Prediction Of Poor Neurological Outcome Research Articles

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

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.

Aneurysmal Subarachnoid Hemorrhage.

Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.

Admission interleukin-6 is associated with post resuscitation organ dysfunction and predicts long-term neurological outcome after out-of-hospital ventricular fibrillation

Aim of the studyTo study plasma concentrations of interleukin-6 (IL-6), high-sensitivity C-reactive protein (hs-CRP) and S-100B during intensive care after out-of-hospital cardiac arrest from ventricular fibrillation (OHCA-VF), and their associations with the duration of ischemia, organ dysfunction and long-term neurological outcome. Materials and methodsA 12-month prospective observational multicentre study was conducted in 21 Finnish intensive care units in 2011. IL-6, hs-CRP and S-100B were measured at 0–6h, 24h, 48h and 96h after ICU admission. Associations with the time to return of spontaneous circulation (ROSC), sequential organ failure assessment (SOFA) scores divided into tertiles and 12-month cerebral performance category (CPC) were tested. ResultsOf 186 OHCA-VF patients included in the study, 110 (59.1%) patients survived with good neurological outcome (CPC 1–2) 12 months after cardiac arrest. Admission plasma concentrations of IL-6 but not hs-CRP were higher with prolonged time to ROSC (p<0.001, 0.203, respectively), in patients with subsequent higher SOFA scores (p<0.001, 0.069) and poor long-term neurological outcome (CPC 3–5) (p<0.001, 0.315). S-100B concentrations over time were higher in patients with CPC of 3–5 (p<0.001). The area under the curve for prediction of poor 12-month outcome for admission levels was 0.711 IL-6, 0.663 for S-100B and 0.534 for hs-CRP. With multivariate logistic regression analysis only admission IL-6 (p=0.046, OR 1.006, 95% CI 1.000–1.011/ng/L) was an independent predictor of poor neurological outcome. ConclusionAdmission high IL-6, but not hs-CRP or S-100B, is associated with extra-cerebral organ dysfunction and along with age and time to ROSC are independent predictors for 12-month poor neurologic outcome (CPC 3–5).

The relation of early hypernatremia with clinical outcome in patients suffering from aneurysmal subarachnoid hemorrhage

ObjectiveSodium dysregulation in the course after aneurysmal subarachnoid hemorrhage (aSAH) has been identified as one contributor to adverse clinical outcome. However, the correlation of acute dysnatremia and early brain injury (EBI) remains unclear. We investigated the early course and prognostic relevance of changes in serum sodium concentrations and its relation to EBI after aSAH. MethodsRetrospectively, the serum sodium concentration (SSC) of 264 patients with aSAH was analyzed. The first SSC was obtained within 8h after initial ictus and then repeatedly analyzed every 8h over the first five days. Incidence of hypernatremia (defined as SSC>145mmol/l) was correlated with initial neurological condition according to World Federation of Neurological Surgeons grade (WFNS), incidence of delayed cerebral ischemia (DCI) and clinical outcome at 12 month according to modified Rankin Scale (mRS). ResultsWithin 56h, 82 patients (31.1%) developed hypernatremia which correlated significantly with initial neurological condition (p<0.001). Initial SSC within 8h after SAH did not correlate with patient outcome at 12 month (r=−0.026, p=0.694), however SSC obtained 56h after ictus did significantly (r=0.365, p<0.001; OR 4.14 95% CI (1.84–9.31)). A correlation with the incidence of DCI was not found (r=0.079, p=0.217). ConclusionThe occurrence of hypernatremia within 56h after aSAH was shown to be an independent predictor for poor neurological outcome. Early serum sodium levels after aSAH can be considered as surrogate markers to predict outcome after aSAH irrespective to the occurrence of DCI. However, prospective studies are necessary to validate this concept.

