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Carroll EE, Der-Nigoghossian C, Alkhachroum A, Appavu B, Gilmore E, Kromm J, Rohaut B, Rosanova M, Sitt JD, Claassen J. Common Data Elements for Disorders of Consciousness: Recommendations from the Electrophysiology Working Group. Neurocrit Care 2023; 39:578-585. [PMID: 37606737 DOI: 10.1007/s12028-023-01795-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Electroencephalography (EEG) has long been recognized as an important tool in the investigation of disorders of consciousness (DoC). From inspection of the raw EEG to the implementation of quantitative EEG, and more recently in the use of perturbed EEG, it is paramount to providing accurate diagnostic and prognostic information in the care of patients with DoC. However, a nomenclature for variables that establishes a convention for naming, defining, and structuring data for clinical research variables currently is lacking. As such, the Neurocritical Care Society's Curing Coma Campaign convened nine working groups composed of experts in the field to construct common data elements (CDEs) to provide recommendations for DoC, with the main goal of facilitating data collection and standardization of reporting. This article summarizes the recommendations of the electrophysiology DoC working group. METHODS After assessing previously published pertinent CDEs, we developed new CDEs and categorized them into "disease core," "basic," "supplemental," and "exploratory." Key EEG design elements, defined as concepts that pertained to a methodological parameter relevant to the acquisition, processing, or analysis of data, were also included but were not classified as CDEs. RESULTS After identifying existing pertinent CDEs and developing novel CDEs for electrophysiology in DoC, variables were organized into a framework based on the two primary categories of resting state EEG and perturbed EEG. Using this categorical framework, two case report forms were generated by the working group. CONCLUSIONS Adherence to the recommendations outlined by the electrophysiology working group in the resting state EEG and perturbed EEG case report forms will facilitate data collection and sharing in DoC research on an international level. In turn, this will allow for more informed and reliable comparison of results across studies, facilitating further advancement in the realm of DoC research.
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Affiliation(s)
- Elizabeth E Carroll
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, New York, NY, USA
| | | | | | - Brian Appavu
- Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Emily Gilmore
- Divisions of Neurocritical Care and Emergency Neurology and Epilepsy, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Yale New Haven Hospital, New Haven, CT, USA
| | - Julie Kromm
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Benjamin Rohaut
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, Centre national de la recherche scientifique, Assistance Publique-Hôpitaux de Paris, Neurosciences, Hôpital de La Pitié Salpêtrière, Paris, France
| | - Mario Rosanova
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Jacobo Diego Sitt
- Paris Brain Institute (ICM), Centre national de la recherche scientifique, Paris, France
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
- NewYork-Presbyterian Hospital, New York, NY, USA.
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2
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Oishi T, Triplett JD, Laughlin RS, Hocker SE, Berini SE, Hoffman EM. Short-Acting Neuromuscular Blockade Improves Inter-rater Reliability of Median Somatosensory Evoked Potentials in Post-cardiac arrest Prognostication. Neurocrit Care 2023; 38:600-611. [PMID: 36123569 DOI: 10.1007/s12028-022-01601-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/29/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although median nerve somatosensory evoked potentials are routinely used for prognostication in comatose cardiac arrest survivors, myogenic artifact can reduce inter-rater reliability, leading to unreliable or inaccurate results. To minimize this risk, we determined the benefit of neuromuscular blockade agents in improving the inter-rater reliability and signal-to-noise ratio of SSEPs in the context of prognostication. METHODS Thirty comatose survivors of cardiac arrest were enrolled in the study, following the request from an intensivist to complete an SSEP for prognostication. Right and left median nerve SSEPs were obtained from each patient, before and after administration of an NMB agent. Clinical histories and outcomes were retrospectively reviewed. The SSEP recordings before and after NMB were randomized and reviewed by five blinded raters, who assessed the latency and amplitude of cortical and noncortical potentials (vs. absence of response) as well as the diagnostic quality of cortical recordings. The inter-rater reliability of SSEP interpretation before and after NMB was compared via Fleiss' κ score. RESULTS Following NMB administration, Fleiss' κ score for cortical SSEP interpretation significantly improved from 0.37 to 0.60, corresponding to greater agreement among raters. The raters were also less likely to report the cortical recordings as nondiagnostic following NMB (40.7% nondiagnostic SSEPs pre-NMB; 17% post-NMB). The SNR significantly improved following NMB, especially when the pre-NMB SNR was low (< 10 dB). Across the raters, there were three patients whose SSEP interpretation changed from bilaterally absent to bilaterally present after NMB was administered (potential false positives without NMB). CONCLUSIONS NMB significantly improves the inter-rater reliability and SNR of median SSEPs for prognostication among comatose cardiac arrest survivors. To ensure the most reliable prognostic information in comatose post-cardiac arrest survivors, pharmacologic paralysis should be consistently used before recording SSEPs.
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Affiliation(s)
- Tatsuya Oishi
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA.
| | - James D Triplett
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
- Department of Neurology, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Ruple S Laughlin
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Sarah E Berini
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Ernest M Hoffman
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
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Comanducci A, Boly M, Claassen J, De Lucia M, Gibson RM, Juan E, Laureys S, Naccache L, Owen AM, Rosanova M, Rossetti AO, Schnakers C, Sitt JD, Schiff ND, Massimini M. Clinical and advanced neurophysiology in the prognostic and diagnostic evaluation of disorders of consciousness: review of an IFCN-endorsed expert group. Clin Neurophysiol 2020; 131:2736-2765. [PMID: 32917521 DOI: 10.1016/j.clinph.2020.07.015] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 07/06/2020] [Accepted: 07/26/2020] [Indexed: 12/13/2022]
Abstract
The analysis of spontaneous EEG activity and evoked potentialsis a cornerstone of the instrumental evaluation of patients with disorders of consciousness (DoC). Thepast few years have witnessed an unprecedented surge in EEG-related research applied to the prediction and detection of recovery of consciousness after severe brain injury,opening up the prospect that new concepts and tools may be available at the bedside. This paper provides a comprehensive, critical overview of bothconsolidated and investigational electrophysiological techniquesfor the prognostic and diagnostic assessment of DoC.We describe conventional clinical EEG approaches, then focus on evoked and event-related potentials, and finally we analyze the potential of novel research findings. In doing so, we (i) draw a distinction between acute, prolonged and chronic phases of DoC, (ii) attempt to relate both clinical and research findings to the underlying neuronal processes and (iii) discuss technical and conceptual caveats.The primary aim of this narrative review is to bridge the gap between standard and emerging electrophysiological measures for the detection and prediction of recovery of consciousness. The ultimate scope is to provide a reference and common ground for academic researchers active in the field of neurophysiology and clinicians engaged in intensive care unit and rehabilitation.
