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Murakami Y, Hongo T, Yumoto T, Kosaki Y, Iida A, Maeyama H, Inoue F, Ichiba T, Nakao A, Naito H. Prognostic value of grey-white matter ratio obtained within two hours after return of spontaneous circulation in out-of-hospital cardiac arrest survivors: A multicenter, observational study. Resusc Plus 2024; 19:100746. [PMID: 39238950 PMCID: PMC11375279 DOI: 10.1016/j.resplu.2024.100746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2024] [Revised: 07/28/2024] [Accepted: 08/02/2024] [Indexed: 09/07/2024] Open
Abstract
Background Grey-white matter ratio (GWR) measured by head computed tomography (CT) scan is known as a neurological prognostication tool for out-of-hospital cardiac arrest (OHCA) survivors. The prognostic value of GWR obtained early (within two hours after return of spontaneous circulation [ROSC]) remains a matter of debate. Methods We conducted a multicenter, retrospective, observational study at five hospitals. We included adult OHCA survivors who underwent head CT within two hours following ROSC. GWR values were measured using head CT. Average GWR values were calculated by the mean of the GWR-basal ganglia and GWR-Cerebrum. We divided the patients into poor or favorable neurological outcome groups defined by Glasgow-Pittsburgh Cerebral Performance Category scores. The predictive accuracy of GWR performance was assessed using the area under the curve (AUC). The sensitivities and specificities for predicting poor outcome were examined. Results Of 377 eligible patients, 281 (74.5%) showed poor neurological outcomes at one month after ROSC. Average GWR values of the poor neurological outcome group were significantly lower than those of the favorable neurological outcome. The average GWR value to predict neurological outcome with Youden index was 1.24 with AUC of 0.799. When average GWR values were 1.15 or lower, poor neurological outcomes could be predicted with 100% specificity. Conclusions GWR values measured by head CT scans early (within two hours after ROSC) demonstrated moderate predictive performance for overall ROSC patients. When limited to the patients with GWR values of 1.15 or lower, poor neurological outcomes could be predicted with high specificity.
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Affiliation(s)
- Yuya Murakami
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
- Department of Emergency and Critical Care Medicine, Tsuyama Chuo Hospital, Tsuyama, 1756, Tsuyama, Okayama 708-0841, Japan
| | - Takashi Hongo
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
- Department of Emergency, Okayama Saiseikai General Hospital, 2-25 Kokutai-cho, Okayama Kita-ku, Okayama, 700-8511, Japan
| | - Tetsuya Yumoto
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
| | - Yoshinori Kosaki
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
| | - Atsuyoshi Iida
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
- Department of Emergency Medicine, Japanese Red Cross Okayama Hospital, 2-1-1 Aoe, Kita-ku, Okayama, Okayama, 700-8607 Japan
| | - Hiroki Maeyama
- Department of Emergency and Critical Care Medicine, Tsuyama Chuo Hospital, Tsuyama, 1756, Tsuyama, Okayama 708-0841, Japan
| | - Fumiya Inoue
- Department of Emergency Medicine, Hiroshima City Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, Hiroshima 730-8518, Japan
| | - Toshihisa Ichiba
- Department of Emergency Medicine, Hiroshima City Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, Hiroshima 730-8518, Japan
| | - Atsunori Nakao
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
| | - Hiromichi Naito
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
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Van Roy S, Hsu L, Ho J, Scirica BM, Fischer D, Snider SB, Lee JW. Quantitative and Radiological Assessment of Post-cardiac-Arrest Comatose Patients with Diffusion-Weighted Magnetic Resonance Imaging. Neurocrit Care 2024:10.1007/s12028-024-02087-y. [PMID: 39164537 DOI: 10.1007/s12028-024-02087-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/29/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Although magnetic resonance imaging, particularly diffusion-weighted imaging, has increasingly been used as part of a multimodal approach to prognostication in patients who are comatose after cardiac arrest, the performance of quantitative analysis of apparent diffusion coefficient (ADC) maps, as compared to standard radiologist impression, has not been well characterized. This retrospective study evaluated quantitative ADC analysis to the identification of anoxic brain injury by diffusion abnormalities on standard clinical magnetic resonance imaging reports. METHODS The cohort included 204 previously described comatose patients after cardiac arrest. Clinical outcome was assessed by (1) 3-6 month post-cardiac-arrest cerebral performance category and (2) coma recovery to following commands. Radiological evaluation was obtained from clinical reports and characterized as diffuse, cortex only, deep gray matter structures only, or no anoxic injury. Quantitative analyses of ADC maps were obtained in specific regions of interest (ROIs), whole cortex, and whole brain. A subgroup analysis of 172 was performed after eliminating images with artifacts and preexisting lesions. RESULTS Radiological assessment outperformed quantitative assessment over all evaluated regions (area under the curve [AUC] 0.80 for radiological interpretation and 0.70 for the occipital region, the best performing ROI, p = 0.011); agreement was substantial for all regions. Radiological assessment still outperformed quantitative analysis in the subgroup analysis, though by smaller margins and with substantial to near-perfect agreement. When assessing for coma recovery only, the difference was no longer significant (AUC 0.83 vs. 0.81 for the occipital region, p = 0.70). CONCLUSIONS Although quantitative analysis eliminates interrater differences in the interpretation of abnormal diffusion imaging and avoids bias from other prediction modalities, clinical radiologist interpretation has a higher predictive value for outcome. Agreement between radiological and quantitative analysis improved when using high-quality scans and when assessing for coma recovery using following commands. Quantitative assessment may thus be more subject to variability in both clinical management and scan quality than radiological assessment.
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Affiliation(s)
- Sam Van Roy
- Division of EEG and Epilepsy, Department of Neurology, Brigham and Women's Hospital, 60 Fenwood Rd, Boston, MA, 02115, USA
| | - Liangge Hsu
- Division of Neuroradiology, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Joseph Ho
- Division of EEG and Epilepsy, Department of Neurology, Brigham and Women's Hospital, 60 Fenwood Rd, Boston, MA, 02115, USA
| | - Benjamin M Scirica
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David Fischer
- Department of Neurology, Hospital of Pennsylvania, Philadelphia, PA, USA
| | - Samuel B Snider
- Division of Neurocritical Care, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jong Woo Lee
- Division of EEG and Epilepsy, Department of Neurology, Brigham and Women's Hospital, 60 Fenwood Rd, Boston, MA, 02115, USA.
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3
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Iten M, Moser A, Wagner F, Haenggi M. Performance of the MRI lesion pattern score in predicting neurological outcome after out of hospital cardiac arrest: a retrospective cohort analysis. Crit Care 2024; 28:215. [PMID: 38956665 PMCID: PMC11220945 DOI: 10.1186/s13054-024-05007-w] [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: 04/17/2024] [Accepted: 06/27/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Despite advances in resuscitation practice, patient survival following cardiac arrest remains poor. The utilization of MRI in neurological outcome prognostication post-cardiac arrest is growing and various classifications has been proposed; however a consensus has yet to be established. MRI, though valuable, is resource-intensive, time-consuming, costly, and not universally available. This study aims to validate a MRI lesion pattern score in a cohort of out of hospital cardiac arrest patients at a tertiary referral hospital in Switzerland. METHODS This cohort study spanned twelve months from February 2021 to January 2022, encompassing all unconscious patients aged ≥ 18 years who experienced out-of-hospital cardiac arrest of any cause and were admitted to the intensive care unit (ICU) at Inselspital, University Hospital Bern, Switzerland. We included patients who underwent the neuroprognostication process, assessing the performance and validation of a MRI scoring system. RESULTS Over the twelve-month period, 137 patients were admitted to the ICU, with 52 entering the neuroprognostication process and 47 undergoing MRI analysis. Among the 35 MRIs indicating severe hypoxic brain injury, 33 patients (94%) experienced an unfavourable outcome (UO), while ten (83%) of the twelve patients with no or minimal MRI lesions had a favourable outcome. This yielded a sensitivity of 0.94 and specificity of 0.83 for predicting UO with the proposed MRI scoring system. The positive and negative likelihood ratios were 5.53 and 0.07, respectively, resulting in an accuracy of 91.49%. CONCLUSION We demonstrated the effectiveness of the MLP scoring scheme in predicting neurological outcome in patients following cardiac arrest. However, to ensure a comprehensive neuroprognostication, MRI results need to be combined with other assessments. While neuroimaging is a promising objective tool for neuroprognostication, given the absence of sedation-related confounders-compared to electroencephalogram (EEG) and clinical examination-the current lack of a validated scoring system necessitates further studies. Incorporating standardized MRI techniques and grading systems is crucial for advancing the reliability of neuroimaging for neuroprognostication. TRIAL REGISTRATION Registry of all Projects in Switzerland (RAPS) 2020-01761.
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Affiliation(s)
- Manuela Iten
- Department of Intensive Care Medicine, Inselspital, University Hospital Bern, Bern, Switzerland.
| | - Antonia Moser
- Department of Intensive Care Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Franca Wagner
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Matthias Haenggi
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
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4
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Lang M, Kenda M, Scheel M, Martola J, Wheeler M, Owen S, Johnsson M, Annborn M, Dankiewicz J, Deye N, Düring J, Friberg H, Halliday T, Jakobsen JC, Lascarrou JB, Levin H, Lilja G, Lybeck A, McGuigan P, Rylander C, Sem V, Thomas M, Ullén S, Undén J, Wise MP, Cronberg T, Wassélius J, Nielsen N, Leithner C, Moseby-Knappe M. Standardised and automated assessment of head computed tomography reliably predicts poor functional outcome after cardiac arrest: a prospective multicentre study. Intensive Care Med 2024; 50:1096-1107. [PMID: 38900283 PMCID: PMC11245448 DOI: 10.1007/s00134-024-07497-2] [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: 03/13/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE Application of standardised and automated assessments of head computed tomography (CT) for neuroprognostication after out-of-hospital cardiac arrest. METHODS Prospective, international, multicentre, observational study within the Targeted Hypothermia versus Targeted Normothermia after out-of-hospital cardiac arrest (TTM2) trial. Routine CTs from adult unconscious patients obtained > 48 h ≤ 7 days post-arrest were assessed qualitatively and quantitatively by seven international raters blinded to clinical information using a pre-published protocol. Grey-white-matter ratio (GWR) was calculated from four (GWR-4) and eight (GWR-8) regions of interest manually placed at the basal ganglia level. Additionally, GWR was obtained using an automated atlas-based approach. Prognostic accuracies for prediction of poor functional outcome (modified Rankin Scale 4-6) for the qualitative assessment and for the pre-defined GWR cutoff < 1.10 were calculated. RESULTS 140 unconscious patients were included; median age was 68 years (interquartile range [IQR] 59-76), 76% were male, and 75% had poor outcome. Standardised qualitative assessment and all GWR models predicted poor outcome with 100% specificity (95% confidence interval [CI] 90-100). Sensitivity in median was 37% for the standardised qualitative assessment, 39% for GWR-8, 30% for GWR-4 and 41% for automated GWR. GWR-8 was superior to GWR-4 regarding prognostic accuracies, intra- and interrater agreement. Overall prognostic accuracy for automated GWR (area under the curve [AUC] 0.84, 95% CI 0.77-0.91) did not significantly differ from manually obtained GWR. CONCLUSION Standardised qualitative and quantitative assessments of CT are reliable and feasible methods to predict poor functional outcome after cardiac arrest. Automated GWR has the potential to make CT quantification for neuroprognostication accessible to all centres treating cardiac arrest patients.
