Rates Of Good Neurologic Outcome Research Articles

Prospective, multicenter, Turkish out-of-hospital cardiac arrest study: TROHCA.

There is no sufficient data to provide a clear picture of out-of-hospital cardiac arrest (OHCA) across Türkiye. This study is the first to present the prognostic outcomes of OHCA cases and the factors associated with these outcomes. The study was conducted in a prospective, observational, multicenter design under the leadership of the Emergency Medicine Association of Turkey Resuscitation Study Group. OHCA cases aged 18 years and over who were admitted to 28 centers from Türkiye were included in the study. Survived event, return of spontaneous circulation (ROSC), survival to hospital discharge, and neurological outcome at discharge were investigated as primary outcomes. One thousand and three patients were included in the final analysis. 61.1% of the patients were male, and the average age was 67.0 ± 15.2. Cardiopulmonary resuscitation (CPR) was performed on 86.5% of the patients in the prehospital period by emergency medical service, and bystander CPR was performed on only 2.9% by nonhealth-care providers. As a result, the survived event rate was found to be 6.9%. The survival rate upon hospital discharge was 4.4%, with 2.7% of patients achieving a good neurological outcome upon discharge. In addition, the overall ROSC and sustained ROSC rates were 45.2% and 33.4%, respectively. In the multiple logistic regression analysis, male gender, initial shockable rhythm, a shorter prehospital duration of CPR, and the lack of CPR requirement in the emergency department were determined to be independent predictors for the survival to hospital discharge. Compared to global data, survival to hospital discharge and good neurological outcome rates appear to be lower in our study. We conclude that this result is related to low bystander CPR rates. Although not the focus of this study, inadequate postresuscitative care and intensive care support should also be discussed in this regard. It is obvious that this issue should be carefully addressed through political moves in the health and social fields.

Predicting the probability of good neurological outcome after in-hospital cardiac arrest based on prearrest factors: validation of the good outcome following attempted resuscitation 2 (GO-FAR 2) score.

The Good Outcome Following Attempted Resuscitation (GO-FAR) 2 score is a prognostic tool developed to support decision-making for do-not-attempt-resuscitation (DNAR) orders by predicting neurological outcomes after in-hospital cardiac arrest (IHCA) based on prearrest variables. However, this scoring system requires further validation. We aimed to validate the GO-FAR 2 score for predicting good neurological outcome in Korean patients with IHCA. A single-centre registry of adult patients with IHCA from 2013 to 2017 was analysed. The primary outcome was discharge with good neurological outcome (Cerebral Performance Category score of 1 or 2). The patients were divided into four categories according to the GO-FAR 2 score: very poor (≥ 5), poor (2-4), average (-3 to 1), and above-average (< -3) likelihood of good neurological outcome. Of 1,011 patients (median age, 65years), 63.1% were men. The rate of good neurological outcome was 16.0%. The proportions of patients categorised as having very poor, poor, average, and above-average probability of good neurological outcome were 3.9%, 18.3%, 70.2%, and 7.6%, respectively. In each category, good neurological outcome was observed in 0%, 1.1%, 16.8%, and 53.2%, respectively. Among patients in below-average categories (very poor + poor, GO-FAR 2 score ≥ 2), only 0.9% had good outcome. GO-FAR 2 score ≥ 2 showed a sensitivity of 98.8% and a negative predictive value of 99.1% in predicting good neurological outcome. The GO-FAR 2 score can predict neurological outcome after IHCA. In particular, GO-FAR 2 score ≥ 2 may support decision-making for DNAR orders.

Surgical and Endovascular Treatment of Saccular Posterior Inferior Cerebellar Artery Aneurysms: Systematic Review and Meta-Analysis

The optimal treatment modality for saccular aneurysms of the posterior inferior cerebellar artery (PICA) remains unclear. A previous meta-analysis on the topic included a heterogenous study population, limiting the conclusions that can be drawn from its results. The aim of this study was to perform a systematic review and meta-analysis to compare outcomes of microsurgical and endovascular treatment (EVT) of these aneurysms. A search of 4 online databases was performed for studies describing the management of saccular PICA aneurysms. The primary outcome was complete aneurysm occlusion. Data were also collected on neurologic outcomes, cranial nerve palsies, and requirement for re-treatment. A random effects model was used for calculation of pooled proportions. Our protocol was registered with PROSPERO (CRD42021232784). A total of 17 studies were included in the final analysis, reporting the treatment outcomes of 455 aneurysms, with a mean follow-up of 20 months. The pooled occlusion rates were 94.8% (95% confidence interval [CI] 90.6%-97.8%) for surgical treatment and 69.1% (95% CI 55.0%-81.7%) for EVT. Pooled rates of good neurologic outcome (modified Rankin scale score ≤2, Glasgow Outcome Scale score ≥4) at last follow-up were 78.1% (95% CI 67.4%-87.1%) for surgery and 77.6% (95% CI 67.9%-86.0%) for EVT. This meta-analysis demonstrates that in the treatment of saccular PICA aneurysms, microsurgical clipping results in superior angiographic outcomes, similar functional outcomes, but higher rates of lower cranial nerve palsy compared with EVT. Further studies are required to assess the duration and severity of cranial nerve palsies following surgical treatment, and long-term aneurysm occlusion and the requirement for re-intervention following EVT.