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Affiliation(s)
- A Comanducci
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - M Boly
- Department of Neurology and Department of Psychiatry, University of Wisconsin, Madison, USA; Wisconsin Institute for Sleep and Consciousness, Department of Psychiatry, University of Wisconsin-Madison, Madison, USA
| | - J Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - M De Lucia
- Laboratoire de Recherche en Neuroimagerie, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - R M Gibson
- The Brain and Mind Institute and the Department of Physiology and Pharmacology, Western Interdisciplinary Research Building, N6A 5B7 University of Western Ontario, London, Ontario, Canada
| | - E Juan
- Wisconsin Institute for Sleep and Consciousness, Department of Psychiatry, University of Wisconsin-Madison, Madison, USA; Amsterdam Brain and Cognition, Department of Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - S Laureys
- Coma Science Group, Centre du Cerveau, GIGA-Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; Fondazione Europea per la Ricerca Biomedica Onlus, Milan 20063, Italy
| | - L Naccache
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; Sorbonne Université, UPMC Université Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - A M Owen
- The Brain and Mind Institute and the Department of Physiology and Pharmacology, Western Interdisciplinary Research Building, N6A 5B7 University of Western Ontario, London, Ontario, Canada
| | - M Rosanova
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy; Fondazione Europea per la Ricerca Biomedica Onlus, Milan 20063, Italy
| | - A O Rossetti
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - C Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA
| | - J D Sitt
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - N D Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| | - M Massimini
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy; Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
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Katyal N, Singh I, Narula N, Idiculla PS, Premkumar K, Beary JM, Nattanmai P, Newey CR. Continuous Electroencephalography (CEEG) in Neurological Critical Care Units (NCCU): A Review. Clin Neurol Neurosurg 2020; 198:106145. [PMID: 32823186 DOI: 10.1016/j.clineuro.2020.106145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/20/2020] [Accepted: 08/07/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Nakul Katyal
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Ishpreet Singh
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Naureen Narula
- Staten Island University Hospital, Department of Pulmonary- critical Care Medicine, 475 Seaview Avenue Staten Island, NY, 10305, United States.
| | - Pretty Sara Idiculla
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Keerthivaas Premkumar
- University of Missouri, Department of biological sciences, Columbia, MO 65211, United States.
| | - Jonathan M Beary
- A. T. Still University, Department of Neurobehavioral Sciences, Kirksville, MO, United States.
| | - Premkumar Nattanmai
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Christopher R Newey
- Cleveland clinic Cerebrovascular center, 9500 Euclid Avenue, Cleveland, OH 44195, United States.
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Rothstein TL. SSEP retains its value as predictor of poor outcome following cardiac arrest in the era of therapeutic hypothermia. Crit Care 2019; 23:327. [PMID: 31647028 PMCID: PMC6813072 DOI: 10.1186/s13054-019-2576-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/19/2019] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES To re-evaluate the role of median nerve somatosensory evoked potentials (SSEPs) and bilateral loss of the N20 cortical wave as a predictor of unfavorable outcome in comatose patients following cardiac arrest (CA) in the therapeutic hypothermia (TH) era. METHODS Review the results and conclusions drawn from isolated case reports and small series of comatose patients following CA in which the bilateral absence of N20 response has been associated with recovery, and evaluate the proposal that SSEP can no longer be considered a reliable and accurate predictor of unfavorable neurologic outcome. RESULTS There are many methodological limitations in those patients reported in the literature with severe post anoxic encephalopathy who recover despite having lost their N20 cortical potential. These limitations include lack of sufficient clinical and neurologic data, severe core body hypothermia, specifics of electrophysiologic testing, technical issues such as background noise artifacts, flawed interpretations sometimes related to interobserver inconsistency, and the extreme variability in interpretation and quality of SSEP analysis among different clinicians and hospitals. CONCLUSIONS The absence of the SSEP N20 cortical wave remains one of the most reliable early prognostic tools for identifying unfavorable neurologic outcome in the evaluation of patients with severe anoxic-ischemic encephalopathy whether or not they have been treated with TH. When confounding factors are eliminated the false positive rate (FPR) approaches zero.
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Affiliation(s)
- Ted L Rothstein
- Department of Neurology, George Washington University, Washington, DC, USA.
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6
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Azabou E, Navarro V, Kubis N, Gavaret M, Heming N, Cariou A, Annane D, Lofaso F, Naccache L, Sharshar T. Value and mechanisms of EEG reactivity in the prognosis of patients with impaired consciousness: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:184. [PMID: 30071861 PMCID: PMC6091014 DOI: 10.1186/s13054-018-2104-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 06/22/2018] [Indexed: 12/21/2022]
Abstract
Background Electroencephalography (EEG) is a well-established tool for assessing brain function that is available at the bedside in the intensive care unit (ICU). This review aims to discuss the relevance of electroencephalographic reactivity (EEG-R) in patients with impaired consciousness and to describe the neurophysiological mechanisms involved. Methods We conducted a systematic search of the term “EEG reactivity and coma” using the PubMed database. The search encompassed articles published from inception to March 2018 and produced 202 articles, of which 42 were deemed relevant, assessing the importance of EEG-R in relationship to outcomes in patients with impaired consciousness, and were therefore included in this review. Results Although definitions, characteristics and methods used to assess EEG-R are heterogeneous, several studies underline that a lack of EEG-R is associated with mortality and unfavorable outcome in patients with impaired consciousness. However, preserved EEG-R is linked to better odds of survival. Exploring EEG-R to nociceptive, auditory, and visual stimuli enables a noninvasive trimodal functional assessment of peripheral and central sensory ascending pathways that project to the brainstem, the thalamus and the cerebral cortex. A lack of EEG-R in patients with impaired consciousness may result from altered modulation of thalamocortical loop activity by afferent sensory input due to neural impairment. Assessing EEG-R is a valuable tool for the diagnosis and outcome prediction of severe brain dysfunction in critically ill patients. Conclusions This review emphasizes that whatever the etiology, patients with impaired consciousness featuring a reactive electroencephalogram are more likely to have a favorable outcome, whereas those with a nonreactive electroencephalogram are prone to having an unfavorable outcome. EEG-R is therefore a valuable prognostic parameter and warrants a rigorous assessment. However, current assessment methods are heterogeneous, and no consensus exists. Standardization of stimulation and interpretation methods is needed.
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Affiliation(s)
- Eric Azabou
- Department of Physiology and Department of Critical Care Medicine, Raymond Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Inserm UMR 1173 Infection and Inflammation, University of Versailles Saint Quentin (UVSQ), University Paris-Saclay, Garches, Paris, France. .,Clinical Neurophysiology Unit, Raymond Poincaré Hospital - Assistance - Publique Hôpitaux de Paris, INSERM U1173, University of Versailles-Saint Quentin (UVSQ), 104 Boulevard Raymond Poincaré, Garches, 92380, Paris, France.
| | - Vincent Navarro
- Department of Clinical Neurophysiology, Pitié-Salpêtrière Hospital, AP-HP, Inserm UMRS 1127, CNRS UMR 7225, Sorbonne Universities, Université Pierre et Marie Curie - UPMC Université Paris 06, Paris, France
| | - Nathalie Kubis
- Department of Clinical Physiology, Lariboisière Hospital, AP-HP, Inserm U965, University of Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Martine Gavaret
- Department of Clinical Neurophysiology, Sainte-Anne Hospital, Inserm U894, University Paris-Descartes, Paris, France
| | - Nicholas Heming
- Department of Physiology and Department of Critical Care Medicine, Raymond Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Inserm UMR 1173 Infection and Inflammation, University of Versailles Saint Quentin (UVSQ), University Paris-Saclay, Garches, Paris, France
| | - Alain Cariou
- Medical ICU, Cochin Hospital, AP-HP, Paris Cardiovascular Research Center, INSERM U970, Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Djillali Annane
- Department of Physiology and Department of Critical Care Medicine, Raymond Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Inserm UMR 1173 Infection and Inflammation, University of Versailles Saint Quentin (UVSQ), University Paris-Saclay, Garches, Paris, France
| | - Fréderic Lofaso
- Department of Physiology and Department of Critical Care Medicine, Raymond Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Inserm UMR 1173 Infection and Inflammation, University of Versailles Saint Quentin (UVSQ), University Paris-Saclay, Garches, Paris, France
| | - Lionel Naccache
- Department of Clinical Neurophysiology, Pitié-Salpêtrière Hospital, AP-HP, Inserm UMRS 1127, CNRS UMR 7225, Sorbonne Universities, Université Pierre et Marie Curie - UPMC Université Paris 06, Paris, France
| | - Tarek Sharshar
- Department of Neuro-Intensive Care Medicine, Sainte-Anne Hospital, Paris-Descartes University, Paris, France
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André-Obadia N, Zyss J, Gavaret M, Lefaucheur JP, Azabou E, Boulogne S, Guérit JM, McGonigal A, Merle P, Mutschler V, Naccache L, Sabourdy C, Trébuchon A, Tyvaert L, Vercueil L, Rohaut B, Delval A. Recommendations for the use of electroencephalography and evoked potentials in comatose patients. Neurophysiol Clin 2018; 48:143-169. [DOI: 10.1016/j.neucli.2018.05.038] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/07/2018] [Indexed: 12/21/2022] Open
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Abstract
Cardiac arrest is a common cause of coma with frequent poor outcomes. Palliative medicine teams are often called upon to discuss the scope of treatment and future care in cases of anoxic brain injury. Understanding prognostic tools in this setting would help medical teams communicate more effectively with patients’ families and caregivers and may promote improved quality of life overall. This article reviews multiple tools that are useful in determining outcomes in the setting of postarrest anoxic brain injury.
