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Shao R, Wang T, Hang C, An L, Wang X, Zhang L, Yu J, Shan Z, Yang Q, Tang Z. Alteration in early resting‑state functional MRI activity in comatose survivors of cardiac arrest: a prospective cohort study. Crit Care 2024; 28:260. [PMID: 39095884 PMCID: PMC11295486 DOI: 10.1186/s13054-024-05045-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 07/21/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND This study aimed to explore the characteristics of abnormal regional resting-state functional magnetic resonance imaging (rs-fMRI) activity in comatose patients in the early period after cardiac arrest (CA), and to investigate their relationships with neurological outcomes. We also explored the correlations between jugular venous oxygen saturation (SjvO2) and rs-fMRI activity in resuscitated comatose patients. We also examined the relationship between the amplitude of the N20-baseline and the rs-fMRI activity within the intracranial conduction pathway of somatosensory evoked potentials (SSEPs). METHODS Between January 2021 and January 2024, eligible post-resuscitated patients were screened to undergo fMRI examination. The amplitude of low-frequency fluctuation (ALFF), fractional ALFF (fALFF), and regional homogeneity (ReHo) of rs-fMRI blood oxygenation level-dependent (BOLD) signals were used to characterize regional neural activity. Neurological outcomes were evaluated using the Glasgow-Pittsburgh cerebral performance category (CPC) scale at 3 months after CA. RESULTS In total, 20 healthy controls and 31 post-resuscitated patients were enrolled in this study. The rs-fMRI activity of resuscitated patients revealed complex changes, characterized by increased activity in some local brain regions and reduced activity in others compared to healthy controls (P < 0.05). However, the mean ALFF values of the whole brain were significantly greater in CA patients (P = 0.011). Among the clusters of abnormal rs-fMRI activity, the cluster values of ALFF in the left middle temporal gyrus and inferior temporal gyrus and the cluster values of ReHo in the right precentral gyrus, superior frontal gyrus and middle frontal gyrus were strongly correlated with the CPC score (P < 0.001). There was a strong correlation between the mean ALFF and SjvO2 in CA patients (r = 0.910, P < 0.001). The SSEP N20-baseline amplitudes in CA patients were negatively correlated with thalamic rs-fMRI activity (all P < 0.001). CONCLUSIONS This study revealed that abnormal rs-fMRI BOLD signals in resuscitated patients showed complex changes, characterized by increased activity in some local brain regions and reduced activity in others. Abnormal BOLD signals were associated with neurological outcomes in resuscitated patients. The mean ALFF values of the whole brain were closely related to SjvO2 levels, and changes in the thalamic BOLD signals correlated with the N20-baseline amplitudes of SSEP responses. TRIAL REGISTRATION NCT05966389 (Registered July 27, 2023).
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Affiliation(s)
- Rui Shao
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Tao Wang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Chenchen Hang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Le An
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Xingsheng Wang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Luying Zhang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Jingfei Yu
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Zhenyu Shan
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Qi Yang
- Department of Radiology, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China.
| | - Ziren Tang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China.
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Aalberts N, Westhall E, Johnsen B, Hahn K, Kenda M, Cronberg T, Friberg H, Preuß S, Ploner CJ, Storm C, Nee J, Leithner C, Endisch C. Cortical somatosensory evoked potential amplitudes and clinical outcome after cardiac arrest: a retrospective multicenter study. J Neurol 2023; 270:5999-6009. [PMID: 37639017 PMCID: PMC10632270 DOI: 10.1007/s00415-023-11951-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE Bilaterally absent cortical somatosensory evoked potentials (SSEPs) reliably predict poor outcome in comatose cardiac arrest (CA) patients. Cortical SSEP amplitudes are a recent prognostic extension; however, amplitude thresholds, inter-recording, and inter-rater agreement remain uncertain. METHODS In a retrospective multicenter cohort study, we determined cortical SSEP amplitudes of comatose CA patients using a standardized evaluation pathway. We studied inter-recording agreement in repeated SSEPs and inter-rater agreement by four raters independently determining 100 cortical SSEP amplitudes. Primary outcome was assessed using the cerebral performance category (CPC) upon intensive care unit discharge dichotomized into good (CPC 1-3) and poor outcome (CPC 4-5). RESULTS Of 706 patients with SSEPs with median 3 days after CA, 277 (39.2%) had good and 429 (60.8%) poor outcome. Of patients with bilaterally absent cortical SSEPs, one (0.8%) survived with CPC 3 and 130 (99.2%) had poor outcome. Otherwise, the lowest cortical SSEP amplitude in good outcome patients was 0.5 µV. 184 (42.9%) of 429 poor outcome patients had lower cortical SSEP amplitudes. In 106 repeated SSEPs, there were 6 (5.7%) with prognostication-relevant changes in SSEP categories. Following a standardized evaluation pathway, inter-rater agreement was almost perfect with a Fleiss' kappa of 0.88. INTERPRETATION Bilaterally absent and cortical SSEP amplitudes below 0.5 µV predicted poor outcome with high specificity. A standardized evaluation pathway provided high inter-rater and inter-recording agreement. Regain of consciousness in patients with bilaterally absent cortical SSEPs rarely occurs. High-amplitude cortical SSEP amplitudes likely indicate the absence of severe brain injury.
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Affiliation(s)
- Noelle Aalberts
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Erik Westhall
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Birger Johnsen
- Department of Clinical Neurophysiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark
| | - Katrin Hahn
- Department of Neurology, Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Kenda
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- BIH Charité Junior Digital Clinician Scientist Program, BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Intensive and Perioperative Care, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Sandra Preuß
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph J Ploner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jens Nee
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Endisch
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Benghanem S, Pruvost-Robieux E, Bouchereau E, Gavaret M, Cariou A. Prognostication after cardiac arrest: how EEG and evoked potentials may improve the challenge. Ann Intensive Care 2022; 12:111. [PMID: 36480063 PMCID: PMC9732180 DOI: 10.1186/s13613-022-01083-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/07/2022] [Indexed: 12/13/2022] Open
Abstract
About 80% of patients resuscitated from CA are comatose at ICU admission and nearly 50% of survivors are still unawake at 72 h. Predicting neurological outcome of these patients is important to provide correct information to patient's relatives, avoid disproportionate care in patients with irreversible hypoxic-ischemic brain injury (HIBI) and inappropriate withdrawal of care in patients with a possible favorable neurological recovery. ERC/ESICM 2021 algorithm allows a classification as "poor outcome likely" in 32%, the outcome remaining "indeterminate" in 68%. The crucial question is to know how we could improve the assessment of both unfavorable but also favorable outcome prediction. Neurophysiological tests, i.e., electroencephalography (EEG) and evoked-potentials (EPs) are a non-invasive bedside investigations. The EEG is the record of brain electrical fields, characterized by a high temporal resolution but a low spatial resolution. EEG is largely available, and represented the most widely tool use in recent survey examining current neuro-prognostication practices. The severity of HIBI is correlated with the predominant frequency and background continuity of EEG leading to "highly malignant" patterns as suppression or burst suppression in the most severe HIBI. EPs differ from EEG signals as they are stimulus induced and represent the summated activities of large populations of neurons firing in synchrony, requiring the average of numerous stimulations. Different EPs (i.e., somato sensory EPs (SSEPs), brainstem auditory EPs (BAEPs), middle latency auditory EPs (MLAEPs) and long latency event-related potentials (ERPs) with mismatch negativity (MMN) and P300 responses) can be assessed in ICU, with different brain generators and prognostic values. In the present review, we summarize EEG and EPs signal generators, recording modalities, interpretation and prognostic values of these different neurophysiological tools. Finally, we assess the perspective for futures neurophysiological investigations, aiming to reduce prognostic uncertainty in comatose and disorders of consciousness (DoC) patients after CA.