Incidence, characteristics and predictors of mortality following cardiac arrest in ICUs of a German university hospital: A retrospective cohort study.

Cardiac arrest in intensive care is a rarely studied type of in-hospital cardiac arrest. This study examines the incidence, characteristics, risk factors for mortality as well as long-term prognosis following cardiac arrest in intensive care. Retrospective cohort study. Five noncardiac surgical ICUs (41 surgical and 37 medical beds) at a German university hospital between 2016 and 2019. Adults experiencing cardiac arrest defined as the need for chest compressions and/or defibrillation occurring for the first time on the ICU. Primary endpoint: occurrence of cardiac-arrest in the ICU. Secondary endpoints: diagnostic and therapeutic measures; risk factors and marginal probabilities of no-return of spontaneous circulation; rates of return of spontaneous circulation, hospital discharge, 1-year-survival and 1-year-neurological outcome. A total of 114 cardiac arrests were observed out of 14 264 ICU admissions; incidence 0.8%; 95% confidence interval (CI) 0.7 to 1.0; 45.6% received at least one additional diagnostic test, such as blood gas analysis (36%), echocardiography (19.3%) or chest x-ray (9.9%) with a resulting change in therapy in 52%, (more frequently in those with a return of spontaneous circulation vs none, P = 0.023). Risk factors for no-return of spontaneous circulation were cardiac comorbidities (OR 5.4; 95% CI, 1.4 to 20.7) and continuous renal replacement therapy (OR 5.9; 95% CI, 1.7 to 20.8). Bicarbonate levels greater than 21 mmol 1 were associated with a higher mortality risk in combination either with cardiac comorbid-ities (bicarbonate <21 mmol I-1: 13%; 21 to 26 mmolI-1 45%; >26mmolI-1:42%)orwithaSOFA at least 2 (bicarbonate <21 mmolI-1 8%; 21 to 26 mmolI-1: 40%; >26mmolI-1: 37%). "In-hospital mortality was 78.1% (n = 89); 1-year-survival-rate was 10.5% (95% CI, 5.5 to 17.7) and survival with a good neurological outcome was 6.1% (95% CI, 2.5 to 12.2). Cardiac arrest in ICU is a rare complication with a high mortality and low rate of good neurological outcome. The development of a structured approach to resuscitation should include all available resources of an ICU and adequately consider the complete diagnostic and therapeutic spectra as our results indicate that these are still underused. The development of prediction models of death should take into account cardiac and hepatic comorbidities, continuous renal replacement therapy, SOFA at least 2 before cardiac arrest and bicarbonate level. Further research should concentrate on identifying early predictors and on the prevention of cardiac arrest in ICU.

250 Advanced management of out of hospital cardiac arrest: a single-centre experience in a tertiary cardiac intensive care unit