Letter by Eastwood et al Regarding Article, “Association Between Postresuscitation Partial Pressure of Arterial Carbon Dioxide and Neurological Outcome in Patients With Post–Cardiac Arrest Syndrome”

We read the article by Roberts and colleagues1 with interest. Although we agree that hypocapnia has been demonstrated to be common and is a predictor of poor neurological outcome after cardiac arrest, we are concerned that the findings may lack external validity. In a recent study involving 16 542 patients admitted to 125 Australian and New Zealand intensive care units after cardiac arrest between 2000 and 2011,2 we found that hypocapnia and …

Abstract 337: Impact of High Glucose Level at Admission on Thirty Days Clinical Outcomes for the Out-of-Hospital Cardiac Arrest Patients With Acute Coronary Event Undergoing Coronary Intervention With Hypothermia Therapy

Background: The aim of this study was to evaluate the effect of hyperglycemia at admission on the 30-days clinical outcomes of the patients (pts) with cardiac arrest due to acute coronary event (ACE) undergoing PCI with mild therapeutic hypothermia (MHT). Methods: Data over a five-year period (2005-2009) were obtained for 452 patients treated with MHT from a multicenter registry in Japan. Of these patients, all of 185 pts were diagnosed with ACE by emergency angiography immediately after recovery of spontaneous circulation (ROSC), and were subsequently treated with MHT and PCI. These patients were divided into groups based on the blood glucose (BS) at admission by receiver operating characteristics; Group A: BS at admission &gt;=306mg/dl and Group B: BS at admission &lt;306mg/dl. Cerebral performance category (CPC) with levels 1 (Normal mental performance), 2 (moderate disability), 3 (severe disability), 4 (vegetative state), 5 (death) was used at 30days. Poor neurologic outcome was defined in CPC 3, 4 and 5. Results: Patient demographics of Group A (n=67) were younger (mean age 57 vs. 63, p&lt;0.0001), longer time from arrest to ROSC (35min. vs. 24 min., p=0.0004). The proportions of shockable rhythm and the time to achieve target temperature were not different. The rates of STEMI was more seen in Group A (76.1%) compared with Group B (63.6%); however, there was no significant differences (p=0.0781). There was no significantly different in mortality rate (25.4% vs. 17.8%, p=0.2202) between the two groups, however, neurologic outcome was significantly better in group B compared with group A (35.8% vs. 65.3%, p=0.0001). Logistic regression analysis revealed that the predictors of poor neurologic outcome were unshockable rhythm (Odds ratio [OR]: 3.82, p=0.0026), age over 70 (OR: 9.3, p&lt;0.0001), time from collapse to ROSC (OR 1.04, p&lt;0.0001), and BS at admission over 306mg/dl (OR: 3.8, p=0.0005). Conclusions: High glucose level at admission did not affect the mortality; however, had an impact on neurologic outcome for the patients with ROSC after cardiac arrest due to ACS undergoing PCI with MHT.

Prognostic value of changes in spinal cord signal intensity on magnetic resonance imaging in patients with cervical compressive myelopathy

Background contextSignal intensity on preoperative cervical magnetic resonance imaging (MRI) of the spinal cord has been shown to be a potential predictor of outcome of surgery for cervical compressive myelopathy. However, the prognostic value of such signal remains controversial. One reason for the controversy is the lack of proper quantitative methods to assess MRI signal intensity. PurposeTo quantify signal intensity and to correlate intramedullary signal changes on MRI T1- and T2-weighted images (WIs) with clinical outcome and prognosis. Study designRetrospective case study. Patient samplePatients (n=148; cervical spondylotic myelopathy, n=102 and ossified posterior longitudinal ligament, n=46) who underwent surgery for cervical compressive myelopathy and had high signal intensity change on sagittal T2-WI MRI before surgery between 2006 and 2010. Outcome measureNeurologic assessment was conducted with the Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy. The rate of neurologic improvement was calculated with the use of preoperative and postoperative JOA scores. MethodsQuantitative analysis of MRI signal on both T1- and T2-WIs via use of the signal intensity ratio (SIR; signal intensity of lesion relative to that at C7-T1 disc level) was performed. Correlations between SIR on T1- and T2-WIs and preoperative JOA score, JOA improvement rate, disease duration, and MRI morphologic classification (cystic or diffuse type) were analyzed. Multivariate regression analysis for JOA improvement rate was also analyzed. In a substudy, 25 patients underwent follow-up MRI starting from 6 months after surgery to analyze the relationship between changes in SIR on follow-up MRI and clinical outcome. ResultsSIR on T1-WIs, but not SIR on T2-WIs, correlated with postoperative neurologic improvement. The disease duration correlated negatively with SIR on T1-WIs and JOA improvement rate but not with SIR on T2-WIs. SIR on T2-WIs of “cystic type” was significantly greater than of “diffuse type,” but SIR on T1-WI and JOA improvement rate were not different in the two types. Stepwise multivariate regression analysis indicated that SIR on T1-WIs and long disease duration were significant predictors of postoperative neurologic outcome. SIR on follow-up T1-WI and changes in SIR on T1-WI after surgery correlated positively with postoperative improvement rate. SIR on follow-up T2-WI and changes on T2-WI correlated negatively with postoperative neurologic improvement. ConclusionsOur results suggest that low intensity signal on preoperative T1-WIs but not T2-WIs correlated with poor postoperative neurologic outcome. Furthermore, decreased signal intensity on postoperative T1-WIs and increased signal intensity on postoperative T2-WIs are predictors of poor neurologic outcome.

