Usefulness of neuron specific enolase in prognostication after cardiac arrest: Impact of age and time to ROSC

Different neuroprognostication thresholds of neuron-specific enolase in shockable and non-shockable out-of-hospital cardiac arrest: a prospective multicenter observational study in Korea (the KORHN-PRO registry)

BACKGROUND

Serum neuron-specific enolase (NSE) is the only recommended biomarker for multimodal prognostication in postcardiac arrest patients, but low sensitivity of absolute NSE threshold limits its utility. This study aimed to evaluate the prognostic performance of serum NSE for poor neurologic outcome in out-of-hospital cardiac arrest (OHCA) survivors based on their initial rhythm and to determine the NSE cutoff values with false positive rate (FPR) < 1% for each group.

METHODS

This study included OHCA survivors who received targeted temperature management (TTM) and had serum NSE levels measured at 48 h after return of spontaneous circulation in the Korean Hypothermia Network, a prospective multicenter registry from 22 university-affiliated teaching hospitals in South Korea between October 2015 and December 2018. The primary outcome was poor outcome at 6 month, defined as a cerebral performance category of 3-5.

RESULTS

Of 623 patients who underwent TTM with NSE measured 48 h after the return of spontaneous circulation, 245 had an initial shockable rhythm. Median NSE level was significantly higher in the non-shockable group than in the shockable group (104.6 [40.6-228.4] vs. 25.9 [16.7-53.4] ng/mL, P < 0.001). Prognostic performance of NSE assessed by area under the receiver operating characteristic curve to predict poor outcome was significantly higher in the non-shockable group than in the shockable group (0.92 vs 0.86). NSE cutoff values with an FPR < 1% in the non-shockable and shockable groups were 69.3 (sensitivity of 42.1%) and 102.7 ng/mL (sensitivity of 76%), respectively.

CONCLUSION

NSE prognostic performance and its cutoff values with FPR < 1% for predicting poor outcome in OHCA survivors who underwent TTM differed between shockable and non-shockable rhythms, suggesting postcardiac arrest survivor heterogeneity. Trial registration KORHN-PRO, NCT02827422. Registered 11 September 2016-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02827422.

Therapeutic Hypothermia Following Cardiac Arrest After the TTM2 trial - More Questions Raised Than Answered

For almost 20 years, therapeutic hypothermia has been a cornerstone of modern post-cardiac arrest care lowering mortality, and improvin neurologic outcome compared to conventional therapy. This was challenged by the first TTM-trial in 2013, which did not show a benefit for hypothermia at 33°C compared to controlled normothermia at 36°C. Now, the TTM2 trial showed no benefit of hypothermia compared to fever prevention alone. While TTM1 and TTM2 suggest that hypothermia might not be helpful, a deep dive into the trials reveals that this conclusion does not hold true. Here, we focus on patient selection, suboptimal application of hypothermia, interaction of standard sedation with hypothermia, high incidence of post-arrest fever, and withdrawal of life support based on per-protocol neurologic prognostication in the TTM2-trial. Of particular interest, contemporary trials and registries using intravascular cooling in TTM-like patients repeatedly reported much lower mortality rates than those described in both TTM1 and TTM2.

Association Between Procalcitonin Level at 72 Hours After Cardiac Arrest and Neurological Outcomes in Cardiac Arrest Survivors

The association between procalcitonin (PCT) level measured 72 hours after cardiac arrest (CA) and neurological outcomes is unknown. We aimed to examine the association of serial PCT levels up to 72 hours with neurological outcomes in patients who underwent targeted temperature management (TTM) after CA. This retrospective observational study included adult comatose patients with CA undergoing TTM (33℃ for 24 hours) at the Chonnam National University Hospital in Gwangju, Korea, between January 2018 and December 2020. PCT levels were measured at admission and at 24, 48, and 72 hours after CA. The presence of early-onset infections (within 7 days after CA) was confirmed by reviewing clinical, radiological, and microbiological data. The primary outcome was poor neurological outcomes at 6 months and was defined by cerebral performance category 3-5. Among the CA survivors, 118 were included and 67 (56.8%) had poor neurological outcomes. The PCT level at 72 hours in the poor outcome group (3.01 [0.88-12.71]) was higher than that in good outcome group (0.56 [0.18-1.32]). The multivariate analysis revealed that the PCT level at 72 hours (adjusted odds ratio 1.241; 95% confidence interval, 1.059-1.455) was independently associated with poor neurological outcomes, showed good performance for poor outcomes (area under the receiver operating characteristic curve of 0.823), and was not associated with early-onset infections. The PCT level at 72 hours after CA can be helpful in predicting prognosis, and it did not correlate with early-onset infections in the study.