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Affiliation(s)
- Margareta Lang
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Martin Kenda
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Digital Clinician Scientist Program, Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Juha Martola
- HUS Medical Imaging Center, Radiology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Matthew Wheeler
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - Stephanie Owen
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - Mikael Johnsson
- Department of Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Martin Annborn
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Nicolas Deye
- Department of Medical and Toxicological Intensive Care Unit, Inserm UMR-S 942, Assistance Publique des Hopitaux de Paris, Lariboisière University Hospital, Paris, France
| | - Joachim Düring
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Malmö, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Malmö, Sweden
| | - Thomas Halliday
- Department of Operation and Intensive Care, Linköping University Hospital, Linköping, Sweden
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean-Baptiste Lascarrou
- Medecine Intensive Reanimation, Movement-Interactions-Performance,, Nantes Université, CHU Nantes, MIP, UR 4334, 44000, Nantes, France
| | - Helena Levin
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Research and Education, Skåne University Hospital, Lund, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Anna Lybeck
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Peter McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Christian Rylander
- Anaesthesia and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Victoria Sem
- Department of Anaesthesia and Intensive Care, Central Hospital of Karlstad, Karlstad, Sweden
| | - Matthew Thomas
- Intensive Care Unit, University Hospitals Bristol and Weston, Bristol, UK
| | - Susann Ullén
- Clinical Studies Sweden‑Forum South, Skåne University Hospital, Lund, Sweden
| | - Johan Undén
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Operation and Intensive Care, Hallands Hospital Halmstad, Halmstad, Sweden
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Johan Wassélius
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Christoph Leithner
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
- Department of Neurology, Skåne University Hospital, Lund, Sweden.
- Department of Rehabilitation, Skåne University Hospital, 22185, Lund, Sweden.
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Case NP, Callaway CW, Elmer J, Coppler PJ. Simple approach to quantify hypoxic-ischemic brain injury severity from computed tomography imaging files after cardiac arrest. Resuscitation 2024; 195:110050. [PMID: 37977348 PMCID: PMC10922650 DOI: 10.1016/j.resuscitation.2023.110050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Grey-white ratio (GWR) can estimate severity of cytotoxic cerebral edema secondary to hypoxic-ischemic brain injury after cardiac arrest and predict progression to death by neurologic criteria (DNC). Current approaches to calculating GWR are not standardized and have variable interrater reliability. We tested if measures of variance of brain density on early computed tomographic (CT) imaging after cardiac arrest could predict DNC. METHODS We performed a retrospective cohort study, identifying post-arrest patients treated between 2011 and 2020 at our single center. We extracted demographic data from our registry and Digital Imaging and Communication in Medicine (DICOM) files for each patient's first brain CT. We analyzed slices 15-20 of each DICOM, corresponding to the level of the basal ganglia while accommodating differences in patient anatomy. We extracted pixel arrays and converted the radiodensities to Hounsfield units (HU). To focus on brain tissue densities, we excluded HU > 60 and < 10. We calculated the variance of each patient's HU distribution and the difference between the means of a two-group Gaussian finite mixture model. We compared these novel metrics to existing measures of cerebral edema, then randomly divided our data into 80% training and 20% test sets and used logistic regression to predict DNC. RESULTS Of 1,133 included subjects, 457 (40%) were female, mean (standard deviation) age was 58 (16) years, and 115 (10%) progressed to DNC. CTs were obtained a median [interquartile range] of 4.2 [2.8-5.7] hours post-arrest. Our novel measures correlated weakly with GWR. HU variance, but not difference between mixture model means, differed significantly between subjects with and without sulcal or cistern effacement. GWR outperformed our novel measures in predicting progression to DNC with an area under the receiver operating characteristic curve (AUC) of 0.82, compared to HU variance (AUC = 0.73) and the difference between mixture model means (AUC = 0.56). CONCLUSION There are differences in the distribution of HU on post-arrest CT in patients with qualitative measures of cerebral edema. Current methods to quantify cerebral edema outperform simple measures of attenuation variance on early brain CT. Further analyses could investigate if these measures of variance, or other distributional characteristics of brain density, have improved predictive performance on brain CTs obtained later in the clinical course or derived from discrete regions of anatomical interest.
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Affiliation(s)
- Nicholas P Case
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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6
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Srinivasan V, Hall J, Wahlster S, Johnson NJ, Branch K. Associations between clinical characteristics of cardiac arrest and early CT head findings of hypoxic ischaemic brain injury following out-of-hospital cardiac arrest. Resuscitation 2023; 190:109858. [PMID: 37270091 DOI: 10.1016/j.resuscitation.2023.109858] [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: 03/01/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND/OBJECTIVE Post-cardiac arrest patients are vulnerable to hypoxic-ischaemic brain injury (HIBI), but HIBI may not be identified until computed tomography (CT) scan of the brain is obtained post-resuscitation and stabilization. We aimed to evaluate the association of clinical arrest characteristics with early CT findings of HIBI to identify those at the highest risk for HIBI. METHODS This is a retrospective analysis of out-of-hospital cardiac arrest (OHCA) patients who underwent whole-body imaging. Head CT reports were analyzed with an emphasis on findings suggestive of HIBI; HIBI was present if any of the following were noted on the neuroradiologist read: global cerebral oedema, sulcal effacement, blurred grey-white junction, and ventricular compression. The primary exposure was duration of cardiac arrest. Secondary exposures included age, cardiac vs noncardiac etiology, and witnessed vs unwitnessed arrest. The primary outcome was CT findings of HIBI. RESULTS A total of 180 patients (average age 54 years, 32% female, 71% White, 53% witnessed arrest, 32% cardiac etiology of arrest, mean CPR duration of 15 ± 10 minutes) were included in this analysis. CT findings of HIBI were seen in 47 (48.3%) patients. Multivariate logistic regression demonstrated a significant association between CPR duration and HIBI (adjusted OR = 1.1, 95% CI 1.01-1.11, p < 0.01). CONCLUSION Signs of HIBI are commonly seen on CT head within 6 hours of OHCA, occurring in approximately half of patients, and are associated with CPR duration. Determining risk factors for abnormal CT findings can help clinically identify patients at higher risk for HIBI and target interventions appropriately.
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Affiliation(s)
- Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington School of Medicine, United States.
| | - Jane Hall
- Department of Emergency Medicine, University of Washington School of Medicine, United States
| | - Sarah Wahlster
- Department of Neurology, University of Washington School of Medicine, United States; Department of Neurosurgery, University of Washington School of Medicine, United States; Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, United States
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington School of Medicine, United States; Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, United States
| | - Kelley Branch
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, United States
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7
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Miller AC, Dodi AE, Moskowitz A. Longer CPR durations are associated with early ischemic changes on head CT-A perhaps simple finding in need of complex understanding. Resuscitation 2023; 190:109920. [PMID: 37541608 DOI: 10.1016/j.resuscitation.2023.109920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023]
Affiliation(s)
- Ashley C Miller
- Division of Critical Care Medicine, Montefiore Medical Center, The Bronx, NY, United States
| | - Amos E Dodi
- Division of Critical Care Medicine, Montefiore Medical Center, The Bronx, NY, United States
| | - Ari Moskowitz
- Division of Critical Care Medicine, Montefiore Medical Center, The Bronx, NY, United States.
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8
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Amorim E, Zheng WL, Jing J, Ghassemi MM, Lee JW, Wu O, Herman ST, Pang T, Sivaraju A, Gaspard N, Hirsch L, Ruijter BJ, Tjepkema-Cloostermans MC, Hofmeijer J, van Putten MJAM, Westover MB. Neurophysiology State Dynamics Underlying Acute Neurologic Recovery After Cardiac Arrest. Neurology 2023; 101:e940-e952. [PMID: 37414565 PMCID: PMC10501085 DOI: 10.1212/wnl.0000000000207537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 05/04/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Epileptiform activity and burst suppression are neurophysiology signatures reflective of severe brain injury after cardiac arrest. We aimed to delineate the evolution of coma neurophysiology feature ensembles associated with recovery from coma after cardiac arrest. METHODS Adults in acute coma after cardiac arrest were included in a retrospective database involving 7 hospitals. The combination of 3 quantitative EEG features (burst suppression ratio [BSup], spike frequency [SpF], and Shannon entropy [En]) was used to define 5 distinct neurophysiology states: epileptiform high entropy (EHE: SpF ≥4 per minute and En ≥5); epileptiform low entropy (ELE: SpF ≥4 per minute and <5 En); nonepileptiform high entropy (NEHE: SpF <4 per minute and ≥5 En); nonepileptiform low entropy (NELE: SpF <4 per minute and <5 En), and burst suppression (BSup ≥50% and SpF <4 per minute). State transitions were measured at consecutive 6-hour blocks between 6 and 84 hours after return of spontaneous circulation. Good neurologic outcome was defined as best cerebral performance category 1-2 at 3-6 months. RESULTS One thousand thirty-eight individuals were included (50,224 hours of EEG), and 373 (36%) had good outcome. Individuals with EHE state had a 29% rate of good outcome, while those with ELE had 11%. Transitions out of an EHE or BSup state to an NEHE state were associated with good outcome (45% and 20%, respectively). No individuals with ELE state lasting >15 hours had good recovery. DISCUSSION Transition to high entropy states is associated with an increased likelihood of good outcome despite preceding epileptiform or burst suppression states. High entropy may reflect mechanisms of resilience to hypoxic-ischemic brain injury.
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Affiliation(s)
- Edilberto Amorim
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands.
| | - Wei-Long Zheng
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Jin Jing
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Mohammad M Ghassemi
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Jong Woo Lee
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Ona Wu
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Susan T Herman
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Trudy Pang
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Adithya Sivaraju
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Nicolas Gaspard
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Lawrence Hirsch
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Barry J Ruijter
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Marleen C Tjepkema-Cloostermans
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Jeannette Hofmeijer
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Michel J A M van Putten
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - M Brandon Westover
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
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Crawford AH, Beltran E, Danciu C, Yaffy D. Clinical presentation, diagnosis, treatment, and outcome in 8 dogs and 2 cats with global hypoxic-ischemic brain injury (2010-2022). J Vet Intern Med 2023; 37:1428-1437. [PMID: 37316975 PMCID: PMC10365066 DOI: 10.1111/jvim.16790] [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: 01/02/2023] [Accepted: 05/27/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Global hypoxic-ischemic brain injury (GHIBI) results in variable degrees of neurological dysfunction. Limited data exists to guide prognostication on likelihood of functional recovery. HYPOTHESIS Prolonged duration of hypoxic-ischemic insult and absence of neurological improvement in the first 72 hours are negative prognostic indicators. ANIMALS Ten clinical cases with GHIBI. METHODS Retrospective case series describing 8 dogs and 2 cats with GHIBI, including clinical signs, treatment, and outcome. RESULTS Six dogs and 2 cats experienced cardiopulmonary arrest or anesthetic complication in a veterinary hospital and were promptly resuscitated. Seven showed progressive neurological improvement within 72 hours of the hypoxic-ischemic insult. Four fully recovered and 3 had residual neurological deficits. One dog presented comatose after resuscitation at the primary care practice. Magnetic resonance imaging confirmed diffuse cerebral cortical swelling and severe brainstem compression and the dog was euthanized. Two dogs suffered out-of-hospital cardiopulmonary arrest, secondary to a road traffic accident in 1 and laryngeal obstruction in the other. The first dog was euthanized after MRI that identified diffuse cerebral cortical swelling with severe brainstem compression. In the other dog, spontaneous circulation was recovered after 22 minutes of cardiopulmonary resuscitation. However, the dog remained blind, disorientated, and ambulatory tetraparetic with vestibular ataxia and was euthanized 58 days after presentation. Histopathological examination of the brain confirmed severe diffuse cerebral and cerebellar cortical necrosis. CONCLUSIONS AND CLINICAL IMPORTANCE Duration of hypoxic-ischemic insult, diffuse brainstem involvement, MRI features, and rate of neurological recovery could provide indications of the likelihood of functional recovery after GHIBI.