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Affiliation(s)
- Sarah Benghanem
- grid.411784.f0000 0001 0274 3893Medical ICU, Cochin Hospital, Assistance Publique – Hôpitaux de Paris (AP-HP), 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France ,grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,After ROSC Network, Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Estelle Pruvost-Robieux
- grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,Neurophysiology and Epileptology Department, GHU Psychiatry and Neurosciences, Sainte Anne, 75014 Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Eléonore Bouchereau
- Department of Neurocritical Care, G.H.U Paris Psychiatry and Neurosciences, 1, Rue Cabanis, 75014 Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Martine Gavaret
- grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,Neurophysiology and Epileptology Department, GHU Psychiatry and Neurosciences, Sainte Anne, 75014 Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Alain Cariou
- grid.411784.f0000 0001 0274 3893Medical ICU, Cochin Hospital, Assistance Publique – Hôpitaux de Paris (AP-HP), 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France ,grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,After ROSC Network, Paris, France ,grid.462416.30000 0004 0495 1460Paris-Cardiovascular-Research-Center (Sudden-Death-Expertise-Center), INSERM U970, Paris, France
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Nawfal O, El Halabi T, Dib G, Dirani M, Beydoun A. Bilateral Reappearance of the N20 Potential in a Normothermic Young Woman Post-Anoxic Brain Injury. J Clin Neurophysiol 2022; 39:e21-e25. [PMID: 35239554 DOI: 10.1097/wnp.0000000000000928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Hypoxic-ischemic brain injury is a well-known consequence of cardiac arrest and providing an accurate prognostication remains a challenge, especially in decisions related to withdrawal of care. Bilateral absence of the cortical response (N20 potential) on median somatosensory evoked potentials, on days 1 to 3 after the return of spontaneous circulation, is widely considered as the most reliable predictor of poor outcome with a high specificity and a low false-positive rate. The authors describe the case of a young comatose woman after hypoxic injury because of cardiac arrest whose initial median somatosensory evoked potentials revealed bilateral absence of the N20 response associated with evidence of selective injury to both perirolandic cortices and basal ganglia on brain MRI. This patient made a substantial recovery associated with bilateral reappearance of the N20 potential and resolution of the neuroimaging abnormalities.This case revealed that an acute selective and reversible hypoxic injury to both perirolandic cortices may lead to a temporary loss of the N20 responses and an inaccurate prediction of poor outcome after cardiac arrest. It emphasizes on the importance of adopting a multimodal approach in the prognostic assessment of survivors of cardiac arrest.
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Affiliation(s)
- Omar Nawfal
- American University of Beirut Medical Center, Beirut, Lebanon
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Benghanem S, Nguyen LS, Gavaret M, Mira JP, Pène F, Charpentier J, Marchi A, Cariou A. SSEP N20 and P25 amplitudes predict poor and good neurologic outcomes after cardiac arrest. Ann Intensive Care 2022; 12:25. [PMID: 35290522 PMCID: PMC8924339 DOI: 10.1186/s13613-022-00999-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/27/2022] [Indexed: 11/18/2022] Open
Abstract
Background To assess in comatose patients after cardiac arrest (CA) if amplitudes of two somatosensory evoked potentials (SSEP) responses, namely, N20-baseline (N20-b) and N20–P25, are predictive of neurological outcome. Methods Monocentric prospective study in a tertiary cardiac center between Nov 2019 and July-2021. All patients comatose at 72 h after CA with at least one SSEP recorded were included. The N20-b and N20–P25 amplitudes were automatically measured in microvolts (µV), along with other recommended prognostic markers (status myoclonus, neuron-specific enolase levels at 2 and 3 days, and EEG pattern). We assessed the predictive value of SSEP for neurologic outcome using the best Cerebral Performance Categories (CPC1 or 2 as good outcome) at 3 months (main endpoint) and 6 months (secondary endpoint). Specificity and sensitivity of different thresholds of SSEP amplitudes, alone or in combination with other prognostic markers, were calculated. Results Among 82 patients, a poor outcome (CPC 3–5) was observed in 78% of patients at 3 months. The median time to SSEP recording was 3(2–4) days after CA, with a pattern “bilaterally absent” in 19 patients, “unilaterally present” in 4, and “bilaterally present” in 59 patients. The median N20-b amplitudes were different between patients with poor and good outcomes, i.e., 0.93 [0–2.05]µV vs. 1.56 [1.24–2.75]µV, respectively (p < 0.0001), as the median N20–P25 amplitudes (0.57 [0–1.43]µV in poor outcome vs. 2.64 [1.39–3.80]µV in good outcome patients p < 0.0001). An N20-b > 2 µV predicted good outcome with a specificity of 73% and a moderate sensitivity of 39%, although an N20–P25 > 3.2 µV was 93% specific and only 30% sensitive. A low voltage N20-b < 0.88 µV and N20–P25 < 1 µV predicted poor outcome with a high specificity (sp = 94% and 93%, respectively) and a moderate sensitivity (se = 50% and 66%). Association of “bilaterally absent or low voltage SSEP” patterns increased the sensitivity significantly as compared to “bilaterally absent” SSEP alone (se = 58 vs. 30%, p = 0.002) for prediction of poor outcome. Conclusion In comatose patient after CA, both N20-b and N20–P25 amplitudes could predict both good and poor outcomes with high specificity but low to moderate sensitivity. Our results suggest that caution is needed regarding SSEP amplitudes in clinical routine, and that these indicators should be used in a multimodal approach for prognostication after cardiac arrest. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00999-6.