Abstract Aims Out-of-hospital cardiac arrest (OHCA) affects around 1/1000 person-years. Following return of spontaneous circulation (ROSC), the patient can manifest neurological impairment. A targeted temperature management (TTM) protocol is recommended to prevent hypoxic–ischaemic brain damage in patients with coma after cardiac arrest. Neuro-prognostication remains substantial for the prediction of clinical outcomes. To study clinical characteristics, overall survival, and neurological outcome of patients with Glasgow Coma Scale (GCS) &amp;lt;8 after ROSC following an OHCA of presumed cardiac cause at our Institution. Secondly, to investigate determinants of a negative neurological outcome. Methods Observational retrospective study evaluating all patients with OHCA of presumed cardiac cause and with GCS &amp;lt; 8 after ROSC treated in an intensive cardiac care unit of a tertiary centre. The study period was from January 2017 to December 2020. Results One-hundred and five patients out of 107 patients initially selected were included in the study (77% male, mean age 67 years). At 30 days, mortality was 41% and 53% of patients had a poor neurological outcome (Cerebral Performance Category, CPC, 3–5). Sixty-nine patients (66%) underwent TTM. In regard of the circumstances of OHCA, index event in a private place [OR = 3.12 (1.43–7.11), P = 0.005], ineffective rhythm changes during resuscitation manoeuvres [OR = 2.40 (1.05–5.47), P = 0.037] and a greater amount of adrenaline administered during resuscitation [OR = 1.62 (1.27–2.06), P &amp;lt; 0.001] were related to a worse neurological outcome. A history of diabetes mellitus [OR = 3.35 (1.26–8.91), P = 0.015], blood lactates at presentation [OR = 1.33 (1.15—1.53), P &amp;lt; 0.001], neuron-specific enolase (NSE) at presentation [OR = 1.055 (1.022–1.089), P &amp;lt; 0.001] and as peak [OR = 1.034 (1.013–1.054), P &amp;lt; 0.001] were associated with a worse neurological outcome. Among the neurological examinations, the presence of status epilepticus on the EEG [OR = 13.97 (1.73–113.02), P = 0.013] was a predictor of a poor neurological outcome. Treatment with targeted temperature management did not show a significant impact in terms of outcome at univariate analysis [OR = 1.226 (0.547–2.748), P = 0.62]. Two models were developed with multivariate logistic regression for the prediction of neurological outcome. The first one, on a statistical basis, considers pupil reactivity after ROSC, NSE as peak and left ventricular ejection fraction (AUC = 92%). The second model, on a clinical basis, considers age, first blood lactate value and NSE as peak (AUC = 89 %). Finally, the performance of the multiparametric MIRACLE score was tested in our population (AUC 0.81 for neurological outcome at 30 days). Conclusions In our population, at 30 days after cardiac arrest, survival rate and the rate of good neurological outcome were comparable to those of the major international registries and studies. Even though patients treated with TTM did not demonstrate significant differences in terms of neurological outcome, this might be related to study-sample size and patient selection. Results in the literature are still controversial on this topic. The MIRACLE score showed a good performance, making it suitable for clinical use in our population. Similarly, the proposed multivariate models are potentially useful for the elaboration of simple and effective prognostic scores in neurological risk stratification.

Temporal trends in the use of targeted temperature management after cardiac arrest and association with outcome: insights from the Paris Sudden Death Expertise Centre

PurposeRecent doubts regarding the efficacy may have resulted in a loss of interest for targeted temperature management (TTM) in comatose cardiac arrest (CA) patients, with uncertain consequences on outcome. We aimed to identify a change in TTM use and to assess the relationship between this change and neurological outcome.MethodsWe used Utstein data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing CA data from all secondary and tertiary hospitals located in the Great Paris area, France) between May 2011 and December 2017. All cases of non-traumatic OHCA patients with stable return of spontaneous circulation (ROSC) were included. After adjustment for potential confounders, we assessed the relationship between changes over time in the use of TTM and neurological recovery at discharge using the Cerebral Performance Categories (CPC) scale.ResultsBetween May 2011 and December 2017, 3925 patients were retained in the analysis, of whom 1847 (47%) received TTM. The rate of good neurological outcome at discharge (CPC 1 or 2) was higher in TTM patients as compared with no TTM (33% vs 15%, P < 0.001). Gender, age, and location of CA did not change over the years. Bystander CPR increased from 55% in 2011 to 73% in 2017 (P < 0.001) and patients with a no-flow time longer than 3 min decreased from 53 to 38% (P < 0.001). The use of TTM decreased from 55% in 2011 to 37% in 2017 (P < 0.001). Meanwhile, the rate of patients with good neurological recovery remained stable (19 to 23%, P = 0.76). After adjustment, year of CA occurrence was not associated with outcome.ConclusionsWe report a progressive decrease in the use of TTM in post-cardiac arrest patients over the recent years. During this period, neurological outcome remained stable, despite an increase in bystander-initiated resuscitation and a decrease in “no flow” duration.

Association between early advanced life support and good neurological outcome in out of hospital cardiac arrest: A propensity score analysis.