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Affiliation(s)
- Abbe Harper Crawford
- Clinical Science and ServicesRoyal Veterinary College, Hawkshead Lane, North MymmsHatfield AL9 7TAUnited Kingdom
| | - Elsa Beltran
- Clinical Science and ServicesRoyal Veterinary College, Hawkshead Lane, North MymmsHatfield AL9 7TAUnited Kingdom
| | - Cecilia‐Gabriella Danciu
- Clinical Science and ServicesRoyal Veterinary College, Hawkshead Lane, North MymmsHatfield AL9 7TAUnited Kingdom
| | - Dylan Yaffy
- Pathobiology and Population SciencesRoyal Veterinary College, Hawkshead Lane, North MymmsHatfield AL9 7TAUnited Kingdom
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10
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Wahlster S, Danielson K, Craft L, Matin N, Town JA, Srinivasan V, Schubert G, Carlbom D, Kim F, Johnson NJ, Tirschwell D. Factors Associated with Early Withdrawal of Life-Sustaining Treatments After Out-of-Hospital Cardiac Arrest: A Subanalysis of a Randomized Trial of Prehospital Therapeutic Hypothermia. Neurocrit Care 2023; 38:676-687. [PMID: 36380126 DOI: 10.1007/s12028-022-01636-7] [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: 05/28/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The objective of this study is to describe incidence and factors associated with early withdrawal of life-sustaining therapies based on presumed poor neurologic prognosis (WLST-N) and practices around multimodal prognostication after out-of-hospital cardiac arrest (OHCA). METHODS We performed a subanalysis of a randomized controlled trial assessing prehospital therapeutic hypothermia in adult patients admitted to nine hospitals in King County with nontraumatic OHCA between 2007 and 2012. Patients who underwent tracheal intubation and were unconscious following return of spontaneous circulation were included. Our outcomes were (1) incidence of early WLST-N (WLST-N within < 72 h from return of spontaneous circulation), (2) factors associated with early WLST-N compared with patients who remained comatose at 72 h without WLST-N, (3) institutional variation in early WLST-N, (4) use of multimodal prognostication, and (5) use of sedative medications in patients with early WLST-N. Analysis included descriptive statistics and multivariable logistic regression. RESULTS We included 1,040 patients (mean age was 65 years, 37% were female, 41% were White, and 44% presented with arrest due to ventricular fibrillation) admitted to nine hospitals. Early WLST-N accounted for 24% (n = 154) of patient deaths and occurred in half (51%) of patients with WLST-N. Factors associated with early WLST-N in multivariate regressions were older age (odds ratio [OR] 1.02, 95% confidence interval [CI]: 1.01-1.03), preexisting do-not-attempt-resuscitation orders (OR 4.67, 95% CI: 1.55-14.01), bilateral absent pupillary reflexes (OR 2.4, 95% CI: 1.42-4.10), and lack of neurological consultation (OR 2.60, 95% CI: 1.52-4.46). The proportion of patients with early WLST-N among all OHCA admissions ranged from 19-60% between institutions. A head computed tomography scan was obtained in 54% (n = 84) of patients with early WLST-N; 22% (n = 34) and 5% (n = 8) underwent ≥ 1 and ≥ 2 additional prognostic tests, respectively. Prognostic tests were more frequently performed when neurological consultation occurred. Most patients received sedating medications (90%) within 24 h before early WLST-N; the median time from last sedation to early WLST-N was 4.2 h (interquartile range 0.4-15). CONCLUSIONS Nearly one quarter of deaths after OHCA were due to early WLST-N. The presence of concerning neurological examination findings appeared to impact early WLST-N decisions, even though these are not fully reliable in this time frame. Lack of neurological consultation was associated with early WLST-N and resulted in underuse of guideline-concordant multimodal prognostication. Sedating medications were often coadministered prior to early WLST-N and may have further confounded the neurological examination. Standardizing prognostication, restricting early WLST-N, and a multidisciplinary approach including neurological consultation might improve outcomes after OHCA.
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Affiliation(s)
- Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA.
- Department of Anesthesiology, University of Washington, Seattle, WA, USA.
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
| | - Kyle Danielson
- Airlift Northwest, University of Washington Medicine, Seattle, WA, USA
| | - Lindy Craft
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Nassim Matin
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
| | - James A Town
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Glenn Schubert
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
| | - David Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Francis Kim
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicholas J Johnson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - David Tirschwell
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
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Park JY, Kim YH, Ahn SJ, Lee JH, Lee DW, Hwang SY, Song YG. Association between the extent of diffusion restriction on brain diffusion-weighted imaging and neurological outcomes after an out-of-hospital cardiac arrest. Resuscitation 2023; 187:109761. [PMID: 36898602 DOI: 10.1016/j.resuscitation.2023.109761] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/16/2023] [Accepted: 03/01/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND This study evaluated the association between the extent of diffusion restriction on brain diffusion-weighted imaging (DWI) and neurological outcomes in patients who underwent targeted temperature management (TTM) after an out-of-hospital cardiac arrest (OHCA). METHODS Patients who underwent brain magnetic resonance imaging within 10 days of OHCA between 2012 and 2021 were analysed. The extent of diffusion restriction was described according to the modified DWI Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS). The 35 predefined brain regions were assigned a score if diffuse signal changes were concordantly present in DWI scans and apparent diffusion coefficient maps. The primary outcome was an unfavourable neurological outcome at 6 months. The sensitivity, specificity, and receiver operating characteristic (ROC) curves for the measured parameters were analysed. Cut-off values were determined to predict the primary outcome. The predictive cut-off DWI-ASPECTS was internally validated using five-fold cross-validation. RESULTS Of the 301 patients, 108 (35.9%) had 6-month favourable neurological outcomes. Patients with unfavourable outcomes had higher whole-brain DWI-ASPECTS (median, 31 [26-33] vs. 0 [0-1], P < 0.001) than those with favourable outcomes. The area under the ROC curve (AUROC) of whole-brain DWI-ASPECTS was 0.957 (95% confidence interval [CI] 0.928-0.977). A cut-off value of ≥8 for unfavourable neurological outcomes had specificity and sensitivity of 100% (95% CI 96.6-100) and 89.6% (95% CI 84.4-93.6), respectively. The mean AUROC was 0.956. CONCLUSION More extensive diffusion restriction on DWI-ASPECTS in patients with OHCA who underwent TTM was associated with 6-month unfavourable neurological outcomes. Running title: Diffusion restriction and neurological outcomes after cardiac arrest.
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Affiliation(s)
- Jong Yoon Park
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Seong Jun Ahn
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Jun Ho Lee
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Dong Woo Lee
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Seong Youn Hwang
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Yun Gyu Song
- Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
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12
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Keijzer HM, Duering M, Pasternak O, Meijer FJA, Verhulst MMLH, Tonino BAR, Blans MJ, Hoedemaekers CWE, Klijn CJM, Hofmeijer J. Free water corrected diffusion tensor imaging discriminates between good and poor outcomes of comatose patients after cardiac arrest. Eur Radiol 2023; 33:2139-2148. [PMID: 36418623 PMCID: PMC9935650 DOI: 10.1007/s00330-022-09245-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/26/2022] [Accepted: 10/16/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Approximately 50% of comatose patients after cardiac arrest never regain consciousness. Cerebral ischaemia may lead to cytotoxic and/or vasogenic oedema, which can be detected by diffusion tensor imaging (DTI). Here, we evaluate the potential value of free water corrected mean diffusivity (MD) and fractional anisotropy (FA) based on DTI, for the prediction of neurological recovery of comatose patients after cardiac arrest. METHODS A total of 50 patients after cardiac arrest were included in this prospective cohort study in two Dutch hospitals. DTI was obtained 2-4 days after cardiac arrest. Outcome was assessed at 6 months, dichotomised as poor (cerebral performance category 3-5; n = 20) or good (n = 30) neurological outcome. We calculated the whole brain mean MD and FA and compared between patients with good and poor outcomes. In addition, we compared a preliminary prediction model based on clinical parameters with or without the addition of MD and FA. RESULTS We found significant differences between patients with good and poor outcome of mean MD (good: 726 [702-740] × 10-6 mm2/s vs. poor: 663 [575-736] × 10-6 mm2/s; p = 0.01) and mean FA (0.30 ± 0.03 vs. 0.28 ± 0.03; p = 0.03). An exploratory prediction model combining clinical parameters, MD and FA increased the sensitivity for reliable prediction of poor outcome from 60 to 85%, compared to the model containing clinical parameters only, but confidence intervals are overlapping. CONCLUSIONS Free water-corrected MD and FA discriminate between patients with good and poor outcomes after cardiac arrest and hold the potential to add to multimodal outcome prediction. KEY POINTS • Whole brain mean MD and FA differ between patients with good and poor outcome after cardiac arrest. • Free water-corrected MD can better discriminate between patients with good and poor outcome than uncorrected MD. • A combination of free water-corrected MD (sensitive to grey matter abnormalities) and FA (sensitive to white matter abnormalities) holds potential to add to the prediction of outcome.
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Affiliation(s)
- Hanneke M Keijzer
- Department of Neurology, Rijnstate Hospital, P.O. box 9555, 6800 TA, Arnhem, The Netherlands.
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC, Nijmegen, The Netherlands.
| | - Marco Duering
- Institute for Stroke and Dementia Research (ISD), University Hospital LMU, 81377, Munich, Munich, Germany
- Medical Image Analysis Centre (MIAC AG), Basel and qbig, Department of Biomedical Engineering, University of Basel, CH-4051, Basel, Switzerland
| | - Ofer Pasternak
- Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Frederick J A Meijer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, 6500 HC, Nijmegen, The Netherlands
| | - Marlous M L H Verhulst
- Department of Neurology, Rijnstate Hospital, P.O. box 9555, 6800 TA, Arnhem, The Netherlands
- Department of Clinical Neurophysiology, Faculty of Science and Technology, University of Twente, 7522 NB, Enschede, The Netherlands
| | - Bart A R Tonino
- Department of Radiology, Rijnstate Hospital, 6800 TA, Arnhem, The Netherlands
| | - Michiel J Blans
- Department of Intensive Care Medicine, 6800 TA, Rijnstate Hospital, Arnhem, The Netherlands
| | - Cornelia W E Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Centre, 6500 HC, Nijmegen, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC, Nijmegen, The Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, P.O. box 9555, 6800 TA, Arnhem, The Netherlands
- Department of Clinical Neurophysiology, Faculty of Science and Technology, University of Twente, 7522 NB, Enschede, The Netherlands
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13
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Brain injury markers in blood predict signs of hypoxic ischaemic encephalopathy on head computed tomography after cardiac arrest. Resuscitation 2023; 184:109668. [PMID: 36563954 DOI: 10.1016/j.resuscitation.2022.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND/AIM Signs of hypoxic ischaemic encephalopathy (HIE) on head computed tomography (CT) predicts poor neurological outcome after cardiac arrest. We explore whether levels of brain injury markers in blood could predict the likelihood of HIE on CT. METHODS Retrospective analysis of CT performed at 24-168 h post cardiac arrest on clinical indication within the Target Temperature Management after out-of-hospital cardiac arrest-trial. Biomarkers prospectively collected at 24- and 48 h post-arrest were analysed for neuron specific enolase (NSE), neurofilament light (NFL), total-tau and glial fibrillary acidic protein (GFAP). HIE was assessed through visual evaluation and quantitative grey-white-matter ratio (GWR) was retrospectively calculated on Swedish subjects with original images available. RESULTS In total, 95 patients were included. The performance to predict HIE on CT (performed at IQR 73-116 h) at 48 h was similar for all biomarkers, assessed as area under the receiving operating characteristic curve (AUC) NSE 0.82 (0.71-0.94), NFL 0.79 (0.67-0.91), total-tau 0.84 (0.74-0.95), GFAP 0.79 (0.67-0.90). The predictive performance of biomarker levels at 24 h was AUC 0.72-0.81. At 48 h biomarker levels below Youden Index accurately excluded HIE in 77.3-91.7% (negative predictive value) and levels above Youden Index correctly predicted HIE in 73.3-83.7% (positive predictive value). NSE cut-off at 48 h was 48 ng/ml. Elevated biomarker levels irrespective of timepoint significantly correlated with lower GWR. CONCLUSION Biomarker levels can assess the likelihood of a patient presenting with HIE on CT and could be used to select suitable patients for CT-examination during neurological prognostication in unconscious cardiac arrest patients.
