables predictive of favorable and poor outcome for hanging and TTM patients with excellent accuracy. CONCLUSION Cardiac arrest hanging patients had worse outcome than non-CA patients. Targeted temperature management CA patients had worse unadjusted survival and neurologic outcome than non-TTM patients. These findings may be explained by their higher severity of illness, variable TTM implementation, and differences in post-CA management. Future prospective studies are necessary to ascertain the effect of TTM on hanging outcome and to validate our Classification and Regression Trees models. LEVEL OF EVIDENCE Therapeutic study, level IV; prognostic study, level III.
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Affiliation(s)
- Cindy H. Hsu
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
- University of Michigan, Ann Arbor, Michigan
| | - Bryce E. Haac
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mack Drake
- University of Kentucky, Lexington, Kentucky
| | | | - Alberto Aiolfi
- Los Angeles County/University of Southern California Medical Center, Los Angeles, CA
| | - Kenji Inaba
- Los Angeles County/University of Southern California Medical Center, Los Angeles, CA
| | | | | | - Joseph Galante
- University of California Davis Medical Center, Davis, California
| | - Emily M. Tibbits
- University of California Davis Medical Center, Davis, California
| | | | - David Carlbom
- University of Washington/Harborview Medical Center, Seattle, Washington
| | | | - Mayur B. Patel
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Christian Chan
- Loma Linda University Medical Center, Loma Linda, California
| | | | | | | | | | | | | | | | - Clifton Callaway
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | - Ivan N. Co
- University of Michigan, Ann Arbor, Michigan
| | - Debbie Y. Madhok
- San Francisco General Hospital/University of California San Francisco, San Francisco, California
| | - Bryan Darger
- San Francisco General Hospital/University of California San Francisco, San Francisco, California
| | | | - Lara Spence
- Harbor UCLA Medical Center, Torrance, California
| | - Thomas M. Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Deborah M. Stein
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
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172
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Amplitude-Integrated Electroencephalography Predicts Outcome in Patients with Coma After Acute Brain Injury. Neurosci Bull 2018; 34:639-646. [PMID: 29948839 DOI: 10.1007/s12264-018-0241-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/25/2018] [Indexed: 12/22/2022] Open
Abstract
Prognostication of coma patients after brain injury is important, yet challenging. In this study, we evaluated the predictive value of amplitude-integrated electroencephalography (aEEG) for neurological outcomes in coma patients. From January 2013 to January 2016, 128 coma patients after acute brain injury were prospectively enrolled and monitored with aEEG. The 6-month neurological outcome was evaluated using the Cerebral Performance Category Scale. aEEG monitoring commenced at a median of 7.5 days after coma onset. Continuous normal voltage predicted a good 6-month neurological outcome with a sensitivity of 93.6% and specificity of 85.2%. In contrast, continuous extremely low voltage, burst-suppression, or a flat tracing was correlated with poor 6-month neurological outcome with a sensitivity of 76.5% and specificity of 100%. In conclusion, aEEG is a promising predictor of 6-month neurological outcome for coma patients after acute brain injury.
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173
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Standardized EEG interpretation in patients after cardiac arrest: Correlation with other prognostic predictors. Resuscitation 2018. [DOI: 10.1016/j.resuscitation.2018.03.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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174
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175
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Dai C, Wang Z, Wei L, Chen G, Chen B, Zuo F, Li Y. Combining early post-resuscitation EEG and HRV features improves the prognostic performance in cardiac arrest model of rats. Am J Emerg Med 2018; 36:2242-2248. [PMID: 29661665 DOI: 10.1016/j.ajem.2018.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/27/2018] [Accepted: 04/07/2018] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Early and reliable prediction of neurological outcome remains a challenge for comatose survivors of cardiac arrest (CA). The purpose of this study was to evaluate the predictive ability of EEG, heart rate variability (HRV) features and the combination of them for outcome prognostication in CA model of rats. METHODS Forty-eight male Sprague-Dawley rats were randomized into 6 groups (n=8 each) with different cause and duration of untreated arrest. Cardiopulmonary resuscitation was initiated after 5, 6 and 7min of ventricular fibrillation or 4, 6 and 8min of asphyxia. EEG and ECG were continuously recorded for 4h under normothermia after resuscitation. The relationships between features of early post-resuscitation EEG, HRV and 96-hour outcome were investigated. Prognostic performances were evaluated using the area under receiver operating characteristic curve (AUC). RESULTS All of the animals were successfully resuscitated and 27 of them survived to 96h. Weighted-permutation entropy (WPE) and normalized high frequency (nHF) outperformed other EEG and HRV features for the prediction of survival. The AUC of WPE was markedly higher than that of nHF (0.892 vs. 0.759, p<0.001). The AUC was 0.954 when WPE and nHF were combined using a logistic regression model, which was significantly higher than the individual EEG (p=0.018) and HRV (p<0.001) features. CONCLUSIONS Earlier post-resuscitation HRV provided prognostic information complementary to quantitative EEG in the CA model of rats. The combination of EEG and HRV features leads to improving performance of outcome prognostication compared to either EEG or HRV based features alone.