Circulating Leukocyte as an Inflammatory Biomarker: Association with Fibrinogen and Neuronal Damage in Acute Ischemic Stroke

Background and Purpose

Leukocytes and fibrinogen are inflammatory markers involved in circulating and central inflammatory response after ischemic stroke. However, the interaction between circulating leukocytes and serum fibrinogen and neuronal injury in acute ischemic stroke (AIS) patients is still unclear. The present study aimed to investigate the association between circulating leukocyte and serum fibrinogen and neuronal injury respectively in AIS.

Methods

A cross-section study with 431 hospitalized AIS patients from department of neurology was performed. Circulating leukocytes and fibrinogen were measured, and neuron-specific enolase (NSE) was detected to evaluate central neuronal damage. A propensity score matching method was used to minimize the effects of confounding factors. The relationship between leukocytes and NSE and fibrinogen was analyzed by linear curve fitting analysis and multiple logistic regression models respectively.

Results

The mean levels of NSE, leukocyte, and fibrinogen were significantly higher in the matched AIS group (n=89) than those of in the healthy control group (n=89) (all p<0.05). Both serum NSE and fibrinogen were increased with the increasing of leukocyte in AIS patients (both p<0.05). Smoothed plots suggested that there are linear relationships between leukocyte and NSE and fibrinogen respectively. Multiple logistic regression analysis showed the OR (95%) for the relationship between leukocyte and high NSE were 1.13 (1.01-1.26, p=0.031) and 1.13 (1.00-1.28, p=0.048), and between leukocyte and high fibrinogen were 1.40 (1.22-1.61, p<0.001) and 1.35 (1.15-1.58, p<0.001) in all AIS patients before and after adjusting for potential confounders.

Conclusion

Our study suggests that elevated circulating leukocyte was associated with high fibrinogen and neuronal injury in AIS. Therefore, there may be potential targets among circulating leukocyte, fibrinogen and NSE that should be intervened to reduce inflammatory reaction after ischemic stroke.

Serum levels of neuron-specific enolase as a prognostic factor for disease progression in patients with GET/NEN in the pancreas and the small intestine

The aim of this study was to assess the usefulness of neuron-specific enolase (NSE) concentrations as a prognostic factor in patients with neuroendocrine neoplasms and to determine the relationship between NSE and clinicopathological features. Serum NSE levels were measured in 179 NEN patients before treatment. It was found that NSE levels in patients with a primary pancreatic location were higher compared to patients with a small intestine lesion (P = 0.015). NSE levels were significantly higher in patients with primary pancreatic location with histological grade G2 compared with the group with low-grade G1 (P = 0.047). Patients with initial liver involvement showed significantly higher NSE levels compared to patients with tumour location in the pancreas (P = 0.009). Statistical analysis confirmed that higher NSE levels were associated with disease progression (P = 0.001) in both the overall study group and in patients with tumours in the pancreas and small intestine. During treatment monitoring, an increase in median NSE concentrations was observed in patients with persistent progression with subsequent blood draws, and a decrease in NSE concentrations was observed in patients with disease stabilisation. We showed that NSE concentrations have prognostic value for progression-free survival in addition to primary liver involvement. In conclusion, the most important results of the study include the demonstration of an association between NSE concentrations and clinical status, which confirms its usefulness in patient monitoring and as a potential predictive indicator for progression-free survival in patients with NENs.