Early brain computed tomography findings are associated with outcome in patients treated with therapeutic hypothermia after out-of-hospital cardiac arrest

BackgroundThis study evaluated the association between the results of immediate brain computed tomography (CT) scans and outcome in patients who were treated with therapeutic hypothermia after cardiac arrest. The evaluation was based on the changes in the ratio of gray matter to white matter.MethodsA total of 167 patients who were successfully resuscitated after cardiac arrest from March 2009 to December 2011 were included in this study. We selected 51 patients who received a brain CT scan within 1 hour after the return of spontaneous circulation (ROSC) and who had been treated with therapeutic hypothermia. Circular regions of measurement (10 mm2) were placed over regions of interest (ROIs), and the average attenuations in gray matter (GM) and white matter (WM) were recorded in the basal ganglia, at the level of the centrum semiovale and in the high convexity area. Three GM-to-WM ratios (GWRs) were calculated: one for the basal ganglia, one for the cerebrum and the average of the two. The neurological outcomes were assessed using the Cerebral Performance Category (CPC) scale at the time of hospital discharge, and a good neurological outcome was defined as a CPC score of 1 or 2.ResultsThe average GWR was the strongest predictor of poor neurological outcome as determined using receiver operating characteristic curves (basal ganglia area under the curve (AUC) = 0.716; cerebrum AUC = 0.685; average AUC = 0.747). An average GWR < 1.14 predicted a poor neurological outcome with a sensitivity of 13.3% (95% confidence interval (CI) 3.8-30.7), a specificity of 100% (95% CI 83.9-100), a positive predictive value of 100% (95% CI 2.5-100), and a negative predictive value of 44.7% (CI 28.9-58.9).ConclusionsOur study demonstrated that low GWRs in the immediate brain CT scans of patients treated with therapeutic hypothermia after ROSC were associated with poor neurological outcomes. Immediate brain CT scans could help predict outcome after cardiac arrest.

Changes in Neuron-Specific Enolase are More Suitable Than Its Absolute Serum Levels for the Prediction of Neurologic Outcome in Hypothermia-Treated Patients with Out-of-Hospital Cardiac Arrest

To determine neurologic outcome in patients with out-of-hospital cardiac arrest (OHCA) and treatment with mild therapeutic hypothermia (MTH). Seventy-three consecutive OHCA patients treated with MTH were retrospectively analyzed. Serum neuron-specific enolase (NSE) was measured 24, 48, and 72 h after admission. In patients with no motor response 48 h after termination of analgosedation (n = 40), clinical neurological examination and evoked potentials (EPs) were determined. Neurological outcome was assessed after 2 months based on the cerebral performance categories (CPC), and categorized as good (CPC 1-3) or poor (CPC 4 and 5). Forty-three patients had a CPC score of 1-3 and 30 patients had a CPC 4-5. The best predictive value for poor neurologic outcome was an increase of NSE by ≥4.3 ng/mL between day 1 and day 2 (sensitivity 80 %, specificity 100 %, positive predictive value (PPV) 100 %, negative predictive value 86 %). Absolute NSE values were less reliable in the prediction of poor outcome with the highest sensitivity (88 %) and specificity (95 %) if values reached ≥36.3 ng/mL on day 3. Somatosensory EPs (SSEPs) showed a specificity of 100 % and PPV of 100 %; however, sensitivity for evoked potentials was low (29 %). Intriguingly, two initially comatose patients with excessive NSE values (24 h NSE: 101 and 256 ng/mL, and 48 h NSE: 93 and 110 ng/mL, respectively) had physiological SSEPs and regained a CPC score of 1. In patients treated with MTH after OHCA changes in NSE are more suitable than its absolute serum levels for the prediction of poor neurologic outcome. Since unequivocal prediction of poor neurologic outcome is of utmost importance in these patients the decision to limit therapy must be based on several prediction tools with the highest PPV and specificity including SSEPs.