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Affiliation(s)
- Chenxi Dai
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Zhi Wang
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Liang Wei
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Gang Chen
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Bihua Chen
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Feng Zuo
- Department of information technology, Third Military Medical University, Chongqing 400038, China
| | - Yongqin Li
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China.
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176
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Velly L, Perlbarg V, Boulier T, Adam N, Delphine S, Luyt CE, Battisti V, Torkomian G, Arbelot C, Chabanne R, Jean B, Di Perri C, Laureys S, Citerio G, Vargiolu A, Rohaut B, Bruder N, Girard N, Silva S, Cottenceau V, Tourdias T, Coulon O, Riou B, Naccache L, Gupta R, Benali H, Galanaud D, Puybasset L, Constantin JM, Chastre J, Amour J, Vezinet C, Rouby JJ, Raux M, Langeron O, Degos V, Bolgert F, Weiss N, Similowski T, Demoule A, Duguet A, Tollard E, Veber B, Lotterie JA, SANCHEZ-PENA P, Génestal M, Patassini M. Use of brain diffusion tensor imaging for the prediction of long-term neurological outcomes in patients after cardiac arrest: a multicentre, international, prospective, observational, cohort study. Lancet Neurol 2018; 17:317-326. [DOI: 10.1016/s1474-4422(18)30027-9] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 01/23/2018] [Accepted: 01/24/2018] [Indexed: 01/19/2023]
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177
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van Zijl JC, Beudel M, de Jong BM, van der Naalt J, Zutt R, Lange F, van den Bergh WM, Elting JWJ, Tijssen MAJ. The interrelation between clinical presentation and neurophysiology of posthypoxic myoclonus. Ann Clin Transl Neurol 2018; 5:386-396. [PMID: 29687017 PMCID: PMC5899907 DOI: 10.1002/acn3.514] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 11/20/2017] [Indexed: 11/16/2022] Open
Abstract
Objective Posthypoxic myoclonus (PHM) in the first few days after resuscitation can be divided clinically into generalized and focal (uni‐ and multifocal) subtypes. The former is associated with a subcortical origin and poor prognosis in patients with postanoxic encephalopathy (PAE), and the latter with a cortical origin and better prognosis. However, use of PHM as prognosticator in PAE is hampered by the modest objectivity in its clinical assessment. Therefore, we aimed to obtain the anatomical origin of PHM with use of neurophysiological investigations, and relate these to its clinical presentation. Methods This study included 20 patients (56 ± 18 y/o, 68% M, 2 survived, 1 excluded) with EEG‐EMG‐video recording. Three neurologists classified PHM into generalized or focal PHM. Anatomical origin (cortical/subcortical) was assessed with basic and advanced neurophysiology (Jerk‐Locked Back Averaging, coherence analysis). Results Clinically assessed origin of PHM did not match the result obtained with neurophysiology: cortical PHM was more likely present in generalized than in focal PHM. In addition, some cases demonstrated co‐occurrence of cortical and subcortical myoclonus. Patients that recovered from PAE had cortical myoclonus (1 generalized, 1 focal). Interpretation Hypoxic damage to variable cortical and subcortical areas in the brain may lead to mixed and varying clinical manifestations of myoclonus that differ of those patients with myoclonus generally encountered in the outpatient clinic. The current clinical classification of PHM is not adequately refined to play a pivotal role in guiding treatment decisions to withdraw care. Our neurophysiological characterization of PHM provides specific parameters to be used in designing future comprehensive studies addressing the potential role of PHM as prognosticator in PAE.