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Choudhary R. Multimodel quantitative analysis of somatosensory evoked potentials after cardiac arrest with graded hypothermia. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:1846-1849. [PMID: 28268685 DOI: 10.1109/embc.2016.7591079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiac arrest (CA) is one of the most prominent causes of morbidity and mortality in adults. Therapeutic hypothermia (TH) is a recommended treatment to improve survival and functional outcome following CA, however, it is unclear what degree of TH is most beneficial. It has been suggested that TH of 33°C provides no survival or outcome benefits over TH of 36°C. Additionally, there is a lack of verified objective quantitative prognostic tools for comatose CA patients under TH. In this study, we calculated three quantitative markers of somatosensory evoked potentials (SSEP) to examine their potential to track recovery in the early period following CA under graded TH. A total of 16 rats were randomly divided among 4 temperature groups (n=4/group): normothermia (N0, 36.5-37.5°C), hypothermia 1 (H1, 30-32°C), hypothermia 2 (H2, 32-34°C) and hypothermia 3 (H3, 34-36°C). All rats underwent a 15min baseline SSEP recording followed by 9min asphyxial-CA, resulting in severe cerebral injury, and immediate temperature management following resuscitation for 6 hours. SSEP recordings were maintained in 15 min intervals from 30min-4hrs after resuscitation. The N10 amplitude, N10 latency and quantitative SSEP phase space area (qSSEP-PSA) were calculated for the early recovery period and normalized to their respective baselines. Functional recovery was determined by the neurological deficit scale (NDS). N10 amplitude was significantly larger in H1, H2 and H3 compared to N0. N10 latency was significantly longer in H1 than all temperature groups and all hypothermia groups had significantly longer latencies than N0. qSSEP-PSA had significantly better recovery in H1 and H2 than N0. Animals with good outcome (72hr NDS>50) had better recovery of all markers. N10 amplitude was significantly correlated with N10 latency and qSSEP-PSA. The results importantly demonstrate that quantified SSEPs have the potential to objectively track recovery following CA with graded TH.
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Callaway CW, Soar J, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O'Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J. Part 4: Advanced Life Support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2016; 132:S84-145. [PMID: 26472860 DOI: 10.1161/cir.0000000000000273] [Citation(s) in RCA: 234] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Azabou E, Fischer C, Mauguiere F, Vaugier I, Annane D, Sharshar T, Lofaso F. Prospective Cohort Study Evaluating the Prognostic Value of Simple EEG Parameters in Postanoxic Coma. Clin EEG Neurosci 2016; 47:75-82. [PMID: 26545818 DOI: 10.1177/1550059415612375] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 09/20/2015] [Indexed: 11/16/2022]
Abstract
We prospectively studied early bedside standard EEG characteristics in 61 acute postanoxic coma patients. Five simple EEG features, namely, isoelectric, discontinuous, nonreactive to intense auditory and nociceptive stimuli, dominant delta frequency, and occurrence of paroxysms were classified yes or no. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristic curve (AUC) of each of these variables for predicting an unfavorable outcome, defined as death, persistent vegetative state, minimally conscious state, or severe neurological disability, as assessed 1 year after coma onset were computed as well as Synek's score. The outcome was unfavorable in 56 (91.8%) patients. Sensitivity, specificity, PPV, NPV, and AUC of nonreactive EEG for predicting an unfavorable outcome were 84%, 80%, 98%, 31%, and 0.82, respectively; and were all very close to the ones of Synek score>3, which were 82%, 80%, 98%, 29%, and 0.81, respectively. Specificities for predicting an unfavorable outcome were 100% for isoelectric, discontinuous, or dominant delta activity EEG. These 3 last features were constantly associated to unfavorable outcome. Absent EEG reactivity strongly predicted an unfavorable outcome in postanoxic coma, and performed as accurate as a Synek score>3. Analyzing characteristics of some simple EEG features may easily help nonneurophysiologist physicians to investigate prognostic issue of postanoxic coma patient. In this study (a) discontinuous, isoelectric, or delta-dominant EEG were constantly associated with unfavorable outcome and (b) nonreactive EEG performed prognostic as accurate as a Synek score>3.
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Affiliation(s)
- Eric Azabou
- Department of Physiology and Functional Explorations and Department of Critical Care Medicine, Assistance Publique- Hôpitaux de Paris (AP-HP), Raymond Poincaré Hospital, INSERM U1173, University of Versailles St Quentin (UVSQ), Garches, France Department of Clinical Neurophysiology, Hospices Civils de Lyon, Neurological Hospital of Lyon, Lyon Neuroscience Research Center (CRNL), Brain Dynamics and Cognition Team (Dycog), INSERM U1028, CNRS UMR5292, Université Lyon 1, Lyon, France
| | - Catherine Fischer
- Department of Clinical Neurophysiology, Hospices Civils de Lyon, Neurological Hospital of Lyon, Lyon Neuroscience Research Center (CRNL), Brain Dynamics and Cognition Team (Dycog), INSERM U1028, CNRS UMR5292, Université Lyon 1, Lyon, France
| | - François Mauguiere
- Department of Clinical Neurophysiology, Hospices Civils de Lyon, Neurological Hospital of Lyon, Lyon Neuroscience Research Center (CRNL), Brain Dynamics and Cognition Team (Dycog), INSERM U1028, CNRS UMR5292, Université Lyon 1, Lyon, France
| | - Isabelle Vaugier
- Department of Physiology and Functional Explorations and Department of Critical Care Medicine, Assistance Publique- Hôpitaux de Paris (AP-HP), Raymond Poincaré Hospital, INSERM U1173, University of Versailles St Quentin (UVSQ), Garches, France
| | - Djillali Annane
- Department of Physiology and Functional Explorations and Department of Critical Care Medicine, Assistance Publique- Hôpitaux de Paris (AP-HP), Raymond Poincaré Hospital, INSERM U1173, University of Versailles St Quentin (UVSQ), Garches, France
| | - Tarek Sharshar
- Department of Physiology and Functional Explorations and Department of Critical Care Medicine, Assistance Publique- Hôpitaux de Paris (AP-HP), Raymond Poincaré Hospital, INSERM U1173, University of Versailles St Quentin (UVSQ), Garches, France
| | - Fréderic Lofaso
- Department of Physiology and Functional Explorations and Department of Critical Care Medicine, Assistance Publique- Hôpitaux de Paris (AP-HP), Raymond Poincaré Hospital, INSERM U1173, University of Versailles St Quentin (UVSQ), Garches, France
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Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy MA, Thompson TM, Zimmerman JL. Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S465-82. [PMID: 26472996 PMCID: PMC4959439 DOI: 10.1161/cir.0000000000000262] [Citation(s) in RCA: 1018] [Impact Index Per Article: 113.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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13
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Abstract
To determine the optimal use and indications of electroencephalography (EEG) in critical care management of acute brain injury (ABI). An electronic literature search was conducted for articles in English describing electrophysiological monitoring in ABI from January 1990 to August 2013. A total of 165 studies were included. EEG is a useful monitor for seizure and ischemia detection. There is a well-described role for EEG in convulsive status epilepticus and cardiac arrest (CA). Data suggest EEG should be considered in all patients with ABI and unexplained and persistent altered consciousness and in comatose intensive care unit (ICU) patients without an acute primary brain condition who have an unexplained impairment of mental status. There remain uncertainties about certain technical details, e.g., the minimum duration of EEG studies, the montage, and electrodes. Data obtained from both EEG and EP studies may help estimate prognosis in ABI patients, particularly following CA and traumatic brain injury. Data supporting these recommendations is sparse, and high quality studies are needed. EEG is used to monitor and detect seizures and ischemia in ICU patients and indications for EEG are clear for certain disease states, however, uncertainty remains on other applications.