Can Blood Ammonia Level, Prehospital Time, and Return of Spontaneous Circulation Predict Neurological Outcomes of Out-of-Hospital Cardiac Arrest Patients? A Nationwide, Retrospective Cohort Study

Background: This study aimed to test if blood ammonia levels at hospital arrival, considering prehospital time and the patient’s condition (whether return of spontaneous circulation [ROSC] was achieved at hospital arrival), can predict neurological outcomes after out-of-hospital cardiac arrest (OHCA). Methods: This was a retrospective cohort study on data from a nationwide OHCA registry in Japan. Patients over 17 years old and whose blood ammonia levels had been recorded were included. The primary outcome was favorable neurological outcome at 30 days after OHCA. Blood ammonia levels, prehospital time, and the combination of the two were evaluated using the receiver operating characteristic curve to predict favorable outcomes. Then, cut-off blood ammonia values were determined based on whether ROSC was achieved at hospital arrival. Results: Blood ammonia levels alone were sufficient to predict favorable outcomes. The overall cut-off ammonia value for favorable outcomes was 138 μg/dL; values were different for patients with ROSC (96.5 μg/dL) and those without ROSC (156 μg/dL) at hospital arrival. Conclusions: Our results using patient data from a large OHCA registry showed that blood ammonia levels at hospital arrival can predict neurological outcomes, with different cut-off values for patients with or without ROSC at hospital arrival.

Gray-White Matter Ratio at the Level of the Basal Ganglia as a Predictor of Neurologic Outcomes in Cardiac Arrest Survivors: A Literature Review

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.

Neurofilament light compared to neuron-specific enolase as a predictor of unfavourable outcome after out-of-hospital cardiac arrest

AIM

We compared the prognostic abilities of neurofilament light (NfL) and neuron-specific enolase (NSE) in patients resuscitated from out-of-hospital cardiac arrest (OHCA) of various aetiologies.

METHODS

We analysed frozen blood samples obtained at 24 and 48 hours from OHCA patients treated in 21 Finnish intensive care units in 2010 and 2011. We defined unfavourable outcome as Cerebral Performance Category (CPC) 3-5 at 12 months after OHCA. We evaluated the prognostic ability of the biomarkers by calculating the area under the receiver operating characteristic curves (AUROCs [95% confidence intervals]) and compared these with a bootstrap method.

RESULTS

Out of 248 adult patients, 12-month outcome was unfavourable in 120 (48.4%). The median (interquartile range) NfL concentrations for patients with unfavourable and those with favourable outcome, respectively, were 688 (146-1804) pg/mL vs. 31 (17-61) pg/mL at 24 h and 1162 (147-4361) pg/mL vs. 36 (21-87) pg/mL at 48 h, p < 0.001 for both. The corresponding NSE concentrations were 13.3 (7.2-27.3) µg/L vs. 8.5 (5.8-13.2) µg/L at 24 h and 20.4 (8.1-56.6) µg/L vs. 8.2 (5.9-12.1) µg/L at 48 h, p < 0.001 for both. The AUROCs to predict an unfavourable outcome were 0.90 (0.86-0.94) for NfL vs. 0.65 (0.58-0.72) for NSE at 24 h, p < 0.001 and 0.88 (0.83-0.93) for NfL and 0.73 (0.66-0.81) for NSE at 48 h, p < 0.001.

CONCLUSION

Compared to NSE, NfL demonstrated superior accuracy in predicting long-term unfavourable outcome after OHCA.

Neuron-Specific Enolase (NSE) Predicts Long-Term Mortality in Adult Patients after Cardiac Arrest: Results from a Prospective Trial

Background: We investigated whether Neuron-specific enolase (NSE) serum concentration predicts long-term mortality and poor neurological outcome in adult cardiac arrest patients. Methods: Within this prospective observational study, we included consecutive adult patients admitted to the intensive care unit (ICU) after cardiac arrest. NSE was measured upon ICU admission and on days 1, 2, 3, 5 and 7. Results: Of 403 patients, 176 (43.7%) survived. Median follow-up duration was 43.7 months (IQR 14.3 to 63.0 months). NSE levels on day 3 were increased more than threefold in non-survivors compared to survivors (median NSE (ng/mL) 19.8 (IQR 15.7 to 27.8) vs. 72.6 (IQR 26 to 194)) and showed the highest prognostic performance for mortality compared to other days of measurement, with an AUC of 0.81 and an adjusted hazard ratio of 1.55 (95% CI 1.41 to 1.71, p < 0.001). Subgroup analysis showed an excellent sensitivity and negative predictive value of 100% of NSE in patients <54 years of age. Conclusion: NSE measured three days after cardiac arrest is associated with long-term mortality and neurological outcome and may provide prognostic information that improves clinical decision making. Particularly in the subgroup of younger patients (<54 years), NSE showed excellent negative predictive value.

