Prediction Of Neurological Outcome Research Articles

Termination of Resuscitation Rules to Predict Neurological Outcomes in Out-of-Hospital Cardiac Arrest for an Intermediate Life Support Prehospital System

Aim: Futile resuscitation can lead to unnecessary transports for out-of-hospital cardiac arrest (OHCA). The Basic Life Support (BLS) and Advanced Life Support (ALS) termination of resuscitation (TOR) guidelines have been validated with good results in North America. This study aims to evaluate the performance of these two rules in predicting neurological outcomes of OHCA patients in Singapore, which has an intermediate life support Emergency Medical Services (EMS) system. Methods: A retrospective cohort study was carried out on Singapore OHCA data collected from April 2010 to May 2012 for the Pan-Asian Resuscitation Outcomes Study (PAROS). The outcomes of each rule were compared to the actual neurological outcomes of the patients. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and predicted transport rates of each test were evaluated. Results: A total of 2,193 patients had cardiac arrest of presumed cardiac etiology. TOR was recommended for 1,411 patients with the BLS-TOR rule, with a specificity of 100% (91.9, 100.0) for predicting poor neurological outcomes, PPV 100% (99.7, 100.0), sensitivity 65.7% (63.6, 67.7), NPV 5.6% (4.1, 7.5), and transportation rate 35.6%. Using the ALS-TOR rule, TOR was recommended for 587 patients, specificity 100% (91.9, 100.0) for predicting poor neurological outcomes, PPV 100% (99.4, 100.0), sensitivity 27.3% (25.4, 29.3), NPV 2.7% (2.0, 3.7), and transportation rate 73.2%. BLS-TOR predicted survival (any neurological outcome) with specificity 93.4% (95% CI 85.3, 97.8) versus ALS-TOR 98.7% (95% CI 92.9, 99.8). Conclusion: Both the BLS and ALS-TOR rules had high specificities and PPV values in predicting neurological outcomes, the BLS-TOR rule had a lower predicted transport rate while the ALS-TOR rule was more accurate in predicting futility of resuscitation. Further research into unique local cultural issues would be useful to evaluate the feasibility of any system-wide implementation of TOR.

Prognostic value of the recovery time of continuous normal voltage in amplitude-integrated electroencephalography in out-of-hospital cardiac arrest patients treated with therapeutic hypothermia: a retrospective study.

BackgroundThe early prediction of neurological outcomes in postcardiac arrest patients treated with therapeutic hypothermia (TH) remains challenging. Amplitude-integrated electroencephalography (aEEG) is a type of quantitative EEG. A particular cutoff time from the return of spontaneous circulation (ROSC) to the recovery of a normal aEEG trace for predicting a good neurological outcome has not yet been established. The purpose of the present study was to examine the relation between neurological outcomes and the continuous normal voltage (CNV) recovery time in adult comatose survivors of cardiac arrest treated with TH and identify the recovery time cutoff for predicting a good neurological outcome.MethodsWe retrospectively evaluated adult survivors of cardiac arrest with initial shockable rhythm treated with TH and monitored with aEEG. A good outcome was defined as a cerebral performance category (CPC) of 1 or 2 at hospital discharge. A CNV trace was considered as the normal aEEG trace, and the CNV recovery time was defined as the time from ROSC to the initial CNV trace.ResultsThe study included 30 patients, and of these patients, 22 had recovery of CNV trace. The median CNV recovery time was shorter among patients with a good outcome than that among those with a poor outcome (10.7 h [interquartile range (IQR), 7.4–15.8 h] vs. 28.6 h [IQR, 26.9–29.3 h]; p = 0.003). The area under the receiver operating characteristic curve of the CNV recovery time for predicting a good neurological outcome was 0.95 (95 % CI 0.86–1; p = 0.003), and the optimal cutoff was 23 h. The recovery of CNV trace within 23 h had a sensitivity of 89 %, specificity of 100 %, positive predictive value of 100 %, and negative predictive value of 86 % for predicting a good neurological outcome in all the patients, including the eight patients without recovery of CNV trace.ConclusionsA CNV recovery time cutoff of 23 h might help predict a good neurological outcome in adult survivors of cardiac arrest treated with TH.