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Affiliation(s)
- Jonathan C van Zijl
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Martijn Beudel
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Bauke M de Jong
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Joukje van der Naalt
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Rodi Zutt
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Fiete Lange
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands.,Department of Clinical Neurophysiology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Walter M van den Bergh
- Department of Critical Care University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Jan-Willem J Elting
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands.,Department of Clinical Neurophysiology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
| | - Marina A J Tijssen
- Department of Neurology University Medical Center Groningen (UMCG) University of Groningen Hanzeplein 1 9700 RB Groningen Netherlands
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178
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Eertmans W, Genbrugge C, Vander Laenen M, Boer W, Mesotten D, Dens J, Jans F, De Deyne C. The prognostic value of bispectral index and suppression ratio monitoring after out-of-hospital cardiac arrest: a prospective observational study. Ann Intensive Care 2018; 8:34. [PMID: 29500559 PMCID: PMC5834415 DOI: 10.1186/s13613-018-0380-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/26/2018] [Indexed: 01/10/2023] Open
Abstract
Background We investigated the ability of bispectral index (BIS) monitoring to predict poor neurological outcome in out-of-hospital cardiac arrest (OHCA) patients fully treated according to guidelines. Results In this prospective, observational study, 77 successfully resuscitated OHCA patients were enrolled in whom BIS, suppression ratio (SR) and electromyographic (EMG) values were continuously monitored during the first 36 h after the initiation of targeted temperature management at 33 °C. The Cerebral Performance Category (CPC) scale was used to define patients’ outcome at 180 days after OHCA (CPC 1–2: good–CPC 3–5: poor neurological outcome). Using mean BIS and SR values calculated per hour, receiver operator characteristics curves were constructed to determine the optimal time point and threshold to predict poor neurological outcome. At 180 days post-cardiac arrest, 39 patients (51%) had a poor neurological outcome. A mean BIS value ≤ 25 at hour 12 predicted poor neurological outcome with a sensitivity of 49% (95% CI 30–65%), a specificity of 97% (95% CI 85–100%) and false positive rate (FPR) of 6% (95% CI 0–29%) [AUC: 0.722 (0.570–0.875); p = 0.006]. A mean SR value ≥ 3 at hour 23 predicted poor neurological with a sensitivity of 74% (95% CI 56–87%), a specificity of 92% (95% CI 78–98%) and FPR of 11% (95% CI 3–29%) [AUC: 0.836 (0.717–0.955); p < 0.001]. No relationship was found between mean EMG and BIS < 25 (R2 = 0.004; p = 0.209). Conclusion This study found that mean BIS ≤ 25 at hour 12 and mean SR ≥ 3 at hour 23 might be used to predict poor neurological outcome in an OHCA population with a presumed cardiac cause. Since no correlation was observed between EMG and BIS < 25, our calculated BIS threshold might assist with poor outcome prognostication following OHCA.
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Affiliation(s)
- Ward Eertmans
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium. .,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Cornelia Genbrugge
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Margot Vander Laenen
- Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Willem Boer
- Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Dieter Mesotten
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Jo Dens
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Frank Jans
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Cathy De Deyne
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
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179
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Quantitative EEG exploration of sedation in post-resuscitation care. Resuscitation 2018; 124:A13-A14. [DOI: 10.1016/j.resuscitation.2017.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 12/28/2017] [Indexed: 11/20/2022]
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180
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Ocular bobbing/dipping after cardiac arrest may be a post-anoxic myoclonus. Resuscitation 2018; 124:e7. [DOI: 10.1016/j.resuscitation.2018.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/03/2018] [Indexed: 11/17/2022]
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181
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Solari D, Miroz JP, Oddo M. Opening a Window to the Injured Brain: Non-invasive Neuromonitoring with Quantitative Pupillometry. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [DOI: 10.1007/978-3-319-73670-9_38] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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182
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Harvey D, Butler J, Groves J, Manara A, Menon D, Thomas E, Wilson M. Management of perceived devastating brain injury after hospital admission: a consensus statement from stakeholder professional organizations. Br J Anaesth 2018; 120:138-145. [DOI: 10.1016/j.bja.2017.10.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/20/2017] [Accepted: 10/23/2017] [Indexed: 11/28/2022] Open
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183
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Postanoxic alpha, theta or alpha-theta coma: Clinical setting and neurological outcome. Resuscitation 2017; 124:118-125. [PMID: 29275174 DOI: 10.1016/j.resuscitation.2017.12.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/10/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022]
Abstract
AIM The aim of this study was to determine the prognosis of 26 consecutive adults with alpha coma (AC), theta coma (TC) or alpha-theta coma (ATC) following CRA and to describe the clinical setting and EEG features of these patients. METHODS We retrospective analyzed a prospectively collected cohort of adult patients diagnosed as having AC, TC or ATC after CRA between January 2008 and June 2016. None of patients included in this analysis underwent therapeutic hypothermia (TH). Neurological outcome was expressed as the best score 6 months after CRA using the five-point Glasgow-Pisttsburgh Cerebral Performance Categories (CPC) RESULTS: Twenty-six patients were identified with a diagnosis of postanoxic AC, TC or ATC coma. There were 20 (77%) men and 6 (23%) women. The mean age was 63 ± 16 years. The most frequent EEG pattern was TC (21 patients, 80%), followed by AC (3 patients, 12%) and ATC (2 patients, 8%). The cardiac rhythm as primary origin of the CRA was ventricular fibrillation (VF) in 16 patients (61.5%), asystole in 8 patients (34.6%) and ventricular tachycardia (VT) in one patient (3.8%). The presence of EEG reactivity was present in 8 patients (30%). The mortality rate was 85%. Of the 4 surviving patients, two (3.8%) had moderate disability (CPC 2), one (3.8%) had severe disability (CPC 3) and one (3.8%) reached a good recovery. The age was significantly lower in survivors 46.2 ± 10.8 versus nonsurvivors 63.3 ± 15.5 (p = 0.04). There was increased association of EEG reactivity with survival (p = 0.07). CONCLUSION Hypoxic-ischemic AC, TC and ATC are associated with a poor prognosis and a high rate of mortality. In younger patients with AC, TC and ATC and incomplete forms showing reactivity on the EEG, there is a greater probability of clinical recovery.