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Affiliation(s)
- Sarah Benghanem
- Medical ICU, Cochin Hospital, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Medical School, University of Paris, Paris, France. .,After ROSC Network, Paris, France. .,INSERM 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Sainte Anne Hospital, Paris, France.
| | - Lee S Nguyen
- CMC Ambroise Paré, Research and Innovation, Neuilly-sur-Seine, France
| | - Martine Gavaret
- Medical School, University of Paris, Paris, France.,Neurophysiology Department, GHU Psychiatrie et Neurosciences, Sainte Anne Hospital, Paris, France.,INSERM 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Sainte Anne Hospital, Paris, France
| | - Jean-Paul Mira
- Medical ICU, Cochin Hospital, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Medical School, University of Paris, Paris, France
| | - Frédéric Pène
- Medical ICU, Cochin Hospital, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Medical School, University of Paris, Paris, France
| | - Julien Charpentier
- Medical ICU, Cochin Hospital, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Angela Marchi
- Medical School, University of Paris, Paris, France.,Neurophysiology Department, GHU Psychiatrie et Neurosciences, Sainte Anne Hospital, Paris, France.,INSERM 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Sainte Anne Hospital, Paris, France
| | - Alain Cariou
- Medical ICU, Cochin Hospital, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Medical School, University of Paris, Paris, France.,After ROSC Network, Paris, France.,Paris-Cardiovascular-Research-Center (Sudden-Death-Expertise-Center), INSERM U970, Paris, France
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Pruvost-Robieux E, Marchi A, Martinelli I, Bouchereau E, Gavaret M. Evoked and Event-Related Potentials as Biomarkers of Consciousness State and Recovery. J Clin Neurophysiol 2022; 39:22-31. [PMID: 34474424 PMCID: PMC8715993 DOI: 10.1097/wnp.0000000000000762] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
SUMMARY The definition of consciousness has been the subject of great interest for many scientists and philosophers. To better understand how evoked potentials may be identified as biomarkers of consciousness and recovery, the different theoretical models sustaining neural correlates of consciousness are reviewed. A multimodal approach can help to better predict clinical outcome in patients presenting with disorders of consciousness. Evoked potentials are inexpensive and easy-to-implement bedside examination techniques. Evoked potentials are an integral part of prognostic evaluation, particularly in cases of cognitive motor dissociation. Prognostic criteria are well established in postanoxic disorders of consciousness, especially postcardiac arrest but are less well determined in other etiologies. In the early examination, bilateral absence of N20 in disorder of consciousness patients is strongly associated with unfavorable outcome (i.e., death or unresponsive wakefulness syndrome) especially in postanoxic etiologies. This predictive value is lower in other etiologies and probably also in children. Both N20 and mismatch negativity are proven outcome predictors for acute coma. Many studies have shown that mismatch negativity and P3a are characterized by a high prognostic value for awakening, but some patients presenting unresponsive wakefulness syndrome also process a P3a. The presence of long-latency event-related potential components in response to stimuli is indicative of a better recovery. All neurophysiological data must be integrated within a multimodal approach combining repeated clinical evaluation, neuroimaging, functional imaging, biology, and neurophysiology combining passive and active paradigms.
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Affiliation(s)
- Estelle Pruvost-Robieux
- Neurophysiology Department, GHU Paris Psychiatry & Neurosciences, Sainte Anne, Paris, France
- Paris University, Paris, France
| | - Angela Marchi
- Neurophysiology Department, GHU Paris Psychiatry & Neurosciences, Sainte Anne, Paris, France
| | - Ilaria Martinelli
- Department of Neurosciences, St. Agostino-Estense Hospital, Azienda Ospedaliero, Universitaria di Modena, Modena, Italy;
| | - Eléonore Bouchereau
- Department of Anesthesiology and intensive care, GHU Paris Psychiatry & Neurosciences, Sainte Anne, Paris, France; and
| | - Martine Gavaret
- Neurophysiology Department, GHU Paris Psychiatry & Neurosciences, Sainte Anne, Paris, France
- Paris University, Paris, France
- INSERM UMR 1266, Paris, France
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Liu Y, Huang H, Su Y, Wang M, Zhang Y, Chen W, Liu G, Jiang M. The Combination of N60 with Mismatch Negativity Improves the Prediction of Awakening from Coma. Neurocrit Care 2021; 36:727-737. [PMID: 34291392 DOI: 10.1007/s12028-021-01308-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Our objective was to evaluate the use of event-related potentials and the middle-latency somatosensory evoked potential (MLSEP) for the prediction of awakening in coma, determine the evaluation day that evoked potentials (EPs) best predict an awakening outcome, and determine whether the mismatch negativity (MMN) combined with the MLSEP, when recorded at 7 days after coma, improved the prediction of awakening from coma. METHODS Design prospective blinded cohort study. Setting neurointensive care unit of a university hospital. Patients 113 consecutive patients who were severely comatose, whose etiologies of coma included stroke (65 patients), hypoxic-ischemic encephalopathy (28 patients), intracranial infection (6 patients), and other (14 patients). Interventions none. Measurements we gathered Glasgow Coma Scale scores and recorded EPs for all patients who were comatose at 7, 14, and 30 days after coma onset, unless the patients returned to consciousness. The EPs examined included the MLSEP, the middle-latency auditory evoked potential, the N100, and the MMN. With telephone follow-up after 3 months, the patients were classified as awakening or nonawakening according to Glasgow Outcome Scale. RESULTS When predicting an awakening outcome, at least the unilateral presence of the N60 had the highest sensitivity (82.7%), whereas the presence of the MMN showed the highest specificity (82.0%). The area under the receiver operating characteristic curve for the EPs were high at 7 days after coma onset. At 7 days after coma onset, the combination of the N60 and MMN offered good predictive performance for awakening (area under the receiver operating characteristic curve = 0.852, 95% confidence interval 0.765-0.940), with increased sensitivity (70.0%) and improved specificity (91.7%). CONCLUSIONS The N60 and MMN were the strongest prognostic factors for an awakening outcome. Furthermore, at 7 days after coma onset, the combination of the N60 and MMN improved the prediction of an awakening outcome in patients who were comatose.
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Affiliation(s)
- Yifei Liu
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Huijin Huang
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingying Su
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Miao Wang
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weibi Chen
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Gang Liu
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mengdi Jiang
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
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Lilja L, Thuccani M, Joelsson S, Nilsson J, Redfors P, Lundgren P, Rylander C. The capacity of neurological pupil index to predict absence of somatosensory evoked potentials after cardiac arrest-A study protocol. Acta Anaesthesiol Scand 2021; 65:852-858. [PMID: 33735459 DOI: 10.1111/aas.13822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anoxic-ischemic brain injury is the most common cause of death after cardiac arrest (CA). Robust methods to detect severe injury with a low false positive rate (FPR) for poor neurological outcome include the pupillary light reflex (PLR) and somatosensory evoked potentials (SSEP). The PLR can be assessed manually or with automated pupillometry which provides the neurological pupil index (NPi). We aim to describe the interrelation between NPi values and the absence of SSEP cortical response and to evaluate the capacity of NPi to predict the absence of cortical SSEP response in comatose patients after CA. METHODS A total of 50 patients will be included in an explorative, prospective, observational study of adult (>18 years) comatose survivors of CA admitted to intensive care in a university hospital. NPi assessed with a hand-held pupillometer will be compared to SSEP signals recorded >48 hours after CA. Primary outcomes are sensitivity, specificity, and odds ratio for NPi to predict bilateral absence of the SSEP N20 signal, with NPi values corresponding to <5% FPRs of SSEP absence. Secondary outcomes are the PLR and SSEP sensitivity, specificity, and odds ratio for poor neurological outcome at hospital discharge and death at 30 days. DISCUSSION The PLR and SSEP may have a systematic interrelation, and a certain NPi threshold could potentially predict the absence of cortical SSEP response. If this can be concluded from the present study, SSEP testing could be excluded in certain patients to save resources in the multimodal prognostication after CA. Editorial comment The interrelation between loss of the pupillary light reflex (PLR) and the loss of cortical response to a somatosensory evoked potential (SSEP) in comatose cardiac arrest patients is not known. This exploratory prospective study is designed to evaluate whether a specific degree of attenuated PLR, as measured by semiautomated pupillometry, can predict the bilateral loss of cortical SSEP response in severe anoxic/ischemic brain injury. Such an interrelation between the two methods would enable the use of pupillometry rather than the more resource demanding SSEP for neurologic prognostication in post cardiac arrest patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT04720482, Registered 21 January 2021, retrospectively registered.