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Soar J, Callaway CW, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O’Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J, Andersen LW, Berg KM, Sandroni C, Lin S, Lavonas EJ, Golan E, Alhelail MA, Chopra A, Cocchi MN, Cronberg T, Dainty KN, Drennan IR, Fries M, Geocadin RG, Gräsner JT, Granfeldt A, Heikal S, Kudenchuk PJ, Lagina AT, Løfgren B, Mhyre J, Monsieurs KG, Mottram AR, Pellis T, Reynolds JC, Ristagno G, Severyn FA, Skrifvars M, Stacey WC, Sullivan J, Todhunter SL, Vissers G, West S, Wetsch WA, Wong N, Xanthos T, Zelop CM, Zimmerman J. Part 4: Advanced life support. Resuscitation 2015; 95:e71-120. [DOI: 10.1016/j.resuscitation.2015.07.042] [Citation(s) in RCA: 214] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Taccone FS, Crippa IA, Dell'Anna AM, Scolletta S. Neuroprotective strategies and neuroprognostication after cardiac arrest. Best Pract Res Clin Anaesthesiol 2015; 29:451-64. [PMID: 26670816 DOI: 10.1016/j.bpa.2015.08.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/20/2015] [Indexed: 12/23/2022]
Abstract
Neurocognitive disturbances are common among survivors of cardiac arrest (CA). Although initial management of CA, including bystander cardiopulmonary resuscitation, optimal chest compression, and early defibrillation, has been implemented continuously over the last years, few therapeutic interventions are available to minimize or attenuate the extent of brain injury occurring after the return of spontaneous circulation. In this review, we discuss several promising drugs that could provide some potential benefits for neurological recovery after CA. Most of these drugs have been investigated exclusively in experimental CA models and only limited clinical data are available. Further research, which also considers combined neuroprotective strategies that target multiple pathways involved in the pathophysiology of postanoxic brain injury, is certainly needed to demonstrate the effectiveness of these interventions in this setting. Moreover, the evaluation of neurological prognosis of comatose patients after CA remains an important challenge that requires the accurate use of several tools. As most patients with CA are currently treated with targeted temperature management (TTM), combined with sedative drug therapy, especially during the hypothermic phase, the reliability of neurological examination in evaluating these patients is delayed to 72-96 h after admission. Thus, additional tests, including electrophysiological examinations, brain imaging and biomarkers, have been largely implemented to evaluate earlier the extent of brain damage in these patients.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium.
| | - Ilaria Alice Crippa
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
| | - Antonio Maria Dell'Anna
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
| | - Sabino Scolletta
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
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Wang JT, Young GB, Connolly JF. Prognostic Value of Evoked Responses and Event-Related Brain Potentials in. Can J Neurol Sci 2014; 31:438-50. [PMID: 15595246 DOI: 10.1017/s0317167100003619] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The behaviourally unresponsive patient, unable to exhibit the presence of cognition, constitutes a conundrum for health care specialists. Prognostic uncertainty impedes accurate management decisions and the application of ethical principles. An early, reliable prognosis is highly desirable. In this review investigations studying comatose patients with coma of different etiologies were selected. It is concluded that objective prognostication is enhanced by the use of electrophysiological tests. Persistent abnormalities of brainstem auditory evoked potentials and short-latency somatosensory evoked potentials reliably indicate the likelihood of irreversible neurological deficit or death. Meanwhile, the presence of “cognitive” event-related brain potentials (e.g., P300 and mismatch negativity) reflects the functional integrity of higher level information processing and, therefore, the likelihood of capacity for cognition. An approach that combines clinical and electrophysiological values provides optimal prediction of outcome and level of disability.
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Affiliation(s)
- Jing Tian Wang
- Cognitive Electrophysiology Laboratory, New York State Psychiatric Institute, New York, USA
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17
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Rothstein TL. Therapeutic hypothermia does not diminish the vital and necessary role of SSEP in predicting unfavorable outcome in anoxic-ischemic coma. Clin Neurol Neurosurg 2014; 126:205-9. [DOI: 10.1016/j.clineuro.2014.08.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 08/20/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
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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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Su YY, Wang M, Chen WB, Fu P, Yang QL, Li HL, Wang XM, Wang L. Early prediction of poor outcome in severe hemispheric stroke by EEG patterns and gradings. Neurol Res 2014; 35:512-6. [PMID: 23711325 DOI: 10.1179/1743132813y.0000000205] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES To find out the EEG abnormal patterns in massive cerebral hemispheric infarction (MCHI) and their correlation with poor outcome, and to construct an EEG grading for predicting the outcome of MCHI patients. METHODS Between 2000 and 2010, 162 patients with MCHI who met the selection criterions were selected for this study. All the patients underwent EEG examinations within 3 days after stroke onset and repeated on day 2 and 3. We classified the EEG recordings into 9 patterns and anglicized the correlation between EEG patterns and outcome. Then according to the results of the correlation between EEG patterns and outcome we constructed an EEG grading for predicting the outcome of MCHI patients. RESULTS We revealed that patterns of dominant alpha without reactivity, RAWOD, burst-suppression, α/θ-coma, epileptiform activity (without burst-suppression), and generalized suppression were correlated to poor outcome. We further modified the Young grading according to the correlation between EEG patterns and outcome. We found that the modified grading was superior to existing EEG gradings in predicting the outcome of MCHI patients, and it could predict the outcome of MCHI more accurately. CONCLUSIONS MCHI is common in N-ICU (Neurology Intensive Care Unit). The EEG analysis would detect the degree of brain lesion during the ischemia within the acute stage after stroke onset. The EEG evaluation might assist the neurophysicians to predict outcome of patients and make decisions on the treatments.