Neuron-specific enolase and long-term neurological outcome after OHCA - A validation study

AIMS

To investigate what NSE levels predict long-term neurological prognosis at 24, 48 and 72 hours after ROSC in a cohort of out-of-hospital cardiac arrest and to validate previously suggested NSE cut-offs, including the latest ERC guidelines (2021).

METHODS

Patients admitted to intensive care units in four hospitals in Southern Sweden between 2014-2018 were included. Blood samples were handled by a single local laboratory. The primary outcome was neurological outcome according to the Cerebral Performance Category (CPC) scale at 2-6 months after cardiac arrest.

RESULTS

368 patients were included for analysis. A ≤2% false positive rate for the prediction of poor neurological outcome was achieved with an NSE cut-off value of >101 μg/L at 48 hours and >80 μg/L at 72 hours. The cut-off suggested by the recent ERC guidelines of >60 μg/L at 48 and/or 72 hours generated a false positive rate of 4.3% (95 %CI 0.9-7.4%).

CONCLUSION

A local validation study of the ability of serum levels of neuron-specific enolase to predict long-term poor neurological outcome after out-of-hospital cardiac arrest generated higher cut-offs than suggested by previous publications.

European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care

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.

European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care

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.

Serum neurofilament measurement improves clinical risk scores for outcome prediction after cardiac arrest: results of a prospective study

Background

A recent study found serum neurofilament light chain (NfL) levels to be strongly associated with poor neurological outcome in patients after cardiac arrest. Our aim was to confirm these findings in an independent validation study and to investigate whether NfL improves the prognostic value of two cardiac arrest-specific risk scores.

Methods

This prospective, single-center study included 164 consecutive adult after out-of-hospital cardiac arrest (OHCA) patients upon intensive care unit admission. We calculated two clinical risk scores (OHCA, CAHP) and measured NfL on admission within the first 24 h using the single molecule array NF-light^® assay. The primary endpoint was neurological outcome at hospital discharge assessed with the cerebral performance category (CPC) score.

Results

Poor neurological outcome (CPC > 3) was found in 60% (98/164) of patients, with 55% (91/164) dying within 30 days of hospitalization. Compared to patients with favorable outcome, NfL was 14-times higher in patients with poor neurological outcome (685 ± 1787 vs. 49 ± 111 pg/mL), with an adjusted odds ratio of 3.4 (95% CI 2.1 to 5.6, p < 0.001) and an area under the curve (AUC) of 0.82. Adding NfL to the clinical risk scores significantly improved discrimination of both the OHCA score (from AUC 0.82 to 0.89, p < 0.001) and CAHP score (from AUC 0.89 to 0.92, p < 0.05). Adding NfL to both scores also resulted in significant improvement in reclassification statistics with a Net Reclassification Index (NRI) of 0.58 (p < 0.001) for OHCA and 0.83 (p < 0.001) for CAHP.

Conclusions

Admission NfL was a strong outcome predictor and significantly improved two clinical risk scores regarding prognostication of neurological outcome in patients after cardiac arrest. When confirmed in future outcome studies, admission NfL should be considered as a standard laboratory measures in the evaluation of OHCA patients.

Neurofilament light as an outcome predictor after cardiac arrest: a post hoc analysis of the COMACARE trial

Purpose

Neurofilament light (NfL) is a biomarker reflecting neurodegeneration and acute neuronal injury, and an increase is found following hypoxic brain damage. We assessed the ability of plasma NfL to predict outcome in comatose patients after out-of-hospital cardiac arrest (OHCA). We also compared plasma NfL concentrations between patients treated with two different targets of arterial carbon dioxide tension (PaCO₂), arterial oxygen tension (PaO₂), and mean arterial pressure (MAP).

