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Yu J, Zhou A, Li Y. Clinical value of miR-191-5p in predicting the neurological outcome after out-of-hospital cardiac arrest. Ir J Med Sci 2021; 191:1607-1612. [PMID: 34462890 DOI: 10.1007/s11845-021-02745-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/15/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The diagnostic and prognostic value of microRNAs (miRNA) in human disease has been confirmed in a number of clinical studies. AIMS The purpose of this study was to investigate the predictive value of miR-191-5p in the neurological outcome of patients recovering from out-of-hospital cardiac arrest (OHCA). METHODS A total of 260 patients undergoing the target temperature management trial were analyzed. The expression level of serum miR-191-5p was detected by qRT-PCR at 48 h after return of spontaneous circulation (ROSC). ROC curve was established to evaluate the ability of miR-191-5p as a biomarker for predicting adverse neurological outcomes after OHCA. Kaplan-Meier curve and Cox regression analysis were used for survival analysis. RESULTS One hundred eighteen patients (45%) had poor neurological outcomes at 6 months. The expression level of serum miR-191-5p in patients with poor neurological outcomes was significantly lower than that in patients with good neurological prognosis (P < 0.001) and was not associated with TTM trial. The AUC, sensitivity, and specificity of the ROC curve were 0.899, 84.7%, and 82.4%, respectively, suggesting that the level of miR-191-5p had the ability to predict neurological outcome. By the end of the experiment, 88 patients (34%) were dead. Results of survival analysis showed that lower miR-191-5p expression level was significantly associated with lower survival rate (HR: 0.344, 95% CI = 0.208-0.567, P < 0.001). CONCLUSIONS The level of miR-191-5p was down-regulated in patients with poor neurological outcomes, and it could be used as a promising novel biomarker for prediction of neurological outcome and survival after OHCA.
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Affiliation(s)
- Jie Yu
- Clinical Skills Training Center, Affiliated Hospital of Weifang Medical University, Shandong, 261031, China.
| | - Aihua Zhou
- Department of Neurology, Affiliated Hospital of Weifang Medical University, Shandong, 261031, China
| | - Ying Li
- Department of Urology Surgery, Affiliated Hospital of Weifang Medical University, Shandong, 261031, China
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Hirsch KG, Fischbein N, Mlynash M, Kemp S, Bammer R, Eyngorn I, Tong J, Moseley M, Venkatasubramanian C, Caulfield AF, Albers G. Prognostic value of diffusion-weighted MRI for post-cardiac arrest coma. Neurology 2020; 94:e1684-e1692. [PMID: 32269116 DOI: 10.1212/wnl.0000000000009289] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 11/01/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To validate quantitative diffusion-weighted imaging (DWI) MRI thresholds that correlate with poor outcome in comatose cardiac arrest survivors, we conducted a clinician-blinded study and prospectively obtained MRIs from comatose patients after cardiac arrest. METHODS Consecutive comatose post-cardiac arrest adult patients were prospectively enrolled. MRIs obtained within 7 days after arrest were evaluated. The clinical team was blinded to the DWI MRI results and followed a prescribed prognostication algorithm. Apparent diffusion coefficient (ADC) values and thresholds differentiating good and poor outcome were analyzed. Poor outcome was defined as a Glasgow Outcome Scale score of ≤2 at 6 months after arrest. RESULTS Ninety-seven patients were included, and 75 patients (77%) had MRIs. In 51 patients with MRI completed by postarrest day 7, the prespecified threshold of >10% of brain tissue with an ADC <650 ×10-6 mm2/s was highly predictive for poor outcome with a sensitivity of 0.63 (95% confidence interval [CI] 0.42-0.80), a specificity of 0.96 (95% CI 0.77-0.998), and a positive predictive value (PPV) of 0.94 (95% CI 0.71-0.997). The mean whole-brain ADC was higher among patients with good outcomes. Receiver operating characteristic curve analysis showed that ADC <650 ×10-6 mm2/s had an area under the curve of 0.79 (95% CI 0.65-0.93, p < 0.001). Quantitative DWI MRI data improved prognostication of both good and poor outcomes. CONCLUSIONS This prospective, clinician-blinded study validates previous research showing that an ADC <650 ×10-6 mm2/s in >10% of brain tissue in an MRI obtained by postarrest day 7 is highly specific for poor outcome in comatose patients after cardiac arrest.
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Affiliation(s)
- Karen G Hirsch
- From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles.
| | - Nancy Fischbein
- From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles
| | - Michael Mlynash
- From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles
| | - Stephanie Kemp
- From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles
| | - Roland Bammer
- From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles
| | - Irina Eyngorn
- From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles
| | - Julia Tong
- From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles
| | - Michael Moseley
- From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles
| | - Chitra Venkatasubramanian
- From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles
| | - Anna Finley Caulfield
- From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles
| | - Gregory Albers
- From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles
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Kim TJ, Kim JM, Lee JS, Park SH, Jeong HB, Choi JK, Kim K, Bae HM, Ko SB. Prognostication of neurological outcome after cardiac arrest using wavelet phase coherence analysis of cerebral oxygen. Resuscitation 2020; 150:41-49. [PMID: 32194164 DOI: 10.1016/j.resuscitation.2020.02.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/20/2020] [Accepted: 02/24/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND The prognosis for cardiac arrest (CA) is associated with the degree of cerebral ischemia. We investigated the relationship between the wavelet coherence of cerebral oxyhemoglobin (HbO2) among different channels and outcomes after CA. Moreover, we aimed to develop a prognostication method after CA. METHODS Eighty-three post-resuscitation patients were included. The HbO2 data were collected during the post-resuscitation period (median day, 1) using functional near-infrared spectroscopy. The coherence between sections of prefrontal HbO2 oscillations in five frequency intervals (I, 0.6-2 Hz; II, 0.15-0.6 Hz; III, 0.05-0.15 Hz; IV, 0.02-0.05 Hz; and V, 0.0095-0.02 Hz) were analyzed. We evaluated the outcomes using cerebral performance category (CPC) scores (good outcome, CPC ≤ 2 and poor outcome, CPC ≥ 3) at 3 months after CA. Additionally, the predictive method was developed using the biomarker and coherence value after CA. RESULTS Among the included patients, 19 patients (22.9%) had a good outcome. Poor outcome group had significantly lower phase coherence in the myogenic frequency interval III compared to good outcome group (0.36 ± 0.14 vs. 0.54 ± 0.18, P < 0.001). The predictive method using neuron-specific enolase (NSE) and interval III value demonstrated good discrimination (area under the curve 0.919; 95% confidence interval, 0.850-0.989). CONCLUSIONS The predictive method using NSE and phase coherence of HbO2 in the interval III from the vascular smooth muscle cells could be a useful tool for prognosticating after CA. This suggests that evaluating cerebral ischemia using phase coherence of HbO2 might be a helpful outcome predictor following CA.
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Affiliation(s)
- Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea; Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae-Myoung Kim
- Department of Electrical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea
| | - Soo-Hyun Park
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hae-Bong Jeong
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jong-Kwan Choi
- Department of Electrical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyeon-Min Bae
- Department of Electrical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea; Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
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Wei R, Wang C, He F, Hong L, Zhang J, Bao W, Meng F, Luo B. Prediction of poor outcome after hypoxic-ischemic brain injury by diffusion-weighted imaging: A systematic review and meta-analysis. PLoS One 2019; 14:e0226295. [PMID: 31881032 PMCID: PMC6934311 DOI: 10.1371/journal.pone.0226295] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 11/24/2019] [Indexed: 01/16/2023] Open
Abstract
Accurate prediction of the neurological outcome following hypoxic-ischemic brain injury (HIBI) remains difficult. Diffusion-weighted imaging (DWI) can detect acute and subacute brain abnormalities following global cerebral hypoxia. Therefore, DWI can be used to predict the outcomes of HIBI. To this end, we searched the PubMed, EMBASE, and Cochrane Library databases for studies that examine the diagnostic accuracy of DWI in predicting HIBI outcomes in adult patients between January1995 and September 2019. Next, we conducted a comprehensive meta-analysis using the Meta-DiSc and several complementary techniques. Following the application of inclusion and exclusion criteria, a total of 28 studies were included with 98 data subsets. The overall sensitivity and specificity, with 95% confidence interval, were 0.613(0.599-0.628) and 0.958(0.947-0.967), respectively, and the area under the curve was 0.9090. Significant heterogeneity among the included studies and a threshold effect were observed (p<0.001). Different positive indices were the major sources for the heterogeneity, followed by the anatomical region examined, both of which significantly affected the prognostic accuracy. In conclusion, we demonstrated that DWI can be an instrumental modality in predicting the outcome of HIBI with good prognostic accuracy. However, the lack of clear and generally accepted positive indices limits its clinical application. Therefore, using more reliable positive indices and combining DWI with other clinical predictors may improve the diagnostic accuracy of HIBI.