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Affiliation(s)
- Linus Lilja
- Department of Anaesthesiology and Intensive Care Medicine Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Meena Thuccani
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Sara Joelsson
- Department of Clinical Neurophysiology Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Josefin Nilsson
- Department of Clinical Neurophysiology Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Peter Lundgren
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Prehospen—Centre for Prehospital Research University of Borås Borås Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
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9
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Elmer J, Kane N. Evoking signs of recovery after cardiac arrest: The SSEP 'present versus absent' dichotomy has shifted, now size matters. Resuscitation 2021; 163:195-197. [PMID: 33930503 DOI: 10.1016/j.resuscitation.2021.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Jonathan Elmer
- Departments of Emergency Medicine, Critical Care Medicine and Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Nick Kane
- The Grey Walter Department of Clinical Neurophysiology, Southmead Hospital, Bristol, BS10 5NB, UK
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Carrai R, Spalletti M, Scarpino M, Lolli F, Lanzo G, Cossu C, Bonizzoli M, Socci F, Lazzeri C, Amantini A, Grippo A. Are neurophysiologic tests reliable, ultra-early prognostic indices after cardiac arrest? Neurophysiol Clin 2021; 51:133-144. [PMID: 33573889 DOI: 10.1016/j.neucli.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES Determining early and reliable prognosis in comatose subjects after cardiac arrest is a central component of post-cardiac arrest care both for developing realistic prognostic expectations for families, and for better determining which resources are mobilized or withheld for individual patients. The aim of the study was to evaluate the prognostic accuracy of EEG and SEP patterns during the very early period (within the first 6 h) after cardiac arrest. METHODS We retrospectively analysed comatose patients after CA, either inside or outside the hospital, in which prognostic evaluation was made during the first 6 h from CA. Prognostic evaluation comprised clinical evaluation (GCS and pupillary light reflex) and neurophysiological (electroencephalography (EEG) and somatosensory evoked potentials (SEP)) studies. Prognosis was evaluated with regards to likelihood of recovery of consciousness and also likelihood of failure to regain consciousness. RESULTS Forty-one comatose patients after cardiac arrest were included. All patients with continuous and nearly continuous EEG recovered consciousness. Isoelectric EEG was always associated with poor outcome. Burst-suppression, suppression and discontinuous patterns were usually associated with poor outcome although some consciousness recovery was observed. Bilaterally absent SEP responses were always associated with poor outcome. Continuous and nearly continuous EEG patterns were never associated with bilaterally absent SEP. CONCLUSIONS During the very early period following cardiac arrest (first 6 h), EEG and SEP maintain their high predictive value to predict respectively recovery and failure of recovery of consciousness. A very early EEG exam allows identification of patients with very high probability of a good outcome, allowing rapid use of the most appropriate therapeutic procedures.
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Affiliation(s)
- Riccardo Carrai
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy; IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy.
| | - Maddalena Spalletti
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy; IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Maenia Scarpino
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy; IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Francesco Lolli
- Dipartimento di Scienze Biomediche Mario Serio, Università di Firenze, Florence, Italy
| | - Giovanni Lanzo
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy
| | - Cesarina Cossu
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy
| | - Manuela Bonizzoli
- Unità di Terapia Intensiva, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy
| | - Filippo Socci
- Unità di Terapia Intensiva, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy
| | - Chiara Lazzeri
- Unità di Terapia Intensiva, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy
| | - Aldo Amantini
- IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Antonello Grippo
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Florence, Italy; IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
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11
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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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Beuchat I, Novy J, Barbella G, Oddo M, Rossetti AO. EEG patterns associated with present cortical SSEP after cardiac arrest. Acta Neurol Scand 2020; 142:181-185. [PMID: 32392619 DOI: 10.1111/ane.13264] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/23/2020] [Accepted: 05/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND After cardiac arrest (CA), present cortical somatosensory evoked potentials (N20 response of SSEPs) have low predictive value for good outcome and might be redundant with EEG. AIMS To determine whether specific features, or rather global, standardized EEG assessments, are reliably associated with cortical SSEP occurrence after cardiac arrest (CA). METHODS In a prospective CA registry, EEGs recorded within 72 hours were scored according to the ACNS nomenclature, and also categorized into "benign," "malignant," and "highly malignant." Correlations between EEGs and SSEPs (bilaterally absent vs present), and between EEGs/SSEPs and outcome (good: CPC 1-2) were assessed. RESULTS Among 709 CA episodes, 532 had present N20 and 366 "benign EEGs." While EEG categories as well as background, epileptiform features, and reactivity differed significantly between patients with and without N20 (each P < .001), only "benign EEG" was almost universally associated with present N20: 99.5% (95%CI: 97.9%-99.9%) PPV. The combination of "benign EEG" and present N20 showed similar PPV for good outcome as "benign" EEG alone: 69.0% (95% CI: 65.2-72.4) vs 68.6% (95% CI: 64.9-72.0). CONCLUSION Global EEG ("benign") assessment, rather than single EEG features, can reliably predict cortical SSEP occurrence. SSEP adjunction does not increase EEG prognostic performance toward good outcome. SSEP could therefore be omitted in patients with "benign EEG."
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Affiliation(s)
- Isabelle Beuchat
- Department of Neurology Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne Lausanne Switzerland
- Department of Neurology Brigham and Women's Hospital Harvard Medical School Boston MAUSA
| | - Jan Novy
- Department of Neurology Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne Lausanne Switzerland
| | - Giuseppina Barbella
- Department of Neurology Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne Lausanne Switzerland
- Neurology Unit IRCCS Policlinico San Donato Milan Italy
| | - Mauro Oddo
- Department of Intensive Care Medicine Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne Lausanne Switzerland
| | - Andrea O. Rossetti
- Department of Neurology Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne Lausanne Switzerland
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13
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Glimmerveen AB, Keijzer HM, Ruijter BJ, Tjepkema-Cloostermans MC, van Putten MJAM, Hofmeijer J. Relevance of Somatosensory Evoked Potential Amplitude After Cardiac Arrest. Front Neurol 2020; 11:335. [PMID: 32425878 PMCID: PMC7212397 DOI: 10.3389/fneur.2020.00335] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/07/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: We present relations of SSEP amplitude with neurological outcome and of SSEP amplitude with EEG amplitude in comatose patients after cardiac arrest. Methods: This is a post hoc analysis of a prospective cohort study in comatose patients after cardiac arrest. Amplitude of SSEP recordings obtained within 48-72 h, and EEG patterns obtained at 12 and 24h after cardiac arrest were related to good (CPC 1-2) or poor (CPC 3-5) outcome at 6 months. In 39% of the study population multiple SSEP measurements were performed. Additionally, SSEP amplitude was related to mean EEG amplitude. Results: We included 138 patients (77% poor outcome). Absent SSEP responses, a N20 amplitude <0.4 μV within 48-72 h, and suppressed or synchronous EEG with suppressed background at 12 or 24 h after cardiac arrest were invariably associated with a poor outcome. Combined, these tests reached a sensitivity for prediction of poor outcome up to 58 at 100% specificity. N20 amplitude increased with a mean of 0.55 μV per day in patients with a poor outcome, and remained stable with a good outcome. There was no statistically significant correlation between SSEP and EEG amplitudes in 182 combined SSEP and EEG measurements (R 2 < 0.01). Conclusions: N20 amplitude <0.4 μV is invariably associated with poor outcome. There is no correlation between SSEP and EEG amplitude. Significance: SSEP amplitude analysis may contribute to outcome prediction after cardiac arrest.