Low apparent diffusion coefficient cluster-based analysis of diffusion-weighted MRI for prognostication of out-of-hospital cardiac arrest survivors

ObjectiveRecent studies suggested quantitative analysis of diffusion-weighted magnetic resonance imaging as a promising tool for early prognostication of cardiac arrest patients. However, most of their methods involve significant manual image handling often subjective and difficult to reproduce. Therefore developing a computerized analysis method using easy-to-define characteristics would be useful. MethodsComatose out-of-hospital cardiac arrest (OHCA) patients who underwent brain MRI between January 2008 and July 2012 were identified from an OHCA registry. Apparent diffusion coefficient (ADC) axial images were analyzed using a program to detect and characterize clusters of low ADC pixels from six brain regions including frontal, occipital, parietal, rolandic and temporal and basal ganglia region. Identified clusters were ranked according to size, mean ADC and minimum ADC to assess the regional maximum cluster size (MCS), lowest mean ADC (LMEAN) and lowest minimum ADC (LMIN). Their power to predict poor outcome, defined as 6-month CPC 3 or higher, was assessed by contingency table analyses. Results51 OHCA patients were eligible during the study period. The sensitivities of MCS, LMEAN and LMIN to detect poor outcome varied according to brain region from 62.5 to 90.0%, 50.0 to 72.5% and 42.5 to 82.5% with their specificities set to 100%, respectively. The MCS of occipital region showed most favorable test profile (sensitivity 90%, specificity 100%; AUROC 0.940, 95% confidence interval 0.874–1.000). ConclusionThe cluster-based computerized image analysis might be a simple but useful method for prediction of poor neurologic outcome. Future studies validating its prognostic performance are required.

Novel Methods to Predict Increased Intracranial Pressure During Intensive Care and Long-Term Neurologic Outcome After Traumatic Brain Injury

Intracranial pressure monitoring is standard of care after severe traumatic brain injury. Episodes of increased intracranial pressure are secondary injuries associated with poor outcome. We developed a model to predict increased intracranial pressure episodes 30 mins in advance, by using the dynamic characteristics of continuous intracranial pressure and mean arterial pressure monitoring. In addition, we hypothesized that performance of current models to predict long-term neurologic outcome could be substantially improved by adding dynamic characteristics of continuous intracranial pressure and mean arterial pressure monitoring during the first 24 hrs in the ICU. Prognostic modeling. Noninterventional, observational, retrospective study. The Brain Monitoring with Information Technology dataset consisted of 264 traumatic brain injury patients admitted to 22 neuro-ICUs from 11 European countries. None. Predictive models were built with multivariate logistic regression and Gaussian processes, a machine learning technique. Predictive attributes were Corticosteroid Randomisation After Significant Head Injury-basic and International Mission for Prognosis and Clinical Trial design in TBI-core predictors, together with time-series summary statistics of minute-by-minute mean arterial pressure and intracranial pressure. Increased intracranial pressure episodes could be predicted 30 mins ahead with good calibration (Hosmer-Lemeshow p value 0.12, calibration slope 1.02, calibration-in-the-large -0.02) and discrimination (area under the receiver operating curve = 0.87) on an external validation dataset. Models for prediction of poor neurologic outcome at six months (Glasgow Outcome Score 1-2) based only on static admission data had 0.72 area under the receiver operating curve; adding dynamic information of intracranial pressure and mean arterial pressure during the first 24 hrs increased performance to 0.90. Similarly, prediction of Glasgow Outcome Score 1-3 was improved from 0.68 to 0.87 when including dynamic information. The dynamic information in continuous mean arterial pressure and intracranial pressure monitoring allows to accurately predict increased intracranial pressure in the neuro-ICU. Adding information of the first 24 hrs of intracranial pressure and mean arterial pressure monitoring to known baseline risk factors allows very accurate prediction of long-term neurologic outcome at 6 months.