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Affiliation(s)
- Ruili Wei
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chaonan Wang
- Department of Geriatrics, Shulan (Hangzhou) Hospital, Hangzhou, China
| | - Fangping He
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lirong Hong
- Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Jie Zhang
- Department of Rehabilitation, Hangzhou Hospital of Zhejiang CAPR, Hangzhou, China
| | - Wangxiao Bao
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fangxia Meng
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Benyan Luo
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Wiley SL, Razavi B, Krishnamohan P, Mlynash M, Eyngorn I, Meador KJ, Hirsch KG. Quantitative EEG Metrics Differ Between Outcome Groups and Change Over the First 72 h in Comatose Cardiac Arrest Patients. Neurocrit Care 2019. [PMID: 28646267 DOI: 10.1007/s12028-017-0419-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Forty to sixty-six percent of patients resuscitated from cardiac arrest remain comatose, and historic outcome predictors are unreliable. Quantitative spectral analysis of continuous electroencephalography (cEEG) may differ between patients with good and poor outcomes. METHODS Consecutive patients with post-cardiac arrest hypoxic-ischemic coma undergoing cEEG were enrolled. Spectral analysis was conducted on artifact-free contiguous 5-min cEEG epochs from each hour. Whole band (1-30 Hz), delta (δ, 1-4 Hz), theta (θ, 4-8 Hz), alpha (α, 8-13 Hz), beta (β, 13-30 Hz), α/δ power ratio, percent suppression, and variability were calculated and correlated with outcome. Graphical patterns of quantitative EEG (qEEG) were described and categorized as correlating with outcome. Clinical outcome was dichotomized, with good neurologic outcome being consciousness recovery. RESULTS Ten subjects with a mean age = 50 yrs (range = 18-65) were analyzed. There were significant differences in total power (3.50 [3.30-4.06] vs. 0.68 [0.52-1.02], p = 0.01), alpha power (1.39 [0.66-1.79] vs 0.27 [0.17-0.48], p < 0.05), delta power (2.78 [2.21-3.01] vs 0.55 [0.38-0.83], p = 0.01), percent suppression (0.66 [0.02-2.42] vs 73.4 [48.0-97.5], p = 0.01), and multiple measures of variability between good and poor outcome patients (all values median [IQR], good vs. poor). qEEG patterns with high or increasing power or large power variability were associated with good outcome (n = 6). Patterns with consistently low or decreasing power or minimal power variability were associated with poor outcome (n = 4). CONCLUSIONS These preliminary results suggest qEEG metrics correlate with outcome. In some patients, qEEG patterns change over the first three days post-arrest.
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Affiliation(s)
| | - Babak Razavi
- Department of Neurology and Neurological Sciences, Stanford University, 300 Pasteur Drive, MC 5778, Stanford, CA, 94305, USA
| | - Prashanth Krishnamohan
- Department of Neurology and Neurological Sciences, Stanford University, 300 Pasteur Drive, MC 5778, Stanford, CA, 94305, USA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University, 300 Pasteur Drive, MC 5778, Stanford, CA, 94305, USA
| | - Irina Eyngorn
- Department of Neurology and Neurological Sciences, Stanford University, 300 Pasteur Drive, MC 5778, Stanford, CA, 94305, USA
| | - Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University, 300 Pasteur Drive, MC 5778, Stanford, CA, 94305, USA
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences, Stanford University, 300 Pasteur Drive, MC 5778, Stanford, CA, 94305, USA.
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Increased Heat Generation in Postcardiac Arrest Patients During Targeted Temperature Management Is Associated With Better Outcomes. Crit Care Med 2019; 46:1133-1138. [PMID: 29620555 DOI: 10.1097/ccm.0000000000003154] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Assess if amount of heat generated by postcardiac arrest patients to reach target temperature (Ttarget) during targeted temperature management is associated with outcomes by serving as a proxy for thermoregulatory ability, and whether it modifies the relationship between time to Ttarget and outcomes. DESIGN Retrospective cohort study. SETTING Urban tertiary-care hospital. PATIENTS Successfully resuscitated targeted temperature management-treated adult postarrest patients between 2008 and 2015 with serial temperature data and Ttarget less than or equal to 34°C. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Time to Ttarget was defined as time from targeted temperature management initiation to first recorded patient temperature less than or equal to 34°C. Patient heat generation ("heat units") was calculated as inverse of average water temperature × hours between initiation and Ttarget × 100. Primary outcome was neurologic status measured by Cerebral Performance Category score; secondary outcome was survival, both at hospital discharge. Univariate analyses were performed using Wilcoxon rank-sum tests; multivariate analyses used logistic regression. Of 203 patients included, those with Cerebral Performance Category score 3-5 generated less heat before reaching Ttarget (median, 8.1 heat units [interquartile range, 3.6-21.6 heat units] vs median, 20.0 heat units [interquartile range, 9.0-33.5 heat units]; p = 0.001) and reached Ttarget quicker (median, 2.3 hr [interquartile range, 1.5-4.0 hr] vs median, 3.6 hr [interquartile range, 2.0-5.0 hr]; p = 0.01) than patients with Cerebral Performance Category score 1-2. Nonsurvivors generated less heat than survivors (median, 8.1 heat units [interquartile range, 3.6-20.8 heat units] vs median, 19.0 heat units [interquartile range, 6.5-33.5 heat units]; p = 0.001) and reached Ttarget quicker (median, 2.2 hr [interquartile range, 1.5-3.8 hr] vs median, 3.6 hr [interquartile range, 2.0-5.0 hr]; p = 0.01). Controlling for average water temperature between initiation and Ttarget, the relationship between outcomes and time to Ttarget was no longer significant. Controlling for location, witnessed arrest, age, initial rhythm, and neuromuscular blockade use, increased heat generation was associated with better neurologic (adjusted odds ratio, 1.01 [95% CI, 1.00-1.03]; p = 0.039) and survival (adjusted odds ratio, 1.01 [95% CI, 1.00-1.03]; p = 0.045) outcomes. CONCLUSIONS Increased heat generation during targeted temperature management initiation is associated with better outcomes at hospital discharge and may affect the relationship between time to Ttarget and outcomes.
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Gardiner D, Shaw DM, Kilcullen JK, Dalle Ave AL. Intensive care for organ preservation: A four-stage pathway. J Intensive Care Soc 2019; 20:335-340. [PMID: 31695738 DOI: 10.1177/1751143719840254] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Intensive care for organ preservation (ICOP) is defined as the initiation or pursuit of intensive care not to save the patient's life, but to protect and optimize organs for transplantation. Analysis When a patient has devastating brain injury that might progress to organ donation this can be conceptualized as evolving through four consecutive stages: (1) instability, (2) stability, (3) futility and (4) finality. ICOP might be applied at any of these stages, raising different ethical issues. Only in the stage of finality is the switch from neurointensive care to ICOP ethically justified. Conclusion The difference between the stages is that during instability, stability and futility the focus must be neurointensive care which seeks the patient's recovery or an accurate neurological prognostication, while finality focuses on withdrawal of life-sustaining therapy and commencement of comfort care, which may include ICOP for deceased donation.
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Affiliation(s)
- Dale Gardiner
- Adult Intensive Care Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David M Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Jack K Kilcullen
- Medical Critical Care Services, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Anne L Dalle Ave
- Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland
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Nguyen PL, Alreshaid L, Poblete RA, Konye G, Marehbian J, Sung G. Targeted Temperature Management and Multimodality Monitoring of Comatose Patients After Cardiac Arrest. Front Neurol 2018; 9:768. [PMID: 30254606 PMCID: PMC6141756 DOI: 10.3389/fneur.2018.00768] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/24/2018] [Indexed: 01/14/2023] Open
Abstract
Out-of-hospital cardiac arrest (CA) remains a leading cause of sudden morbidity and mortality; however, outcomes have continued to improve in the era of targeted temperature management (TTM). In this review, we highlight the clinical use of TTM, and provide an updated summary of multimodality monitoring possible in a modern ICU. TTM is neuroprotective for survivors of CA by inhibiting multiple pathophysiologic processes caused by anoxic brain injury, with a final common pathway of neuronal death. Current guidelines recommend the use of TTM for out-of-hospital CA survivors who present with a shockable rhythm. Further studies are being completed to determine the optimal timing, depth and duration of hypothermia to optimize patient outcomes. Although a multidisciplinary approach is necessary in the CA population, neurologists and neurointensivists are central in selecting TTM candidates and guiding patient care and prognostic evaluation. Established prognostic tools include clinal exam, SSEP, EEG and MR imaging, while functional MRI and invasive monitoring is not validated to improve outcomes in CA or aid in prognosis. We recommend that an evidence-based TTM and prognostication algorithm be locally implemented, based on each institution's resources and limitations. Given the high incidence of CA and difficulty in predicting outcomes, further study is urgently needed to determine the utility of more recent multimodality devices and studies.