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14
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Kirschen MP, Berman JI, Liu H, Ouyang M, Mondal A, Griffis H, Levow C, Winters M, Lang SS, Huh J, Huang H, Berg RA, Vossough A, Topjian A. Association Between Quantitative Diffusion-Weighted Magnetic Resonance Neuroimaging and Outcome After Pediatric Cardiac Arrest. Neurology 2022; 99:e2615-e2626. [PMID: 36028319 PMCID: PMC9754647 DOI: 10.1212/wnl.0000000000201189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/15/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Diffusion MRI can quantify the extent of hypoxic-ischemic brain injury after cardiac arrest. Our objective was to determine the association between the adult-derived threshold of apparent diffusion coefficient (ADC) <650 × 10-6 mm2/s in >10% of brain tissue and an unfavorable outcome after pediatric cardiac arrest. Since ADC decreases exponentially as a function of increasing age, we determined the association between (1) having >10% of brain tissue below a novel age-dependent ADC threshold, and (2) age-normalized whole-brain mean ADC and unfavorable outcome. METHODS This was a retrospective study of patients aged ≤18 years who had cardiac arrest and a clinically obtained brain MRI within 7 days. The primary outcome was unfavorable neurologic status at hospital discharge based on the Pediatric Cerebral Performance Category score. ADC images were extracted from 3-direction diffusion imaging. We determined whether each patient had >10% of voxels with an ADC below prespecified thresholds. We computed the whole-brain mean ADC for each patient. RESULTS One hundred thirty-four patients were analyzed. Patients with ADC <650 × 10-6 mm2/s in >10% of voxels had 15 times higher odds (95% CI 5-65) of an unfavorable outcome compared with patients with ADC <650 × 10-6 mm2/s (area under the receiver operating characteristic curve [AUROC] 0.72 [95% CI 0.63-0.80]). These ADC criteria had a sensitivity and specificity of 0.49 and 0.94, respectively, and positive and negative predictive values of 0.93 and 0.52, respectively, for an unfavorable outcome. The age-dependent ADC threshold that yielded optimal sensitivity and specificity for unfavorable outcomes was <300 × 10-6 mm2/s below each patient's predicted whole-brain mean ADC. The sensitivity, specificity, and positive and negative predictive values for this ADC threshold were 0.53, 0.96, 0.96, and 0.54, respectively (odds ratio [OR] 26.4 [95% CI 7.5-168.3]; AUROC 0.74 [95% CI 0.66-0.83]). Lower age-normalized whole-brain mean ADC was also associated with an unfavorable outcome (OR 0.42 [0.24-0.64], AUROC 0.76 [95% CI 0.66-0.82]). DISCUSSION Quantitative diffusion thresholds on MRI within 7 days after cardiac arrest were associated with an unfavorable outcome in children. The age-independent ADC threshold was highly specific for predicting an unfavorable outcome. However, the specificity and sensitivity increased when using age-dependent ADC thresholds. Age-dependent ADC thresholds may improve prognostic accuracy and require further investigation in larger cohorts. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that quantitative diffusion-weighted imaging within 7 days postarrest can predict an unfavorable clinical outcome in children.
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Affiliation(s)
- Matthew P Kirschen
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
| | - Jeffrey I Berman
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Hongyan Liu
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Minhui Ouyang
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Antara Mondal
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Heather Griffis
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Cindee Levow
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Madeline Winters
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Shih-Shan Lang
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jimmy Huh
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Hao Huang
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert A Berg
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Arastoo Vossough
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Alexis Topjian
- From the Departments of Anesthesiology and Critical Care Medicine (M.P.K., C.L., M.W., J.H., R.A.B., A.T.), and Radiology (J.I.B., M.O., H.H., A.V.); Data Science and Biostatistics Unit (H.L., A.M., H.G.), Department of Biomedical and Health Informatics, and Department of Neurosurgery (S.-S.L.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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15
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Lang M, Leithner C, Scheel M, Kenda M, Cronberg T, During J, Rylander C, Annborn M, Dankiewicz J, Deye N, Halliday T, Lascarrou JB, Matthew T, McGuigan P, Morgan M, Thomas M, Ullén S, Undén J, Nielsen N, Moseby-Knappe M. Prognostic accuracy of head computed tomography for prediction of functional outcome after out-of-hospital cardiac arrest: Rationale and design of the prospective TTM2-CT-substudy. Resusc Plus 2022; 12:100316. [PMID: 36267356 PMCID: PMC9576971 DOI: 10.1016/j.resplu.2022.100316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 09/19/2022] [Indexed: 11/30/2022] Open
Abstract
Background Head computed tomography (CT) is a guideline recommended method to predict functional outcome after cardiac arrest (CA), but standardized criteria for evaluation are lacking. To date, no prospective trial has systematically validated methods for diagnosing hypoxic-ischaemic encephalopathy (HIE) on CT after CA. We present a protocol for validation of pre-specified radiological criteria for assessment of HIE on CT for neuroprognostication after CA. Methods/design This is a prospective observational international multicentre substudy of the Targeted Hypothermia versus Targeted Normothermia after out-of-hospital cardiac arrest (TTM2) trial. Patients still unconscious 48 hours post-arrest at 13 participating hospitals were routinely examined with CT. Original images will be evaluated by examiners blinded to clinical data using a standardized protocol. Qualitative assessment will include evaluation of absence/presence of "severe HIE". Radiodensities will be quantified in pre-specified regions of interest for calculation of grey-white matter ratios (GWR) at the basal ganglia level. Functional outcome will be dichotomized into good (modified Rankin Scale 0-3) and poor (modified Rankin Scale 4-6) at six months post-arrest. Prognostic accuracies for good and poor outcome will be presented as sensitivities and specificities with 95% confidence intervals (using pre-specified cut-offs for quantitative analysis), descriptive statistics (Area Under the Receiver Operating Characteristics Curve), inter- and intra-rater reliabilities according to STARD guidelines. Conclusions The results from this prospective trial will validate a standardized approach to radiological evaluations of HIE on CT for prediction of functional outcome in comatose CA patients.The TTM2 trial and the TTM2 CT substudy are registered at ClinicalTrials.gov NCT02908308 and NCT03913065.
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Affiliation(s)
- Margareta Lang
- Department of Clinical Sciences Lund, Radiology, Lund University, Helsingborg Hospital, Helsingborg, Sweden,Corresponding author at: Helsingborg Hospital, Department of Radiology, 252 23 Helsingborg, Sweden.
| | - Christoph Leithner
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Germany
| | - Martin Kenda
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Germany,Berlin Institute of Health at Charité, Universitätsmedizin Berlin, Germany
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Joachim During
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Christian Rylander
- Department of Surgical Sciences, Anaesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Martin Annborn
- Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University, Lund, Sweden
| | - Nicolas Deye
- Department of Medical and Toxicological Intensive Care Unit, Lariboisière Hospital, Paris, France
| | - Thomas Halliday
- Department of Operation and Intensive Care, Linköping University Hospital, Linköping, Sweden
| | | | - Thomas Matthew
- Intensive Care Unit, University Hospitals, Bristol and Weston, England, United Kingdom
| | - Peter McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland, United Kingdom
| | - Matt Morgan
- Department of Intensive Care, the Royal Perth Hospital, Perth, Australia,Department of Intensive Care, The University Hospital of Wales, Cardiff, United Kingdom,School of Medicine, Curtin University, Perth, Australia
| | - Matthew Thomas
- University Hospitals, Bristol and Weston, United Kingdom
| | - Susann Ullén
- Clinical Studies Sweden – Forum South, Skåne University Hospital, Lund, Sweden
| | - Johan Undén
- Department of Clinical Science Lund, Lund, Sweden,Department of Operation and Intensive Care, Hallands Hospital Halmstad, Halmstad, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
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16
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Lee S, You Y, Ahn HJ, Park JS, Jeong W, Kang C, Min JH, In YN. Comparison of intracranial pressure changes in out-of-hospital cardiac arrest patients with and without malignant blood-brain barrier disruption. Clin Exp Emerg Med 2022; 9:296-303. [PMID: 36624996 PMCID: PMC9834819 DOI: 10.15441/ceem.22.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/21/2022] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE In the present study, intracranial pressure (ICP) changes were investigated in out-ofhospital cardiac arrest (OHCA) patients with and without malignant blood-brain barrier (BBB) disruption who underwent target temperature management. METHODS This prospective, single-center, observational study was conducted from June 2019 to December 2021. ICP and albumin quotient values were measured on days 1, 2, 3, and 4 of hospitalization. Malignant BBB disruption was defined as the sum of scores for the degree of BBB disruption ≥9 on days 1 to 4. RESULTS ICP in OHCA patients without malignant BBB disruption on days 1, 2, 3, and 4 of hospitalization was 9.58±0.53, 12.32±0.65, 14.39±0.76, and 13.88±0.87 mmHg, respectively, and in OHCA patients with malignant BBB disruption 13.65±0.74, 15.72±0.67, 16.10±0.92, and 15.22±0.87 mmHg, respectively (P<0.001, P<0.001, P=0.150, and P=0.280, respectively). The P-values of changes in ICP between days 1 and 2, days 2 and 3, and days 3 and 4 of hospitalization in OHCA patients without malignant BBB disruption were P<0.001, P=0.001, and P=0.540, respectively, and in OHCA patients with malignant BBB disruption were P=0.002, P=0.550, and P=0.100, respectively. CONCLUSION Among OHCA patients treated with target temperature management, ICP was higher on days 1 and 2 of hospitalization and an increase in ICP occurred earlier with malignant BBB disruption than without malignant BBB disruption.
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Affiliation(s)
- Seungwoo Lee
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Korea,Correspondence to: Yeonho You Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea E-mail:
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Korea,Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Korea,Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Jin Hong Min
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea,Department of Emergency Medicine, Chungnam National University Sejong Hospital, Sejong, Korea
| | - Yong Nam In
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea,Department of Emergency Medicine, Chungnam National University Sejong Hospital, Sejong, Korea
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17
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Keijzer HM, Lange PAM, Meijer FJA, Tonino BAR, Blans MJ, Klijn CJM, Hoedemaekers CWE, Hofmeijer J, Helmich RC. MRI markers of brain network integrity relate to neurological outcome in postanoxic coma. Neuroimage Clin 2022; 36:103171. [PMID: 36058165 PMCID: PMC9446009 DOI: 10.1016/j.nicl.2022.103171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 12/14/2022]
Abstract
AIM Current multimodal approaches leave approximately half of the comatose patients after cardiac arrest with an indeterminate prognosis. Here we investigated whether early MRI markers of brain network integrity can distinguish between comatose patients with a good versus poor neurological outcome six months later. METHODS We performed a prospective cohort study in 48 patients after cardiac arrest submitted in a comatose state to the Intensive Care Unit of two Dutch hospitals. MRI was performed at three days after cardiac arrest, including resting state functional MRI and diffusion-tensor imaging (DTI). Resting state fMRI was used to quantify functional connectivity within ten resting-state networks, and DTI to assess mean diffusivity (MD) in these same networks. We contrasted two groups of patients, those with good (n = 29, cerebral performance category 1-2) versus poor (n = 19, cerebral performance category 3-5) outcome at six months. Mutual associations between functional connectivity, MD, and clinical outcome were studied. RESULTS Patients with good outcome show higher within-network functional connectivity (fMRI) and higher MD (DTI) than patients with poor outcome across 8/10 networks, most prominent in the default mode network, salience network, and visual network. While the anatomical distribution of outcome-related changes was similar for functional connectivity and MD, the pattern of inter-individual differences was very different: functional connectivity showed larger inter-individual variability in good versus poor outcome, while the opposite was observed for MD. Exploratory analyses suggested that it is possible to define network-specific cut-off values that could help in outcome prediction: (1) high functional connectivity and high MD, associated with good outcome; (2) low functional connectivity and low MD, associated with poor outcome; (3) low functional connectivity and high MD, associated with uncertain outcome. DISCUSSION Resting-state functional connectivity and mean diffusivity-three days after cardiac arrest are strongly associated with neurological recovery-six months later in a complementary fashion. The combination of fMRI and MD holds potential to improve prediction of outcome.