Systematic combined noncontrast CT–CT angiography in the management of unexplained nontraumatic coma

BackgroundNontraumatic impaired consciousness is a common issue in emergency departments with a serious but widely variable prognosis. Study objectivesThe aim of this prospective study was to evaluate the ability of systematic combined noncontrast computed tomography (NCCT)/computed tomography angiography (CTA) imaging, firstly to provide a neurologic prognosis and secondly to ensure early detection of basilar artery occlusion (BAO), in unexplained nontraumatic impaired consciousness management. MethodsCombined NCCT/CTA imaging was performed on 65 patients with impaired consciousness and no history of trauma prospectively over 14 months in a single center. Images were assessed based on visual and quantitative criteria. Clinical outcome was assessed using the modified Rankin Scale at 3 months. Statistical analysis aimed to identify the prognostic value of combined NCCT/CTA imaging and its ability for early BAO detection. ResultsThis study shows that combined NCCT/CTA imaging was a significant predictor of poor neurological outcome, with a positive predictive value of 94.6%. The combination was also crucial for early detection of BAO, given that 42.8% of cases were misdiagnosed with NCCT alone. Basilar artery occlusion represented 10.8% of all unexplained nontraumatic impaired consciousness. ConclusionsSystematic combined NCCT/CTA imaging is an efficient tool for predicting poor neurologic prognosis in cases of unexplained nontraumatic impaired consciousness and is also essential for detecting BAO.

Coenzyme Q10 levels are low and associated with increased mortality in post-cardiac arrest patients

AimSurvival after cardiac arrest (CA) is limited by the profound neurologic insult from ischemia–reperfusion injury. Therapeutic options are limited. Previous data suggest a benefit of coenzyme Q10 (CoQ10) in post-arrest patients. We hypothesized that plasma CoQ10 levels would be low after CA and associated with poorer outcomes. MethodsProspective observational study of post-arrest patients presenting to a tertiary care center. CoQ10 levels were drawn 24h after return of spontaneous circulation (ROSC) and compared to healthy controls. Levels of inflammatory cytokines and biomarkers were analyzed. Primary endpoints were survival to discharge and neurologic status at time of discharge. Results23 CA subjects and 16 healthy controls were enrolled. CoQ10 levels in CA patients (0.28μmolL−1, inter-quartile range (IQR): 0.22–0.39) were significantly lower than in controls (0.75μmolL−1, IQR: 0.61–1.08, p<0.0001). The mean CoQ10 level in CA patients who died was significantly lower than in those who survived (0.27 vs 0.47μmolL−1, p=0.007). There was a significant difference in median CoQ10 level between patients with a good vs poor neurological outcome (0.49μmolL−1, IQR: 0.30–0.67 vs 0.27μmolL−1, IQR: 0.21–0.30, p=0.02). CoQ10 was a statistically significant predictor of poor neurologic outcome (adjusted p=0.02) and in-hospital mortality (adjusted p=0.026). ConclusionCoQ10 levels are low in human subjects with ROSC after cardiac arrest as compared to healthy controls. CoQ10 levels were lower in those who died, as well as in those with a poor neurologic outcome.

Beyond herniation

Few data are available on the use of brainstem auditory evoked potentials (BAEPs) in combination with other electrophysiological tools to assess prognosis of comatose survivors from cardiac arrest (CA).Retrospective analysis of data from all adult patients (>18 years of age) admitted to our Dept of Intensive Care after CA over a 6-year period who were comatose (Glasgow Coma Scale <9) on admission, had been treated with targeted temperature management and had BAEP testing. We collected variables related to CA, as well as electroencephalography (EEG) findings, N20 somatosensory evoked potentials, and the presence of I, III and/or V waves on BAEP testing. Outcome was assessed at 3 months using the Cerebral Performance Categories (3–5 = poor outcome).We studied 65 patients; 48 (74%) had a poor neurological outcome. BAEP assessment was performed day 3 [3,4] after the CA. At least one of the three waves was absent bilaterally in 34 patients (52%); of these patients, 29 (85%) had a poor neurological outcome (sensitivity 60%, specificity 71%, positive predictive value [PPV] 85% and negative predictive value [NPV] 39%). Three patients (5%) had bilateral absence of all three waves, all of whom had a poor neurological outcome.In this series of patients after CA, at least one of the BAEP waves was absent bilaterally in half the survivors; however, their use for prediction of poor neurological outcome remains limited.