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Affiliation(s)
- Peggy L Nguyen
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Laith Alreshaid
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Roy A Poblete
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Geoffrey Konye
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jonathan Marehbian
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Gene Sung
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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9
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Chung-Esaki HM, Mui G, Mlynash M, Eyngorn I, Catabay K, Hirsch KG. The neuron specific enolase (NSE) ratio offers benefits over absolute value thresholds in post-cardiac arrest coma prognosis. J Clin Neurosci 2018; 57:99-104. [PMID: 30145080 DOI: 10.1016/j.jocn.2018.08.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 08/13/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Serum neuron-specific enolase (NSE) levels have been shown to correlate with neurologic outcome in comatose survivors of cardiac arrest but use of absolute NSE thresholds is limited. This study describes and evaluates a novel approach to analyzing NSE, the NSE ratio, and evaluates the prognostic utility of NSE absolute value thresholds and trends over time. METHODS 100 consecutive adult comatose cardiac arrest survivors were prospectively enrolled. NSE levels were assessed at 24, 48, and 72 h post-arrest. Primary outcome was the Glasgow Outcome Score (GOS) at 6 months post-arrest; good outcome was defined as GOS 3-5. Absolute and relative NSE values (i.e. the NSE ratio), peak values, and the trend in NSE over 72 h were analyzed. RESULTS 98 patients were included. 42 (43%) had a good outcome. Five good outcome patients had peak NSE >33 µg/L (34.9-46.4 µg/L). NSE trends between 24 and 48 h differed between outcome groups (decrease by 3.0 µg/L (0.9-7.0 µg/L) vs. increase by 13.4 µg/L (-3.7 to 69.4 µg/L), good vs. poor, p = 0.004). The 48:24 h NSE ratio differed between the good and poor outcome groups (0.8 (0.6-0.9) vs. 1.4 (0.8-2.5), p = 0.001), and a 48:24 h ratio of ≥1.7 was 100% specific for poor outcome. CONCLUSIONS The NSE ratio is a unique method to quantify NSE changes over time. Values greater than 1.0 indicate increasing NSE and may be reflective of ongoing neuronal injury. The NSE ratio obviates the need for an absolute value cut-off.
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Affiliation(s)
| | - Gracia Mui
- University of Connecticut, Department of Neurology, Farmington, CT, United States
| | - Michael Mlynash
- Stanford University Stroke Center, Stanford, CA, United States
| | - Irina Eyngorn
- Stanford University Stroke Center, Stanford, CA, United States
| | - Kyle Catabay
- Stanford University, Department of Anesthesia, Stanford, CA, United States
| | - Karen G Hirsch
- Stanford University, Department of Neurology, Stanford, CA, United States.
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Wallin E, Larsson IM, Kristofferzon ML, Larsson EM, Raininko R, Rubertsson S. Acute brain lesions on magnetic resonance imaging in relation to neurological outcome after cardiac arrest. Acta Anaesthesiol Scand 2018; 62:635-647. [PMID: 29363101 DOI: 10.1111/aas.13074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 12/12/2017] [Accepted: 12/19/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) of the brain including diffusion-weighted imaging (DWI) is reported to have high prognostic accuracy in unconscious post-cardiac arrest (CA) patients. We documented acute MRI findings in the brain in both conscious and unconscious post-CA patients treated with target temperature management (TTM) at 32-34°C for 24 h as well as the relation to patients' neurological outcome after 6 months. METHODS A prospective observational study with MRI was performed regardless of the level of consciousness in post-CA patients treated with TTM. Neurological outcome was assessed using the Cerebral Performance Categories scale and dichotomized into good and poor outcome. RESULTS Forty-six patients underwent MRI at 3-5 days post-CA. Patients with good outcome had minor, mainly frontal and parietal, lesions. Acute hypoxic/ischemic lesions on MRI including DWI were more common in patients with poor outcome (P = 0.007). These lesions affected mostly gray matter (deep or cortical), with or without involvement of the underlying white matter. Lesions in the occipital and temporal lobes, deep gray matter and cerebellum showed strongest associations with poor outcome. Decreased apparent diffusion coefficient, was more common in patients with poor outcome. CONCLUSIONS Extensive acute hypoxic/ischemic MRI lesions in the cortical regions, deep gray matter and cerebellum detected by visual analysis as well as low apparent diffusion coefficient values from quantitative measurements were associated with poor outcome. Patients with good outcome had minor hypoxic/ischemic changes, mainly in the frontal and parietal lobes.
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Affiliation(s)
- E. Wallin
- Department of Surgical Sciences, Anaesthesiology& Intensive Care; Uppsala University; Uppsala Sweden
| | - I.-M. Larsson
- Department of Surgical Sciences, Anaesthesiology& Intensive Care; Uppsala University; Uppsala Sweden
| | - M.-L. Kristofferzon
- Faculty of Health and Occupational Studies; Department of Health and Caring Sciences; University of Gävle; Gävle Sweden
- Department of Public Health and Caring Sciences; Uppsala University; Uppsala Sweden
| | - E.-M. Larsson
- Department of Surgical Sciences, Radiology; Uppsala University; Uppsala Sweden
| | - R. Raininko
- Department of Surgical Sciences, Radiology; Uppsala University; Uppsala Sweden
| | - S. Rubertsson
- Department of Surgical Sciences, Anaesthesiology& Intensive Care; Uppsala University; Uppsala Sweden
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Asgari S, Moshirvaziri H, Scalzo F, Ramezan-Arab N. Quantitative measures of EEG for prediction of outcome in cardiac arrest subjects treated with hypothermia: a literature review. J Clin Monit Comput 2018; 32:977-992. [DOI: 10.1007/s10877-018-0118-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 02/22/2018] [Indexed: 12/14/2022]
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12
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Rossetti AO. Clinical neurophysiology for neurological prognostication of comatose patients after cardiac arrest. Clin Neurophysiol Pract 2017; 2:76-80. [PMID: 30214976 PMCID: PMC6123903 DOI: 10.1016/j.cnp.2017.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/13/2017] [Accepted: 03/13/2017] [Indexed: 12/01/2022] Open
Abstract
A multimodal prognostic approach is recommended after cardiac arrest. EEG (background and, reactivity, repetitive epileptiform features) and SSEP are core assessments. Some outlook into long-latency evoked potentials is offered.
Early prognostication of outcome in comatose patients after cardiac arrest represents a daunting task for clinicians, also considering the nowadays commonly used targeted temperature management with sedation in the first 24–48 h. A multimodal approach is currently recommended, in order to minimize the risks of false-positive prediction of poor outcome, including clinical examination off sedation, EEG (background characterization and reactivity, occurrence of repetitive epileptiform features), and early-latency SSEP responses represent the core assessments in this setting; they may be complemented by biochemical markers and neuroimaging. This paper, which relies on a recent comprehensive review, focuses on an updated review of EEG and SSEP, and also offers some outlook into long-latency evoked potentials, which seem promising in clinical use.
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Affiliation(s)
- Andrea O Rossetti
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Université de Lausanne (UNIL), Lausanne, Switzerland
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13
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Becker DA, Schiff ND, Becker LB, Holmes MG, Fins JJ, Horowitz JM, Devinsky O. A major miss in prognostication after cardiac arrest: Burst suppression and brain healing. EPILEPSY & BEHAVIOR CASE REPORTS 2016; 7:1-5. [PMID: 28053858 PMCID: PMC5198796 DOI: 10.1016/j.ebcr.2016.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/12/2016] [Accepted: 09/13/2016] [Indexed: 11/18/2022]
Abstract
We report a case with therapeutic hypothermia after cardiac arrest where meaningful recovery far exceeded anticipated negative endpoints following cardiac arrest with loss of brainstem reflexes and subsequent status epilepticus. This man survived and recovered after an out-of-hospital cardiac arrest followed by a 6-week coma with absent motor responses and 5 weeks of burst suppression. Standard criteria suggested no chance of recovery. His recovery may relate to the effect of burst-suppression on EEG to rescue neurons near neuronal cell death. Further research to understand the mechanisms of therapeutic hypothermia and late restoration of neuronal functional capacity may improve prediction and aid end-of-life decisions after cardiac arrest.