Out-of-hospital cardiac arrest (OHCA) is an important public health problem. The French organization, combining OHCA basic life support (BLS) and advanced life support (ALS), has been recently questioned. The study was conducted to evaluate the association between early ALS (E-ALS) arrival and good neurological outcome at 1 month in nontraumatic OHCA patients. Retrospective cohort study using data from RéAC, multicentre OHCA database since June 2011. Adult patients with nontraumatic cardiac arrest were identified, and firefighters' (BLS) arrival time was recorded. The main analysis was performed after multiple imputation, using propensity score matching with a variable ratio. Sensitivity analyses were also performed. The exposure was early ALS (E-ALS), start of ALS before. or simultaneously with BLS. The primary outcome was the cerebral performance category (CPC) at day 30 after the cardiac arrest (1-2 vs 3-5), while cumulative incidence of return of spontaneous circulation (ROSC) defined secondary outcomes. Between January 2013 and January 2016, a total of 30 672 adult nontraumatic OHCA with resuscitation were identified, from whom 20 804 were included, 2711 in the E-ALS group and 18 093 in the control group. Based on the matched sample, patients in the E-ALS group had a significantly lower rate of good neurological outcome than those in the control group (OR, 0.95; 95% CI, 0.93-0.96). Sensitivity analyses were mostly consistent with this result. Cumulative incidence of ROSC was higher in delayed ALS (D-ALS) group. This study showed that patients in the E-ALS group were less likely to have a good neurological outcome. One explanation of this unexpected result could be the total duration of resuscitation performed, which may be interrupted prematurely in cases of E-ALS.

Computed Tomography Angiography Spot Sign as an Indicator for Ultra-Early Stereotactic Aspiration of Intracerebral Hemorrhage.

Ultra-early surgical clot removal relieves mechanical compression on adjacent normal brain tissue and limits the toxic effects of a hematoma, which might improve the outcomes in patients with intracerebral hemorrhage (ICH); however, hematoma expansion frequently occurs within 20 hours after the ictus, and this limits the use of ultra-early surgery. Computed tomography angiography spot sign was recently validated as an important predictor of hematoma expansion in patients with ICH. Fifty-nine patients with ICH and negative spot sign who received ultra-early stereotactic aspiration (<6 hours after ictus; n= 32 [Ultra-early group]) or routine stereotactic aspiration (≥6 hours after ictus; n= 27 [Routine group]) were included in retrospective analysis. The percentage of rebleeding was not significantly different between the 2 groups. Perihematoma edema 7 days after surgery in the Ultra-early group was significantly less frequent than that in the Routine group. For long-term outcomes, the proportion of patient fatalities and Glasgow Outcome Scale score were not significantly different between the 2 groups; however, for patients with severe symptoms, the rate of good neurological outcome in the Ultra-early group was higher than that in the Routine group. Ultra-early stereotactic aspiration might decrease the volume of perihematoma edema and improve the functional outcomes to some extent, without increasing the recurrence of ICH and patient fatalities. Our findings suggest that using negative spot sign as an indicator for performing ultra-early stereotactic aspiration could be a safe and effective protocol for ICH patients.

Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis.

There is currently controversy on the ideal anesthesia strategy during mechanical thrombectomy for acute ischemic stroke. We performed a systematic review and meta-analysis of studies comparing clinical and angiographic outcomes of patients undergoing general anesthesia (GA group) and those receiving either local anesthesia or conscious sedation (non-GA group). A literature search on anesthesia and endovascular treatment of acute ischemic stroke was performed. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome at 90 days (modified Rankin Score≤2), symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, and time to groin puncture. Twenty-two studies (3 randomized controlled trials and 19 observational studies), including 4716 patients (1819 GA and 2897 non-GA) were included. In the nonadjusted analysis, patients in the GA group had higher odds of death (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.66-2.45) and respiratory complications (OR, 1.70; 95% CI, 1.22-2.37) and lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48-0.64) compared with the non-GA group. There was no difference in procedure time between the 2 primary comparison groups. When adjusting for baseline National Institutes of Health Stroke Scale, GA was still associated with lower odds of good functional outcome (OR, 0.59; 95% CI, 0.29-0.94). When considering studies performed in the stent-retriever/aspiration era, there was no significant difference in good neurological outcome rates (OR, 0.84; 95% CI, 0.67-1.06). Acute ischemic stroke patients undergoing intra-arterial therapy may have worse outcomes when treated with GA as compared with conscious sedation/local anesthesia. However, major limitations of current evidence (ie, retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to answer this question.