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Affiliation(s)
- Hanneke M Keijzer
- Department of Neurology, Rijnstate Hospital, 6800 TA Arnhem, the Netherlands; Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands.
| | - Puck A M Lange
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Frederick J A Meijer
- Department of Medical Imaging, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Bart A R Tonino
- Department of Radiology, Rijnstate Hospital, 6800 TA Arnhem, the Netherlands
| | - Michiel J Blans
- Department of Intensive Care Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Cornelia W E Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, 6800 TA Arnhem, the Netherlands; Department of Clinical Neurophysiology, University of Twente, Faculty of Science and Technology, 7522 NB Enschede, the Netherlands
| | - Rick C Helmich
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
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18
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Lang M, Nielsen N, Ullén S, Abul-Kasim K, Johnsson M, Helbok R, Leithner C, Cronberg T, Moseby-Knappe M. A pilot study of methods for prediction of poor outcome by head computed tomography after cardiac arrest. Resuscitation 2022; 179:61-70. [PMID: 35931271 DOI: 10.1016/j.resuscitation.2022.07.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/18/2022] [Accepted: 07/27/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION In Sweden, head computed tomography (CT) is commonly used for prediction of neurological outcome after cardiac arrest, as recommended by guidelines. We compare the prognostic ability and interrater variability of routine and novel CT methods for prediction of poor outcome. METHODS Retrospective study including patients from Swedish sites within the Target Temperature Management after out-of-hospital cardiac arrest trial examined with CT. Original images were assessed by two independent radiologists blinded from clinical data with eye-balling without pre-specified criteria, and with a semi-quantitative assessment. Grey-white-matter ratios (GWR) were quantified using models with 4-20 manually placed regions of interest. Prognostic abilities and interrater variability were calculated for prediction of poor outcome (modified Rankin Scale 4-6 at six months) for early (<24h) and late (≥24h) examinations. RESULTS 68/106 (64%) of included patients were examined <24h post-arrest. Eye-balling predicted poor outcome with 89-100% specificity and 15-78% sensitivity. GWR <24h predicted neurological outcome with unsatisfactory to satisfactory Area Under the Receiver Operating Characteristics Curve (AUROC: 0.54-0.64). GWR ≥24h yielded very good to excellent AUROC (0.80-0.93). Sensitivities increased >2-3 fold in examinations performed after 24h compared to early examinations. Combining eye-balling with GWR<1.15 predicted poor outcome without false positives with sensitivities remaining acceptable. CONCLUSION In our cohort, qualitative and quantitative CT methods predicted poor outcome with high specificity and low to moderate sensitivity. Sensitivity increased relevantly after the first 24 hours after CA. Interrater variability poses a problem and indicates the need to standardise brain CT evaluation to increase the methodś safety.
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Affiliation(s)
- Margareta Lang
- Department of Clinical Sciences Lund, Radiology, Lund University, Helsingborg Hospital, Lund, Sweden.
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Helsingborg Hospital, Lund, Sweden
| | - Susann Ullén
- Clinical Studies Sweden ‑ Forum South, Skåne University Hospital, Lund, Sweden
| | - Kasim Abul-Kasim
- Department of Clinical Sciences Lund, Radiology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Mikael Johnsson
- Department of Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Raimund Helbok
- Department of Neurology, Neurological Intensive Care Unit, Medical University Innsbruck, Innsbruck, Austria
| | - Christoph Leithner
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Germany
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
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19
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Kwon SH, Oh SH, Jang J, Kim SH, Park KN, Youn CS, Kim HJ, Lim JY, Kim HJ, Bang HJ. Can Optic Nerve Sheath Images on a Thin-Slice Brain Computed Tomography Reconstruction Predict the Neurological Outcomes in Cardiac Arrest Survivors? J Clin Med 2022; 11:jcm11133677. [PMID: 35806962 PMCID: PMC9267811 DOI: 10.3390/jcm11133677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/28/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
We analyzed the prognostic performance of optic nerve sheath diameter (ONSD) on thin-slice (0.6 mm) brain computed tomography (CT) reconstruction images as compared to routine-slice (4 mm) images. We conducted a retrospective analysis of brain CT images taken within 2 h after cardiac arrest. The maximal ONSD (mONSD) and optic nerve sheath area (ONSA) were measured on thin-slice images, and the routine ONSD (rONSD) and gray-to-white matter ratio (GWR) were measured on routine-slice images. We analyzed their area under the receiver operator characteristic curve (AUC) and the cutoff values for predicting a poor 6-month neurological outcome (a cerebral performance category score of 3–5). Of the 159 patients analyzed, 113 patients had a poor outcome. There was no significant difference in rONSD between the outcome groups (p = 0.116). Compared to rONSD, mONSD (AUC 0.62, 95% CI: 0.54–0.70) and the ONSA (AUC 0.63, 95% CI: 0.55–0.70) showed better prognostic performance and had higher sensitivities to determine a poor outcome (mONSD, 20.4% [95% CI, 13.4–29.0]; ONSA, 16.8% [95% CI, 10.4–25.0]; rONSD, 7.1% [95% CI, 3.1–13.5]), with specificity of 95.7% (95% CI, 85.2–99.5). A combined cutoff value obtained by both the mONSD and GWR improved the sensitivity (31.0% [95% CI, 22.6–40.4]) of determining a poor outcome, while maintaining a high specificity. In conclusion, rONSD was clinically irrelevant, but the mONSD had an increased sensitivity in cutoff having acceptable specificity. Combination of the mONSD and GWR had an improved prognostic performance in these patients.
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Affiliation(s)
- Sung Ho Kwon
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.H.K.); (K.N.P.); (C.S.Y.); (H.J.K.); (J.Y.L.); (H.J.K.); (H.J.B.)
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.H.K.); (K.N.P.); (C.S.Y.); (H.J.K.); (J.Y.L.); (H.J.K.); (H.J.B.)
- Correspondence: ; Tel.: +82-2-2258-1988; Fax: +82-2-2258-1997
| | - Jinhee Jang
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Soo Hyun Kim
- Department of Emergency Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Korea;
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.H.K.); (K.N.P.); (C.S.Y.); (H.J.K.); (J.Y.L.); (H.J.K.); (H.J.B.)
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.H.K.); (K.N.P.); (C.S.Y.); (H.J.K.); (J.Y.L.); (H.J.K.); (H.J.B.)
| | - Han Joon Kim
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.H.K.); (K.N.P.); (C.S.Y.); (H.J.K.); (J.Y.L.); (H.J.K.); (H.J.B.)
| | - Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.H.K.); (K.N.P.); (C.S.Y.); (H.J.K.); (J.Y.L.); (H.J.K.); (H.J.B.)
| | - Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.H.K.); (K.N.P.); (C.S.Y.); (H.J.K.); (J.Y.L.); (H.J.K.); (H.J.B.)
| | - Hyo Jin Bang
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.H.K.); (K.N.P.); (C.S.Y.); (H.J.K.); (J.Y.L.); (H.J.K.); (H.J.B.)
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20
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Goh J, Eramanis LM, Milne M, Boller M. Brain magnetic resonance imaging and histopathology findings in a dog with global brain ischaemia following cardiopulmonary arrest. Aust Vet J 2022; 100:433-439. [PMID: 35656570 PMCID: PMC9546154 DOI: 10.1111/avj.13178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/27/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
Abstract
Background Global brain ischaemia following cardiopulmonary arrest is uncommonly reported in veterinary medicine yet neurologic injury after arrest is a known morbidity. Case report An 18‐week‐old male entire Cavalier King Charles Spaniel‐Poodle was referred following 3 days of neurologic abnormalities after cardiopulmonary arrest. After resuscitation, the animal had decerebrate rigidity, a stuporous mentation and intermittent episodes of vocalisation and apnoea. A brain magnetic resonance imaging (MRI) was undertaken 4 days after cardiopulmonary arrest, with standard sequences (T1‐weighted, T2‐weighted and fluid‐attenuated inversion recovery) as well as diffusion‐weighted imaging to better discern ischaemic injury and cytotoxic oedema for prognostic reasons. MRI findings were consistent with global brain ischaemia affecting the hippocampus, cerebellum and substantia nigra, the latter two not previously identified in canine cases of global brain ischaemia. The patient was euthanased on day eight post‐cardiopulmonary arrest due to a lack of neurological improvement and developing sepsis as a complication. Ante‐mortem identification of affected areas of the brain was confirmed on histological examination, with evidence of ischaemic injury seen in the cerebrum, hippocampus, cerebellum, basal nuclei and thalamus. Conclusion This report describes ante‐mortem MRI and postmortem findings in a dog with global brain ischaemia following cardiopulmonary arrest. A multimodal approach to neuroprognostication in patients recovering from cardiopulmonary arrest is recommended.
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Affiliation(s)
- J Goh
- U‐Vet Animal Hospital, University of Melbourne 250 Princes Highway Werribee Victoria 3030 Australia
| | - LM Eramanis
- Small Animal Specialist Hospital Level 1, 1 Richardson Place North Ryde New South Wales 2113 Australia
| | - M Milne
- VetCT 185‐187 High Street, Suite 11 Ground Floor Fremantle Western Australia 6160 Australia
| | - M Boller
- U‐Vet Animal Hospital, University of Melbourne 250 Princes Highway Werribee Victoria 3030 Australia
- Central Victoria Veterinary Hospital, VCA Canada 760 Roderick Street Victoria British Columbia V8X 2R3 Canada
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21
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Hagberg G, Ihle-Hansen H, Sandset EC, Jacobsen D, Wimmer H, Ihle-Hansen H. Long Term Cognitive Function After Cardiac Arrest: A Mini-Review. Front Aging Neurosci 2022; 14:885226. [PMID: 35721022 PMCID: PMC9204346 DOI: 10.3389/fnagi.2022.885226] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality worldwide. With better pre- and inhospital treatment, including cardiopulmonary resuscitation (CPR) as an integrated part of public education and more public-access defibrillators available, OHCA survival has increased over the last decade. There are concerns, after successful resuscitation, of cerebral hypoxia and degrees of potential acquired brain injury with resulting poor cognitive functioning. Cognitive function is not routinely assessed in OHCA survivors, and there is a lack of consensus on screening methods for cognitive changes. This narrative mini-review, explores available evidence on hypoxic brain injury and long-term cognitive function in cardiac arrest survivors and highlights remaining knowledge deficits.
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22
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Sekhon MS, Griesdale DE. Low field magnetic resonance imaging: A "beds-eye-d" view into hypoxic ischemic brain injury after cardiac arrest. Resuscitation 2022; 176:55-57. [PMID: 35605800 DOI: 10.1016/j.resuscitation.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
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23
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Prognosis After Cardiac Arrest: The Additional Value of DWI and FLAIR to EEG. Neurocrit Care 2022; 37:302-313. [DOI: 10.1007/s12028-022-01498-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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24
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Routine Reporting of Grey-White Matter differentiation in Early Brain Computed Tomography in comatose patients after cardiac arrest: a substudy of the COACT trial. Resuscitation 2022; 175:13-18. [DOI: 10.1016/j.resuscitation.2022.03.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 01/27/2023]
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25
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Zhou F, Wang H, Jian M, Wang Z, He Y, Duan H, Gan L, Cao Y. Gray-White Matter Ratio at the Level of the Basal Ganglia as a Predictor of Neurologic Outcomes in Cardiac Arrest Survivors: A Literature Review. Front Med (Lausanne) 2022; 9:847089. [PMID: 35372375 PMCID: PMC8967346 DOI: 10.3389/fmed.2022.847089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/09/2022] [Indexed: 02/05/2023] Open
Abstract
Loss of gray-white matter discrimination is the primary early imaging finding within of cranial computed tomography in cardiac arrest survivors, and this has been also regarded as a novel predictor for evaluating neurologic outcome. As displayed clearly on computed tomography and based on sensitivity to hypoxia, the gray-white matter ratio at basal ganglia (GWR-BG) region was frequently detected to assess the neurologic outcome by several studies. The specificity of GWR-BG is 72.4 to 100%, while the sensitivity is significantly different. Herein we review the mechanisms mediating cerebral edema following cardiac arrest, demonstrate the determination procedures with respect to GWR-BG, summarize the related researches regarding GWR-BG in predicting neurologic outcomes within cardiac arrest survivors, and discuss factors associated with predicting the accuracy of this methodology. Finally, we describe the effective measurements to increase the sensitivity of GWR-BG in predicting neurologic outcome.