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Affiliation(s)
- Danielle A. Becker
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Nicholas D. Schiff
- Department of Neurology, Weill Cornell Medical Center, New York, NY, United States
| | - Lance B. Becker
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Manisha G Holmes
- Department of Neurology, New York University Medical Center, New York, NY, United States
| | - Joseph J. Fins
- Department of Internal Medicine, Weill Cornell Medical Center, New York, NY, United States
| | - James M. Horowitz
- Division of Cardiology, Department of Internal Medicine, Weill Cornell Medical Center, New York, NY, United States
| | - Orrin Devinsky
- Department of Neurology, New York University Medical Center, New York, NY, United States
- Corresponding author at: Department of Neurology, New York University Medical Center, 223 East 34th Street, New York, NY 10016, United States.Department of NeurologyNew York University Medical Center223 East 34th StreetNew YorkNY10016United States
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14
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Cortical somatosensory evoked high-frequency (600Hz) oscillations predict absence of severe hypoxic encephalopathy after resuscitation. Clin Neurophysiol 2016; 127:2561-9. [PMID: 27291874 DOI: 10.1016/j.clinph.2016.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/09/2016] [Accepted: 04/14/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Following cardiac arrest (CA), hypoxic encephalopathy (HE) frequently occurs and hence reliable neuroprognostication is crucial to decide on the extent of intensive care. Several investigations predict severe HE leading to persistent unresponsive wakefulness or death, with high specificity. Only few studies attempted to predict absence of severe HE. Cortical somatosensory evoked high-frequency (600Hz) oscillation (HFO) bursts indicate the presence of highly synchronized spiking activity in the primary somatosensory cortex. Since global neuronal damage characterizes severe HE preserved cortical HFOs may early exclude severe HE. METHODS We determined amplitudes of early and late HFO bursts in 302 comatose CA patients after median nerve somatosensory evoked potential (SSEPs) and clinical outcome upon intensive care unit discharge using the cerebral performance category (CPC) scale. RESULTS We detected significant early HFO bursts in 146 patients and late HFO bursts in 95 patients. Only one of 27 unresponsive wakefulness patients had a late HFO burst amplitude above 70nV and all seventeen patients who died despite higher amplitudes died from non-neurological causes. CONCLUSIONS High-frequency SSEP components can reliably be studied in comatose CA patients using standard equipment. SIGNIFICANCE Late HFO burst amplitudes above 70nV largely exclude severe HE incompatible with regaining consciousness.
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15
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Neurological prognostication of outcome in patients in coma after cardiac arrest. Lancet Neurol 2016; 15:597-609. [PMID: 27017468 DOI: 10.1016/s1474-4422(16)00015-6] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/23/2015] [Accepted: 01/12/2016] [Indexed: 11/24/2022]
Abstract
Management of coma after cardiac arrest has improved during the past decade, allowing an increasing proportion of patients to survive, thus prognostication has become an integral part of post-resuscitation care. Neurologists are increasingly confronted with raised expectations of next of kin and the necessity to provide early predictions of long-term prognosis. During the past decade, as technology and clinical evidence have evolved, post-cardiac arrest prognostication has moved towards a multimodal paradigm combining clinical examination with additional methods, consisting of electrophysiology, blood biomarkers, and brain imaging, to optimise prognostic accuracy. Prognostication should never be based on a single indicator; although some variables have very low false positive rates for poor outcome, multimodal assessment provides resassurance about the reliability of a prognostic estimate by offering concordant evidence.
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16
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Westhall E, Rossetti AO, van Rootselaar AF, Wesenberg Kjaer T, Horn J, Ullén S, Friberg H, Nielsen N, Rosén I, Åneman A, Erlinge D, Gasche Y, Hassager C, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wetterslev J, Wise MP, Cronberg T. Standardized EEG interpretation accurately predicts prognosis after cardiac arrest. Neurology 2016; 86:1482-90. [PMID: 26865516 PMCID: PMC4836886 DOI: 10.1212/wnl.0000000000002462] [Citation(s) in RCA: 253] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/01/2015] [Indexed: 01/17/2023] Open
Abstract
Objective: To identify reliable predictors of outcome in comatose patients after cardiac arrest using a single routine EEG and standardized interpretation according to the terminology proposed by the American Clinical Neurophysiology Society. Methods: In this cohort study, 4 EEG specialists, blinded to outcome, evaluated prospectively recorded EEGs in the Target Temperature Management trial (TTM trial) that randomized patients to 33°C vs 36°C. Routine EEG was performed in patients still comatose after rewarming. EEGs were classified into highly malignant (suppression, suppression with periodic discharges, burst-suppression), malignant (periodic or rhythmic patterns, pathological or nonreactive background), and benign EEG (absence of malignant features). Poor outcome was defined as best Cerebral Performance Category score 3–5 until 180 days. Results: Eight TTM sites randomized 202 patients. EEGs were recorded in 103 patients at a median 77 hours after cardiac arrest; 37% had a highly malignant EEG and all had a poor outcome (specificity 100%, sensitivity 50%). Any malignant EEG feature had a low specificity to predict poor prognosis (48%) but if 2 malignant EEG features were present specificity increased to 96% (p < 0.001). Specificity and sensitivity were not significantly affected by targeted temperature or sedation. A benign EEG was found in 1% of the patients with a poor outcome. Conclusions: Highly malignant EEG after rewarming reliably predicted poor outcome in half of patients without false predictions. An isolated finding of a single malignant feature did not predict poor outcome whereas a benign EEG was highly predictive of a good outcome.
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Affiliation(s)
- Erik Westhall
- Authors' affiliations are listed at the end of the article.
| | | | | | | | - Janneke Horn
- Authors' affiliations are listed at the end of the article
| | - Susann Ullén
- Authors' affiliations are listed at the end of the article
| | - Hans Friberg
- Authors' affiliations are listed at the end of the article
| | - Niklas Nielsen
- Authors' affiliations are listed at the end of the article
| | - Ingmar Rosén
- Authors' affiliations are listed at the end of the article
| | - Anders Åneman
- Authors' affiliations are listed at the end of the article
| | - David Erlinge
- Authors' affiliations are listed at the end of the article
| | - Yvan Gasche
- Authors' affiliations are listed at the end of the article
| | | | - Jan Hovdenes
- Authors' affiliations are listed at the end of the article
| | | | - Michael Kuiper
- Authors' affiliations are listed at the end of the article
| | - Tommaso Pellis
- Authors' affiliations are listed at the end of the article
| | - Pascal Stammet
- Authors' affiliations are listed at the end of the article
| | | | | | - Matt P Wise
- Authors' affiliations are listed at the end of the article
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Choi WS, Kim JJ, Yang HJ. Brain Magnetic Resonance Imaging in Patients with Favorable Outcomes after Out-of-Hospital Cardiac Arrest: Many Have Encephalopathy Even with a Good Cerebral Performance Category Score. Korean J Crit Care Med 2015. [DOI: 10.4266/kjccm.2015.30.4.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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18
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Cardiac arrest and therapeutic hypothermia. Trends Cardiovasc Med 2015; 26:337-44. [PMID: 26603661 DOI: 10.1016/j.tcm.2015.10.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 10/05/2015] [Accepted: 10/05/2015] [Indexed: 11/22/2022]
Abstract
Therapeutic hypothermia for patients who remain comatose following resuscitation from a cardiac arrest improves both survival and neurologic outcomes. Although this therapy has been incorporated into the guidelines for routine post-resuscitation care and has been in clinical use for over a decade, significant questions and controversies remain. In this review, we discuss these questions in the context of the current evidence and provide a practical framework to help guide clinicians.