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Affiliation(s)
- Ying Ying Su
- Neurological Intensive Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Taccone F, Cronberg T, Friberg H, Greer D, Horn J, Oddo M, Scolletta S, Vincent JL. How to assess prognosis after cardiac arrest and therapeutic hypothermia. Crit Care 2014; 18:202. [PMID: 24417885 PMCID: PMC4056000 DOI: 10.1186/cc13696] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The prognosis of patients who are admitted in a comatose state following successful resuscitation after cardiac arrest remains uncertain. Although the introduction of therapeutic hypothermia (TH) and improvements in post-resuscitation care have significantly increased the number of patients who are discharged home with minimal brain damage, short-term assessment of neurological outcome remains a challenge. The need for early and accurate prognostic predictors is crucial, especially since sedation and TH may alter the neurological examination and delay the recovery of motor response for several days. The development of additional tools, including electrophysiological examinations (electroencephalography and somatosensory evoked potentials), neuroimaging and chemical biomarkers, may help to evaluate the extent of brain injury in these patients. Given the extensive literature existing on this topic and the confounding effects of TH on the strength of these tools in outcome prognostication after cardiac arrest, the aim of this narrative review is to provide a practical approach to post-anoxic brain injury when TH is used. We also discuss when and how these tools could be combined with the neurological examination in a multimodal approach to improve outcome prediction in this population.
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Sandroni C, Cavallaro F, Callaway CW, Sanna T, D'Arrigo S, Kuiper M, Della Marca G, Nolan JP. Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 1: patients not treated with therapeutic hypothermia. Resuscitation 2013; 84:1310-23. [PMID: 23811182 DOI: 10.1016/j.resuscitation.2013.05.013] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 05/16/2013] [Accepted: 05/20/2013] [Indexed: 11/30/2022]
Abstract
AIMS AND METHODS To systematically review the accuracy of early (≤7 days) predictors of poor outcome defined as death or vegetative state (Cerebral Performance Categories [CPC] 4-5) or death, vegetative state or severe disability (CPC 3-5) in comatose survivors from cardiac arrest not treated using therapeutic hypothermia (TH). PubMed, Scopus and the Cochrane Database of Systematic reviews were searched for eligible studies. Sensitivity, specificity, false positive rates (FPR) for each predictor were calculated and results of predictors with similar time points and outcome definitions were pooled. Quality of evidence (QOE) was evaluated according to the GRADE guidelines. RESULTS 50 studies (2828 patients) were included in final analysis. Presence of myoclonus at 24-48h, bilateral absence of short-latency somatosensory evoked potential (SSEP) N20 wave at 24-72h, absence of electroencephalographic activity >20-21μV ≤72h and absence of pupillary reflex at 72h predicted CPC 4-5 with 0% FPR and narrow (<10%) 95% confidence intervals. Absence of SSEP N20 wave at 24h predicted CPC 3-5 with 0% [0-8] FPR. Serum thresholds for 0% FPR of biomarkers neuron specific enolase (NSE) and S-100B were highly inconsistent among studies. Most of the studies had a low or very low QOE and did not report blinding of the treating team from the results of the investigated predictor. CONCLUSIONS In comatose resuscitated patients not treated with TH presence of myoclonus, absence of pupillary reflex, bilateral absence of N20 SSEP wave and low EEG voltage each predicted poor outcome early and accurately, but with a relevant risk of bias.
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Affiliation(s)
- Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy.
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22
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Topjian AA, Berg RA, Bierens JJLM, Branche CM, Clark RS, Friberg H, Hoedemaekers CWE, Holzer M, Katz LM, Knape JTA, Kochanek PM, Nadkarni V, van der Hoeven JG, Warner DS. Brain resuscitation in the drowning victim. Neurocrit Care 2013; 17:441-67. [PMID: 22956050 DOI: 10.1007/s12028-012-9747-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Drowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32-34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating non-convulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific post-resuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.
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Affiliation(s)
- Alexis A Topjian
- The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Suite 7C23, Philadelphia, PA 19104, USA.
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Claassen J, Taccone FS, Horn P, Holtkamp M, Stocchetti N, Oddo M. Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM. Intensive Care Med 2013; 39:1337-51. [PMID: 23653183 DOI: 10.1007/s00134-013-2938-4] [Citation(s) in RCA: 247] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 04/14/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Recommendations for EEG monitoring in the ICU are lacking. The Neurointensive Care Section of the ESICM assembled a multidisciplinary group to establish consensus recommendations on the use of EEG in the ICU. METHODS A systematic review was performed and 42 studies were included. Data were extracted using the PICO approach, including: (a) population, i.e. ICU patients with at least one of the following: traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, stroke, coma after cardiac arrest, septic and metabolic encephalopathy, encephalitis, and status epilepticus; (b) intervention, i.e. EEG monitoring of at least 30 min duration; (c) control, i.e. intermittent vs. continuous EEG, as no studies compared patients with a specific clinical condition, with and without EEG monitoring; (d) outcome endpoints, i.e. seizure detection, ischemia detection, and prognostication. After selection, evidence was classified and recommendations developed using the GRADE system. RECOMMENDATIONS The panel recommends EEG in generalized convulsive status epilepticus and to rule out nonconvulsive seizures in brain-injured patients and in comatose ICU patients without primary brain injury who have unexplained and persistent altered consciousness. We suggest EEG to detect ischemia in comatose patients with subarachnoid hemorrhage and to improve prognostication of coma after cardiac arrest. We recommend continuous over intermittent EEG for refractory status epilepticus and suggest it for patients with status epilepticus and suspected ongoing seizures and for comatose patients with unexplained and persistent altered consciousness. CONCLUSIONS EEG monitoring is an important diagnostic tool for specific indications. Further data are necessary to understand its potential for ischemia assessment and coma prognostication.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Division of Critical Care Neurology, Columbia University Medical Center, New York, NY, USA
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Zheng X, Chen M, Li J, Cao F. Prognosis in prolonged coma patients with diffuse axonal injury assessed by somatosensory evoked potentia. Neural Regen Res 2013; 8:948-54. [PMID: 25206387 PMCID: PMC4145927 DOI: 10.3969/j.issn.1673-5374.2013.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 11/30/2012] [Indexed: 11/29/2022] Open
Abstract
A total of 43 prolonged coma patients with diffuse axonal injury received the somatosensory evoked potential examination one month after injury in the First Affiliated Hospital, School of Medicine, Zhejiang University in China. Somatosensory evoked potentials were graded as normal, abnormal or absent (grades I–III) according to N20 amplitude and central conduction time. The outcome in patients with grade III somatosensory evoked potential was in each case unfavorable. The prognostic accuracy of grade III somatosensory evoked potential for unfavorable and non-awakening outcome was 100% and 80%, respectively. The prognostic accuracy of grade I somatosensory evoked potential for favorable and wakening outcome was 86% and 100%, respectively. These results suggest that somatosensory evoked potential grade is closely correlated with coma severity and degree of recovery. Somatosensory evoked potential is a valuable diagnostic tool to assess prognosis in prolonged coma patients with diffuse axonal injury.