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Affiliation(s)
| | - Hanneke M Keijzer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands.,Department of Intensive Care Medicine and Neurology, Donders Institute for Brain Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - Barry J Ruijter
- Clinical Neurophysiology, Technical Medical Centre, University of Twente, Enschede, Netherlands
| | - Marleen C Tjepkema-Cloostermans
- Clinical Neurophysiology, Technical Medical Centre, University of Twente, Enschede, Netherlands.,Department of Neurology and Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Michel J A M van Putten
- Clinical Neurophysiology, Technical Medical Centre, University of Twente, Enschede, Netherlands.,Department of Neurology and Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands.,Clinical Neurophysiology, Technical Medical Centre, University of Twente, Enschede, Netherlands
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14
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Added value of somato-sensory evoked potentials amplitude for prognostication after cardiac arrest. Resuscitation 2020; 149:17-23. [DOI: 10.1016/j.resuscitation.2020.01.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 12/31/2019] [Accepted: 01/22/2020] [Indexed: 12/13/2022]
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15
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Glimmerveen AB, Ruijter BJ, Keijzer HM, Tjepkema-Cloostermans MC, van Putten MJ, Hofmeijer J. Association between somatosensory evoked potentials and EEG in comatose patients after cardiac arrest. Clin Neurophysiol 2019; 130:2026-2031. [DOI: 10.1016/j.clinph.2019.08.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 06/21/2019] [Accepted: 08/18/2019] [Indexed: 12/30/2022]
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16
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Electrophysiologic Monitoring in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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van Putten MJ, Jansen C, Tjepkema-Cloostermans MC, Beernink TM, Koot R, Bosch F, Beishuizen A, Hofmeijer J. Postmortem histopathology of electroencephalography and evoked potentials in postanoxic coma. Resuscitation 2019; 134:26-32. [DOI: 10.1016/j.resuscitation.2018.12.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/17/2018] [Accepted: 12/10/2018] [Indexed: 02/04/2023]
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Abstract
PURPOSE The reliability of somatosensory evoked potentials (SSEPs) in predicting outcome in comatose survivors of cardiac arrest treated with therapeutic hypothermia (TH) has been questioned. We investigated whether the absence of cortical (N20) responses was a reliable predictor of a nonawakening in the setting of TH. METHODS A retrospective review was conducted in cardiac arrest survivors treated with TH admitted to a single tertiary care hospital from April, 2010 to March, 2013 who underwent SSEP testing at various time points after cardiac arrest. N20 responses were categorized as normal, present but abnormal, bilaterally absent, or inadequate for interpretation. Neurologic outcome was assessed at discharge by the Cerebral Performance Category Scale (CPC). RESULTS Ninety-three SSEP studies were performed in 73 patients. Fourteen patients had absent N20 responses; all had poor outcome (CPC 4-5). Eleven patients had absent N20 s during hypothermia, three of whom had follow-up SSEPs after rewarming and cortical responses remained absent. Fifty-seven patients had N20 peaks identified and had variable outcomes. Evaluation of 1 or more N20 peaks was limited or inadequate in 11.4% of SSEPs performed during the cooling because of artifact. CONCLUSIONS Somatosensory evoked potentials remain a reliable prognostic indicator in patients undergoing TH. The limited sample size of patients who had SSEP performed during TH and repeated after normothermia added to the effect of self-fulfilling prophecy limit the interpretation of the reliability of this testing when performed during cooling. Further prospective, multicenter, large scale studies correlating cortical responses in SSEPs during and after TH are warranted. Technical challenges are commonplace during TH and caution is advised in the interpretation of suboptimal recordings.
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Gobert F, Dailler F, Fischer C, André-Obadia N, Luauté J. Proving cortical death after vascular coma: Evoked potentials, EEG and neuroimaging. Clin Neurophysiol 2018; 129:1105-1116. [PMID: 29621638 DOI: 10.1016/j.clinph.2018.02.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 02/13/2018] [Accepted: 02/24/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Several studies have shown that bilateral abolition of somatosensory evoked potentials after a nontraumatic coma has 100% specificity for nonawakening with ethical consequences for active care withdrawal. We propose to evaluate the prognostic value of bilateral abolished cortical components of SEPs in severe vascular coma. METHODS A total of 144 comatose patients after subarachnoid haemorrhage were evaluated by multimodal evoked potentials (EPs); 7 patients presented a bilateral abolition of somatosensory and auditory EPs. Their prognosis value was interpreted with respect to brainstem auditory EPs, EEG, and structural imaging. RESULTS One patient emerged from vegetative state during follow-up; 6 patients did not return to consciousness. The main neurophysiological difference was a cortical reactivity to pain preserved in the patient who returned to consciousness. This patient had focal sub-cortical lesions, which could explain the abolition of primary cortical components by a bilateral deafferentation of somatosensory and auditory pathways. CONCLUSIONS This is the first report of a favourable outcome after a multimodal abolition of primary cortex EPs in vascular coma. For the 3 cases of vascular coma with preserved brainstem function, EEG reactivity and cortical EPs were abolished by a diffuse ischaemia close to cerebral anoxia. SIGNIFICANCE The complementarity of EPs, EEG, and imaging must be emphasised if therapeutic limitations are considered to avoid over-interpretation of the prognosis value of EPs.