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19
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Oh SH, Park KN, Shon YM, Kim YM, Kim HJ, Youn CS, Kim SH, Choi SP, Kim SC. Continuous Amplitude-Integrated Electroencephalographic Monitoring Is a Useful Prognostic Tool for Hypothermia-Treated Cardiac Arrest Patients. Circulation 2015; 132:1094-103. [PMID: 26269576 PMCID: PMC4572885 DOI: 10.1161/circulationaha.115.015754] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 07/13/2015] [Indexed: 01/26/2023]
Abstract
Supplemental Digital Content is available in the text. Modern treatments have improved the survival rate following cardiac arrest, but prognostication remains a challenge. We examined the prognostic value of continuous electroencephalography according to time by performing amplitude-integrated electroencephalography on patients with cardiac arrest receiving therapeutic hypothermia.
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Affiliation(s)
- Sang Hoon Oh
- From Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.H.O., K.N.P., Y.-M.K., H.J.K., C.S.Y., S.H.K., S.P.C.); Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (Y.-M.S.); and Department of Respiratory and Critical Care Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.C.K.)
| | - Kyu Nam Park
- From Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.H.O., K.N.P., Y.-M.K., H.J.K., C.S.Y., S.H.K., S.P.C.); Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (Y.-M.S.); and Department of Respiratory and Critical Care Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.C.K.).
| | - Young-Min Shon
- From Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.H.O., K.N.P., Y.-M.K., H.J.K., C.S.Y., S.H.K., S.P.C.); Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (Y.-M.S.); and Department of Respiratory and Critical Care Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.C.K.)
| | - Young-Min Kim
- From Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.H.O., K.N.P., Y.-M.K., H.J.K., C.S.Y., S.H.K., S.P.C.); Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (Y.-M.S.); and Department of Respiratory and Critical Care Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.C.K.)
| | - Han Joon Kim
- From Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.H.O., K.N.P., Y.-M.K., H.J.K., C.S.Y., S.H.K., S.P.C.); Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (Y.-M.S.); and Department of Respiratory and Critical Care Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.C.K.)
| | - Chun Song Youn
- From Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.H.O., K.N.P., Y.-M.K., H.J.K., C.S.Y., S.H.K., S.P.C.); Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (Y.-M.S.); and Department of Respiratory and Critical Care Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.C.K.)
| | - Soo Hyun Kim
- From Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.H.O., K.N.P., Y.-M.K., H.J.K., C.S.Y., S.H.K., S.P.C.); Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (Y.-M.S.); and Department of Respiratory and Critical Care Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.C.K.)
| | - Seung Pill Choi
- From Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.H.O., K.N.P., Y.-M.K., H.J.K., C.S.Y., S.H.K., S.P.C.); Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (Y.-M.S.); and Department of Respiratory and Critical Care Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.C.K.)
| | - Seok Chan Kim
- From Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.H.O., K.N.P., Y.-M.K., H.J.K., C.S.Y., S.H.K., S.P.C.); Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (Y.-M.S.); and Department of Respiratory and Critical Care Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (S.C.K.)
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Abstract
Cardiopulmonary resuscitation, basic life support and early defibrillation are leading to more survivors of out-of-hospital cardiac arrest reaching hospital. Once stabilised on an intensive care unit, it can be difficult to predict the neurological outcome using clinical criteria alone, particularly with modern management using sedation, neuromuscular blockade and hypothermia. If we are to prevent ongoing futile life support, it is important to try to identify the majority of patients who, despite best efforts, will not make a meaningful recovery. Somatosensory evoked potentials are widely available electrophysiological tests that can provide an objective biomarker of a poor neurological outcome and assist in predicting the prognosis.
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Affiliation(s)
- Nick Kane
- Grey Walter Department of Clinical Neurophysiology, North Bristol NHS Trust, Bristol, UK
| | - Agyepong Oware
- Grey Walter Department of Clinical Neurophysiology, North Bristol NHS Trust, Bristol, UK
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Wares CM, Heffner AC, Ward SL, Pearson DA. ED prognostication of comatose cardiac arrest patients undergoing therapeutic hypothermia is unreliable. Am J Emerg Med 2015; 33:802-6. [PMID: 25858162 DOI: 10.1016/j.ajem.2014.12.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 12/19/2014] [Accepted: 12/21/2014] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) improves patient survival with good neurologic outcome after cardiac arrest. The value of early clinician prognostication in the emergency department (ED) has not been studied in this patient population. OBJECTIVE To determine if physicians can accurately predict survival and neurologic outcome at hospital discharge of resuscitated, comatose out-of-hospital cardiac arrest (OHCA) patients treated in a post-cardiac arrest clinical pathway that included TH. METHODS This was a prospective, observational study conducted at a tertiary referral center. Participants were physicians involved in the resuscitation of OHCA patients treated with a clinical pathway that included TH. Immediately after patient resuscitation in the ED, physicians recorded their prediction of patient survival and neurologic outcome on a standardized questionnaire. Neurologic outcome was assessed by the cerebral performance category. RESULTS Forty-two physicians completed questionnaires on 17 patients enrolled from October 2009 to March 2010. Sensitivity and specificity of physician prediction of patient survival were 0.67 (95% confidence interval [CI], 0.45-0.83) and 0.82 (95% CI, 0.59-0.94), respectively, with an area under the curve of 0.74 (95% CI, 0.61-0.88), a positive likelihood ratio (+LR) of 3.72 (95% CI, 1.30-11.02), and a -LR of 0.40 (95% CI, 0.21-0.77). Sensitivity and specificity of physician prediction of good neurologic outcome were 0.40 (95% CI, 0.20-0.64) and 0.69 (95% CI, 0.50-0.84), respectively, with an area under the curve of 0.55 (95% CI, 0.39-0.70), a +LR of 1.29 (95% CI, 0.56-3.03), and a -LR of 0.87 (95% CI, 0.53-1.41). CONCLUSIONS Physicians poorly prognosticate both survival and neurologic outcome in comatose OHCA patients undergoing TH. Premature prognostication in the ED is unreliable and should be avoided.
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Affiliation(s)
- Catherine M Wares
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
| | - Alan C Heffner
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC; Department of Internal Medicine, Division of Critical Care, Carolinas Medical Center, Charlotte, NC
| | - Shana L Ward
- Dickson Advanced Analytics Group, Carolinas Health Care System, Charlotte, NC
| | - David A Pearson
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
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Efficacy of diffusion-weighted magnetic resonance imaging performed before therapeutic hypothermia in predicting clinical outcome in comatose cardiopulmonary arrest survivors. Resuscitation 2014; 88:132-7. [PMID: 25541428 DOI: 10.1016/j.resuscitation.2014.11.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/13/2014] [Accepted: 11/28/2014] [Indexed: 11/22/2022]
Abstract
AIM OF THE STUDY To develop a clinically relevant and qualitative brain magnetic resonance imaging (MRI) scoring system for acute stage comatose cardiac arrest patients. METHODS Consecutive comatose post-cardiopulmonary arrest patients were prospectively enrolled. Routine brain MRI sequences were scored by two independent and blinded experts. Predefined brain regions were qualitatively scored on diffusion-weighted imaging (DWI) sequences according to the severity of the abnormality on a scale from 0 to 4. The mean score provided by the raters determined poor outcome defined under the Cerebral Performance Categories 3, 4, or 5. DWI scans were repeated after therapeutic hypothermia (TH). The same qualitative scoring system was applied and results were compared to the initial scores. RESULTS Out of 24 recruited patients, 19 with brain MRI scans were included. Of the 19 included patients, seven showed a good outcome at hospital discharge and 12 patients showed poor neurologic outcome. Median time from the arrest to the initial DWI was 166min (IQR 114-240min). At 100% specificity, the overall, cortex, and cortex plus deep grey nuclei scores predicted poor patient outcome with a sensitivity of 91.7-100% (95% CI). Follow-up DWI scans after TH showed worse results than initial scans. CONCLUSION A qualitative MRI scoring system effectively assessed the severity of hypoxic-ischaemic brain injury following cardiopulmonary arrest. The scoring system may provide useful prognostic information in comatose cardiopulmonary arrest patients.