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184
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Mattsson N, Zetterberg H, Nielsen N, Blennow K, Dankiewicz J, Friberg H, Lilja G, Insel PS, Rylander C, Stammet P, Aneman A, Hassager C, Kjaergaard J, Kuiper M, Pellis T, Wetterslev J, Wise M, Cronberg T. Serum tau and neurological outcome in cardiac arrest. Ann Neurol 2017; 82:665-675. [PMID: 28981963 PMCID: PMC5725735 DOI: 10.1002/ana.25067] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/02/2017] [Accepted: 10/04/2017] [Indexed: 02/03/2023]
Abstract
Objective To test serum tau as a predictor of neurological outcome after cardiac arrest. Methods We measured the neuronal protein tau in serum at 24, 48, and 72 hours after cardiac arrest in 689 patients in the prospective international Target Temperature Management trial. The main outcome was poor neurological outcome, defined as Cerebral Performance Categories 3–5 at 6 months. Results Increased tau was associated with poor outcome at 6 months after cardiac arrest (median = 38.5, interquartile range [IQR] = 5.7–245ng/l in poor vs median = 1.5, IQR = 0.7–2.4ng/l in good outcome, for tau at 72 hours, p < 0.0001). Tau improved prediction of poor outcome compared to using clinical information (p < 0.0001). Tau cutoffs had low false‐positive rates (FPRs) for good outcome while retaining high sensitivity for poor outcome. For example, tau at 72 hours had FPR = 2% (95% CI = 1–4%) with sensitivity = 66% (95% CI = 61–70%). Tau had higher accuracy than serum neuron‐specific enolase (NSE; the area under the receiver operating characteristic curve was 0.91 for tau vs 0.86 for NSE at 72 hours, p = 0.00024). During follow‐up (up to 956 days), tau was significantly associated with overall survival. The accuracy in predicting outcome by serum tau was equally high for patients randomized to 33 °C and 36 °C targeted temperature after cardiac arrest. Interpretation Serum tau is a promising novel biomarker for prediction of neurological outcome in patients with cardiac arrest. It may be significantly better than serum NSE, which is recommended in guidelines and currently used in clinical practice in several countries to predict outcome after cardiac arrest. Ann Neurol 2017;82:665–675
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Affiliation(s)
- Niklas Mattsson
- Clinical Memory Research Unit, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Clinical Sciences, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Molecular Neuroscience, UCL Institute of Neurology, London, United Kingdom.,UK Dementia Research Institute, London, United Kingdom
| | - Niklas Nielsen
- Department of Clinical Sciences, Anesthesia, and Intensive Care, Lund University, Helsingborg Hospital, Lund, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anesthesia, and Intensive Care, Lund University, Skåne University Hospital, Lund, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences, 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
| | - Pascal Stammet
- Department of Anesthesia and Intensive Care, Luxembourg Hospital Center, Luxembourg
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Christian Hassager
- Department of Cardiology B2142, Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology B2142, Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Michael Kuiper
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Tommaso Pellis
- Anesthesia and Intensive Care, Card. G. Panico Hospital Agency, Tricase, Italy
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Center of Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark
| | - Matthew Wise
- Adult Critical Care, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
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185
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Johnsen B, Nøhr KB, Duez CHV, Ebbesen MQ. The Nature of EEG Reactivity to Light, Sound, and Pain Stimulation in Neurosurgical Comatose Patients Evaluated by a Quantitative Method. Clin EEG Neurosci 2017; 48:428-437. [PMID: 28844160 DOI: 10.1177/1550059417726475] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
EEG reactivity (EEG-R) is regarded as an important parameter in coma prognosis but knowledge is sparse on the nature of EEG changes due to different kinds of stimulation and their prognostic significance. EEG-R was quantified in a study of 39 comatose neurosurgical patients. Six 30-second standardized visual, auditory, and painful stimulations were applied. EEG-R in the delta, theta, alpha, and beta band was normalized in z-scores as the power of a stimulation epoch relative to average power of 6 resting epochs. Outcome measure was 3 months Glasgow Outcome Scale. Increase in EEG activity was related to poor outcome, was more common (13.4% of tests), and grew continuously during the 30-second stimulation epoch. Decrease in EEG activity was related to good outcome, was rarer (2.5%), and peaked around 15 seconds. Pain was the most provocative stimulation (20.4%) followed by sound (8.7%) and eye-opening (6.7%). Discrimination between good (n = 6) and poor (n = 33) outcome was best in the theta and alpha bands for pain stimulation in the first 10-20 seconds and for sound stimulation in the first 5 to 10 seconds, eye-opening did not discriminate. Increase in activity predicted poor outcome with a high specificity 100% (CI = 52%-100%) and a modest sensitivity of 39% (CI = 23%-58%). Decrease in activity predicted good outcome with a high specificity of 100% (CI = 87%-100%) and a modest sensitivity of 33% (CI = 6%-76%). This quantitative study reveals new knowledge about the nature of EEG-R, which contribute to the development of more reliable and objective clinical procedures for outcome prediction.