ELEVATED AT ADMISSION SERUM NEURON SPECIFIC ENOLASE AND HYPERGLYCEMIA ARE PREDICTORS OF POOR OUTCOME OF POST-RESUSCITATION PATIENTS

Background: Optimal survival following sudden cardiac arrest requires heart and brain resuscitation. In patients who achieve cardiac resuscitation, brain recovery from anoxic injury is variable. Neurological sequelae range from complete recovery to coma with brain death. Thus, ideally outcome assessment would incorporate functional and neurologic status. Objective: Evaluation of the prognostic yield of estimation of at admission random blood glucose (RBG) and serum neuron specific enolase (NSE) levels, and determination of the value of NSE serum level re-estimation 48 hours after admission in resuscitated post-cardiac arrest patients. Patients and Methods: The study included 90 cardiac arrest patients; 75 were out-of-hospital and 15 were in-hospital cardiac arrest. All patients received mild therapeutic hypothermia irrespective of the initial rhythm admission. Blood samples were obtained for estimation of RBG and serum SNE. At 48-hours after admission, serum NSE was re-estimated, and the percentage of change in relation to at-admission level was calculated. Clinical evaluation was conducted using the Acute Physiology and Chronic Health Evaluation (APACHE II). Mortality rate throughout duration of ICU stay was determined. Neurologic outcomes were evaluated using the Cerebral Performance Category (CPC) score collectively as favorable neurological outcome (CPC score of 1-2) or unfavorable outcome (CPC score of 3-5). Results: Mean time elapsed till return of spontaneous circulation (ROSC) since arrival to emergency department was 14.3±3.6; range: 8-19 minutes. Mean ICU stay was 16.3±7.4; range: 3-30 days. Thirty-one patients died (34.4%), 18 patients (20%) had unfavorable neurological outcome (CPC-3), and 41 patients (45.6%) had favorable outcome. Mean at admission RBG levels were significantly higher in non-survivors compared to survivors, with significantly higher levels in survivors had unfavorable outcome compared to those had favorable outcome. Mean levels of serum NSE estimated at admission and 48-hours, and percentage of change were significantly higher in non-survivors compared to survivors, with significantly higher levels in survivors had unfavorable outcome compared to those had favorable outcome. There was a negative significant correlation between survival rate and favorable neurologic outcome and levels of RBG and NSE, patient's age, time till ROSC and APACHE II score. ROSC curve and regression analyses were defined at admission hyperglycemia as the highly significant specific predictor for mortality and high serum NSE kinetics for prediction of unfavorable neurologic outcome. Conclusion: Hyperglycemia could specifically predict mortality and high serum NSE levels estimated at admission and 48-hours later, with elevated percentage of increase which could specifically predict poor neurologic outcome of resuscitated post-arrest patients.

Rate of Perihematomal Edema Expansion Predicts Outcome After Intracerebral Hemorrhage.

Intracerebral hemorrhage is a devastating disorder with no current treatment. Whether perihematomal edema is an independent predictor of neurologic outcome is controversial. We sought to determine whether perihematomal edema expansion rate predicts outcome after intracerebral hemorrhage. Retrospective cohort study. Tertiary medical center. One hundred thirty-nine consecutive supratentorial spontaneous intracerebral hemorrhage patients 18 years or older admitted between 2000 and 2013. None. Intracerebral hemorrhage, intraventricular hemorrhage, and perihematomal edema volumes were measured from CT scans obtained at presentation, 24-hours, and 72-hours postintracerebral hemorrhage. Perihematomal edema expansion rate was the difference between initial and follow-up perihematomal edema volumes divided by the time interval. Logistic regression was performed to evaluate the relationship between 1) perihematomal edema expansion rate at 24 hours and 90-day mortality and 2) perihematomal edema expansion rate at 24 hours and 90-day modified Rankin Scale score. Perihematomal edema expansion rate between admission and 24-hours postintracerebral hemorrhage was a significant predictor of 90-day mortality (odds ratio, 2.97; 95% CI, 1.48-5.99; p = 0.002). This association persisted after adjusting for all components of the intracerebral hemorrhage score (odds ratio, 2.21; 95% CI, 1.05-4.64; p = 0.04). Similarly, higher 24-hour perihematomal edema expansion rate was associated with poorer modified Rankin Scale score in an ordinal shift analysis (odds ratio, 2.40; 95% CI, 1.37-4.21; p = 0.002). The association persisted after adjustment for all intracerebral hemorrhage score components (odds ratio, 2.07; 95% CI, 1.12-3.83; p = 0.02). Faster perihematomal edema expansion rate 24-hours postintracerebral hemorrhage is associated with worse outcome. Perihematomal edema may represent an attractive translational target for secondary injury after intracerebral hemorrhage.