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The authors reply. Crit Care Med 2014; 42:e800. [PMID: 25402305 DOI: 10.1097/ccm.0000000000000683] [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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Effect of mild hypothermic cardiopulmonary bypass on the amplitude of somatosensory-evoked potentials. J Neurosurg Anesthesiol 2014; 26:161-6. [PMID: 24492514 DOI: 10.1097/ana.0000000000000016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Several neurophysiological techniques are used to intraoperatively assess cerebral functioning during surgery and intensive care, but the introduction of hypothermia as a means of intraoperative neuroprotection has brought their reliability into question. The present study aimed to evaluate the effect of mild hypothermia on somatosensory-evoked potentials' (SSEPs) amplitude and latency in a cohort of cardiopulmonary bypass (CPB) patients as the temperature reached the steady-state. MATERIALS AND METHODS The amplitude and latency of 4 different SSEP signals--N9, N13, P14/N18 interpeak, and N20/P25--were evaluated retrospectively in 84 patients undergoing CPB during normothermic (36°C±0.43°C) and mild hypothermic (32°C±1.38°C) conditions. SSEPs were recorded in normothermia immediately after the induction of anesthesia and in hypothermia as the temperature reached its steady-state, specifically, when the nasopharyngeal temperature was equivalent to the rectal temperature (±0.5°C). A paired-samples t test was performed for each SSEP to test the differences in latencies and amplitudes between normothermic and hypothermic conditions. RESULTS Compared with normothermia, hypothermia not only significantly increased the latency of all SSEPs, N9 (P<0.001), N13 (P<0.001), P14/N18 (P<0.001), and N20/P25 (P<0.001), but also the amplitude of N9 (P<0.001) and N20/P25 (P<0.001). CONCLUSIONS The increased amplitude in particularly of cortical SSEPs (N20/P25), detected specifically during steady-state hypothermia, seems to support the clinical utility of this methodology in monitoring the brain function not only during cardiac surgery with CPB, but also in other settings like therapeutic hypothermia procedures in an intensive care unit.
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Perman SM, Ellenberg JH, Grossestreuer AV, Gaieski DF, Leary M, Abella BS, Carr BG. Shorter time to target temperature is associated with poor neurologic outcome in post-arrest patients treated with targeted temperature management. Resuscitation 2014; 88:114-9. [PMID: 25447429 DOI: 10.1016/j.resuscitation.2014.10.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 10/20/2014] [Accepted: 10/28/2014] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Time to achieve target temperature varies substantially for patients who undergo targeted temperature management (TTM) after cardiac arrest. The association between arrival at target temperature and neurologic outcome is poorly understood. We hypothesized that shorter time from initiation of cooling to target temperature ("induction") will be associated with worse neurologic outcome, reflecting more profound underlying brain injury and impaired thermoregulatory control. METHODS This was a multicenter retrospective study analyzing data from the Penn Alliance for Therapeutic Hypothermia (PATH) Registry. We examined the association between time from arrest to return of spontaneous circulation (ROSC) ("downtime"), ROSC to initiation of TTM ("pre-induction") and "induction" with cerebral performance category (CPC). RESULTS A total of 321 patients were analyzed, of whom 30.8% (99/321) had a good neurologic outcome. Downtime for survivors with good outcome was 11 (IQR 6-27) min vs. 21 (IQR 10-36) min (p=0.002) for those with poor outcome. Pre-induction did not vary between good and poor outcomes (98 (IQR 36-230) min vs. 114 (IQR 34-260) (p=ns)). Induction time in the good outcome cohort was 237 (IQR 142-361) min compared to 180 (IQR 100-276) min (p=0.004). Patients were categorized by induction time (<120min, 120-300min, >300min). Using multivariable logistic regression adjusted for age, initial rhythm, and downtime, induction time >300min was associated with good neurologic outcome when compared to those with an induction time <120min. CONCLUSION In this multicenter cohort of post-arrest TTM patients, shorter induction time was associated with poor neurologic outcome.
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Affiliation(s)
- Sarah M Perman
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, CO, United States.
| | - Jonas H Ellenberg
- University of Pennsylvania, Perelman School of Medicine, Department of Biostatistics and Epidemiology, Philadelphia, PA, United States
| | - Anne V Grossestreuer
- University of Pennsylvania, Department of Emergency Medicine, Center for Resuscitation Science, Philadelphia, PA, United States
| | - David F Gaieski
- University of Pennsylvania, Perelman School of Medicine, Department of Emergency Medicine, Philadelphia, PA, United States; University of Pennsylvania, Department of Emergency Medicine, Center for Resuscitation Science, Philadelphia, PA, United States
| | - Marion Leary
- University of Pennsylvania, Department of Emergency Medicine, Center for Resuscitation Science, Philadelphia, PA, United States
| | - Benjamin S Abella
- University of Pennsylvania, Perelman School of Medicine, Department of Emergency Medicine, Philadelphia, PA, United States; University of Pennsylvania, Department of Emergency Medicine, Center for Resuscitation Science, Philadelphia, PA, United States
| | - Brendan G Carr
- University of Pennsylvania, Perelman School of Medicine, Department of Biostatistics and Epidemiology, Philadelphia, PA, United States; University of Pennsylvania, Perelman School of Medicine, Department of Emergency Medicine, Philadelphia, PA, United States
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Westhall E, Rosén I, Rossetti AO, van Rootselaar AF, Kjaer TW, Horn J, Ullén S, Friberg H, Nielsen N, Cronberg T. Electroencephalography (EEG) for neurological prognostication after cardiac arrest and targeted temperature management; rationale and study design. BMC Neurol 2014; 14:159. [PMID: 25267568 PMCID: PMC4440598 DOI: 10.1186/s12883-014-0159-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 07/29/2014] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Electroencephalography (EEG) is widely used to assess neurological prognosis in patients who are comatose after cardiac arrest, but its value is limited by varying definitions of pathological patterns and by inter-rater variability. The American Clinical Neurophysiology Society (ACNS) has recently proposed a standardized EEG-terminology for critical care to address these limitations. METHODS/DESIGN In the TTM-trial, 399 post cardiac arrest patients who remained comatose after rewarming underwent a routine EEG. The presence of clinical seizures, use of sedatives and antiepileptic drugs during the EEG-registration were prospectively documented. DISCUSSION A well-defined terminology for interpreting post cardiac arrest EEGs is critical for the use of EEG as a prognostic tool. TRIAL REGISTRATION The TTM-trial is registered at ClinicalTrials.gov (NCT01020916).
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Affiliation(s)
- Erik Westhall
- />Department of Clinical Sciences, Division of Clinical Neurophysiology, Lund University, Lund, Sweden
| | - Ingmar Rosén
- />Department of Clinical Sciences, Division of Clinical Neurophysiology, Lund University, Lund, Sweden
| | - Andrea O Rossetti
- />Department of Neurology, CHUV and University of Lausanne, Lausanne, Switzerland
| | - Anne-Fleur van Rootselaar
- />Department of Neurology/Clinical Neurophysiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Troels Wesenberg Kjaer
- />Department of Clinical Neurophysiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Janneke Horn
- />Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Susann Ullén
- />R&D Centre Skane, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- />Department of Clinical Sciences, Division of Intensive and Perioperative Care, Lund University, Lund, Sweden
| | - Niklas Nielsen
- />Department of Anaesthesia and Intensive Care, Intensive Care Unit, Helsingborg Hospital, Helsingborg, Sweden
| | - Tobias Cronberg
- />Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
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Schorl M, Valerius-Kukula SJ, Kemmer TP. Median-evoked somatosensory potentials in severe brain injury: Does initial loss of cortical potentials exclude recovery? Clin Neurol Neurosurg 2014; 123:25-33. [DOI: 10.1016/j.clineuro.2014.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 04/27/2014] [Accepted: 05/03/2014] [Indexed: 11/28/2022]
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Automated Auditory Mismatch Negativity Paradigm Improves Coma Prognostic Accuracy After Cardiac Arrest and Therapeutic Hypothermia. J Clin Neurophysiol 2014; 31:356-61. [DOI: 10.1097/wnp.0000000000000082] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Hirsch KG, Mlynash M, Jansen S, Persoon S, Eyngorn I, Krasnokutsky MV, Wijman CA, Fischbein NJ. Prognostic Value of A Qualitative Brain MRI Scoring System After Cardiac Arrest. J Neuroimaging 2014; 25:430-7. [DOI: 10.1111/jon.12143] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 05/12/2014] [Accepted: 05/25/2014] [Indexed: 11/29/2022] Open
Affiliation(s)
- Karen G. Hirsch
- Stanford Neurocritical Care Program, Stanford Stroke Center; Stanford University Medical Center; Department of Neurology and Neurological Sciences; Stanford University School of Medicine; Stanford CA
| | - Michael Mlynash
- Stanford Neurocritical Care Program, Stanford Stroke Center; Stanford University Medical Center; Department of Neurology and Neurological Sciences; Stanford University School of Medicine; Stanford CA
| | - Sofie Jansen
- Stanford Neurocritical Care Program, Stanford Stroke Center; Stanford University Medical Center; Department of Neurology and Neurological Sciences; Stanford University School of Medicine; Stanford CA
| | - Suzanne Persoon
- Stanford Neurocritical Care Program, Stanford Stroke Center; Stanford University Medical Center; Department of Neurology and Neurological Sciences; Stanford University School of Medicine; Stanford CA
- Department of Neurology; University Medical Center Utrecht; the Netherlands
| | - Irina Eyngorn
- Stanford Neurocritical Care Program, Stanford Stroke Center; Stanford University Medical Center; Department of Neurology and Neurological Sciences; Stanford University School of Medicine; Stanford CA
| | | | - Christine A.C. Wijman
- Stanford Neurocritical Care Program, Stanford Stroke Center; Stanford University Medical Center; Department of Neurology and Neurological Sciences; Stanford University School of Medicine; Stanford CA
| | - Nancy J. Fischbein
- Department of Radiology; Stanford University School of Medicine; Stanford CA
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Early Multimodal Outcome Prediction After Cardiac Arrest in Patients Treated With Hypothermia*. Crit Care Med 2014; 42:1340-7. [DOI: 10.1097/ccm.0000000000000211] [Citation(s) in RCA: 206] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Bader EBMK. Clinical q & a: translating therapeutic temperature management from theory to practice. Ther Hypothermia Temp Manag 2014; 3:151-7. [PMID: 24834844 DOI: 10.1089/ther.2013.1510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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De Deyne C, Meex I, Dens J. Uneventful neurological outcome in case of late awakening after cardiac arrest treated with hypothermia. Resuscitation 2014; 85:e39. [DOI: 10.1016/j.resuscitation.2013.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 10/30/2013] [Indexed: 11/24/2022]
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Abstract
PURPOSE OF REVIEW Early prognostication in acute brain damage remains a challenge in the realm of critical care. There remains controversy over the most optimal methods that can be utilized to predict outcome. The utility of recently reported prognostic biomarkers and clinical methods will be reviewed. RECENT FINDINGS Recent guidelines touch upon prognostication techniques as part of management recommendations. In addition to novel laboratory values, there have been few reports on the use of clinical parameters, diagnostic imaging techniques, and electrophysiological techniques to assist in prognostication. SUMMARY Although encouraging, newer markers are not capable of providing accurate estimates on outcomes in acute injuries of the central nervous system. Traditional markers of prognostication may not be applicable in the light of newer and effective therapies (i.e. hypothermia). Substantial research in the field of outcome determination is in progress, but these studies need to be interpreted with caution.