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Affiliation(s)
- Birger Johnsen
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kristoffer B Nøhr
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christophe H V Duez
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark.,2 Research Centre for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Mads Q Ebbesen
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
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186
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Abstract
BACKGROUND Myoclonic status may be observed following cardiac arrest and has previously been identified as a poor prognostic indicator in regard to return of neurologic function. We describe a unique situation in post-cardiac arrest patients with myoclonic status and hypothesize possible predictors of a good neurologic outcome. METHODS Case series. RESULTS We illustrate two cases of cardiac arrest due to a respiratory cause in young patients with evidence of illicit drug use at the time of hospital admission that suffered post-ischemic myoclonic status. These patients subsequently recovered with good neurologic outcomes. CONCLUSIONS On rare occasions, myoclonic status does not imply a poor functional outcome following cardiac arrest. Other clinical and demographic characteristics including young age, presence of illicit substances, and primary respiratory causes of arrest may contribute to a severe clinical presentation, with a subsequent good neurologic outcome in a small subset of patients.
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187
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The authors reply. Crit Care Med 2017; 45:e1093-e1094. [DOI: 10.1097/ccm.0000000000002542] [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]
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188
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González‐Cuevas M, Santamarina E, Toledo M, Quintana M, Sala J, Sueiras M, Guzman L, Salas‐Puig J. Response to Dr Voring
et al
. Eur J Neurol 2017; 24:e74. [DOI: 10.1111/ene.13384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 06/28/2017] [Indexed: 11/26/2022]
Affiliation(s)
- M. González‐Cuevas
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Universitat Autonoma de Barcelona Barcelona Spain
| | - E. Santamarina
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Universitat Autonoma de Barcelona Barcelona Spain
| | - M. Toledo
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Universitat Autonoma de Barcelona Barcelona Spain
| | - M. Quintana
- Neurology Department Vall d'Hebron University Hospital Universitat Autonoma de Barcelona Barcelona Spain
| | - J. Sala
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Universitat Autonoma de Barcelona Barcelona Spain
| | - M. Sueiras
- Neurophysiology Department Vall d'Hebron University Hospital Universitat Autonoma de Barcelona Barcelona Spain
| | - L. Guzman
- Neurophysiology Department Vall d'Hebron University Hospital Universitat Autonoma de Barcelona Barcelona Spain
| | - J. Salas‐Puig
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Universitat Autonoma de Barcelona Barcelona Spain
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Abstract
Status epilepticus (SE) is a medical emergency and presents with either a continuous prolonged seizure or multiple seizures without full recovery of consciousness in between them. The goals of treatment are prompt recognition, early seizure termination, and simultaneous evaluation for any potentially treatable cause. Improved understanding of the pathophysiology has led to a more practical definition. New data have emerged regarding the safety and efficacy of alternative agents, which are increasingly used in the management of these patients. Continuous electroencephalogram monitoring is more widely used and has revealed a higher incidence of subclinical seizures than was previously thought.
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Affiliation(s)
- Sudhir Datar
- Section of Neurocritical Care, Departments of Neurology and Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157, USA.