78. Diagnostic accuracy of neurophysiological tests (EEG and SEP) in comatose patients after cardiac arrest: Protocol presentation of Italian Multicentric Study (ProNeCA)

The prediction of neurologic outcome in comatose patients after cardiac arrest (CA) has been investigated and the findings were summarized in a practice parameter of the American Academy of Neurology (1). These guidelines did not include the EEG as a reliable outcome indicator but recent studies on continuous EEG recorded during TH have re-evaluated the role of EEG (2–4). These studies underline the utility of a simplified classification system of EEG patterns and point to which pattern attains reliable predictive value both for good and bad outcomes. These reports are of high clinical relevance because, until today, the possibility of identifying early prognostic indicators of good outcome in patients surviving to CA has not been investigated. At the best of our knowledge, only few multicentre prospective studies (4–6) analyzed the prognostic value of EEG and SEP recorded in the same patient after CA as single predictor but none analyzed the diagnostic accuracy of the association of these two tests. We present the study protocol of Italian Multicentre Study about prognostic value of EEG and SEP in comatose patients after CA (ProNeCA) proposed by study group of “Intraoperative and Intensive Care Clinical Neurophysiology” of the Italian Society of Clinical Neurophysiology.

Abstract TP48: Prediction of Neurologic Outcome after Ischemic Stroke with Volumetric Measurements on CT and MRI

Background: CT perfusion (CTP) and MR diffusion-weighted imaging (DWI) interpretation is typically qualitative. Manual quantitative volumetric measurement is too labor-intensive to be practical in the setting of acute ischemic stroke (AIS). Hypothesis: Compared to a manual technique, automated volumetric analysis of CTP and DWI in AIS patients will be a strong predictor of neurologic outcome at follow-up. Methods: We reviewed 123 inpatients from 2010-2014 with AIS, admission CTP, and clinical follow-up. Using the automated Olea Sphere software, we calculated CTP maps of cerebral blood volume (CBV) and mean transit time (MTT) using oSVD and Bayesian deconvolution. We used the OsiriX software to manually draw regions-of-interest corresponding to CBV and time-to-drain lesion volume on CTP, and core volume on DWI (in 74%). A multivariable ordinal logistic regression model was fitted to the outcome of modified Rankin Scale (mRS) at follow-up with covariates that had a p<0.2 and the primary predictor variables of stroke core, hypoperfused area, or mismatch volume. Mismatch was defined as CBV subtracted from MTT or time-to-drain. Results: Patients had mean (± SD) age of 64 ± 16 years; 54% were male; 91% of strokes were in the anterior circulation; mean NIHSS was 13 ± 8; mRS was 2.6 ± 2.1 at 82 ± 46 days to follow-up. Logistic regression found that stroke core was predictive of outcome with both automatic vs manual processes; the automated processes were predictive of outcome for the hypoperfused area measurements; and neither method of measuring mismatch was predictive for outcome (Table 1). Conclusion: Our data suggests that automated volumetric analysis of the stroke core and hypoperfused area, but not mismatch, provides accurate neurologic prognosis. Compared to manual volumetric measurements, automated software is more time efficient and may have superior predictive ability.