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Kim J, Kim K, Hong S, Kwon B, Yun ID, Choi BS, Jung C, Lee JH, Jo YH, Kim T, Rhee JE, Lee SH. Low apparent diffusion coefficient cluster-based analysis of diffusion-weighted MRI for prognostication of out-of-hospital cardiac arrest survivors. Resuscitation 2013; 84:1393-9. [DOI: 10.1016/j.resuscitation.2013.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Revised: 04/08/2013] [Accepted: 04/09/2013] [Indexed: 11/28/2022]
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Rehabilitation outcome of anoxic-ischaemic encephalopathy survivors with prolonged disorders of consciousness. Resuscitation 2013; 84:1409-15. [DOI: 10.1016/j.resuscitation.2013.05.015] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 05/20/2013] [Accepted: 05/20/2013] [Indexed: 11/19/2022]
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Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: A systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermia. Resuscitation 2013; 84:1324-38. [DOI: 10.1016/j.resuscitation.2013.06.020] [Citation(s) in RCA: 224] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 06/13/2013] [Accepted: 06/23/2013] [Indexed: 12/16/2022]
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Alvarez V, Sierra-Marcos A, Oddo M, Rossetti AO. Yield of intermittent versus continuous EEG in comatose survivors of cardiac arrest treated with hypothermia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R190. [PMID: 24007625 PMCID: PMC4056115 DOI: 10.1186/cc12879] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Accepted: 09/04/2013] [Indexed: 01/10/2023]
Abstract
Introduction Electroencephalography (EEG) has a central role in the outcome prognostication in subjects with anoxic/hypoxic encephalopathy following a cardiac arrest (CA). Continuous EEG monitoring (cEEG) has been consistently developed and studied; however, its yield as compared to repeated standard EEG (sEEG) is unknown. Methods We studied a prospective cohort of comatose adults treated with therapeutic hypothermia (TH) after a CA. cEEG data regarding background activity and epileptiform components were compared to two 20-minute sEEGs extracted from the cEEG recording (one during TH, and one in early normothermia). Results Thirty-four recordings were studied. During TH, the agreement between cEEG and sEEG was 97.1% (95% CI: 84.6 to 99.9%) for background discontinuity and reactivity evaluation, while it was 94.1% (95% CI 80.3 to 99.2%) regarding epileptiform activity. In early normothermia, we did not find any discrepancies. Thus, concordance results were very good during TH (kappa 0.83), and optimal during normothermia (kappa = 1). The median delay between CA and the first EEG reactivity testing was 18 hours (range: 4.75 to 25) for patients with perfect agreement and 10 hours (range: 5.75 to 10.5) for the three patients with discordant findings (P = 0.02, Wilcoxon). Conclusions Standard intermittent EEG has comparable performance with continuous EEG both for variables important for outcome prognostication (EEG reactivity) and identification of epileptiform transients in this relatively small sample of comatose survivors of CA. This finding has an important practical implication, especially for centers where EEG resources are limited.
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Clinical review: Continuous and simplified electroencephalography to monitor brain recovery after cardiac arrest. Crit Care 2013; 17:233. [PMID: 23876221 PMCID: PMC4056658 DOI: 10.1186/cc12699] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
There has been a dramatic change in hospital care of cardiac arrest survivors in recent years, including the use of target temperature management (hypothermia). Clinical signs of recovery or deterioration, which previously could be observed, are now concealed by sedation, analgesia, and muscle paralysis. Seizures are common after cardiac arrest, but few centers can offer high-quality electroencephalography (EEG) monitoring around the clock. This is due primarily to its complexity and lack of resources but also to uncertainty regarding the clinical value of monitoring EEG and of treating post-ischemic electrographic seizures. Thanks to technical advances in recent years, EEG monitoring has become more available. Large amounts of EEG data can be linked within a hospital or between neighboring hospitals for expert opinion. Continuous EEG (cEEG) monitoring provides dynamic information and can be used to assess the evolution of EEG patterns and to detect seizures. cEEG can be made more simple by reducing the number of electrodes and by adding trend analysis to the original EEG curves. In our version of simplified cEEG, we combine a reduced montage, displaying two channels of the original EEG, with amplitude-integrated EEG trend curves (aEEG). This is a convenient method to monitor cerebral function in comatose patients after cardiac arrest but has yet to be validated against the gold standard, a multichannel cEEG. We recently proposed a simplified system for interpreting EEG rhythms after cardiac arrest, defining four major EEG patterns. In this topical review, we will discuss cEEG to monitor brain function after cardiac arrest in general and how a simplified cEEG, with a reduced number of electrodes and trend analysis, may facilitate and improve care.
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40
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Mlynash M, Buckwalter MS, Okada A, Caulfield AF, Venkatasubramanian C, Eyngorn I, Verbeek MM, Wijman CAC. Serum Neuron-Specific Enolase Levels from the Same Patients Differ Between Laboratories: Assessment of a Prospective Post-cardiac Arrest Cohort. Neurocrit Care 2013; 19:161-6. [DOI: 10.1007/s12028-013-9867-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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41
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Tolan NV, Vidal-Folch N, Algeciras-Schimnich A, Singh RJ, Grebe SKG. Individualized correction of neuron-specific enolase (NSE) measurement in hemolyzed serum samples. Clin Chim Acta 2013; 424:216-21. [PMID: 23778024 DOI: 10.1016/j.cca.2013.06.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 05/22/2013] [Accepted: 06/06/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Accuracy of serum neuron-specific enolase (NSE) measurement is paramount, particularly in the context of neurological outcome prognostication. However, NSE measurements are compromised by even slight hemolysis, as it is abundant in red blood cells (RBCs). We derived and validated an individualized hemolysis correction equation in an attempt to reduce the current rejection rate of 14% at our institution. METHODS Intracellular NSE was measured in RBC lysates to determine concentration variability. A correction equation was derived, accounting for both RBC-derived NSE false-elevation and hemoglobin-derived signal quenching. The performance of this individualized correction was evaluated in intentionally hemolyzed samples and accuracy was compared to a generalized correction. RESULTS Significant inter-individual variability of RBC NSE was observed, with an almost two-fold range (15.7-28.5 ng NSE/mg Hb, p<0.001); intra-individual variability was insignificant. The individualized hemolysis correction equation derived: NSE(corr)=NSE(meas)-(Hb(serum))(NSE(RBCs/Hb))+0.0844(Hb(serum))+1.1 corrected 95% of the intentionally hemolyzed samples to within ±5 ng/ml of corresponding baseline NSE concentrations, compared to 74% using a generalized formula. CONCLUSIONS The individualized hemolysis correction provides increased accuracy in the estimation of true serum NSE concentrations for hemolyzed samples, compared to a generalized approach, by accounting for inter-individual RBC NSE variability. Incorporating this correction should reduce sample rejection rates and overall health care costs.