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Affiliation(s)
- Fating Zhou
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hongxia Wang
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Mengyao Jian
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyuan Wang
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yarong He
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Haizhen Duan
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Gan
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Cao
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
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26
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Elmer J, Liu C, Pease M, Arefan D, Coppler PJ, Flickinger K, Mettenburg JM, Baldwin ME, Barot N, Wu S. Deep learning of early brain imaging to predict post-arrest electroencephalography. Resuscitation 2022; 172:17-23. [PMID: 35041875 PMCID: PMC8923981 DOI: 10.1016/j.resuscitation.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Guidelines recommend use of computerized tomography (CT) and electroencephalography (EEG) in post-arrest prognostication. Strong associations between CT and EEG might obviate the need to acquire both modalities. We quantified these associations via deep learning. METHODS We performed a single-center, retrospective study including comatose patients hospitalized after cardiac arrest. We extracted brain CT DICOMs, resized and registered each to a standard anatomical atlas, performed skull stripping and windowed images to optimize contrast of the gray-white junction. We classified initial EEG as generalized suppression, other highly pathological findings or benign activity. We extracted clinical information available on presentation from our prospective registry. We trained three machine learning (ML) models to predict EEG from clinical covariates. We used three state-of-the-art approaches to build multi-headed deep learning models using similar model architectures. Finally, we combined the best performing clinical and imaging models. We evaluated discrimination in test sets. RESULTS We included 500 patients, of whom 218 (44%) had benign EEG findings, 135 (27%) showed generalized suppression and 147 (29%) had other highly pathological findings that were most commonly (93%) burst suppression with identical bursts. Clinical ML models had moderate discrimination (test set AUCs 0.73-0.80). Image-based deep learning performed worse (test set AUCs 0.51-0.69), particularly discriminating benign from highly pathological findings. Adding image-based deep learning to clinical models improved prediction of generalized suppression due to accurate detection of severe cerebral edema. DISCUSSION CT and EEG provide complementary information about post-arrest brain injury. Our results do not support selective acquisition of only one of these modalities, except in the most severely injured patients.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Neurology Division, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Chang Liu
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew Pease
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dooman Arefan
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick J. Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katharyn Flickinger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph M. Mettenburg
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria E. Baldwin
- Department of Neurology, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
| | - Niravkumar Barot
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shandong Wu
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA,Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA,Intelligent Systems Program, University of Pittsburgh, Pittsburgh, PA, USA
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Nutma S, Tjepkema-Cloostermans MC, Ruijter BJ, Tromp SC, van den Bergh WM, Foudraine NA, H M Kornips F, Drost G, Scholten E, Strang A, Beishuizen A, J A M van Putten M, Hofmeijer J. Effects of targeted temperature management at 33°C vs. 36°C on comatose patients after cardiac arrest stratified by the severity of encephalopathy. Resuscitation 2022; 173:147-153. [PMID: 35122892 DOI: 10.1016/j.resuscitation.2022.01.026] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To assess neurological outcome after targeted temperature management (TTM) at 33°C vs. 36°C, stratified by the severity of encephalopathy based on EEG-patterns at 12 and 24h. DESIGN Post hoc analysis of prospective cohort study. SETTING Five Dutch Intensive Care units. PATIENTS 479 adult comatose post-cardiac arrest patients. INTERVENTIONS TTM at 33°C (n=270) or 36°C (n=209) and continuous EEG monitoring. MEASUREMENTS AND MAIN RESULTS Outcome according to the cerebral performance category (CPC) score at 6 months post-cardiac arrest was similar after 33°C and 36°C. However, when stratified by the severity of encephalopathy based on EEG-patterns at 12 and 24h after cardiac arrest, the proportion of good outcome (CPC 1-2) in patients with moderate encephalopathy was significantly larger after TTM at 33°C (66% vs. 45%; Odds Ratios 2.38, 95% CI=1.32-4.30; p=0.004). In contrast, with mild encephalopathy, there was no statistically significant difference in the proportion of patients with good outcome between 33°C and 36°C (88% vs. 81%; OR 1.68, 95% CI=0.65-4.38; p=0.282). Ordinal regression analysis showed a shift towards higher CPC scores when treated with TTM 33°C as compared with 36°C in moderate encephalopathy (cOR 2.39; 95% CI=1.40-4.08; p=0.001), but not in mild encephalopathy (cOR 0.81 95% CI=0.41-1.59; p=0.537). Adjustment for initial cardiac rhythm and cause of arrest did not change this relationship. CONCLUSIONS Effects of TTM probably depend on the severity of encephalopathy in comatose patients after cardiac arrest. These results support inclusion of predefined subgroup analyses based on EEG measures of the severity of encephalopathy in future clinical trials.
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Affiliation(s)
- Sjoukje Nutma
- Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede; Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede.
| | | | - Barry J Ruijter
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede
| | - Selma C Tromp
- Departments of Neurology and Clinical Neurophysiology, St Antonius Hospital, Nieuwegein
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen
| | | | | | - Gea Drost
- Departments of Neurology and Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen
| | - Erik Scholten
- Department of Intensive Care, St Antonius Hospital, Nieuwegein
| | - Aart Strang
- Department of Intensive Care, Rijnstate Hospital, Arnhem
| | | | - Michel J A M van Putten
- Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede; Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede
| | - Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede; Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
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Nam In Y, Ho Lee I, Soo Park J, Mi Kim Data Acquisition D, You Data Acquisition Y, Hong Min J, Jeong W, Jun Ahn H, Kang C, Kook Lee B. Delayed head CT in out-of-hospital cardiac arrest survivors: Does this improve predictive performance of neurological outcome? Resuscitation 2022; 172:1-8. [PMID: 35026330 DOI: 10.1016/j.resuscitation.2022.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND We compared the ability of head computed tomography (HCT) and MRI, respectively, obtained before or after target temperature management to predict neurologic outcomes in out-of-hospital cardiac arrest (OHCA) survivors. METHODS This retrospective study included adult comatose OHCA survivors who underwent neuroimaging scans within 6 h (first HCT) or 72-96 h (second HCT and MRI) after the return of spontaneous circulation (ROSC). We calculated the gray-white matter ratio (GWR), hypoxic-ischemic brain injury presence (loss of boundary at the basal ganglia level [LOB at BG], sulcal effacement at the centrum semiovale [SE at CS], and pseudo-SAH sign), and the overall score based on MRI findings (a total score of 21 brain regions individually scored according to the degree of signal abnormality). RESULTS Overall, 78 patients were included in this analysis, of whom 45 (58%) showed poor outcomes. The second HCT scan showed greater prognostic performance than the first HCT scan for GWR (area under curve 0.92 vs. 0.70), LOB at BG (0.93 vs. 0.65), SE at CS (0.89 vs. 0.64), and pseudo-SAH sign (0.75 vs. 0.51). The overall score on MRI (0.99) showed the highest prognostic performance. However, on the second HCT scan, the combination of GWR and LOB at BG showed prognostic performance (0.96) comparable to the overall score on MRI (P=0.12); the corresponding sensitivity and specificity values were 85.7% and 100%. CONCLUSIONS Overall score on MRI and the combination of GWR and LOB at BG findings on second HCT scans may help predict poor outcomes in OHCA survivors.
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Affiliation(s)
- Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Sejong Chungnam National University Hospital, Daejoen, Republic of Korea
| | - In Ho Lee
- Department of Radiology, College of Medicine, Chungnam National University, 266, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea.
| | - Da Mi Kim Data Acquisition
- Department of Radiology, College of Medicine, Chungnam National University, 266, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | | | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Sejong Chungnam National University Hospital, Daejoen, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
| | - Hong Jun Ahn
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam national University Medical School, Chonnam National Univesity Hospital, Gwangju, Republic of Korea
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Aufderheide TP, Kalra R, Kosmopoulos M, Bartos JA, Yannopoulos D. Enhancing cardiac arrest survival with extracorporeal cardiopulmonary resuscitation: insights into the process of death. Ann N Y Acad Sci 2022; 1507:37-48. [PMID: 33609316 PMCID: PMC8377067 DOI: 10.1111/nyas.14580] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 01/03/2023]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging method of cardiopulmonary resuscitation to improve outcomes from cardiac arrest. This approach targets patients with out-of-hospital cardiac arrest previously unresponsive and refractory to standard treatment, combining approximately 1 h of standard CPR followed by venoarterial extracorporeal membrane oxygenation (VA-ECMO) and coronary artery revascularization. Despite its relatively new emergence for the treatment of cardiac arrest, the approach is grounded in a vast body of preclinical and clinical data that demonstrate significantly improved survival and neurological outcomes despite unprecedented, prolonged periods of CPR. In this review, we detail the principles behind VA-ECMO-facilitated resuscitation, contemporary clinical approaches with outcomes, and address the emerging new understanding of the process of death and capability for neurological recovery.
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Affiliation(s)
- Tom P. Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Jason A. Bartos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
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Mansour A, Fuhrman JD, Ammar FE, Loggini A, Davis J, Lazaridis C, Kramer C, Goldenberg FD, Giger ML. Machine Learning for Early Detection of Hypoxic-Ischemic Brain Injury After Cardiac Arrest. Neurocrit Care 2021; 36:974-982. [PMID: 34873672 PMCID: PMC8647961 DOI: 10.1007/s12028-021-01405-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 11/16/2021] [Indexed: 11/25/2022]
Abstract
Background Establishing whether a patient who survived a cardiac arrest has suffered hypoxic-ischemic brain injury (HIBI) shortly after return of spontaneous circulation (ROSC) can be of paramount importance for informing families and identifying patients who may benefit the most from neuroprotective therapies. We hypothesize that using deep transfer learning on normal-appearing findings on head computed tomography (HCT) scans performed after ROSC would allow us to identify early evidence of HIBI. Methods We analyzed 54 adult comatose survivors of cardiac arrest for whom both an initial HCT scan, done early after ROSC, and a follow-up HCT scan were available. The initial HCT scan of each included patient was read as normal by a board-certified neuroradiologist. Deep transfer learning was used to evaluate the initial HCT scan and predict progression of HIBI on the follow-up HCT scan. A naive set of 16 additional patients were used for external validation of the model. Results The median age (interquartile range) of our cohort was 61 (16) years, and 25 (46%) patients were female. Although findings of all initial HCT scans appeared normal, follow-up HCT scans showed signs of HIBI in 29 (54%) patients (computed tomography progression). Evaluating the first HCT scan with deep transfer learning accurately predicted progression to HIBI. The deep learning score was the most significant predictor of progression (area under the receiver operating characteristic curve = 0.96 [95% confidence interval 0.91–1.00]), with a deep learning score of 0.494 having a sensitivity of 1.00, specificity of 0.88, accuracy of 0.94, and positive predictive value of 0.91. An additional assessment of an independent test set confirmed high performance (area under the receiver operating characteristic curve = 0.90 [95% confidence interval 0.74–1.00]). Conclusions Deep transfer learning used to evaluate normal-appearing findings on HCT scans obtained early after ROSC in comatose survivors of cardiac arrest accurately identifies patients who progress to show radiographic evidence of HIBI on follow-up HCT scans.
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Affiliation(s)
- Ali Mansour
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
- Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Jordan D Fuhrman
- Department of Radiology, University of Chicago, 5841 S. Maryland Ave., Chicago, IL, 60637-1470, USA
| | - Faten El Ammar
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
| | - Andrea Loggini
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
| | - Jared Davis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
- Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Christopher Kramer
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
- Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Fernando D Goldenberg
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA.
- Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Maryellen L Giger
- Department of Radiology, University of Chicago, 5841 S. Maryland Ave., Chicago, IL, 60637-1470, USA.