Impact of CHADS2Score on Neurological Severity and Long-Term Outcome in Atrial Fibrillation-Related Ischemic Stroke

Background and PurposeThe CHADS2 (an acronym for congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack or thromboembolism) score is a widely used system for estimating the risk of stroke in patients with atrial fibrillation. However, how the CHADS2 score is related to stroke severity and outcome in patients with strokes due to atrial fibrillation has not yet been elucidated.MethodsWe enrolled patients with atrial fibrillation who visited our stroke center within 7 days after the onset of acute ischemic stroke between October 2002 and September 2008. CHADS2 scores were categorized into three groups: 0 points, low risk; 1 or 2 points, intermediate risk; and 3-6 points, high risk. Poor neurological state was defined as follows: a National Institutes of Health Stroke Scale (NIHSS) score of ≥2, and a modified Rankin Scale (mRS) score of ≥3 at discharge. Mortality information was ascertained as at December 2008.ResultsA cohort of 298 patients with atrial-fibrillation-related stroke was included in this study. A high-risk CHADS2 score at admission was a powerful predictor of poor neurological outcome [for NIHSS: odds ratio (OR), 4.17; 95% confidence interval (CI), 1.76-9.87; for mRS: OR, 2.97; 95% CI, 1.23-7.16] after controlling for all possible confounders. In addition, a high-risk CHADS2 score was an independent predictor of all causes of death during the follow-up [hazard ratio (HR), 3.01; 95% CI, 1.18-7.65] and vascular death (HR, 12.25; 95% CI, 1.50-99.90).ConclusionsAlthough the CHADS2 score was originally designed to distinguish patients with a future risk of stroke, our study shows that it may also be used to predict poor neurological outcome after atrial-fibrillation-related stroke.

Abstract 17993: Bystander-Initiated Cardiopulmonary Resuscitation Can Maintain Regional Cerebral Oxygen Saturation Levels on Hospital Arrival in Patients with Refractory Out-of-Hospital Cardiac Arrest

Background: Bystander-initiated cardiopulmonary resuscitation (B-CPR) plays a key role in the chain of survival for out-of-hospital cardiac arrest (OHCA) patients. We have previously reported that a low regional cerebral oxygen saturation (rSO2) level is a strong predictor of poor neurological outcome in OHCA patients. Objectives: To assess the association between B-CPR and rSO2 levels measured immediately on hospital arrival. Methods: This study was a prospective cohort study. Of 418 OHCA patients, 186 consecutive non-traumatic, cardiac arrest on arrival (CAOA) patients were prospectively registered. The rSO2 levels were measured with sensors placed on either side of their forehead using a near-infrared spectroscopy (NIRS) device (INVOS, Covidien, US) within 3 minutes after hospital arrival. We monitored rSO2 levels at least for more than one minute and used the lower of the 2 measured rSO2 levels for analysis. Clinical staff performed ordinary post-cardiac-arrest interventions (PCAIs) regardless of rSO2 levels. Primary outcome measure was good neurological outcome (CPC 1/2) at hospital discharge according to the “Utstein-style”. After dividing the eligible 186 patients into the two groups (B-CPR group (n=76) and no B-CPR group (n=110)), we compared the rSO2 levels on hospital arrival and the neurological outcome between the two groups. Results: Among 186 CAOA patients in PCAIs era, 18 patients (9.7%) had good neurological outcome. The B-CPR group patients had more maintained rSO2 levels on hospital arrival with a much higher proportion of good neurological outcome as compared with the no B-CPR group patients (33±20% vs. 22±13%, p=0.00003; 21% vs. 2%, p=0.00005, respectively). Conclusion: The findings suggest that B-CPR for CAOA patients after OHCA contributes to maintaining the rSO2 levels on hospital arrival and improving neurological outcome at hospital discharge even in the PCAIs era.

Abstract 177: Regional Cerebral Oxygen Saturation as a Novel Termination of Resuscitation Rule in Cases of Refractory Out-of-Hospital Cardiac Arrest