Abstract NS10: Rapidly Improving Stroke Symptoms - To Treat or Not to Treat

Background: Acute changes in the NIHSS are common in patients with large artery ischemic stroke. Unfortunately, even small improvements in the NIHSS may be viewed as a reason not to treat with intravenous tPA (IVtPA) among emergency practitioners with less alteplase experience. We sought to quantify outcome of patients denied IVtPA due to NIHSS score change, in an effort to improve future treatment decisions by our emergency practitioners. Methods: A retrospective observational study was conducted using a cohort of acute ischemic stroke patients presenting to our community hospital in southern California between January 1, 2010 and December 31, 2013. All patients in the cohort were denied IVtPA treatment due to perceived "rapidly improving symptoms" suggestive of TIA. The cohort was assembled from our Get with the Guidelines database, with all data verified to validate data accuracy. Descriptive data as well as the NIHSS score prompting the decision against IVtPA, both NIHSS and mRS at discharge, and length of stay (LOS) were entered and analyzed using SPSS. Results: 50 patients were identified for IVtPA non-treatment due to an NIHSS change; patients were 60% male and averaged 71.8 + 11.1 years age. Pre-morbid mRS median was 0. NIHSS median at time of reason not to treat was 3.5. While admission and discharge NIHSS were similar, discharge median mRS was significantly worse than premorbid mRS at 2 (p<0.001), with the majority of patients discharging disabled from their stroke. Length of stay averaged 3.4 + 2.5 days and did not differ by age, gender or stroke subtype, but was positively correlated with discharge NIHSS scores (r=.627; p<0.001) which accounted for 39% of the variance. Conclusion: Change in NIHSS score without total disability resolution is a poor predictor of neurologic outcome after stroke. Regularly sharing discharge outcomes of patients according to IVtPA treatment status may play an important role in changing treatment decision making behaviors among reluctant alteplase users.

Coronary Artery Bypass Grafting: The Usefulness of Neurological Screening

Objective: There is a risk of stroke in patients undergoing coronary artery bypass surgery (CABG) and coincidence of high-grade carotid artery stenosis in ∼6–8% of patients is described. Therefore a preoperative carotid ultrasound is required as a screening tool - but is it a valuable predictor for neurological outcome?

Circulating cell-free DNA is a predictor of short-term neurological outcome in stroke patients treated with intravenous thrombolysis.

Circulating cell-free DNA (cfDNA) has been described as a prognostic marker for several diseases. Its prognostic value for short-term outcome in stroke patients treated with intravenous thrombolysis remains unexplored. cfDNA was measured on admission in 54 tissue plasminogen activator (tPA)-treated patients and 15 healthy controls using a real-time quantitative polymerase chain reaction assay. Neurological outcome was assessed at 48 h. Predictors of neurological improvement were evaluated by logistic regression analysis, and the additional predictive value of cfDNA over clinical variables was determined by integrated discrimination improvement (IDI). Stroke patients presented higher baseline cfDNA than healthy controls (408.5 (179–700.5) vs. 153.5 (66.9–700.5) kilogenome-equivalents/L, p = 0.123). A trend towards lower cfDNA levels was found in patients who neurologically improved at 48 h (269.5 (143.3–680) vs. 504 (345.9–792.3) kilogenome-equivalents/L, p = 0.130). In logistic regression analysis, recanalization at 1 h and cfDNA < 302.75 kilogenome-equivalents/L was independently associated with neurological improvement after adjustment by age, gender and baseline National Institutes of Health Stroke Scale score. The addition of cfDNA to the clinical predictive model improved its discrimination (IDI = 21.2% (9.2–33.3%), p = 0.009). These data suggest that cfDNA could be a surrogate marker for monitoring tPA efficacy by the prediction of short-term neurological outcome.

Can the Assessment of Spontaneous Oscillations by Near Infrared Spectrophotometry Predict Neurological Outcome of Preterm Infants?

The aim was to assess the correlation between cerebral autoregulation and outcome. Included were 31 preterm infants, gestational age 26 1/7 to 32 2/7 and <24h life. Coherence between cerebral total haemoglobin (tHb) or oxygenation index (OI) measured by near-infrared spectrophotometry (NIRS) and systemic heart rate (HR) or arterial blood pressure (MAP) was calculated as a measure of autoregulation. In contrast to previous studies, low coherences in the first 24h were significantly associated with intraventricular haemorrhage, death or abnormal neurodevelopmental outcome at 18 months or later. We suggest that our results can be explained by the concept of a multi-oscillatory-functions-order.