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Intracranial Pressure Patterns and Neurological Outcomes in Out-of-Hospital Cardiac Arrest Survivors after Targeted Temperature Management: A Retrospective Observational Study. J Clin Med 2021; 10:jcm10235697. [PMID: 34884400 PMCID: PMC8658348 DOI: 10.3390/jcm10235697] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/27/2021] [Accepted: 12/02/2021] [Indexed: 11/25/2022] Open
Abstract
We aimed to investigate intracranial pressure (ICP) changes over time and the neurologic prognosis for out-of-hospital cardiac arrest (OHCA) survivors who received targeted temperature management (TTM). ICP was measured immediately after return of spontaneous circulation (ROSC) (day 1), then at 24 h (day 2), 48 h (day 3), and 72 h (day 4), through connecting a lumbar drain catheter to a manometer or a LiquoGuard machine. Neurological outcomes were determined at 3 months after ROSC, and a poor neurological outcome was defined as Cerebral Performance Category 3–5. Of the 91 patients in this study (males, n = 67, 74%), 51 (56%) had poor neurological outcomes. ICP was significantly higher in the poor outcome group at each time point except day 4. ICP elevation was highest between days 2 and 3 in the good outcome group, and between days 1 and 2 in the poor outcome group. However, there was no difference in total ICP elevation between the poor and good outcome groups (3.0 vs. 3.1; p = 0.476). All OHCA survivors who had received TTM had elevated ICP, regardless of neurologic prognosis. However, the changing pattern of ICP levels differed depending on the neurological outcome.
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Sandroni C, Cronberg T, Sekhon M. Brain injury after cardiac arrest: pathophysiology, treatment, and prognosis. Intensive Care Med 2021; 47:1393-1414. [PMID: 34705079 PMCID: PMC8548866 DOI: 10.1007/s00134-021-06548-2] [Citation(s) in RCA: 172] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023]
Abstract
Post-cardiac arrest brain injury (PCABI) is caused by initial ischaemia and subsequent reperfusion of the brain following resuscitation. In those who are admitted to intensive care unit after cardiac arrest, PCABI manifests as coma, and is the main cause of mortality and long-term disability. This review describes the mechanisms of PCABI, its treatment options, its outcomes, and the suggested strategies for outcome prediction.
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Affiliation(s)
- Claudio Sandroni
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy. .,Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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33
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Bertagnoni G, Lupi A, Fedeli M, Sensi G, Nogara M. 18F-fluorodeoxyglucose positron-emitted tomography for predicting neurological outcome in hypoxic-ischemic encephalopathy. Brain Inj 2021; 35:1292-1300. [PMID: 34499582 DOI: 10.1080/02699052.2021.1972154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: 18F-fluorodeoxyglucose positron-emitted tomography (FDG-PET) is a promising yet unexplored functional neuroimaging tool in the study and prognosis of hypoxic-ischemic encephalopathy (HIE) after cardiac arrest or respiratory failure. The present study aimed to correlate clinical data and FDG-PET scans for both analysis and prognostic use. Methods: 24 patients from an intensive rehabilitation ward were retrospectively evaluated. Data collected included age, gender, cause of anoxic event, length of stay in acute and rehabilitation units, discharge destination, and evaluation at admission and discharge using three clinical scales to assess cognitive function, independence and disability. Subjects were identified as good and bad performers on the basis of quantitative analysis of FDG-PET scans with the Cortex ID software. The relation between glucose uptake reduction and neurological outcome was evaluated. Results: good and bad performers presented no statistically significant difference regarding demographical data and in-hospital length of stay. The two categories significantly differed for impairment and disability levels both at admission and at discharge from the inpatient rehabilitation unit. Conclusions: FDG-PET considerably facilitates the early identification of patients with HIE who will have poor neurological outcome and could inform planning for their rehabilitation and care.
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Affiliation(s)
| | - Andrea Lupi
- Division of Nuclear Medicine, Ospedale S. Bortolo, Vicenza, Italy
| | - Marta Fedeli
- Department of Physical Medicine and Rehabilitation, Ospedale S. Bortolo, Vicenza, Italy
| | - Giovanni Sensi
- Department of Physical Medicine and Rehabilitation, Ospedale S. Bortolo, Vicenza, Italy
| | - Matteo Nogara
- School of Physical Medicine and Rehabilitation, University of Padua, Padua Italy
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Wiklund L, Sharma A, Patnaik R, Muresanu DF, Sahib S, Tian ZR, Castellani RJ, Nozari A, Lafuente JV, Sharma HS. Upregulation of hemeoxygenase enzymes HO-1 and HO-2 following ischemia-reperfusion injury in connection with experimental cardiac arrest and cardiopulmonary resuscitation: Neuroprotective effects of methylene blue. PROGRESS IN BRAIN RESEARCH 2021; 265:317-375. [PMID: 34560924 DOI: 10.1016/bs.pbr.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Oxidative stress plays an important role in neuronal injuries after cardiac arrest. Increased production of carbon monoxide (CO) by the enzyme hemeoxygenase (HO) in the brain is induced by the oxidative stress. HO is present in the CNS in two isoforms, namely the inducible HO-1 and the constitutive HO-2. Elevated levels of serum HO-1 occurs in cardiac arrest patients and upregulation of HO-1 in cardiac arrest is seen in the neurons. However, the role of HO-2 in cardiac arrest is not well known. In this review involvement of HO-1 and HO-2 enzymes in the porcine brain following cardiac arrest and resuscitation is discussed based on our own observations. In addition, neuroprotective role of methylene blue- an antioxidant dye on alterations in HO under in cardiac arrest is also presented. The biochemical findings of HO-1 and HO-2 enzymes using ELISA were further confirmed by immunocytochemical approach to localize selective regional alterations in cardiac arrest. Our observations are the first to show that cardiac arrest followed by successful cardiopulmonary resuscitation results in significant alteration in cerebral concentrations of HO-1 and HO-2 levels indicating a prominent role of CO in brain pathology and methylene blue during CPR followed by induced hypothermia leading to superior neuroprotection after return of spontaneous circulation (ROSC), not reported earlier.
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Affiliation(s)
- Lars Wiklund
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Aruna Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
| | - Ranjana Patnaik
- Department of Biomaterials, School of Biomedical Engineering, Indian Institute of Technology, Banaras Hindu University, Varanasi, India
| | - Dafin F Muresanu
- Department of Clinical Neurosciences, University of Medicine & Pharmacy, Cluj-Napoca, Romania; "RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Seaab Sahib
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Z Ryan Tian
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Rudy J Castellani
- Department of Pathology, University of Maryland, Baltimore, MD, United States
| | - Ala Nozari
- Anesthesiology & Intensive Care, Massachusetts General Hospital, Boston, MA, United States
| | - José Vicente Lafuente
- LaNCE, Department of Neuroscience, University of the Basque Country (UPV/EHU), Leioa, Bizkaia, Spain
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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Automated Assessment of Brain CT After Cardiac Arrest-An Observational Derivation/Validation Cohort Study. Crit Care Med 2021; 49:e1212-e1222. [PMID: 34374503 DOI: 10.1097/ccm.0000000000005198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objectives Prognostication of outcome is an essential step in defining therapeutic goals after cardiac arrest. Gray-white-matter ratio obtained from brain CT can predict poor outcome. However, manual placement of regions of interest is a potential source of error and interrater variability. Our objective was to assess the performance of poor outcome prediction by automated quantification of changes in brain CTs after cardiac arrest. Design Observational, derivation/validation cohort study design. Outcome was determined using the Cerebral Performance Category upon hospital discharge. Poor outcome was defined as death or unresponsive wakefulness syndrome/coma. CTs were automatically decomposed using coregistration with a brain atlas. Setting ICUs at a large, academic hospital with circulatory arrest center. Patients We identified 433 cardiac arrest patients from a large previously established database with brain CTs within 10 days after cardiac arrest. Interventions None. Measurements and Main Results Five hundred sixteen brain CTs were evaluated (derivation cohort n = 309, validation cohort n = 207). Patients with poor outcome had significantly lower radiodensities in gray matter regions. Automated GWR_si (putamen/posterior limb of internal capsule) was performed with an area under the curve of 0.86 (95%-CI: 0.80-0.93) for CTs taken later than 24 hours after cardiac arrest (similar performance in the validation cohort). Poor outcome (Cerebral Performance Category 4-5) was predicted with a specificity of 100% (95% CI, 87-100%, derivation; 88-100%, validation) at a threshold of less than 1.10 and a sensitivity of 49% (95% CI, 36-58%, derivation) and 38% (95% CI, 27-50%, validation) for CTs later than 24 hours after cardiac arrest. Sensitivity and area under the curve were lower for CTs performed within 24 hours after cardiac arrest. Conclusions Automated gray-white-matter ratio from brain CT is a promising tool for prediction of poor neurologic outcome after cardiac arrest with high specificity and low-to-moderate sensitivity. Prediction by gray-white-matter ratio at the basal ganglia level performed best. Sensitivity increased considerably for CTs performed later than 24 hours after cardiac arrest.
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Abstract
PURPOSE OF REVIEW Recovery after severe brain injury is variable and challenging to accurately predict at the individual patient level. This review highlights new developments in clinical prognostication with a special focus on the prediction of consciousness and increasing reliance on methods from data science. RECENT FINDINGS Recent research has leveraged serum biomarkers, quantitative electroencephalography, MRI, and physiological time-series to build models for recovery prediction. The analysis of high-resolution data and the integration of features from different modalities can be approached with efficient computational techniques. SUMMARY Advances in neurophysiology and neuroimaging, in combination with computational methods, represent a novel paradigm for prediction of consciousness and functional recovery after severe brain injury. Research is needed to produce reliable, patient-level predictions that could meaningfully impact clinical decision making.
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Treatment and Prognosis After Hypoxic-Ischemic Injury. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00682-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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The Association Between Neurological Prognosis and the Degree of Blood-Brain Barrier Disruption in Cardiac Arrest Survivors Who Underwent Target Temperature Management. Neurocrit Care 2021; 35:815-824. [PMID: 34136993 DOI: 10.1007/s12028-021-01241-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND This study aimed to compare day-specific associations of blood-brain barrier (BBB) disruption with neurological outcome in survivors of out-of-hospital cardiac arrest (OHCA) treated with target temperature management (TTM) and lumbar drainage. METHODS This retrospective single-center study included 68 survivors of OHCA who underwent TTM between April 2018 and December 2019. The albumin quotient (QA) was calculated as QA = albumincerebrospinal fluid/albuminserum immediately (day 1) and 24 (day 2), 48 (day 3), and 72 h (day 4) after the return of spontaneous circulation. The degree of BBB disruption was weighted using the following scoring system: QA value of 0.007 or less (normal), QA value greater than 0.007-0.01 (mild), QA value greater than 0.01-0.02 (moderate), and QA value greater than 0.02 (severe). Points were assigned as follows: 0 (normal), 1 (mild), 4 (moderate), and 9 (severe). Neurological outcome was determined at 6 months after the return of spontaneous circulation, as well as cerebral performance category (CPC), dichotomized as good (CPC score 1-2) and poor (CPC score 3-5) outcome. RESULTS We enrolled 68 patients (48 men, 71%); 37 (54%) patients had a poor neurological outcome. The distributions of poor versus good outcomes at 6 months in patients with moderate and severe BBB disruption were 19 of 22 (80%) vs. 18 of 46 (50%) on day 1, 31 of 37 (79%) vs. 6 of 31 (32%) on day 2, 32 of 37 (81%) vs. 5 of 31 (30%) on day 3, and 32 of 39 (85%) vs. 5 of 29 (30%) on day 4 (P < 0.001), respectively. Using receiver operating characteristic analyses, optimal cutoff values (sensitivity, specificity) of QA levels for the prediction of neurological outcome were as follows: day 1, greater than 0.009 (56.8%, 87.1%); day 2, greater than 0.012 (81.1%, 87.1%); day 3, greater than 0.013 (83.8%, 87.1%); day 4, greater than 0.013 (86.5%, 87.1%); the sum of all time points, greater than 0.039 (89.5%, 79.4%); and scoring system, greater than 9 (91.9%, 87.1%). CONCLUSIONS In this proof of concept study, QA was associated with poor neurological outcome in survivors of OHCA treated with TTM with no contraindication to lumbar drainage. A large multicenter prospective study is needed to validate the utility of BBB disruption as a prognosticator of neurological outcome.
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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40
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Kosmopoulos M, Bartos JA, Yannopoulos D. ST-Elevation Myocardial Infarction Complicated by Out-of-Hospital Cardiac Arrest. Interv Cardiol Clin 2021; 10:359-368. [PMID: 34053622 DOI: 10.1016/j.iccl.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
5-10% of ST-elevated myocardial infarctions (STEMI) present with out-of-hospital cardiac arrest (OHCA). Although this subgroup of patients carries the highest in-hospital mortality among the STEMI population, it is the least likely to undergo coronary angiography and revascularization. Due to the concomitant neurologic injury, patients with OHCA STEMI require prolonged hospitalization and adjustments to standard MI management. This review systematically assesses the course of patients with OHCA STEMI from development of the arrest to hospital discharge, assesses the limiting factors for their treatment access, and presents the evidence-based optimal intervention strategy for this high-risk MI population.