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Affiliation(s)
- Florent Gobert
- Neuro-Intensive Care Unit, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Lyon, France; University Lyon I, Villeurbanne, France.
| | - Frederic Dailler
- Neuro-Intensive Care Unit, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Lyon, France
| | - Catherine Fischer
- University Lyon I, Villeurbanne, France; Department of Clinical Neurophysiology, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Lyon, France
| | - Nathalie André-Obadia
- University Lyon I, Villeurbanne, France; Department of Clinical Neurophysiology, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Lyon, France
| | - Jacques Luauté
- University Lyon I, Villeurbanne, France; Neuro-Rehabilitation Unit, Hospices Civils de Lyon, Neurological Hospital Pierre-Wertheimer, Lyon, France
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Grippo A, Carrai R, Scarpino M, Spalletti M, Lanzo G, Cossu C, Peris A, Valente S, Amantini A. Neurophysiological prediction of neurological good and poor outcome in post-anoxic coma. Acta Neurol Scand 2017; 135:641-648. [PMID: 27480262 DOI: 10.1111/ane.12659] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Investigation of the utility of association between electroencephalogram (EEG) and somatosensory-evoked potentials (SEPs) for the prediction of neurological outcome in comatose patients resuscitated after cardiac arrest (CA) treated with therapeutic hypothermia, according to different recording times after CA. METHODS Glasgow Coma Scale, EEG and SEPs performed at 12, 24 and 48-72 h after CA were assessed in 200 patients. Outcome was evaluated by Cerebral Performance Category 6 months after CA. RESULTS Within 12 h after CA, grade 1 EEG predicted good outcome and bilaterally absent (BA) SEPs predicted poor outcome. Because grade 1 EEG and BA-SEPs were never found in the same patient, the recording of both EEG and SEPs allows us to correctly prognosticate a greater number of patients with respect to the use of a single test within 12 h after CA. At 48-72 h after CA, both grade 2 EEG and BA-SEPs predicted poor outcome with FPR=0.0%. When these neurophysiological patterns are both present in the same patient, they confirm and strengthen their prognostic value, but because they also occurred independently in eight patients, poor outcome is predictable in a greater number of patients. SIGNIFICANCE The combination of EEG/SEP findings allows prediction of good and poor outcome (within 12 h after CA) and of poor outcome (after 48-72 h). Recording of EEG and SEPs in the same patients allows always an increase in the number of cases correctly classified, and an increase of the reliability of prognostication in a single patient due to concordance of patterns.
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Affiliation(s)
- A. Grippo
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica; Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
| | - R. Carrai
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica; Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
| | - M. Scarpino
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica; Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
| | - M. Spalletti
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - G. Lanzo
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - C. Cossu
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - A. Peris
- Unità di terapia Intensiva; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - S. Valente
- Dipartimento Cardiotoracovascolare; AOU Careggi; Florence Italy
| | - A. Amantini
- SODc Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
- Unità di Riabilitazione Neurologica; Fondazione Don Carlo Gnocchi; IRCCS; Florence Italy
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Cortical somatosensory evoked high-frequency (600Hz) oscillations predict absence of severe hypoxic encephalopathy after resuscitation. Clin Neurophysiol 2016; 127:2561-9. [PMID: 27291874 DOI: 10.1016/j.clinph.2016.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/09/2016] [Accepted: 04/14/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Following cardiac arrest (CA), hypoxic encephalopathy (HE) frequently occurs and hence reliable neuroprognostication is crucial to decide on the extent of intensive care. Several investigations predict severe HE leading to persistent unresponsive wakefulness or death, with high specificity. Only few studies attempted to predict absence of severe HE. Cortical somatosensory evoked high-frequency (600Hz) oscillation (HFO) bursts indicate the presence of highly synchronized spiking activity in the primary somatosensory cortex. Since global neuronal damage characterizes severe HE preserved cortical HFOs may early exclude severe HE. METHODS We determined amplitudes of early and late HFO bursts in 302 comatose CA patients after median nerve somatosensory evoked potential (SSEPs) and clinical outcome upon intensive care unit discharge using the cerebral performance category (CPC) scale. RESULTS We detected significant early HFO bursts in 146 patients and late HFO bursts in 95 patients. Only one of 27 unresponsive wakefulness patients had a late HFO burst amplitude above 70nV and all seventeen patients who died despite higher amplitudes died from non-neurological causes. CONCLUSIONS High-frequency SSEP components can reliably be studied in comatose CA patients using standard equipment. SIGNIFICANCE Late HFO burst amplitudes above 70nV largely exclude severe HE incompatible with regaining consciousness.
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Neurological prognostication of outcome in patients in coma after cardiac arrest. Lancet Neurol 2016; 15:597-609. [PMID: 27017468 DOI: 10.1016/s1474-4422(16)00015-6] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/23/2015] [Accepted: 01/12/2016] [Indexed: 11/24/2022]
Abstract
Management of coma after cardiac arrest has improved during the past decade, allowing an increasing proportion of patients to survive, thus prognostication has become an integral part of post-resuscitation care. Neurologists are increasingly confronted with raised expectations of next of kin and the necessity to provide early predictions of long-term prognosis. During the past decade, as technology and clinical evidence have evolved, post-cardiac arrest prognostication has moved towards a multimodal paradigm combining clinical examination with additional methods, consisting of electrophysiology, blood biomarkers, and brain imaging, to optimise prognostic accuracy. Prognostication should never be based on a single indicator; although some variables have very low false positive rates for poor outcome, multimodal assessment provides resassurance about the reliability of a prognostic estimate by offering concordant evidence.
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Zanatta P, Linassi F, Mazzarolo AP, Aricò M, Bosco E, Bendini M, Sorbara C, Ori C, Carron M, Scarpa B. Pain-related Somato Sensory Evoked Potentials: a potential new tool to improve the prognostic prediction of coma after cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:403. [PMID: 26573633 PMCID: PMC4647335 DOI: 10.1186/s13054-015-1119-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 10/28/2015] [Indexed: 11/23/2022]
Abstract
Introduction Early prediction of a good outcome in comatose patients after cardiac arrest still remains an unsolved problem. The main aim of the present study was to examine the accuracy of middle-latency SSEP triggered by a painful electrical stimulation on median nerves to predict a favorable outcome. Methods No- and low-flow times, pupillary reflex, Glasgow motor score and biochemical data were evaluated at ICU admission. The following were considered within 72 h of cardiac arrest: highest creatinine value, hyperthermia occurrence, EEG, SSEP at low- (10 mA) and high-intensity (50 mA) stimulation, and blood pressure reactivity to 50 mA. Intensive care treatments were also considered. Data were compared to survival, consciousness recovery and 6-month CPC (Cerebral Performance Category). Results Pupillary reflex and EEG were statistically significant in predicting survival; the absence of blood pressure reactivity seems to predict brain death within 7 days of cardiac arrest. Middle- and short-latency SSEP were statistically significant in predicting consciousness recovery, and middle-latency SSEP was statistically significant in predicting 6-month CPC outcome. The prognostic capability of 50 mA middle-latency-SSEP was demonstrated to occur earlier than that of EEG reactivity. Conclusions Neurophysiological evaluation constitutes the key to early information about the neurological prognostication of postanoxic coma. In particular, the presence of 50 mA middle-latency SSEP seems to be an early and reliable predictor of good neurological outcome, and its absence constitutes a marker of poor prognosis. Moreover, the absence 50 mA blood pressure reactivity seems to identify patients evolving towards the brain death.