Fibroblast growth factor 23 (FGF-23) is an early predictor of mortality in patients with cardiac arrest

BackgroundPost-cardiac arrest management has seen significant advances with profound improvements in survival and neurologic outcome. However, early prognostication after return of spontaneous circulation remains most challenging. Biomarkers have evolved as helpful tools in identifying patients who are at increased risk of adverse outcome. While fibroblast growth factor 23 (FGF-23) has recently emerged as a promising predictor of mortality in patients with cardiogenic shock, its role in risk stratification in post-resuscitation management remains unresolved. MethodsThis study included 90 patients who had been resuscitated and transferred to the ICU of the University Hospital Heidelberg. Survivors and non-survivors were retrospectively analyzed for known prognostic biomarkers as well as FGF-23 serum levels 24h and 72h post cardiac arrest (CA). ResultsFGF-23 levels were significantly elevated in non-survivors compared to survivors. ROC analysis of FGF-23 levels at 24h and 72h post CA yielded an AUC of 0.759 and 0.726, respectively, for prediction of overall survival after 6 months. FGF-23 levels remained as significant prognosticators after adjusting for age, renal function, and initial cardiac rhythm. FGF-23 levels did not show significant differences in patient outcome after stratification for cardiac origin of CA or left ventricular dysfunction. Furthermore, FGF-23 levels were moderately predictive of poor neurologic outcome in ROC analysis on day 1 and day 3 post CA with an AUC of 0.738 and 0.687, respectively. ConclusionThis study demonstrates elevated FGF-23 serum levels to be potentially helpful in prediction of mortality and poor neurological outcome as early as 24h post cardiac arrest.

Abstract 15924: Early Non-contrast Head Computed Tomography for Prognostication of Neurologic Outcomes Following Cardiac Arrest

Introduction: Prognostication of neurologic outcomes in patients achieving return of spontaneous circulation (ROSC) following cardiac arrest poses a difficult challenge. A low ratio of gray matter to white matter (GWR) attenuation on early non-contrast head computed tomography (NCHCT) may be a specific predictor of poor neurologic outcome following arrest. We sought to validate this finding and to determine if there is a GWR cutoff that is completely specific for predicting poor neurologic outcomes. Methods: We identified 145 patients from our institution with a cardiac arrest between February 2007 and March 2015 who underwent NCHCT within 24 hours following ROSC. GWRs were calculated by measuring the attenuation of 10-15 mm 2 regions of interest in Hounsfield units, identifying the head of the caudate nucleus for gray matter and the posterior limb of the internal capsule for white matter. Neurologic outcomes were recorded by cerebral performance category (CPC) upon hospital discharge. A CPC score of 1 or 2 defined a favorable neurologic outcome, whereas a score of 3, 4, or 5 marked a poor neurologic outcome. Results: Fifty patients had favorable neurologic outcomes, with a median GWR of 1.29 and an interquartile range (IQR) of 1.24-1.34. Ninety-five patients had poor neurologic outcomes, with a median GWR of 1.25 and an IQR of 1.18-1.30. Performance of the GWR as a predictor of neurologic outcome was examined by plotting a receiver operating characteristic curve; the area under the curve was 0.658. However, a GWR below 1.16 was found to have 100% specificity for predicting a poor neurologic outcome following arrest (20 cases, 21.1% sensitivity). Conclusion: In our study, a GWR below 1.16 was shown to be a completely specific predictor of poor neurologic outcome following cardiac arrest. In combination with other modalities, GWR on NCHCT could help guide management by lending prognostic information early in the post arrest course.

Abstract 15538: Serial Measurements of Neuron-specific Enolase and Prediction of Poor Neurological Outcome in Comatose Patients After Out-of-hospital Cardiac Arrest - A TTM Substudy