Hemorrhagic Transformations after Thrombectomy: Risk Factors and Clinical Relevance

Background: Hemorrhagic transformation (HT) is a major complication of acute ischemic stroke, potentially associated with clinical deterioration. We attempted to identify risk factors and evaluated clinical relevance of minor and major HTs following endovascular thrombectomy (ET) in isolated middle cerebral artery (MCA) occlusions. Methods: This is a retrospective single-center analysis of 409 patients with isolated MCA occlusion treated with ET. Patients' and procedural characteristics, severity of HT according to the European Cooperative Acute Stroke Study criteria, and clinical outcomes were analyzed. Multivariate logistic regression models with standard retention criteria (p < 0.1) were used to determine risk factors and clinical relevance of HT. Results are shown as adjusted OR (aOR) and respective 95% CIs. Good neurologic short-term outcome was defined as National Institutes of Health Stroke Scale (NIHSS) score <5 at the day of discharge. Results: Of 299 patients included, hemorrhagic infarction (HI) was detected in 87 patients, while 13 patients developed parenchymal hematoma (PH). Higher age (aOR 0.970, 95% CI 0.947-0.993, p = 0.012), eligibility for intravenous recombinant tissue plasminogen activator (IV rtPA; aOR 0.512, 95% CI 0.267-0.982, p = 0.044), and complete recanalization (TICI 3, aOR 0.408, 95% CI 0.210-0.789, p = 0.008) were associated with a lower risk of HI. Risk factors for HI included higher admission NIHSS score (aOR 1.080, 95% CI 1.010-1.153, p = 0.024) and higher admission glucose levels (aOR 1.493, 95% CI 1.170-1.904, p = 0.001). Further, female sex tended to be associated with a lower risk of HI (aOR 0.601, 95% CI 0.316-1.143, p = 0.121), while a statistical trend was observable for proximal MCA occlusion (aOR 1.856, 95% CI 0.945-3.646, p = 0.073) and a history of hypertension (aOR 2.176, 95% CI 0.932-5.080, p = 0.072) to increase risk of HI. Longer intervals from symptom onset to first digital subtraction angiography runs (aOR 1.013, 95% CI 1.003-1.022, p = 0.009), lower preinterventional Alberta Stroke Program Early CT score (aOR 0.536, 95% CI 0.307-0.936, p = 0.028) and wake-up stroke (aOR 18.540, 95% CI 1.352-254.276, p = 0.029) were associated with PH. Both, PH and HI were independently associated with lower rates of good neurologic outcome (aOR 0.086, 95% CI 0.008-0.902, p = 0.041 and aOR 0.282, 95% CI 0.131-0.606, p = 0.001). Conclusion: Risk of HI following MCA occlusion and subsequent ET is mainly determined by factors influencing infarct severity. Good recanalization results seem to be protective against subsequent HI. Our results support the notion that occurrence of PH after ET is time dependent and risk increases with more extensive early ischemic damage. Both, HI and PH do not seem to be facilitated by bridging therapy with IV rtPA or the use of oral anticoagulants, but were independently associated with more severe neurologic disability. These results support the notion that HI is not a “benign” imaging sign.

The role of the gray-to-white matter ratio to predict the prognosis of cardiac arrest treated with ECMO.

Outcome of patients who have suffered a cardiac arrest (CA), has improved in the past years. However, survival and good neurological outcome rates are still low (1).

Abstract 20023: Impact of Targeted Temperature During Therapeutic Hypothermia: A Pooling Analysis of Published Literature

Introduction: Two small RCTs demonstrated benefit of therapeutic hypothermia (TH) after out-hospital cardiac arrest (OHCA). We explored the benefit of targeted temperature during TH and also performed an updated meta-analysis to determine the intervention effect in the community. Methods: We identified studies by searching electronic databases (MEDLINE, EMBASE and Cochrane Library). We selected RCTs and cohort studies restricted to those reporting achieved temperature during TH after OHCA, and describing mortality and neurological outcomes at discharge. Studies were assessed for risk of bias. Data from all individual hypothermia arms were pooled by achieved temperature. Pooled outcomes were compared across achieved temperatures. Meanwhile, we meta-analyzed controlled studies comparing hypothermia against normothermia. Results: The search identified 32,275 studies of which 24 studies (34 hypothermia arms) were used in the pooling analysis and 14 controlled studies were meta-analyzed. Pooling analysis reported an overall in-hospital mortality of 47.2% with a rate of good neurological outcome at discharge of 38%. There was no difference in hospital mortality (p=0.86) or neurological outcomes at discharge (p=0.32) across temperatures (Figure 1). Sub-group analysis by rhythm showed a non-significant trend towards benefit when the lower temperature were applied to non-shockable rhythms. Meta-analysis demonstrated a MTH mortality (OR 0.51, 95%CI:0.41-0.64, I2=4.1%) and neuro-protective benefit (OR 2.48, 95%CI:1.91-3.22, I2=0%). Conclusions: No discernible clinical benefit was noted based on target temperature achieved. The signal toward potential benefit when applying lower temperature to non-shockable rhythms warrants exploration. Consistent with prior meta-analysis, TH provides mortality and neuro-protective benefit after OHCA even when including cohort studies thought to be more representative of performance in the community.