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Affiliation(s)
- Paolo Zanatta
- Department of Anaesthesia and Intensive Care, Intraoperative and Critical Care Neurophysiology in Cardiac Surgery, Treviso Regional Hospital, Azienda Ospedaliera Ulss 9, Piazzale Ospedale 1, 31100, Treviso, Italy.
| | - Federico Linassi
- Neuromonitoring Project, Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Anna Paola Mazzarolo
- Neuromonitoring Project, Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Maria Aricò
- Neuromonitoring Project, Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Enrico Bosco
- Department of Anaesthesia and Intensive Care, Intraoperative and Critical Care Neurophysiology in Cardiac Surgery, Treviso Regional Hospital, Azienda Ospedaliera Ulss 9, Piazzale Ospedale 1, 31100, Treviso, Italy.
| | - Matteo Bendini
- Unit of Neuroradiology, Treviso Regional Hospital, Piazzale Ospedale, 1, 31100, Treviso, TV, Italy.
| | - Carlo Sorbara
- Department of Anaesthesia and Intensive Care, Intraoperative and Critical Care Neurophysiology in Cardiac Surgery, Treviso Regional Hospital, Azienda Ospedaliera Ulss 9, Piazzale Ospedale 1, 31100, Treviso, Italy.
| | - Carlo Ori
- Department of Anesthesia and Intensive Care, Padova University Hospital, Via 8 Febbraio 1848, 2, 35122, Padova, PD, Italy.
| | - Michele Carron
- Department of Anesthesia and Intensive Care, Padova University Hospital, Via 8 Febbraio 1848, 2, 35122, Padova, PD, Italy.
| | - Bruno Scarpa
- Department of Statistical Sciences, Padova University, Via 8 Febbraio 1848, 2, 35122, Padova, PD, Italy.
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van Putten MJAM, Tjepkema-Cloostermans MC, Hofmeijer J. Infraslow EEG activity modulates cortical excitability in postanoxic encephalopathy. J Neurophysiol 2015; 113:3256-67. [PMID: 25695645 DOI: 10.1152/jn.00714.2014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 02/17/2015] [Indexed: 11/22/2022] Open
Abstract
Infraslow activity represents an important component of physiological and pathological brain function. We study infraslow activity (<0.1 Hz) in 41 patients with postanoxic coma after cardiac arrest, including the relationship between infraslow activity and EEG power in the 3-30 Hz range, using continuous full-band scalp EEG. In all patients, infraslow activity (0.015-0.06 Hz) was present, irrespective of neurological outcome or EEG activity in the conventional frequency bands. In two patients, low-amplitude (10-30 μV) infraslow activity was present while the EEG showed no rhythmic activity above 0.5 Hz. In 13/15 patients with a good outcome and 20/26 patients with a poor one, EEG power in the 3-30 Hz frequency range was correlated with the phase of infraslow activity, quantified by the modulation index. In 9/14 patients with burst-suppression with identical bursts, bursts appeared in clusters, phase-locked to the infraslow oscillations. This is substantiated by a simulation of burst-suppression in a minimal computational model. Infraslow activity is preserved in postanoxic encephalopathy and modulates cortical excitability. The strongest modulation is observed in patients with severe postanoxic encephalopathy and burst-suppression with identical bursts.
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Affiliation(s)
- Michel J A M van Putten
- Department of Neurology and Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, the Netherlands; Clinical Neurophysiology, MIRA-Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands; and
| | - Marleen C Tjepkema-Cloostermans
- Department of Neurology and Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, the Netherlands; Clinical Neurophysiology, MIRA-Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands; and
| | - Jeannette Hofmeijer
- Clinical Neurophysiology, MIRA-Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands; and Department of Neurology, Rijnstate Ziekenhuis, Arnhem, the Netherlands
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Campfens SF, Meskers CGM, Schouten AC, van Putten MJAM, van der Kooij H. Stretch Evoked Potentials in Healthy Subjects and After Stroke: A Potential Measure for Proprioceptive Sensorimotor Function. IEEE Trans Neural Syst Rehabil Eng 2015; 23:643-54. [PMID: 25576572 DOI: 10.1109/tnsre.2015.2388692] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Sensory feedback is of vital importance in motor control, yet rarely assessed in diseases with impaired motor function like stroke. Muscle stretch evoked potentials (StrEPs) may serve as a measure of cortical sensorimotor activation in response to proprioceptive input. The aim of this study is: 1) to determine early and late features of the StrEP and 2) to explore whether StrEP waveform and features can be measured after stroke. Consistency of StrEP waveforms and features was evaluated in 22 normal subjects. StrEP features and similarity between hemispheres were evaluated in eight subacute stroke subjects. StrEPs of normal subjects had a consistent shape across conditions and sessions (mean cross correlation waveforms > 0.75). Stroke subjects showed heterogeneous StrEP waveforms. Stroke subjects presented a normal early peak (40 ms after movement onset) but later peaks had abnormal amplitudes and latencies. No significant differences between stroke subjects with good and poor motor function were found (P > 0.14). With the consistent responses of normal subjects the StrEP meets a prerequisite for potential clinical value. Recording of StrEPs is feasible even in subacute stroke survivors with poor motor function. How StrEP features relate to clinical phenotypes and recovery needs further investigation.
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Clinical Evolution After a Non-reactive Hypothermic EEG Following Cardiac Arrest. Neurocrit Care 2014; 22:403-8. [DOI: 10.1007/s12028-014-0095-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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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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Schorl M, Valerius-Kukula SJ, Kemmer TP. Median-evoked somatosensory potentials in severe brain injury: Does initial loss of cortical potentials exclude recovery? Clin Neurol Neurosurg 2014; 123:25-33. [DOI: 10.1016/j.clineuro.2014.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 04/27/2014] [Accepted: 05/03/2014] [Indexed: 11/28/2022]
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Zhang Y, Wang M, Su YY. The role of middle latency evoked potentials in early prediction of favorable outcomes among patients with severe ischemic brain injuries. J Neurol Sci 2014; 345:112-7. [PMID: 25070207 DOI: 10.1016/j.jns.2014.07.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 07/07/2014] [Accepted: 07/10/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To explore the role of middle latency evoked potentials (EPs) as predictors for favorable outcome in patients with severe ischemic brain injuries by comparing the prognostic ability of short latency somatosensory and auditory evoked potentials (SLSEP and BAEP) with middle latency somatosensory and auditory evoked potentials (MLSEP and MLAEP). METHODS MLSEP, MLAEP, SLSEP and BAEP were recorded in 112 patients with severe ischemic brain injuries (Glasgow Coma Scale ≤ 8). Among them, 83 patients suffered from cerebral ischemic stroke and 29 suffered from anoxic-ischemic encephalopathy after cardiopulmonary resuscitation between 1 and 7 days after the onset of stroke. Outcomes were reviewed 6 months later using the Glasgow Outcome Scale (GOS). A GOS score of 4-5 was considered as a good outcome while a score of 1-3 was considered as poor. RESULTS By using the prognostic authenticity analysis of predictors for good outcome, at least unilateral N20 of the SLSEP exit and at least unilateral N60 of the MLSEP exit showed the highest sensitivity which was 100% (95% CI: 86.7%-100%). The bilateral normal N60 showed a high specificity of 97.5% (95% CI: 90.4%-99.6%). It also showed the highest positive likelihood ratio of 6.25% (95% CI: 1.28%-30.59%), which was superior to N20 of SLSEP, V of BAEP, and Pa of MLAEP. The analysis demonstrated that the area under the curve for MLSEP grading was the highest (0.838) compared to that of SLSEP grading (0.784), MLAEP grading (0.659) and BAEP grading (0.621). CONCLUSIONS Compared with using N20 of SLSEP analysis alone, adding MLSEP improves the outcome prediction in patients with severe ischemic brain injuries. When an outcome is uncertain after initial evaluation using short-latency EPs, MLSEP is valuable to be used from the first week to further improve prognostication in these patients.