Purpose: Neuron-specific enolase (NSE) has been established as a predictor of poor neurological outcome after out-of-hospital cardiac arrest (OHCA). The optimal strategy for evaluation of serial NSE measurements remains unknown. Methods: The Target Temperature Management (TTM) trial biobank holds serial blood samples of OHCA patients, drawn at 24 hours, 48 hours and 72 hours after randomization to targeted temperature of either 33°C or 36°C. We included all patients being comatose at day 3 and investigated the value of NSE to predict poor neurological outcome and death (i.e. cerebral performance category 3-5) at 180 days follow-up. Multiple logistical regression and C-statistics models were used to establish the optimal use of the NSE-values. Results: A total of 550 comatose OHCA patients were included in the study (mean age 65 years, 80% men). At 180-day follow-up 333 (61%) of the patients had a CPC-score of 3 to 5. C-statistics revealed that the strongest predictor for poor CPC-score was the NSE value at 72 hours (AUC=0.85, see table). In a multiple logistic regression model adjusted for sex, age, time to return of spontaneous circulation, shock-able rhythm and lactate-levels at admission the area under the NSE-curve from 24 to 72 hours had the highest odds ratio (OR=4.2, p&lt;.0001). Conclusions: In patients being comatose at day three after OHCA the biomarker NSE is a strong predictor for poor neurological function and death (CPC 3-5) at 180-day follow-up. Adjustment for pre-hospital factors associated with a poor prognosis suggests that the area under the NSE-curve from 24 to 72 hours is a strong independent predictor.

Abstract 17230: Early Continuous EEG Biomarkers Predicts Neurologic Outcome in Post-cardiac Arrest Rats

Introduction: Hypothermic targeted temperature management (TTM) has greatly improved post-cardiac arrest patient outcomes, but also makes prognostication more difficult. In this study, we tested the hypothesis that early continuous EEG biomarkers are associated with neurologic outcome in post-cardiac arrest rats treated with normothermic and hypothermic TTM. Methods: Male rats were instrumented for continuous telemetric EEG (cEEG) recording and then subjected to 8-minute asphyxia cardiac arrest. Eight rats that achieved ROSC underwent either normothermic or hypothermic TTM (37 ± 0.5 °C or 33 ± 0.5 °C) for 24 hours and cEEG monitoring up to 72 hours. Quantitative EEG analysis determined the power density of delta (0.1-4 Hz), theta (4-8 Hz), alpha (8-13 Hz) and sigma (13-18 Hz) frequency bands in all 10 second windows. The mean spectral power and Spearman correlation with time for the first 12 hours after return of spontaneous circulation (ROSC) were calculated and correlated with best neurologic function score (NFS) and survival with good NFS (NFS ≥ 450 out of 500). Results: Over all rats tested, the mean delta band power in the first 12 hours after ROSC was inversely correlated with best neurologic function score and associated with poor outcome (Table and Figure). There was no statistical difference in other frequency bands. Similar findings were present when stratifying into normothermic and hypothermic treatment groups. Conclusions: This study suggests that, the early power density of delta frequency bands from cEEG is a potential predictor of neurologic outcome in a mixed population of rats treated with normothermic and hypothermic TTM.

An observational study of the association between microalbuminuria and increased N-terminal pro-B-type natriuretic peptide in patients with subarachnoid hemorrhage.

BackgroundThe urinary albumin/creatinine ratio (ACR) is a significant neurologic prognostic predictor in patients with aneurysmal subarachnoid hemorrhage (SAH). B-type natriuretic peptide (BNP) plays an important role in body fluid regulation in patients with SAH. The present study was performed to determine whether ACR was independent predictor for unfavorable neurological outcome and ACR was associated with increased N-terminal pro-BNP (NT-pro-BNP) after SAH.MethodsWe studied 61 patients undergoing surgery who were admitted within 48 h after aneurysmal SAH onset between July 2008 and June 2010. Hunt and Hess grade and Fisher grade were recorded at admission. The Glasgow Coma Scale (GCS) score was calculated at admission and daily for seven postoperative days. Arterial blood was sampled at admission and for seven postoperative days to determine the PaO2/FIO2 ratio, C-reactive protein level, troponin I level, and NT-pro-BNP level. Urine was sampled at admission and daily for seven postoperative days to determine ACR and vanillylmandelic acid/creatinine ratio (VMACR). Neurological outcomes were assessed at hospital discharge by using the Glasgow Outcome Scale. Receiver operating characteristic curves were constructed for the predictive variables of unfavorable neurological outcomes, and the area under the curve (AUC) was determined. Multivariate logistic regression analyses were performed for the significant predictors of unfavorable neurological outcomes after SAH. Associations with NT-pro-BNP were evaluated by using the Spearman rank correlation test.ResultsOf the 61 patients, 24 had unfavorable outcomes. The prevalence rate of microalbuminuria was 85 % (52/61). The highest NT-pro-BNP levels were above the normal range in 57 of 61 patients (93 %).According to the AUC, the Hunt and Hess grade, GCS score, the highest ACR, and highest VMACR were significant predictors of neurological outcome. Multivariate logistic regression analyses showed that the highest ACR and Hunt and Hess grade are independent prognostic predictors of unfavorable neurological outcomes. The highest NT-pro-BNP significantly correlated with the highest troponin I, highest ACR, and VMACR on admission.ConclusionsThe highest ACR is an independent prognostic predictor of unfavorable neurological outcomes after SAH. Moreover, plasma NT-pro-BNP elevation may be associated with the development of microalbuminuria.