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190
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Abstract
Prognostication after cardiac arrest often depends primarily on neurological function, and characterizing the extent of neurological injury hinges on neurophysiological testing and clinical neurological examination. The presence of early posthypoxic myoclonus (PHM) following cardiac arrest had been invariably associated with poor outcome, but more recent studies have shown that those with early PHM may survive with good neurological function. Electroencephalographic patterns suggestive of severe brain injury may be more valuable than the presence of PHM itself in portending poor functional status, and phenotyping PHM may also be useful in delineating benign and malignant forms. Patients with early PHM should be evaluated similarly to others who suffer cardiac arrest by using a multimodal approach in determining prognosis until further studies are performed that better characterize early PHM subtypes and their outcomes.
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Affiliation(s)
- Brin Freund
- 1Johns Hopkins Hospital, Department of Neurology, Baltimore, MD
| | - Peter W. Kaplan
- 2Johns Hopkins Bayview Medical Center, Department of Neurology, Baltimore, MD
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191
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Guterman EL, Kim AS, Josephson SA. Neurologic consultation and use of therapeutic hypothermia for cardiac arrest. Resuscitation 2017; 118:43-48. [DOI: 10.1016/j.resuscitation.2017.06.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/23/2017] [Accepted: 06/26/2017] [Indexed: 11/26/2022]
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192
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Pfeiffer C, Nguissi NAN, Chytiris M, Bidlingmeyer P, Haenggi M, Kurmann R, Zubler F, Oddo M, Rossetti AO, De Lucia M. Auditory discrimination improvement predicts awakening of postanoxic comatose patients treated with targeted temperature management at 36 °C. Resuscitation 2017; 118:89-95. [DOI: 10.1016/j.resuscitation.2017.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/29/2017] [Accepted: 07/10/2017] [Indexed: 11/24/2022]
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193
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Vogrig A, Pauletto G. Prognosis of status epilepticus in adults: recent advances and future directions. Eur J Neurol 2017; 24:e48. [DOI: 10.1111/ene.13342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 05/15/2017] [Indexed: 11/28/2022]
Affiliation(s)
- A. Vogrig
- Neurology Clinic; Department of Neurosciences; Santa Maria della Misericordia University Hospital; Udine Italy
| | - G. Pauletto
- Neurology Unit; Department of Neurosciences; Santa Maria della Misericordia University Hospital; Udine Italy
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194
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Lascano AM, Lalive PH, Hardmeier M, Fuhr P, Seeck M. Clinical evoked potentials in neurology: a review of techniques and indications. J Neurol Neurosurg Psychiatry 2017; 88:688-696. [PMID: 28235778 DOI: 10.1136/jnnp-2016-314791] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 01/27/2017] [Accepted: 02/01/2017] [Indexed: 01/11/2023]
Abstract
Evoked potentials (EPs) are a powerful and cost-effective tool for evaluating the integrity and function of the central nervous system. Although imaging techniques, such as MRI, have recently become increasingly important in the diagnosis of neurological diseases, over the past 30 years, many neurologists have continued to employ EPs in specific clinical applications. This review presents an overview of the recent evolution of 'classical' clinical applications of EPs in terms of early diagnosis and disease monitoring and is an extension of a previous review published in this journal in 2005 by Walsh and collaborators. We also provide an update on emerging EPs based on gustatory, olfactory and pain stimulation that may be used as clinically relevant markers of neurodegenerative disorders such as Parkinson's disease, Alzheimer's disease and cortical or peripheral impaired pain perception. EPs based on multichannel electroencephalography recordings, known as high-density EPs, help to better differentiate between healthy subjects and patients and, moreover, they provide valuable spatial information regarding the site of the lesion. EPs are reliable disease-progression biomarkers of several neurological diseases, such as multiple sclerosis and other demyelinating disorders. Overall, EPs are excellent neurophysiological tools that will expand standard clinical practice in modern neurology.
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Affiliation(s)
- Agustina M Lascano
- Department of Clinical Neurosciences, Division of Neurology, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Patrice H Lalive
- Department of Clinical Neurosciences, Division of Neurology, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Martin Hardmeier
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Peter Fuhr
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Margitta Seeck
- Department of Clinical Neurosciences, Division of Neurology, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
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195
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van Zijl JC, Beudel M, Elting JWJ, de Jong BM, van der Naalt J, van den Bergh WM, Rossetti AO, Tijssen MAJ, Horn J. The Inter-rater Variability of Clinical Assessment in Post-anoxic Myoclonus. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2017; 7:470. [PMID: 28966876 PMCID: PMC5618111 DOI: 10.7916/d81r6xbv] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 06/01/2017] [Indexed: 12/01/2022]
Abstract
Background Acute post-anoxic myoclonus (PAM) can be divided into an unfavorable (generalized/subcortical) and more favorable ((multi)focal/cortical) outcome group that could support prognostication in post-anoxic encephalopathy; however, the inter-rater variability of clinically assessing these PAM subtypes is unknown. Methods We prospectively examined PAM patients using a standardized video protocol. Videos were rated by three neurologists who classified PAM phenotype (generalized/(multi)focal), stimulus sensitivity, localization (proximal/distal/both), and severity (Clinical Global Impression-Severity Scale (CGI-S) and Unified Myoclonus Rating Scale (UMRS)). Results Poor inter-rater agreement was found for phenotype and stimulus sensitivity (κ=−0.05), moderate agreement for localization (κ=0.46). Substantial agreement was obtained for the CGI-S (intraclass correlation coefficient (ICC)=0.64) and almost perfect agreement for the UMRS (ICC=0.82). Discussion Clinical assessment of PAM is not reproducible between physicians, and should therefore not be used for prognostication. PAM severity measured by the UMRS appears to be reliable; however, the relation between PAM severity and outcome is unknown.