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Affiliation(s)
- Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Miao Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ying Ying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Tjepkema-Cloostermans MC, Hindriks R, Hofmeijer J, van Putten MJ. Generalized periodic discharges after acute cerebral ischemia: Reflection of selective synaptic failure? Clin Neurophysiol 2014; 125:255-62. [PMID: 24012049 DOI: 10.1016/j.clinph.2013.08.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 07/08/2013] [Accepted: 08/05/2013] [Indexed: 10/26/2022]
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Liguori C, Albanese M, Romigi A, Izzi F, Natoli S, Leonardis F, Leonardis C, Bianchi L, Marciani M, Placidi F. Unexpected total recovery in a patient with post-anoxic complete alpha coma predicted by recording of cortical SEPs. Clin Neurophysiol 2013; 124:2450-3. [DOI: 10.1016/j.clinph.2013.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 05/19/2013] [Accepted: 05/21/2013] [Indexed: 11/16/2022]
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Cronberg T, Brizzi M, Liedholm LJ, Rosén I, Rubertsson S, Rylander C, Friberg H. Neurological prognostication after cardiac arrest—Recommendations from the Swedish Resuscitation Council. Resuscitation 2013; 84:867-72. [DOI: 10.1016/j.resuscitation.2013.01.019] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 01/17/2013] [Indexed: 11/17/2022]
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Kontio T, Toet MC, Hellström-Westas L, van Handel M, Groenendaal F, Stjerna S, Vanhatalo S, de Vries LS. Early neurophysiology and MRI in predicting neurological outcome at 9-10 years after birth asphyxia. Clin Neurophysiol 2013; 124:1089-94. [PMID: 23403266 DOI: 10.1016/j.clinph.2012.12.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 12/18/2012] [Accepted: 12/22/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess whether early somatosensory evoked potentials (SEP) predict long-term neurodevelopmental outcome in normothermic, full-term infants with mild to moderate neonatal encephalopathy (NE), and to compare their predictive value to already available amplitude integrated EEG (aEEG) and magnetic resonance imaging (MRI). METHODS Fifty-six infants with post-asphyxia NE were prospectively recruited, and their SEP, aEEG and MRI data were acquired during the first five days. Follow-up continued to 9-10 years for assessment of neuromotor and neurocognitive development. We analysed SEP latency (N1 component), normality of aEEG background pattern, as well as patterns of injury on the neonatal MRI. Neurological outcome measures at 9-10 years included conventional MRI, Movement-ABC and the WISC-III NL. RESULTS A SEP latency <50 ms during the first five days was associated with a normal neuromotor outcome (p < 0.03), and a prolonged day 3 latency was associated with lower childhood IQ (p = 0.02). The presence of multiple seizures in aEEG, as well as a moderate or severe injury on the neonatal MRI was associated with a poor neuromotor score (p = 0.03 and p < 0.01, respectively). Combination of multiple techniques improved prediction of long-term outcome compared to single modality. CONCLUSION Early SEPs provide information that is comparable to the already available aEEG and MRI paradigms in the prediction of long-term outcome of full-term infants with mild to moderate neonatal encephalopathy. SIGNIFICANCE The present results call for further studies using early SEP to aid early assessment of infants treated with hypothermia.
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Affiliation(s)
- T Kontio
- Department of Children's Clinical Neurophysiology, Helsinki University Hospital, and Department of Neurological Sciences, University of Helsinki, Finland.
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Rothstein TL. Therapeutic hypothermia and reliability of somatosensory evoked potentials in predicting outcome after cardiopulmonary arrest. Neurocrit Care 2012; 17:146-9. [PMID: 22547039 DOI: 10.1007/s12028-012-9696-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The loss of the N20 component on testing median somatosensory evoked potentials (SSEP) has been established as the most reliable indicator of unfavorable prognosis in post-cardiopulmonary arrest patients. With the intervention of therapeutic hypothermia in the management of patients who remain comatose following cardiopulmonary arrest that association is now in dispute. Abandoning SSEP as a key prognostic indicator of neurologic outcome would be a serious loss and cannot be justified.
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Affiliation(s)
- Ted Laurence Rothstein
- Department of Neurology, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC 20037, USA.
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Zanatta P, Messerotti Benvenuti S, Baldanzi F, Bendini M, Saccavini M, Tamari W, Palomba D, Bosco E. Pain-related somatosensory evoked potentials and functional brain magnetic resonance in the evaluation of neurologic recovery after cardiac arrest: a case study of three patients. Scand J Trauma Resusc Emerg Med 2012; 20:22. [PMID: 22463985 PMCID: PMC3355043 DOI: 10.1186/1757-7241-20-22] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 03/31/2012] [Indexed: 01/17/2023] Open
Abstract
This case series investigates whether painful electrical stimulation increases the early prognostic value of both somatosensory-evoked potentials and functional magnetic resonance imaging in comatose patients after cardiac arrest. Three single cases with hypoxic-ischemic encephalopathy were considered. A neurophysiological evaluation with an electroencephalogram and somatosensory-evoked potentials during increased electrical stimulation in both median nerves was performed within five days of cardiac arrest. Each patient also underwent a functional magnetic resonance imaging evaluation with the same neurophysiological protocol one month after cardiac arrest. One patient, who completely recovered, showed a middle latency component at a high intensity of stimulation and the activation of all brain areas involved in cerebral pain processing. One patient in a minimally conscious state only showed the cortical somatosensory response and the activation of the primary somatosensory cortex. The last patient, who was in a vegetative state, did not show primary somatosensory evoked potentials; only the activation of subcortical brain areas occurred. These preliminary findings suggest that the pain-related somatosensory evoked potentials performed to increase the prognosis of comatose patients after cardiac arrest are associated with regional brain activity showed by functional magnetic resonance imaging during median nerves electrical stimulation. More importantly, this cases report also suggests that somatosensory evoked potentials and functional magnetic resonance imaging during painful electrical stimulation may be sensitive and complementary methods to predict the neurological outcome in the acute phase of coma. Thus, pain-related somatosensory-evoked potentials may be a reliable and a cost-effective tool for planning the early diagnostic evaluation of comatose patients.
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Affiliation(s)
- Paolo Zanatta
- Department of Anesthesia and Intensive Care, Neurophysiology, Treviso Regional Hospital, Piazzale Ospedale 1, Treviso, Italy.
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Machado C, Estévez M, Rodríguez R, Carrick FR, Melillo R, Leisman G. Bilateral N20 absence in post-anoxic coma: do you pay attention? Clin Neurophysiol 2011; 123:1264-6. [PMID: 22209660 DOI: 10.1016/j.clinph.2011.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 11/10/2011] [Accepted: 11/11/2011] [Indexed: 11/28/2022]
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