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Affiliation(s)
- Xiujue Zheng
- Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Mantao Chen
- Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Jingqi Li
- Hangzhou Hospital of Zhejiang Armed Police Corps, Hangzhou 310018, Zhejiang Province, China
| | - Fei Cao
- Department of Neurosurgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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HOLLERBACH S, KULLMANN F, BARTSCH H, LÖGL C, GEISSLER A, ZEUNER M, LESER HG, SCHÖLMERICH J. Prediction of outcome in resuscitated patients by clinical course and early somatosensory-evoked potentials. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.6.5.219.227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Predictive value of neurological examination for early cortical responses to somatosensory evoked potentials in patients with postanoxic coma. J Neurol 2011; 259:537-41. [PMID: 21887511 PMCID: PMC3296032 DOI: 10.1007/s00415-011-6224-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Revised: 08/09/2011] [Accepted: 08/11/2011] [Indexed: 11/16/2022]
Abstract
Bilateral absence of cortical N20 responses of median nerve somatosensory evoked potentials (SEP) predicts poor neurological outcome in postanoxic coma after cardiopulmonary resuscitation (CPR). Although SEP is easy to perform and available in most hospitals, it is worthwhile to know how neurological signs are associated with SEP results. The aim of this study was to investigate whether specific clinical neurological signs are associated with either an absent or a present median nerve SEP in patients after CPR. Data from the previously published multicenter prospective cohort study PROPAC (prognosis in postanoxic coma, 2000–2003) were used. Neurological examination, consisting of Glasgow Coma Score (GCS) and brain stem reflexes, and SEP were performed 24, 48, and 72 h after CPR. Positive predictive values for predicting absent and present SEP, as well as diagnostic accuracy were calculated. Data of 407 patients were included. Of the 781 SEPs performed, N20 s were present in 401, bilaterally absent in 299, and 81 SEPs were technically undeterminable. The highest positive predictive values (0.63–0.91) for an absent SEP were found for absent pupillary light responses. The highest positive predictive values (0.71–0.83) for a present SEP were found for motor scores of withdrawal to painful stimuli or better. Multivariate analyses showed a fair diagnostic accuracy (0.78) for neurological examination in predicting an absent or present SEP at 48 or 72 h after CPR. This study shows that neurological examination cannot reliably predict absent or present cortical N20 responses in median nerve SEPs in patients after CPR.
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European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2011; 81:1305-52. [PMID: 20956049 DOI: 10.1016/j.resuscitation.2010.08.017] [Citation(s) in RCA: 751] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e93-e174. [PMID: 20956032 DOI: 10.1016/j.resuscitation.2010.08.027] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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30
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Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP, Adrie C, Alhelail M, Battu P, Behringer W, Berkow L, Bernstein RA, Bhayani SS, Bigham B, Boyd J, Brenner B, Bruder E, Brugger H, Cash IL, Castrén M, Cocchi M, Comadira G, Crewdson K, Czekajlo MS, Davies SR, Dhindsa H, Diercks D, Dine CJ, Dioszeghy C, Donnino M, Dunning J, El Sanadi N, Farley H, Fenici P, Feeser VR, Foster JA, Friberg H, Fries M, Garcia-Vega FJ, Geocadin RG, Georgiou M, Ghuman J, Givens M, Graham C, Greer DM, Halperin HR, Hanson A, Holzer M, Hunt EA, Ishikawa M, Ioannides M, Jeejeebhoy FM, Jennings PA, Kano H, Kern KB, Kette F, Kudenchuk PJ, Kupas D, La Torre G, Larabee TM, Leary M, Litell J, Little CM, Lobel D, Mader TJ, McCarthy JJ, McCrory MC, Menegazzi JJ, Meurer WJ, Middleton PM, Mottram AR, Navarese EP, Nguyen T, Ong M, Padkin A, Ferreira de Paiva E, Passman RS, Pellis T, Picard JJ, Prout R, Pytte M, Reid RD, Rittenberger J, Ross W, Rubertsson S, Rundgren M, Russo SG, Sakamoto T, Sandroni C, Sanna T, Sato T, Sattur S, Scapigliati A, Schilling R, Seppelt I, Severyn FA, Shepherd G, Shih RD, Skrifvars M, Soar J, Tada K, Tararan S, Torbey M, Weinstock J, Wenzel V, Wiese CH, Wu D, Zelop CM, Zideman D, Zimmerman JL. Part 8: Advanced Life Support. Circulation 2010; 122:S345-421. [DOI: 10.1161/circulationaha.110.971051] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Bbttiger BW, Callaway C, Clark RS, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth W, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke (Part II). Int Emerg Nurs 2010; 18:8-28. [DOI: 10.1016/j.ienj.2009.07.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Thenayan EAL, Savard M, Sharpe MD, Norton L, Young B. Electroencephalogram for prognosis after cardiac arrest. J Crit Care 2009; 25:300-4. [PMID: 19781908 DOI: 10.1016/j.jcrc.2009.06.049] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Revised: 06/07/2009] [Accepted: 06/20/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND In assessing neurologic prognosis after cardiac arrest (CA), electroencephalogram (EEG) reactivity has not been specifically included with EEG classifications. Most studies have divided recordings into benign and malignant; however, some patterns within these groups may have greater prognostic significance than such broad classifications. We sought to explore reactivity, with broad classifications and subclassifications for their prognostic significance. METHODS All consecutive adults in coma who had an EEG recording performed at least 1 day after CA or during normothermia after a 24-hour mild hypothermia protocol. Outcomes were dichotomous: recovery of awareness or no recovery of awareness during hospitalization. RESULTS Twenty-nine patients met the inclusion criteria. Of the 18 patients with no reactivity, only 1 recovered awareness; of the 11 patients who demonstrated reactivity, 10 recovered awareness (sensitivity of 90% [95% confidence interval, or CI, 0.57-1] and specificity of 94% [95% CI, 0.7-1]). Of those with benign patterns, 7 recovered awareness and 1 did not; however, those patients demonstrating malignant patterns, 4 recovered and 17 did not (sensitivity of 94% [95% CI, 0.7-1] and a specificity of 63% [95% CI, 0.32-0.88]). None of the 15 patients with suppression or generalized spikes recovered consciousness, and none of these patients demonstrated reactivity. CONCLUSIONS Electroencephalogram reactivity after CA is a relatively favorable EEG feature; generalized suppression or generalized epileptiform activity, without reactivity, is associated with lack of recovery of awareness.
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Affiliation(s)
- Eyad A L Thenayan
- Department of Adult Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Bbttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke (Part 1). Int Emerg Nurs 2009; 17:203-25. [PMID: 19782333 DOI: 10.1016/j.ienj.2009.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIM OF THE REVIEW To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome. METHODS Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment. RESULTS The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology. CONCLUSIONS A growing body of knowledge suggests that the individual components of the postcardiac arrest syndrome are potentially treatable.
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Affiliation(s)
- Jerry P Nolan
- Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom.
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Affiliation(s)
- Ted L Rothstein
- Department of Neurology, Rm 7-402, George Washington University, 2150 Pennsylvania Avenue, NW, Washington, DC 20037, USA.
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Neumar RW, Nolan JP, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Vanden Hoek T. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council. Circulation 2008; 118:2452-83. [PMID: 18948368 DOI: 10.1161/circulationaha.108.190652] [Citation(s) in RCA: 1076] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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36
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Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 2008; 79:350-79. [PMID: 18963350 DOI: 10.1016/j.resuscitation.2008.09.017] [Citation(s) in RCA: 697] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 09/22/2008] [Indexed: 12/12/2022]
Abstract
AIM OF THE REVIEW To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome. METHODS Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment. RESULTS The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology. CONCLUSIONS A growing body of knowledge suggests that the individual components of the post-cardiac arrest syndrome are potentially treatable.
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Affiliation(s)
- Jerry P Nolan
- Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom.
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37
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Abstract
PURPOSE OF REVIEW Persistent coma after cardiac arrest is a source of great emotional and financial cost to grieving family members in particular and the healthcare system in general. Neurologic prognostication helps guide appropriate discussions between family members and healthcare providers. Recent advances in therapeutic care increase the challenges, both medical and financial, on local practitioners. RECENT FINDINGS Evidence-based reviews by prestigious associations add additional support and guidance to the practitioner who must guide family members in this very difficult decision process. Therapeutic hypothermia may alter findings, thus skewing the prognostic abilities of many accepted methodologies. This study reviews the usefulness of clinical examination, electrophysiologic studies, biochemical markers, and imaging modalities in predicting poor neurologic recovery in comatose survivors after cardiac arrest resuscitation. Some data from studies of therapeutic hypothermia are presented. SUMMARY Evidence-based tests of prognostication for neurologic outcome after cardiac arrest are presented. A review of the practice of withdrawal of life-sustaining therapies and the diagnosis of brain death is also provided. The reader is cautioned that most prognostic studies do not include possible amelioration with the use of therapeutic hypothermia.