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Affiliation(s)
- Nicole V Tolan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
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Cronberg T, Horn J, Kuiper MA, Friberg H, Nielsen N. A structured approach to neurologic prognostication in clinical cardiac arrest trials. Scand J Trauma Resusc Emerg Med 2013; 21:45. [PMID: 23759121 PMCID: PMC3691620 DOI: 10.1186/1757-7241-21-45] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 05/29/2013] [Indexed: 01/25/2023] Open
Abstract
Brain injury is the dominant cause of death for cardiac arrest patients who are admitted to an intensive care unit, and the majority of patients die after withdrawal of life sustaining therapy (WLST) based on a presumed poor neurologic outcome. Mild induced hypothermia was found to decrease the reliability of several methods for neurological prognostication. Algorithms for prediction of outcome, that were developed before the introduction of mild hypothermia after cardiac arrest, may have affected the results of studies with hypothermia-treated patients. In previous trials on neuroprotection after cardiac arrest, including the pivotal hypothermia trials, the methods for prognostication and the reasons for WLST were not reported and may have had an effect on outcome. In the Target Temperature Management trial, in which 950 cardiac arrest patients have been randomized to treatment at 33°C or 36°C, neuroprognostication and WLST-decisions are strictly protocolized and registered. Prognostication is delayed to at least 72 hours after the end of the intervention period, thus a minimum of 4.5 days after the cardiac arrest, and is based on multiple parameters to account for the possible effects of hypothermia.
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Abstract
Because pediatric intensive care units (PICUs) improve survival for a range of acute diseases, attention has turned toward ensuring the best possible functional outcomes after critical illness. The neurocritical care of children is of increasing interest. However, the pediatric population encompasses a heterogeneous set of neurologic conditions, with several possible models of how best to address them. This article reviews the special challenges faced by PICUs with regards to diseases, technologies, and skills and the progress that has been made in treatment, monitoring, and prognostication. Recent advances in translational research expected to modify the field in the near-term are described.
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Affiliation(s)
- Joshua Cappell
- Pediatric Critical Care Medicine, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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Prognostic performance of diffusion-weighted MRI combined with NSE in comatose cardiac arrest survivors treated with mild hypothermia. Neurocrit Care 2013; 17:412-20. [PMID: 22932993 DOI: 10.1007/s12028-012-9773-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND MRI-based prognostication of comatose cardiac arrest survivors has shown promising results. However, the technique has not been validated in patients treated with therapeutic hypothermia and it is unknown how it might add to NSE-based prognostication. We sought to evaluate the prognostic performance of regional apparent diffusion coefficient (ADC) in comatose out-of-hospital cardiac arrest (OHCA) patients treated with mild hypothermia and its added value to NSE-based prognostication. METHODS An OHCA registry was analyzed to identify OHCA patients older than 15 who were treated with therapeutic hypothermia and underwent brain MRI between 2008 and 2011. Quantitative measurement of regional ADCs was performed by a radiologist blinded to the clinical outcome. RESULTS Of the 43 eligible patients, 11 (18.6 %) achieved a good outcome (6-month CPC of 1 or 2). The regional ADC of the occipital cortex showed the highest discriminatory power with an area under the curve of receiver operating characteristic (AUROC) of 0.943 (95 % CI, 0.872-1.000) and predicted poor outcomes with a sensitivity of 90.6 % and a specificity of 100 %. The AUROC for NSE levels (48-h) was 0.911 (95 % CI, 0.801-1.000) which was significantly correlated with the regional ADC (Pearson's r = -0.674, p < .001). The ADC-based predictions identified an additional 5 (35.7 %) poor outcome patients out of 14 with 48-h NSE levels less than 78.9 ng/mL, which is the cutoff point suggested in a previous study. However, additional prognostic information was not provided when the 48-h NSE levels were >78.9 ng/mL. CONCLUSIONS Regional ADC-based prognostication was accurate in OHCA patients who were treated with mild hypothermia. However, it only provided additional prognostic information when the 48-h NSE levels indicated a good prognosis (48-h NSE <78.9 ng/mL).
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Rady MY, Verheijde JL. Determining Brain Death After Therapeutic Hypothermia on Nonpulsatile Continuous-Flow Mechanical Circulatory Support Devices. J Cardiothorac Vasc Anesth 2013; 27:e8-9. [DOI: 10.1053/j.jvca.2012.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Indexed: 11/11/2022]
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Friberg H, Rundgren M, Westhall E, Nielsen N, Cronberg T. Continuous evaluation of neurological prognosis after cardiac arrest. Acta Anaesthesiol Scand 2013; 57:6-15. [PMID: 22834632 DOI: 10.1111/j.1399-6576.2012.02736.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2012] [Indexed: 11/30/2022]
Abstract
Post-resuscitation care has changed in the last decade, and outcome after cardiac arrest has improved, thanks to several combined measures. Induced hypothermia has shown a treatment benefit in two randomized trials, but some doubts remain. General care has improved, including the use of emergency coronary intervention. Assessment of neurological function and prognosis in comatose cardiac arrest patient is challenging, especially when treated with hypothermia. In this review, we evaluate the recent literature and discuss the available evidence for prognostication after cardiac arrest in the era of temperature management. Relevant literature was identified searching PubMed and reading published papers in the field, but no standardized search strategy was used. The complexity of predicting outcome after cardiac arrest and induced hypothermia is recognized in the literature, and no single test can predict a poor prognosis with absolute certainty. A clinical neurological examination is still the gold standard, but the results need careful interpretation because many patients are affected by sedatives and by hypothermia. Common adjuncts include neurophysiology, brain imaging and biomarkers, and a multimodal strategy is generally recommended. Current guidelines for prediction of outcome after cardiac arrest and induced hypothermia are not sufficient. Based on our expert opinion, we suggest a multimodal approach with a continuous evaluation of prognosis based on repeated neurological examinations and electroencephalography. Somatosensory-evoked potential is an established method to help determine a poor outcome and is recommended, whereas biomarkers and magnetic resonance imaging are promising adjuncts. We recommend that a decisive evaluation of prognosis is performed at 72 h after normothermia or later in a patient free of sedative and analgetic drugs.
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Affiliation(s)
- H Friberg
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden.
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Rothstein TL. Therapeutic hypothermia and reliability of somatosensory evoked potentials in predicting outcome after cardiopulmonary arrest. Neurocrit Care 2012; 17:146-9. [PMID: 22547039 DOI: 10.1007/s12028-012-9696-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The loss of the N20 component on testing median somatosensory evoked potentials (SSEP) has been established as the most reliable indicator of unfavorable prognosis in post-cardiopulmonary arrest patients. With the intervention of therapeutic hypothermia in the management of patients who remain comatose following cardiopulmonary arrest that association is now in dispute. Abandoning SSEP as a key prognostic indicator of neurologic outcome would be a serious loss and cannot be justified.
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Affiliation(s)
- Ted Laurence Rothstein
- Department of Neurology, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC 20037, USA.
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Goswami S, Prager K, Sladen RN, Wagener G. Reply to Drs Rady and Verheijde. J Cardiothorac Vasc Anesth 2012; 27:e9-10. [PMID: 23089263 DOI: 10.1053/j.jvca.2012.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Indexed: 11/11/2022]
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De Georgia M, Raad B. Prognosis of Coma After Cardiac Arrest in the Era of Hypothermia. Continuum (Minneap Minn) 2012; 18:515-31. [DOI: 10.1212/01.con.0000415425.68900.c6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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50
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Machado C, Estévez M, Rodríguez R, Carrick FR, Melillo R, Leisman G. Bilateral N20 absence in post-anoxic coma: do you pay attention? Clin Neurophysiol 2011; 123:1264-6. [PMID: 22209660 DOI: 10.1016/j.clinph.2011.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 11/10/2011] [Accepted: 11/11/2011] [Indexed: 11/28/2022]
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