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Affiliation(s)
- Jonathan C van Zijl
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Martijn Beudel
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Jan-Willem J Elting
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands.,Department of Clinical Neurophysiology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Bauke M de Jong
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Walter M van den Bergh
- Intensive Care Medicine, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Marina A J Tijssen
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Janneke Horn
- Intensive Care Medicine, Amsterdam Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
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Gul SS, Huesgen KW, Wang KK, Mark K, Tyndall JA. Prognostic utility of neuroinjury biomarkers in post out-of-hospital cardiac arrest (OHCA) patient management. Med Hypotheses 2017; 105:34-47. [PMID: 28735650 DOI: 10.1016/j.mehy.2017.06.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 05/04/2017] [Accepted: 06/23/2017] [Indexed: 12/30/2022]
Abstract
Despite aggressive intervention, patients who survive an out-of-hospital cardiac arrest (OHCA) generally have very poor prognoses, with nationwide survival rates of approximately 10-20%. Approximately 90% of survivors will have moderate to severe neurological injury ranging from moderate cognitive impairment to brain death. Currently, few early prognostic indicators are considered reliable enough to support patients' families and clinicians' in their decisions regarding medical futility. Blood biomarkers of neurological injury after OHCA may be of prognostic value in these cases. When most bodily tissues are oxygen-deprived, cellular metabolism switches from aerobic to anaerobic respiration. Neurons are a notable exception, however, being dependent solely upon aerobic respiration. Thus, after several minutes without circulating oxygen, neurons sustain irreversible damage, and certain measurable biomarkers are released into the circulation. Prior studies have demonstrated value in blood biomarkers in prediction of survival and neurologic impairment after OHCA. We hypothesize that understanding peptide biomarker kinetics in the early return of spontaneous circulation (ROSC) period, especially in the setting of refractory cardiac arrest, may assist clinicians in determining prognosis earlier in acute resuscitation. Specifically, during and after immediate resuscitation and return of ROSC, clinicians and families face a series of important questions regarding patient prognosis, futility of care and allocation of scarce resources such as the early initiation of extracorporeal cardiopulmonary resuscitation (ECPR). The ability to provide early prognostic information in this setting is highly valuable. Currently available, as well as potential biomarkers that could be good candidates in prognostication of neurological outcomes after OHCA or in the setting of refractory cardiac arrest will be reviewed and discussed.
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Affiliation(s)
- S S Gul
- Department of Emergency Medicine, University of Florida, 1329, SW 16th Street, Suite 5270, Gainesville, FL 32608, United States
| | - K W Huesgen
- Department of Emergency Medicine, University of Florida, 1329, SW 16th Street, Suite 5270, Gainesville, FL 32608, United States
| | - K K Wang
- Program for Neurotrauma, Neuroproteomics & Biomarker Research, Department of Psychiatry, McKnight Brain Institute, University of Florida, 1149 Newell Drive, Gainesville, FL 32610, United States
| | - K Mark
- Department of Emergency Medicine, University of Florida, 1329, SW 16th Street, Suite 5270, Gainesville, FL 32608, United States
| | - J A Tyndall
- Department of Emergency Medicine, University of Florida, 1329, SW 16th Street, Suite 5270, Gainesville, FL 32608, United States.