Surgical and endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. We evaluated trends in outcomes and treatment of poor-grade aSAH and performed a meta-analysis evaluating outcomes by treatment modality. We performed a literature search for studies on surgical and endovascular treatment of poor-grade aSAH. We performed a random effects meta-analysis evaluating long-term good neurological outcome, long-term poor neurological outcome and mortality, comparing rates between endovascular and surgical treatments. We performed a subgroup analysis of outcome by treatment timing relative to the aSAH separating treatment timing into three categories: 1) ultra-early (within 48 hours of aSAH); 2) early (between 48 hours-1 week post-aSAH); and 3) delayed (>1 week post-aSAH). We also evaluated trends in treatment modalities and good neurological outcome. Eighty-five non-comparative studies with 4506 patients with poor-grade aSAH were included. The proportion of patients receiving endovascular treatment increased from 10.0% to 62.0% between 1990-2000 and 2010-2014. The rate of good neurological outcome increased from 37.0% to 44.0% over this time period. Long-term good neurological outcome was 38% (95% CI=33-43%) in the endovascular group and 39% (95% CI=34-44%) in the surgical group (P=0.74). Mortality rates were higher in the endovascular group compared to the surgical group (41% versus 31%, P=0.01). Overall, patients receiving ultra-early treatment had the highest rates of good neurological outcome (61% compared to 40% for early and 47% for delayed, P<0.01). Good neurological outcome rates are similar between surgery and endovascular treatment of poor grade aSAH. Ultra-early treatment is associated with improved clinical outcomes.

Deconstructive and Reconstructive Techniques in Treatment of Vertebrobasilar Dissecting Aneurysms: A Systematic Review and Meta-Analysis.

Various endovascular techniques have been applied to the treatment of vertebrobasilar dissecting aneurysms, including parent artery preservation with coiling, stent placement or flow diverter placement, and trapping and proximal occlusion. We performed a systematic review and meta-analysis to study clinical and angiographic outcomes of patients undergoing endovascular treatment of vertebrobasilar dissecting aneurysms. We performed a comprehensive literature search for studies on the endovascular treatment of vertebrobasilar dissecting aneurysms. From each study we abstracted the following data: immediate occlusion, long-term occlusion, long-term good neurologic outcome, perioperative morbidity, perioperative mortality, rebleed (ruptured only), recurrence, and retreatment. We performed subgroup analyses of patients undergoing deconstructive-versus-reconstructive techniques. Meta-analysis was performed by using a random effects model. Seventeen studies with 478 patients were included in this analysis. Sixteen studies had at least 6 months of clinical/angiographic follow-up. Endovascular treatment was associated with high rates of long-term occlusion (87.0%; 95% CI, 74.0%-94.0%) and low recurrence (7.0%; 95% CI, 5.0%-10.0%) and retreatment rates (3.0%; 95% CI, 2.0%-6.0%). Long-term good neurologic outcome was 84.0% (95% CI, 65.0%-94.0%). Deconstructive techniques were associated with higher rates of long-term complete occlusion compared with reconstructive techniques (88.0%; 95% CI, 35.0%-99.0% versus 81.0%; 95% CI, 64.0%-91.0%; P < .0001). Deconstructive and reconstructive techniques were both associated with high rates of good neurologic outcome (86.0%; 95% CI, 68.0%-95.0% versus 92.0%; 95% CI, 86.0%-95.0%; P = .10). Endovascular treatment of vertebrobasilar dissecting aneurysms is associated with high rates of complete occlusion and good long-term neurologic outcomes. Deconstructive techniques are associated with higher occlusion rates. There was no statistical difference in neurologic outcomes between groups, possibly due to low power.