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Ragoschke-Schumm A, Pfeifer R, Marx G, Knoepffler N, Witte OW, Isenmann S. [Early evaluation of neurological prognosis and therapy after cardiopulmonary resuscitation: current opportunities and clinical implications]. DER NERVENARZT 2007; 78:937-43. [PMID: 17520234 DOI: 10.1007/s00115-007-2286-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The developments of cardiopulmonary resuscitation and intensive care medicine have made possible survival after cardiac arrest. However, only 10-30% of patients with initially successful resuscitation later reach a state without severe neurological impairment. Ethical and socioeconomic reasons therefore make early prognosis important for certain patients. There are no reliable parameters for predictions of good clinical outcome. If clinical information is consistent with severe hypoxic brain damage, cortical somatosensory evoked potentials are absent, and neuron-specific enolase values exceed 33-65 microg/l, recovery of consciousness can be excluded. The same result can be predicted if brain imaging shows severe hypoxemic changes or if a myoclonic status occurs on the first day. In summary, the prognosis in patients with cerebral anoxy and cardiopulmonary resuscitation remains poor. Treatment with hypothermia for 24 h is recommended.
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Affiliation(s)
- A Ragoschke-Schumm
- Institut für Diagnostische und Interventionelle Radiologie, Jena, Germany
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39
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Henrich-Noack P, Gorkin AG, Reymann KG. Predictive value of changes in electroencephalogram and excitatory postsynaptic field potential for CA1 damage after global ischaemia in rats. Exp Brain Res 2007; 181:79-86. [PMID: 17431602 DOI: 10.1007/s00221-007-0907-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2005] [Accepted: 02/09/2007] [Indexed: 10/23/2022]
Abstract
Recordings of the electroencephalogram (EEG) are regularly used to asses the severity of transient global ischaemia in rats. Here, we investigated whether the EEG obtained from electrodes placed in the hippocampus does indeed give valuable information about the consequences of an ischaemic event. Furthermore, we evaluated how evoked synaptic responses from the same electrodes placed in the hippocampal CA1 area changed with time and in relation to damage. We performed transient two vessel-occlusion with hypobaric hypotension in rats to induce selective, delayed neuronal death in CA1. Beforehand, the animals had been chronically implanted with electrodes. Stimulating electrodes had been placed into the Schaffer collaterals and recording electrodes into the CA1 area. EEG was recorded from shortly before ischaemia until up to 40 min post-ischaemia. Field excitatory post-synaptic potentials (fEPSP) were recorded before ischaemia or sham-operation and 2 and 7 days afterwards. We found a significant negative correlation between the duration of the EEG amplitude decrease (flattening) and the number of surviving neurons in CA1, which were quantified by histology after 7 days post-ischaemia. However, substantial neuronal damage was only seen when the time of flattening was more than 12 min and outlasted the time of ischaemia. The impairment of synaptic function, measured as the decrease of fEPSP slope 2 days post-ischaemia correlated with the later maturated structural damage in CA1. The fEPSP remained decreased until day 7 post-ischaemia. Animals with no damage (sham condition) showed a transient decrease of the fEPSP slope. In conclusion, our data show that the duration of EEG-flattening predicts the extent of neuronal damage. However, EEG-flattening just during the period of clamping both common carotid arteries--albeit an essential precondition for substantial CA1 cell loss to occur--is not sufficient to predict damage. The degree of impairment of evoked synaptic function of CA1 neurons (fEPSP) 2 days after ischaemia predicts the final extent of damage with significant probability.
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Affiliation(s)
- Petra Henrich-Noack
- Leibniz Institute for Neurobiology, Brenneckestreet 6, 39118, Magdeburg, Germany
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40
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Abstract
Advances in neuroimaging techniques hold significant promise for improving understanding of disorders of consciousness arising from severe brain injuries. We review neuroimaging studies of the vegetative state (VS) and minimally conscious state (MCS), and findings in an unusual case of late emergence from MCS. Multimodal neuroimaging studies using positron emission tomography techniques, functional magnetic resonance imaging, and quantitative electroencephalography and magnetoencephalography quantify variations of residual cerebral activity across these patient populations. The results suggest models to distinguish the pathophysiologic basis of VS and MCS. Less clear are potential brain mechanisms underlying late recovery of communication in rare MCS patients. Diffusion tensor magnetic resonance imaging studies and recent experimental findings suggest that structural remodeling of the brain following severe injury may play a role in late functional recoveries. More generally, relatively long time courses of recovery following severe brain injury emphasize the need to develop markers for identifying patients who may harbor potential for further meaningful recovery. Introduction of neuroimaging into the clinical evaluation process will require developing frameworks for longitudinal assessments of cerebral function. Although limited in number, available studies already provide important insights into underlying brain mechanisms that may help guide development of such assessment strategies.
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Affiliation(s)
- Nicholas D Schiff
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York, NY 10021, USA.
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Abstract
We review the emerging applications of functional and structural neuroimaging techniques for the assessment of patients with disorders of consciousness. Measurements of brain function from patients in the vegetative state (VS) and minimally conscious state (MCS) are compared, and a conceptual organization is developed that suggests models of brain mechanisms associated with different functional levels of recovery. We emphasize developing strategies to place complex brain injuries on a more equal footing using global and regional quantification of resting or activated brain activity using functional imaging techniques alongside more detailed structural assessments of neuronal integrity and axonal connectivity now available. Preliminary studies from several investigative groups suggest that some MCS patients may harbor a functional reserve in the form of recruitable cerebral networks. These findings support developing systematic characterizations of the severely injured brain and suggest that some patients may benefit from improved diagnostic assessments.
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Affiliation(s)
- Nicholas D Schiff
- Laboratory of Cognitive Neuromodulation, Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York, New York 10021, USA.
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Koenig MA, Kaplan PW, Thakor NV. Clinical neurophysiologic monitoring and brain injury from cardiac arrest. Neurol Clin 2006; 24:89-106. [PMID: 16443132 DOI: 10.1016/j.ncl.2005.11.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Electrophysiologic testing continues to play an important role in injury stratification and prognostication in patients who are comatose after cardiac arrest. As discussed previously, however, the adage about treating whole patients, not just the numbers, is relevant in this situation. EEG and SSEP can offer high specificity for discerning poor prognosis as long as they are applied to appropriate patient populations. As discussed previously, EEG and SSEP patterns change during the first hours to days after cardiac arrest and negative prognostic information should not be based solely on studies performed during the first 24 hours. Both electrophysiologic techniques also are susceptible to artifacts that may worsen the electrical patterns artificially and suggest a falsely poor prognosis. EEG is suppressed by anesthetic agents and hypothermia, both of which may produce ECS and burst suppression. Patients who experience respiratory arrest from a toxic ingestion of narcotics or barbiturates, in particular, may present with high-grade EEG patterns initially. Many patients also receive anesthetic medications at the time of tracheal intubation, which may linger beyond their normal half-life in patients who have hepatic or renal insufficiency or concurrent use of interacting medications. SSEP is much less susceptible to sedative anesthetic agents, but hypothermia is demonstrated to prolong evoked potential latencies. As therapeutic hypothermia becomes more common after cardiac arrest, the effect of temperature on electrophysiologic testing needs to be taken into account. The publications discussed previously also emphasize the need to adjust the prognostic value of electro-physiologic tests to the pretest probability of meaningful neurologic recovery in individual patients. Clearly, grade I EEG patterns and normal N20 potentials indicate a much better prognosis in patients who have a short du-ration of cardiac arrest, short duration of coma after resuscitation, and when the studies are performed within the first few days. In patients who remain in coma days after resuscitation and lack appropriate brainstem reflexes, however, even the most normal appearing electrophysiologic patterns do little to change the overall prognosis. Aside from prognostication, electrophysiologic testing holds great promise in defining the basic anatomy and physiology of coma emergence after cardiac arrest. In addition, quantitative EEG and automated evoked potentials have the potential to render these tools less subjective and arcane and more applicable for monitoring patients in the period during and immediately after resuscitation. Quantitative EEG also has great potential asa tool to define the time window for neuroprotective intervention and the means to track the response to such therapies in real time.