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Solari D, Rossetti AO, Carteron L, Miroz JP, Novy J, Eckert P, Oddo M. Early prediction of coma recovery after cardiac arrest with blinded pupillometry. Ann Neurol 2017; 81:804-810. [PMID: 28470675 DOI: 10.1002/ana.24943] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/27/2017] [Accepted: 04/27/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Prognostication studies on comatose cardiac arrest (CA) patients are limited by lack of blinding, potentially causing overestimation of outcome predictors and self-fulfilling prophecy. Using a blinded approach, we analyzed the value of quantitative automated pupillometry to predict neurological recovery after CA. METHODS We examined a prospective cohort of 103 comatose adult patients who were unconscious 48 hours after CA and underwent repeated measurements of quantitative pupillary light reflex (PLR) using the Neurolight-Algiscan device. Clinical examination, electroencephalography (EEG), somatosensory evoked potentials (SSEP), and serum neuron-specific enolase were performed in parallel, as part of standard multimodal assessment. Automated pupillometry results were blinded to clinicians involved in patient care. Cerebral Performance Categories (CPC) at 1 year was the outcome endpoint. RESULTS Survivors (n = 50 patients; 32 CPC 1, 16 CPC 2, 2 CPC 3) had higher quantitative PLR (median = 20 [range = 13-41] vs 11 [0-55] %, p < 0.0001) and constriction velocity (1.46 [0.85-4.63] vs 0.94 [0.16-4.97] mm/s, p < 0.0001) than nonsurvivors. At 48 hours, a quantitative PLR < 13% had 100% specificity and positive predictive value to predict poor recovery (0% false-positive rate), and provided equal performance to that of EEG and SSEP. Reduced quantitative PLR correlated with higher serum neuron-specific enolase (Spearman r = -0.52, p < 0.0001). INTERPRETATION Reduced quantitative PLR correlates with postanoxic brain injury and, when compared to standard multimodal assessment, is highly accurate in predicting long-term prognosis after CA. This is the first prognostication study to show the value of automated pupillometry using a blinded approach to minimize self-fulfilling prophecy. Ann Neurol 2017;81:804-810.
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Affiliation(s)
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Laurent Carteron
- Department of Intensive Care Medicine.,Neuroscience Critical Care Research Group.,Department of Anesthesiology and Intensive Care Medicine, University of Burgundy-Franche-Comté, Besançon, France
| | - John-Paul Miroz
- Department of Intensive Care Medicine.,Neuroscience Critical Care Research Group
| | - Jan Novy
- Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Mauro Oddo
- Department of Intensive Care Medicine.,Neuroscience Critical Care Research Group
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Neuroprognostication after cardiac arrest in the light of targeted temperature management. Curr Opin Crit Care 2017; 23:244-250. [DOI: 10.1097/mcc.0000000000000406] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kaneko T, Fujita M, Ogino Y, Yamamoto T, Tsuruta R, Kasaoka S. Serum neutrophil gelatinase-associated lipocalin levels predict the neurological outcomes of out-of-hospital cardiac arrest victims. BMC Cardiovasc Disord 2017; 17:111. [PMID: 28482803 PMCID: PMC5422998 DOI: 10.1186/s12872-017-0545-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/28/2017] [Indexed: 12/12/2022] Open
Abstract
Background Serum neutrophil gelatinase-associated lipocalin (NGAL) is a well-known biomarker of acute kidney injury. Serum NGAL was recently proposed as a potential predictor of mortality in post cardiac arrest syndrome (PCAS) patients following out-of-hospital cardiac arrest (OHCA). However, the potential predictive value of NGAL for neurological outcomes is unknown. Therefore, we assessed the potential predictive value of NGAL for neurological outcomes after OHCA. We also compared its predictive value with that of neuron-specific enolase (NSE) as an established biomarker. Methods Blood samples were prospectively collected from 43 PCAS patients following OHCA. Serum NGAL was measured on days 1 and 2, and NSE was measured on day 2. These biomarkers were compared between patients with favourable (cerebral performance category [CPC] 1–2) and unfavourable (CPC 3–5) outcomes. Receiver operating characteristic (ROC) curve analysis was performed. Results Serum NGAL and NSE on day 2 (both P < 0.001), but not NGAL on day 1 (P = 0.609), were significantly different between the favourable and unfavourable groups. In ROC curve analysis, the sensitivity and specificity were 83% and 85%, respectively, for NGAL (day 2) at a cutoff value of 204 ng/mL and were 84% and 100% for NSE (day 2) at a cutoff value of 28.8 ng/mL. The area under the ROC curve of NGAL (day 2) was equivalent to that of NSE (day 2) (0.830 vs. 0.918). Additionally, the area under the ROC curve in subgroup of estimated glomerular filtration rate (eGFR) > 20 mL/min/1.73 m2 (n = 38, 0.978 vs. 0.923) showed the potential of NGAL predictability. Conclusions Serum NGAL might predict the neurological outcomes of PCAS patients, and its predictive value was equivalent to that of NSE.
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Affiliation(s)
- Tadashi Kaneko
- Emergency and General Medicine, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
| | - Motoki Fujita
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Yasuaki Ogino
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Takahiro Yamamoto
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Shunji Kasaoka
- Emergency and General Medicine, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
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