Intensity of MRI Gadolinium Enhancement in Cerebral Adrenoleukodystrophy: A Biomarker for Inflammation and Predictor of Outcome following Transplantation in Higher Risk Patients.

Outcomes following hematopoietic stem cell transplantation for higher risk childhood-onset cerebral adrenoleukodystrophy are variable. We explored whether a brain MR imaging gadolinium intensity scoring system improves prediction of neurologic outcome. We developed a 4-point scale of gadolinium intensity relative to the choroid plexus: 0 = no enhancement; 1 = hypointense; 2 = isointense; 3 = hyperintense. The interobserver concordance of the scale was assessed on 30 randomly chosen studies. Scores were generated for 64 evaluable patients and compared with CSF chitotriosidase levels, a known inflammatory marker correlating with outcomes following transplantation. For 25 evaluable higher risk patients (Loes ≥10), the gadolinium intensity score was compared with longer term posttransplantation clinical change. The gadolinium intensity scoring system showed good interobserver reproducibility (κ = 0.72). Of 64 evaluable boys, the score positively correlated with average concomitant CSF chitotriosidase activity in nanograms/milliliter/hour: 0: 2717, n = 5; 1: 3218, n = 13; 2: 6497, n = 23; and 3: 12,030, n = 23 (P < .01). For 25 evaluable higher risk patients, more intense pretransplantation brain MR imaging gadolinium enhancement predicted greater average loss on the adrenoleukodystrophy neurologic function scale following transplantation: 0/1: adrenoleukodystrophy neurologic function scale score difference = 4.3, n = 7; 2/3: adrenoleukodystrophy neurologic function scale score difference = 10.4, n = 18 (P = .05). Gadolinium enhancement intensity on brain MR imaging can be scored simply and reproducibly for cerebral adrenoleukodystrophy. The enhancement score significantly correlates with chitotriosidase. In boys with higher risk cerebral disease (Loes ≥10), the enhancement score itself predicts neurologic outcome following treatment. Such data may help guide treatment decisions for clinicians and families.

Neuron specific enolase and Glasgow motor score remain useful tools for assessing neurological prognosis after out-of-hospital cardiac arrest treated with therapeutic hypothermia

Aim of the studyIdentifying clinical, electrophysiological and biological predictors for 6-month neurological outcome in survivors at day 3 after cardiac arrest (CA) treated with therapeutic hypothermia (TH). MethodsWe conducted a retrospective cohort study of adults comatose after out-of hospital CA treated with TH. All data were collected from medical charts and laboratory files. ResultsBetween January 2010 and March 2013, among the 130 analysed CA survivors, 27 (21%) had a good neurological outcome at 6 months and 103 (79%) had a poor neurological outcome, including 98 deaths. The Glasgow coma score motor response (GCS-M), pupillary reflexes and Neuron Specific Enolase (NSE) were the three best predictors of neurological outcome (P<0.0001). The area under the Receiver Operating Characteristic curve for NSE was 0.92 [0.84–0.99]. ConclusionNSE values, GCS-M scores and pupillary reflexes are the best predictors of poor 6-month outcome after out-of-hospital CA treated with TH. Of these, NSE values have the best-isolated prognostic performance when above 28.8μg/L.