Abstract 102: Out-of-Hospital Cardiac Arrest Clinical Trial Control Groups: Time Capsules for Discovery of Secular Trends---Fraction of Patients with Good Neurological Outcomes, 1985 to Present

Introduction: Over time there have been changes in consensus therapy for out of hospital cardiac arrest (OOHCA), including changes in BLS-ACLS, and recently targeted temperature management. There has been only limited success, however, in determining the effect of specific interventions on neurological outcome using randomized clinical trials (RCT’s) and registries. Hypothesis: The control groups in OOHCA RCT’s can be utilized to identify the presence or absence of potential trends in neurological outcome related to secular changes in care. Methods: Comprehensive online search for RCT’s in OOHCA with n &gt; 50 in control group, and reporting neurological outcome, 1960 to present. Extraction of demographic and outcome variables. Analysis, fraction of resuscitated patients with good neurological outcome (GNO), defined as CPC 1 or 2 as a function of year. Results: n=32 usable RCTS were identified, all since 1985. No significant trends in the fraction of patients with GNO were identified (Figure). There was relatively large variability. Outcomes in the epoch since the promulgation of hypothermia have not changed overall. However, since about 2012 there have been a handful of RCT’s with relatively high fraction of patients with GNO compared to historical norms. Limitations: Retrospective methodology and background regional differences limits significance and applicability, hypothesis generating only. Conclusion: Between 1985 and the present, there were no trends in GNO rates in the control groups of RCTs, possibly indicating lack of efficacy or toxicity with respect to therapies experiencing changing patterns of utilization, or an offsetting change in substrate.

Lack of improved outcomes with increased use of targeted temperature management following out-of-hospital cardiac arrest: A multicenter retrospective cohort study

Study aimsTo assess whether increased use of targeted temperature management (TTM) within an integrated healthcare delivery system resulted in improved rates of good neurologic outcome at hospital discharge (Cerebral Performance Category score of 1 or 2). MethodsRetrospective cohort study of patients with OHCA admitted to 21 medical centers between January 2007 and December 2012. A standardized TTM protocol and educational program were introduced throughout the system in early 2009. Comatose patients eligible for treatment with TTM were included. Adjusted odds of good neurologic outcome at hospital discharge and survival to hospital discharge were assessed using multivariate logistic regression. ResultsA total of 1119 patients were admitted post-OHCA with coma, 59.1% (661 of 1119) of which were eligible for TTM. The percentage of patients treated with TTM markedly increased during the study period: 10.5% in the years preceding (2007–2008) vs. 85.1% in the years following (2011–2012) implementation of the practice improvement initiative. However, unadjusted in-hospital survival (37.3% vs. 39.0%, p=0.77) and good neurologic outcome at hospital discharge (26.3% vs. 26.6%, p=1.0) did not change. The adjusted odds of survival to hospital discharge (AOR 1.0, 95% CI 0.85–1.17) or a good neurologic outcome (AOR 0.94, 95% CI 0.79–1.11) were likewise non-significant. InterpretationDespite a marked increase in TTM rates across hospitals in an integrated delivery system, there was no appreciable change in the crude or adjusted odds of in-hospital survival or good neurologic outcomes at hospital discharge among eligible post-arrest patients.

Abstract 255: Sex Difference of Clinical Outcomes in Patients with Out-of-Hospital Cardiopulmonary Arrest: A Prospective Multicenter Observational Study

OBJECTIVE: There is a strong interest in differences in the outcomes between men and women with out-of-hospital cardiopulmonary arrest (OHCA). The aim of this study is to examine the sex differences of clinical outcomes in patients with OHCA. METHODS: The Japan-Prediction of neurological Outcomes in patients Post cardiac arrest (J-POP) registry is a prospective, multicenter, cohort study to test whether regional cerebral oxygen saturation (rSO2) predicts neurological outcomes in OHCA. In this post-hoc analysis, OHCA were collected after excluding patients exposed to extracorporeal cardiopulmonary bypass from the J-POP registry. The primary outcome measure was a return of spontaneous circulation (ROSC) prior to hospital arrival, and secondary outcome measure was a 90-days neurological outcome. Results: Between May 2011 and July 2012, 1204 consecutive patients, age 72±15 years, 40.4% of women, were examined. Men were younger than women (70±15 vs. 75±15 years, p&lt;0.001), with higher percentage of witness status (53.7% vs. 43.1%, p&lt;0.001), and with higher percentage of rSO2 more than 40% at hospital arrival (12.1% vs. 7.0%, p&lt;0.01), and tended to have higher percentage of cardiac etiology (57.6% vs. 52.4%, p=0.07). 118 (9.8%) patients achieved ROSC prior to hospital arrival. 90-day survival rate was 6.1% (n=73), and 90-day good neurological outcome rate was 3.5% (n=42). Men had higher chance of ROSC (11.7% vs. 7.0%, p&lt;0.01), and good neurological outcome at 90 days (4.6% vs. 1.8%, p=0.01). Multivariate analysis adjusting for age (less than 75 y/o or not), witnessed, received CPR by bystander and etiology revealed that sex male was chosen as an independent predictor for ROSC prior to arrival (RR 1.59, 95%CIs 1.03-2.45). Mantel-Haenszel test adjusting for cardiac etiology also showed that men had higher rate of good neurological outcome (RR 2.47, 95%CIs 1.16-5.23). Conclusion: Our results demonstrate that men had significantly better chance of ROSC regardless of age, received BLS and etiology, and had better neurological prognosis after cardiogenic OHCA. Additional studies are needed to validate these observations for other potential genetic factors.