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Affiliation(s)
- Marinos Kosmopoulos
- Cardiovascular Division, Center for Resuscitation Medicine, University of Minnesota Medical School, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Jason A Bartos
- Cardiovascular Division, Center for Resuscitation Medicine, University of Minnesota Medical School, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Demetris Yannopoulos
- Cardiovascular Division, Center for Resuscitation Medicine, University of Minnesota Medical School, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
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41
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 464] [Impact Index Per Article: 154.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 375] [Impact Index Per Article: 125.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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43
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Nutma S, le Feber J, Hofmeijer J. Neuroprotective Treatment of Postanoxic Encephalopathy: A Review of Clinical Evidence. Front Neurol 2021; 12:614698. [PMID: 33679581 PMCID: PMC7930064 DOI: 10.3389/fneur.2021.614698] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/19/2021] [Indexed: 12/24/2022] Open
Abstract
Postanoxic encephalopathy is the key determinant of death or disability after successful cardiopulmonary resuscitation. Animal studies have provided proof-of-principle evidence of efficacy of divergent classes of neuroprotective treatments to promote brain recovery. However, apart from targeted temperature management (TTM), neuroprotective treatments are not included in current care of patients with postanoxic encephalopathy after cardiac arrest. We aimed to review the clinical evidence of efficacy of neuroprotective strategies to improve recovery of comatose patients after cardiac arrest and to propose future directions. We performed a systematic search of the literature to identify prospective, comparative clinical trials on interventions to improve neurological outcome of comatose patients after cardiac arrest. We included 53 studies on 21 interventions. None showed unequivocal benefit. TTM at 33 or 36°C and adrenaline (epinephrine) are studied most, followed by xenon, erythropoietin, and calcium antagonists. Lack of efficacy is associated with heterogeneity of patient groups and limited specificity of outcome measures. Ongoing and future trials will benefit from systematic collection of measures of baseline encephalopathy and sufficiently powered predefined subgroup analyses. Outcome measurement should include comprehensive neuropsychological follow-up, to show treatment effects that are not detectable by gross measures of functional recovery. To enhance translation from animal models to patients, studies under experimental conditions should adhere to strict methodological and publication guidelines.
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Affiliation(s)
- Sjoukje Nutma
- Department of Neurology, Medisch Spectrum Twente, Enschede, Netherlands
- Clinical Neurophysiology, University of Twente, Enschede, Netherlands
| | - Joost le Feber
- Clinical Neurophysiology, University of Twente, Enschede, Netherlands
| | - Jeannette Hofmeijer
- Clinical Neurophysiology, University of Twente, Enschede, Netherlands
- Department of Neurology, Rijnstate Hospital Arnhem, Arnhem, Netherlands
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Abstract
Cardiac arrest is a catastrophic event with high morbidity and mortality. Despite advances over time in cardiac arrest management and postresuscitation care, the neurologic consequences of cardiac arrest are frequently devastating to patients and their families. Targeted temperature management is an intervention aimed at limiting postanoxic injury and improving neurologic outcomes following cardiac arrest. Recovery of neurologic function governs long-term outcome after cardiac arrest and prognosticating on the potential for recovery is a heavy burden for physicians. An early and accurate estimate of the potential for recovery can establish realistic expectations and avoid futile care in those destined for a poor outcome. This chapter reviews the epidemiology, pathophysiology, therapeutic interventions, prognostication, and neurologic sequelae of cardiac arrest.
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Affiliation(s)
- Rick Gill
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States
| | - Michael Teitcher
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States
| | - Sean Ruland
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States.
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Haller S, van der Lugt A, Ahmad H, von Kummer R. Neuroimaging for Coma Outcome Prediction and Determination of Brain Death. Clin Neuroradiol 2021. [DOI: 10.1007/978-3-319-61423-6_97-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Standardized visual EEG features predict outcome in patients with acute consciousness impairment of various etiologies. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:680. [PMID: 33287874 PMCID: PMC7720582 DOI: 10.1186/s13054-020-03407-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/24/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early prognostication in patients with acute consciousness impairment is a challenging but essential task. Current prognostic guidelines vary with the underlying etiology. In particular, electroencephalography (EEG) is the most important paraclinical examination tool in patients with hypoxic ischemic encephalopathy (HIE), whereas it is not routinely used for outcome prediction in patients with traumatic brain injury (TBI). METHOD Data from 364 critically ill patients with acute consciousness impairment (GCS ≤ 11 or FOUR ≤ 12) of various etiologies and without recent signs of seizures from a prospective randomized trial were retrospectively analyzed. Random forest classifiers were trained using 8 visual EEG features-first alone, then in combination with clinical features-to predict survival at 6 months or favorable functional outcome (defined as cerebral performance category 1-2). RESULTS The area under the ROC curve was 0.812 for predicting survival and 0.790 for predicting favorable outcome using EEG features. Adding clinical features did not improve the overall performance of the classifier (for survival: AUC = 0.806, p = 0.926; for favorable outcome: AUC = 0.777, p = 0.844). Survival could be predicted in all etiology groups: the AUC was 0.958 for patients with HIE, 0.955 for patients with TBI and other neurosurgical diagnoses, 0.697 for patients with metabolic, inflammatory or infectious causes for consciousness impairment and 0.695 for patients with stroke. Training the classifier separately on subgroups of patients with a given etiology (and thus using less training data) leads to poorer classification performance. CONCLUSIONS While prognostication was best for patients with HIE and TBI, our study demonstrates that similar EEG criteria can be used in patients with various causes of consciousness impairment, and that the size of the training set is more important than homogeneity of ACI etiology.
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[Brain death criterion and organ donation: current neuroscientific perspective]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:1519-1530. [PMID: 33180159 PMCID: PMC7686223 DOI: 10.1007/s00103-020-03245-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/09/2020] [Indexed: 11/06/2022]
Abstract
In der akademischen und öffentlichen Debatte wird der irreversible Hirnfunktionsausfall als Kriterium des Todes (Hirntodkriterium) immer wieder hinterfragt. Im vorliegenden Artikel werden 6 prototypische Thesen gegen das Hirntodkriterium diskutiert: 1) Nichtsuperiorität des Gehirns gegenüber anderen Organen, 2) Unsicherheit der Hirntoddiagnostik, 3) erhaltene Schmerzempfindung Hirntoter, 4) (spontane) sexuelle Reifung und erhaltene Reproduktionsfunktion Hirntoter, 5) Symmetrie von Hirntod und Embryonalphase, 6) Gleichsetzung des intensivmedizinisch erhaltenen Restorganismus Hirntoter mit dem lebenden Menschen. Keine dieser Thesen hält einer kritischen Analyse stand. In Deutschland wird das Ganzhirntodkriterium angewendet. Der Hirntod geht mit dem völligen Ausfall jeglicher Empfindung, Bewusstheit, Mimik, Augen‑, Zungen- und Schlundmotorik, Willkürmotorik und Sexualfunktion einher (funktionelle „Enthauptung“). Medizinisch-technisch können andere Organe bzw. ihre Primitivsteuerung ersetzt werden, nicht aber das Gehirn. Das Gehirn, nicht der Körper, ist bestimmend für das menschliche Individuum. Die Gleichsetzung des künstlich erhaltenen Restorganismus, naturphilosophisch als lebendiges System interpretierbar, mit dem Organismus desselben lebenden Menschen wird durch die beliebige Reduzierbarkeit der Anzahl beteiligter Organe ad absurdum geführt. Der irreversible Hirnfunktionsausfall führt unausweichlich zum Herzstillstand, unbehandelt innerhalb von Minuten, unter Intensivtherapie i. d. R. innerhalb von Tagen. Auch beim Embryo/Fötus führt die Fehlanlage des gesamten Gehirns zum (vorgeburtlichen) Tod. Die in Deutschland gesetzliche Richtlinie zur Hirntodfeststellung hat eine im internationalen Vergleich hohe Diagnosesicherheit, es sind damit keine bestätigten Fehldiagnosen aufgetreten.
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48
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Hoedemaekers CWE, Helmich RC. MRI in neuroprognostication after cardiac arrest: It's time for the next step. Resuscitation 2020; 157:264-265. [PMID: 33091536 DOI: 10.1016/j.resuscitation.2020.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Affiliation(s)
| | - Rick C Helmich
- Radboud University Medical Centre, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands; Donders Institute for Brain, Cognition, and Behavior, Centre for Cognitive Neuroimaging, Radboud University Nijmegen, Nijmegen, The Netherlands
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Sandroni C, D'Arrigo S, Cacciola S, Hoedemaekers CWE, Kamps MJA, Oddo M, Taccone FS, Di Rocco A, Meijer FJA, Westhall E, Antonelli M, Soar J, Nolan JP, Cronberg T. Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med 2020; 46:1803-1851. [PMID: 32915254 PMCID: PMC7527362 DOI: 10.1007/s00134-020-06198-w] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/15/2020] [Indexed: 12/17/2022]
Abstract
Purpose To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3–5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA). Methods PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013–April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. Results Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2–5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors. Conclusion In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169) Electronic supplementary material The online version of this article (10.1007/s00134-020-06198-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sonia D'Arrigo
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Sofia Cacciola
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | - Marlijn J A Kamps
- Intensive Care Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Mauro Oddo
- Department of Intensive Care Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arianna Di Rocco
- Department of Public Health and Infectious Disease, Sapienza University, Rome, Italy
| | - Frederick J A Meijer
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Erik Westhall
- Department of ClinicalSciences, Clinical Neurophysiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jasmeet Soar
- Critical Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
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50
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Wang Z, Mascarenhas C, Jia X. Positron Emission Tomography After Ischemic Brain Injury: Current Challenges and Future Developments. Transl Stroke Res 2020; 11:628-642. [PMID: 31939060 PMCID: PMC7347441 DOI: 10.1007/s12975-019-00765-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/22/2019] [Accepted: 12/04/2019] [Indexed: 12/19/2022]
Abstract
Positron emission tomography (PET) is widely used in clinical and animal studies, along with the development of diverse tracers. The biochemical characteristics of PET tracers may help uncover the pathophysiological consequences of cardiac arrest (CA) and ischemic stroke, which include cerebral ischemia and reperfusion, depletion of oxygen and glucose, and neuroinflammation. PubMed was searched for studies of the application of PET for "cardiac arrest," "ischemic stroke," and "targeted temperature management." Available studies were included and classified according to the biochemical properties involved and metabolic processes of PET tracers, and were summarized. The mechanisms of ischemic brain injuries were investigated by PET with various tracers to elucidate the pathological process from the initial decrease of cerebral blood flow (CBF) to the subsequent abnormalities in energy and oxygen metabolism, to the monitoring of inflammation. In general, the trends of cerebral blood flow and oxygen metabolism after ischemic attack are not unidirectional but closely related to the time point of injury and recovery. Glucose metabolism after injury showed significant differences in different brain regions whereas global cerebral metabolic rate of glucose (CMRglc) declined. PET monitoring of neuroinflammation shows comparable efficacy to immunostaining. The technology of PET targeting in brain metabolism and the development of tracers provide new tools to track and evaluate the brain's pathological changes after ischemic brain injury. Despite no existing evidence for an available PET-based prediction method, discoveries of new tracers are expected to provide more possibilities for the whole field.
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Affiliation(s)
- Zhuoran Wang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 43007, China
- Department of Neurosurgery, University of Maryland School of Medicine, 10 South Pine Street, MSTF Building 823, Baltimore, MD, 21201, USA
| | - Conrad Mascarenhas
- Department of Neurosurgery, University of Maryland School of Medicine, 10 South Pine Street, MSTF Building 823, Baltimore, MD, 21201, USA
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, 10 South Pine Street, MSTF Building 823, Baltimore, MD, 21201, USA.
- Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.
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