Methods

We measured NfL concentrations in plasma obtained at intensive care unit admission and at 24, 48, and 72 h after OHCA. We assessed neurological outcome at 6 months and defined a good outcome as Cerebral Performance Category (CPC) 1–2 and poor outcome as CPC 3–5.

Results

Six-month outcome was good in 73/112 (65%) patients. Forty-eight hours after OHCA, the median NfL concentration was 19 (interquartile range [IQR] 11–31) pg/ml in patients with good outcome and 2343 (587–5829) pg/ml in those with poor outcome, p < 0.001. NfL predicted poor outcome with an area under the receiver operating characteristic curve (AUROC) of 0.98 (95% confidence interval [CI] 0.97–1.00) at 24 h, 0.98 (0.97–1.00) at 48 h, and 0.98 (0.95–1.00) at 72 h. NfL concentrations were lower in the higher MAP (80–100 mmHg) group than in the lower MAP (65–75 mmHg) group at 48 h (median, 23 vs. 43 pg/ml, p = 0.04). PaCO₂ and PaO₂ targets did not associate with NfL levels.

Conclusions

NfL demonstrated excellent prognostic accuracy after OHCA. Higher MAP was associated with lower NfL concentrations.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-06218-9) contains supplementary material, which is available to authorized users.

Prognostic Abilities of Serial Neuron-Specific Enolase and Lactate and their Combination in Cardiac Arrest Survivors During Targeted Temperature Management

This study aimed to determine the prognostic ability of serial neuron-specific enolase (NSE) and lactate in cardiac arrest survivors treated with targeted temperature management (TTM) and to investigate whether a combination of NSE and lactate could increase prognostic information. This observational, retrospective, cohort study was conducted between January 2013 and December 2018; data were extracted from an out-of-hospital cardiac arrest registry. We collected serial serum NSE and lactate levels during TTM. The primary endpoint was poor neurological outcome at 28 days from cardiac arrest. Of all 160 included patients, 98 (61.3%) had poor neurological outcomes. Areas under the curves (AUCs) for NSE were 0.797, 0.871, and 0.843 at 24, 48, and 72 h, respectively (all p < 0.05). AUCs for lactate were 0.669, 0.578, 0.634, and 0.620 at 0, 24, 48, and 72 h, respectively (all p < 0.05). Although the combination of initial lactate and NSE at 48 h yielded the highest discovered AUC (0.877) it was not statistically different from that for the 48 h NSE alone (p = 0.692). During the TTM, NSE at 48 h from cardiac arrest was the most robust prognostic marker in comatose cardiac arrest survivors. However, a combination of the 48 h NSE with lactate did not increase the prognostic information.

The usefulness of neuron-specific enolase in cerebrospinal fluid to predict neurological prognosis in cardiac arrest survivors who underwent target temperature management: A prospective observational study

AIM

Cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels increase ahead of serum NSE levels in patients with severe brain injury. We examined the prognostic performance between CSF NSE and serum NSE levels in out-of-cardiac arrest (OHCA) survivors who had undergone target temperature management (TTM).

METHODS

This single-centre prospective observational study included OHCA patients who had undergone TTM. NSE levels were assessed in blood and CSF samples obtained immediately (Day 0), and at 24 h (Day 1), 48 h (Day 2), and 72 h (Day 3) after return of spontaneous circulation (ROSC). The primary outcome was the 6-month neurological outcome.

RESULTS

We enrolled 34 patients (males, 24; 70.6%), and 16 (47.1%) had a poor neurologic outcome. CSF NSE and serum NSE values were significantly higher in the poor outcome group compared to the good outcome group at each time point, except for serum Day 0. CSF NSE and serum NSE had an area under curve (AUC) of 0.819-0.972 and 0.648-0.920, respectively. CSF NSE prognostic performances were significantly higher than serum NSE levels at Day 1 and showed excellent AUC values (0.969; 95% confidence interval [CI] 0.844-0.999) and high sensitivity (93.8%; 95% CI 69.8-99.8) at 100% specificity.

CONCLUSION

We found CSF NSE values were highly predictive and sensitive markers of 6-month poor neurological outcome in OHCA survivors treated with TTM at Day 1 after ROSC. Therefore, CSF NSE levels at day 1 after ROSC can be a useful early prognosticator in OHCA survivors.