Abstract 257: Clinical Decision Tree Model in Patients with Out-of-Hospital Cardiac Arrest for Predicting Neurological Outcome at the Emergency Department

Introduction: The ideal factors for predicting neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA) remain elusive. Hypothesis: We hypothesized that a novel decision tree model using 4 pre-hospital variables can predict neurological outcome after OHCA at the emergency department. Methods: We analyzed 390226 adults in whom resuscitation was attempted after non-traumatic OHCAs in a prospectively recorded nationwide Utstein-style database in Japan over 5 years (2005-2009). The endpoint was 1-month survival with good neurological outcome (cerebral performance category scale, 1-2). We developed a prediction model using data from 4 years (2005-2008, n = 307896), with validation using external data from 2009 ( n = 82330). Results: Overall 1-month survival and good neurological outcome rates were 4.19% and 1.99%, respectively. Multivariate logistic regression analysis indicated the following pre-hospital factors to be significant: shockable initial rhythm (odds ratio [OR] 5.87; 95% confidence interval [CI] 5.23-6.60), emergency medical service (EMS) personnel witnessed (OR 3.40; 95%CI 3.15-3.69), witnessed arrest (OR 3.05; 95%CI 2.83-3.28), and age (OR 3.24; 95%CI 2.97-3.53). Using recursive partitioning analysis with these 4 predictors, we developed a clinical decision tree model: if a witnessed OHCA patient had shockable initial rhythm, the probability of good outcome was 20.0% (age&lt;71) or 10.3% (age&gt;or=71); if an unwitnessed OHCA patient had shockable initial rhythm, the probability of good outcome was 6.8% (age&lt;81) or 1.8% (age&gt;or=81); if a witnessed OHCA patient had unshockable initial rhythm, the probability of good outcome was 3.8% (EMS personnel witnessed arrest) or 1.1% (EMS personnel unwitnessed arrest); if an unwitnessed OHCA patient had unshockable initial rhythm, the probability of good outcome was 0.5% (age&lt;71) or 0.2% (age&gt;or=71). The c-statistics for this model in the groups for development and validation were 0.867 (95%CI 0.861-0.873) and 0.887 (95%CI 0.877-0.896), respectively. Conclusions: Stratification of patients using a decision tree model accurately provides the severity of OHCA classification rules and can predict good neurological outcomes after OHCA at the emergency department.

REMOVED: Regional cerebral oxygen saturation on hospital arrival is a potential novel predictor of neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest

To investigate the association between regional brain oxygen saturation (rSO(2)) on hospital arrival and neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest (OHCA). A prospective cohort study was conducted, registering 179 patients with OHCA who were referred to Senri Critical Care Medical Centre between April 2009 and June 2010. Of these patients, 92 met the inclusion criteria. The primary end point was "neurological outcomes" at hospital discharge according to the "Utstein style" guidelines. The overall rate of good neurological outcome at hospital discharge was 14% (n=13). Sixty-one patients with rSO(2) ≤25% showed poor neurological outcome in the receiver operating curve analysis (optimal cut-off point, 25%; sensitivity, 0.772; specificity, 1.000; positive predictive value, 1.000; area under the curve (AUC), 0.919; p<0.0001). The AUC for rSO(2) was greater than that for base excess (p=0.0461) or lactate (p=0.0128) measured on hospital arrival. Since rSO(2) >40% was previously collated with good neurological outcome after cardiovascular surgery, we categorised our patients into three groups in a post hoc analysis: patients with rSO(2) ≤25% (n=61); patients with rSO(2) 26-40% (n=9) and patients with rSO(2) >40% (n=22). Patients with good neurological outcome were as follows: 0 (0%)/61 with rSO(2) ≤25%; two (22.2%)/9 with rSO(2) 26-40% and 11 (50.0%)/22 with rSO(2) >40% (p<0.0001). rSO(2) on hospital arrival may help predict neurological outcomes at hospital discharge in patients with OHCA.