Background: To better utilize medical resources, basic life support (BLS) and advanced life support (ALS) pre-hospital termination-of-resuscitation (TOR) rules have been developed, validated, and implemented in North America. Recently, “regional cerebral oxygen saturation (rSO2) ≤15%”, as no detectable cortical oxygen value (N-value), has been considered to be a strong predictor of poor neurological outcome in patients with out-of-hospital cardiac arrest (OHCA). Objective: To assess the impact of the N-value as a novel TOR rule. Method: This study was a prospective cohort study. Of 418 OHCA patients, 186 consecutive non-traumatic, cardiac arrest on arrival (CAOA) patients were prospectively registered. The rSO2 were measured with sensors placed on either side of their forehead using a near-infrared spectroscopy (NIRS) device (INVOS, Covidien, US) immediately on hospital arrival. We monitored rSO2 values at least for more than one minute and used the lower of the 2 measured rSO2 values for analysis. Clinical staff performed ordinary post-cardiac-arrest interventions (PCAIs) regardless of rSO2 values. Primary outcome measure was good neurological outcome (CPC =&lt;2) at hospital discharge according to the “Utstein-style”. We calculated the specificity and positive predictive value (PPV) of N-value TOR rule and BLS/ALS TOR rules for identifying CAOA patients without good neurological outcome. Results: Among 186 CAOA patients in the PCAIs era, 18 patients (9.7%) had good neurological outcome at hospital discharge, and the specificity and PPV of N-value, BLS and ALS TOR rules were high. However, N-value TOR rule had relatively high specificity and PPV compared with BLS TOR rule and relatively high sensitivity compared with ALS TOR rule. In addition, NIRS provides non-invasive and objective rSO2 values immediately. Conclusion: The N-value TOR rule may be of considerable help to make decisions to cease futile resuscitative efforts in CAOA patients after OHCA.

Abstract 263: Hyperglycemia: A Poor Prognostic Factor for Neurological Recovery in Patients with Sudden Cardiac Arrest

Background: Hyperglycemia is an independent predictor of mortality in several but not all critically ill populations. Animal cardiac arrest models suggest that hyperglycemia results in poor outcomes. We examined the effects of hyperglycemia in cardiac arrest survivors, focusing on its effects on neurological function. Methods: We evaluated 123 survivors of non-traumatic out-of-hospital cardiac arrest .Data were collected following the Utstein guidelines. Hyperglycemia was defined as any value &gt; 180 mg/dl. Patients who had hyperglycemia were treated with intravenous / subcutaneous insulin at the discretion of the health care team. Neurological status was assessed by Cerebral Performance Category (CPC) scores. Fisher's exact two-tailed test, univariate and multivariate logistic regression were used for analyses. Data are reported as percentage, mean + SD. Results: Of 123 patients studied, 31% had a history of diabetes; however 72 % (88/123) were hyperglycemic. As noted below, those with hyperglycemia had similar characteristics as compared to those with normoglycemia including a history of diabetes. Hyperglycemia was more common in patients treated with hypothermia as compared to those not cooled: 83% (44/53) vs. 64 %( 44/71) respectively (P= 0.01). Poor neurological recovery (CPC &gt; 2) was also seen more often in those with hyperglycemia as compared to those without hyperglycemia (87% vs. 68%) respectively (P= 0.01). Although univariate analysis identified hyperglycemia to be a predictor of poor neurological recovery, it did not worsen neurological recovery in hypothermia treated patients (pNS). Multivariate regression analyses, failed to identify hyperglycemia as a predictor of poor neurological outcome. Conclusion: Hyperglycemia (&gt;180 mg/dl) is extremely common post arrest and is implicated in poor neurological recovery. The early identification and treatment of hyperglycemia is likely justified. Patient Characteristics

Predictors of poor neurologic outcome in patients after cardiac arrest treated with hypothermia: A retrospective study

Introduction Outcome studies in patients with anoxic-ischemic encephalopathy focus on the early and reliable prediction of an outcome no better than a vegetative state or severe disability. We determined the effect of mild therapeutic hypothermia on the validity of the currently used clinical practice parameters. Methods We conducted a retrospective cohort study of adult comatose patients after cardiac arrest treated with hypothermia. All data were collected from medical charts and laboratory files and analyzed from the day of admission to the intensive care unit until day 7, discharge from the intensive care unit or death using the Utstein definitions for the registration of the data. Results We analyzed the data of 103 patients. The combination of an M1 or M2 on the Glasgow Coma Scale or absent pupillary reactions or absent corneal reflexes on day 3 was present in 80.6% of patients with an unfavourable and 11.1% of patients with a favourable outcome. The combination of M1 or M2 and absent pupillary reactions to light and absent corneal reflexes on day 3 was present in 14.9% of patients with an unfavourable and none of the patients with a favourable outcome. None of the patients with a favourable outcome had a bilaterally absent somatosensory evoked potential of the median nerve. The value of electroencephalogram patterns in predicting outcome was low, except for reactivity to noxious stimuli. Conclusions No single clinical or electrophysiological parameter has sufficient accuracy to determine prognosis and decision making in patients after cardiac arrest, treated with hypothermia.