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Affiliation(s)
- Matthew A Koenig
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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44
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Papadelis C, Maglaveras N, Kourtidou-Papadeli C, Bamidis P, Albani M, Chatzinikolaou K, Pappas K. Quantitative multichannel EEG measure predicting the optimal weaning from ventilator in ICU patients with acute respiratory failure. Clin Neurophysiol 2006; 117:752-70. [PMID: 16495143 DOI: 10.1016/j.clinph.2005.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2004] [Revised: 10/30/2005] [Accepted: 12/09/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The objective of this study was to develop a novel quantitative multichannel EEG (qEEG) based analysis method, called Global Field Damping Time (GFDT), in order to detect potential EEG changes of patients admitted to the ICU with acute respiratory failure, and correlate them to the patients' recovery outcome predicting the optimal time-point to disconnect the patient from mechanical ventilation. METHODS Twenty-nine adult patients with acute respiratory failure out of 98 admitted to the Intensive Care Unit of Saint Paul General Hospital were enrolled, and among them only 15 completed the study. The patients were classified in 3 groups according to their outcome after 3 months follow-up. The patients were intubated with fraction of inspired oxygen (FiO2) of 100%. Neurological Deficit Scores (NDS) were measured 24 h after intubation to assess patients' neurological condition. Twenty-four hours after patient's intubation, FiO2 was decreased to 40% (weaning session), followed by a 5 min early recovery session, a 5 min recovery 1 session and a 5 min recovery 2 session. EEG recordings were performed during this experimental procedure. Multichannel EEG segments were processed and fitted into a multivariate autoregressive (mAR) model, and single channel EEG segments into a scalar autoregressive (sAR) model. The mAR and the sAR models of arbitrary order p were decomposed into mp and p oscillators and relaxators, respectively. Damping time of each oscillator and each relaxator, and the Global Field Damping Time (GFDT) as a weighted damping time were estimated for both mAR and sAR models. RESULTS A statistically significant increase of mAR model's GFDT during the weaning session was observed in the subjects of all groups. Comparing the 3 patients' groups, statistically significant differences for mAR model's GFDT were observed for the weaning and early recovery session. Linear regression analysis between NDS and mean mAR model's GFDT showed statistical significance during weaning session, early recovery session, and recovery 1 session. There was no statistical significance for SaO2 in the regression analysis with NDS. The sAR model's GFDT presented worst results in comparison with the mAR modelling GFDT in the identification of hypoxic conditions during weaning session and in the discrimination of patients with acute respiratory failure according to their neurological outcome. CONCLUSIONS Global Field Damping Time as correlated to the patients' neurological outcome appears to be a simple, compact, and substantial novel indicator of cerebral hypoxia and a potential predictor of the optimal time-point to disconnect the patient from the ventilator. SIGNIFICANCE Quantitative EEG seems to be an important tool for ICU clinicians assisting them to decide for the patients' optimal time-point to disconnect the patient from the ventilator.
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Affiliation(s)
- Christos Papadelis
- Laboratory of Medical Informatics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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45
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2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 4: Advanced life support. Resuscitation 2006; 67:213-47. [PMID: 16324990 DOI: 10.1016/j.resuscitation.2005.09.018] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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46
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Kaye P. Early prediction of individual outcome following cardiopulmonary resuscitation: systematic review. Emerg Med J 2006; 22:700-5. [PMID: 16189031 PMCID: PMC1726559 DOI: 10.1136/emj.2004.016253] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Following resuscitation from cardiorespiratory arrest 80% of patients are comatose. Of these patients, 20% will survive and regain consciousness. Is it possible to predict an individual's long term outcome at presentation and alter management accordingly? This review examines the current medical literature and demonstrates it is impossible to predict immediately outcome from hypoxic-ischaemic coma except in a small subgroup of patients with poor premorbid factors. As individual prognosis cannot be determined in the emergency department all patients who do not have significant premorbid features should proceed to a period of supportive care in the intensive care unit. Therapeutic hypothermia should be considered for these patients.
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Affiliation(s)
- P Kaye
- Frenchay Hospital, Bristol, UK.
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47
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Tirschwell DL. COMA IN THE INTENSIVE CARE UNIT. Continuum (Minneap Minn) 2006. [DOI: 10.1212/01.con.0000290437.80323.d2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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48
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Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G, Baubin M, Dirks B, Wenzel V. Erweiterte Reanimationsmaßnahmen für Erwachsene (ALS). Notf Rett Med 2006; 9:38-80. [PMID: 32834772 PMCID: PMC7371819 DOI: 10.1007/s10049-006-0796-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- J. P. Nolan
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - C. D. Deakin
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - J. Soar
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - B. W. Böttiger
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - G. Smith
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - M. Baubin
- Klinik für Anästhesie und allgemeine Intensivmedizin, Universität, Innsbruck, Österreich
| | - B. Dirks
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Prittwitzstraße 43, 89075 Ulm
| | - V. Wenzel
- Klinik für Anästhesie und allgemeine Intensivmedizin, Universität, Innsbruck, Österreich
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49
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Kobylarz EJ, Schiff ND. Neurophysiological correlates of persistent vegetative and minimally conscious states. Neuropsychol Rehabil 2006; 15:323-32. [PMID: 16350975 DOI: 10.1080/09602010443000605] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The evaluation of patients after severe brain injury is a complex process for the clinician, even with the information provided by a detailed neurological examination. The clinical examination often does not provide sufficient information to fully evaluate these patients due to several factors. Limited and inconsistent motor responses may obscure expression of greater cognitive capacities. More importantly, evaluation of the functional integrity of the cerebral cortical, thalamic and basal ganglia system is poorly indicated by the clinical examination in many patients. Neurophysiological studies provide a complementary set of objective data for evaluating brain-injured patients, as well as predicting and following the course of their recovery. This additional information can be of great importance since vegetative patients may be difficult to distinguish clinically from those in the minimally conscious state. This is important because the latter category of patients may have a significantly better prognosis for recovery in the initial phase of injury. Electrodiagnostic and imaging studies can help the practitioner to determine the degree of preserved and recovering neurological function. In this review we will assess the various neurophysiological studies currently at our disposal to evaluate and follow the clinical course of patients who have suffered severe brain injuries.
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Affiliation(s)
- Erik J Kobylarz
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, 1300 York Avenue, New York, NY 10021, USA.
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50
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Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G. European Resuscitation Council Guidelines for Resuscitation 2005. Resuscitation 2005; 67 Suppl 1:S39-86. [PMID: 16321716 DOI: 10.1016/j.resuscitation.2005.10.009] [Citation(s) in RCA: 606] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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