Early prognostication markers in cardiac arrest patients treated with hypothermia

Established prognostication markers, such as clinical findings, electroencephalography (EEG) and biochemical markers, used by clinicians to predict neurological outcome after cardiac arrest (CA) are altered under therapeutic hypothermia (TH) conditions and their validity remains uncertain. MEDLINE and Embase were searched for evidence on the current standards for neurological outcome prediction for out-of-hospital CA patients treated with TH and the validity of a wide range of prognostication markers. Relevant studies that suggested one or several established biomarkers and multimodal approaches for prognostication are included and reviewed. Whilst the prognostic accuracy of various tests after TH has been questioned, pupillary light reflexes and somatosensory evoked potentials are still strongly associated with negative outcome for early prognostication. Increasingly, EEG background activity has also been identified as a valid predictor for outcome after 72 h after CA and a preferred prognostic method in clinical settings. Neuroimaging techniques, such as magnetic resonance imaging and computed tomography, can identify functional and structural brain injury but are not readily available at the patient's bedside because of limited availability and high costs. A multimodal algorithm composed of neurological examination, EEG-based quantitative testing and somatosensory evoked potentials, in conjunction with newer magnetic resonance imaging sequences, if available, holds promise for accurate prognostication in CA patients treated with TH. In order to avoid premature withdrawal of care, prognostication should be performed more than 72 h after CA.

Characteristics of regional cerebral oxygen saturation levels in patients with out-of-hospital cardiac arrest with or without return of spontaneous circulation: A prospective observational multicentre study

AimOur study aimed at filling the fundamental knowledge gap on the characteristics of regional brain oxygen saturation (rSO2) levels in out-of-hospital cardiac arrest (OHCA) patients with or without return of spontaneous circulation (ROSC) upon arrival at the hospital for estimating the quality of cardiopulmonary resuscitation and neurological prognostication in these patients. MethodsWe enrolled 1921 OHCA patients from the Japan – Prediction of Neurological Outcomes in Patients Post-cardiac Arrest Registry and measured their rSO2 immediately upon arrival at the hospital by near-infrared spectroscopy using two independent forehead probes (right and left). We also assessed the percentage of patients with a good neurological outcome (defined as cerebral performance categories 1 or 2) 90 days post cardiac arrest. ResultsAfter 90 days, 79 (4%) patients had good neurological outcomes and a median lower rSO2 level of 15% (15–20%). Compared to patients without ROSC upon arrival at the hospital, those with ROSC had significantly higher rSO2 levels (56% [39–65%] vs. 15% [15–17%], respectively; P<0.01), and significantly correlated right- and left-sided regional brain oxygen saturation levels (R=0.94 vs. 0.66, respectively). In both groups, the percentage of patients with a good 90-day neurological outcome increased significantly in proportion to their rSO2 levels upon arrival at the hospital (P<0.01). ConclusionOur data indicate that measuring rSO2 levels might be effective for both monitoring the quality of resuscitation and neurological prognostication in patients with OHCA.

Hypotension During Endovascular Treatment of Ischemic Stroke Is a Risk Factor for Poor Neurological Outcome.

In retrospective studies, patients receiving general anesthesia for endovascular treatment for acute ischemic stroke have worse neurological outcome compared with patients receiving conscious sedation. It has been suggested that this is caused by general anesthesia-associated hypotension. We investigated the effect of intraprocedural hypotension on neurological outcome. One hundred eight patients with acute ischemic stroke, who underwent endovascular treatment in general anesthesia between 2007 and 2012, were included. Analyzed predictors of neurological outcome were age, sex, comorbidities, baseline National Institutes of Health Stroke Scale, intraprocedural relative changes in mean arterial blood pressure from baseline, blood glucose, modified Thrombolysis in Cerebral Infarction score, and elapsed time from stroke to computed tomography, groin puncture, and recanalization/end of procedure. A fall in mean arterial blood pressure of >40% was an independent predictor for poor neurological outcome (P=0.032), as were higher admission National Institutes of Health Stroke Scale score (P=0.008) and lack of recanalization (P=0.003). Profound intraprocedural hypotension is an independent predictor for poor neurological outcome in patients with acute ischemic stroke undergoing endovascular therapy in general anesthesia.