Prediction Of Neurological Outcome Research Articles

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.

Current Management and Treatment Modalities for Intramedullary Spinal Cord Tumors.

Intramedullary spinal cord tumors are rare central nervous system tumors with unique challenges due to the eloquence of the surrounding tissue. Their treatment and prognosis is largely dependent on tumor histology and patient functionality. The introduction and advancement of microsurgical techniques have made surgery the mainstay of treatment for intramedullary tumors. Tumors that are well demarcated (e.g., ependymomas, hemangioblastomas) can be resected for cure, while more infiltrative tumors (e.g., high-grade astrocytomas) are typically managed with biopsies or limited resections in order to minimize the significant risk of damage to the spinal cord. The use of more aggressive surgical resection for astrocytoma is controversial but may have an increasing role in select cases. The use of intraoperative neurophysiologic monitoring and intraoperative ultrasound may help guide the extent of surgery while minimizing damage to normal tissue. Advances in MRI technology have greatly aided the diagnosis and preoperative planning of intramedullary tumors. Further advances in intraoperative MRI may make this a useful tool in guiding extent of resection. Preoperative functional status is the most important predictor of neurologic outcome, while histology and extent of resection are the most important predictors of progression-free survival. The use of adjuvant radiation and chemotherapy is dependent on patient age and histology but is largely reserved for high-grade tumor histologies or systemic involvement. Children are particularly at risk of radiation-induced injury, and these cases may benefit from more focused stereotactic radiation where necessary. Further studies are needed to support new surgical strategies minimizing destabilization and to investigate new forms of adjuvant therapy to minimize toxicity.

Simultaneous measurement of cerebral hemoglobin oxygen saturation and blood volume in asphyxiated neonates by near-infrared time-resolved spectroscopy.

Hypoxic-ischemic encephalopathy (HIE) usually results in a poor clinical outcome even when treated with hypothermic therapy (HT). Early postnatal changes in cerebral blood oxygenation and hemodynamics may be critical determinants of brain injury and the efficacy of HT. We measured cerebral hemoglobin oxygen saturation (ScO2) and cerebral blood volume (CBV) by near-infrared time-resolved spectroscopy (TRS) in HT-treated and non-HT-treated neonatal HIE patients to assess the influence of these parameters on clinical outcome. We retrospectively compared ScO2, CBV, and clinical outcomes of 11 neonates with HIE: 5 were treated by HT (HT-treated; 33.5°C±0.5°C for 72h starting approximately 6h after delivery) and 6 were not (non-HT-treated). Both CBV and ScO2 were measured by TRS at 6, 24, 48, and 72h after birth. Magnetic resonance imaging (MRI) was performed 1-2weeks after birth to assess brain injury. Five neonates had adverse outcomes (3 HT-treated, 2 non-HT-treated). Of these, 1 died within 3days of birth and 4 had abnormal MRI findings, including basal ganglia, white matter, and/or thalamic lesions. The other 6 neonates had normal MRI findings (favorable outcome). At 6h after birth, CBV was significantly higher in neonates with adverse outcomes compared with those with a favorable outcome. At 24h after birth, ScO2 was significantly higher in neonates with adverse outcomes. Furthermore, we found that combined CBV at 24h after birth plus ScO2 had the best predictive ability for neurological outcome: sensitivity, specificity, positive predictive value, and negative predictive value were all 100%. Early postnatal CBV and ScO2 elevations were predictive of a poor outcome in HIE. Therefore, measuring combined CBV plus ScO2 at 24h after birth can allow more precise prediction of neurological outcome. Control of postnatal CBV and ScO2 is critical for effective HIE treatment.

Neuron-Specific Enolase as a Predictor of Death or Poor Neurological Outcome After Out-of-Hospital Cardiac Arrest and Targeted Temperature Management at 33°C and 36°C

BackgroundNeuron-specific enolase (NSE) is a widely-used biomarker for prognostication of neurological outcome after cardiac arrest, but the relevance of recommended cutoff values has been questioned due to the lack of a standardized methodology and uncertainties over the influence of temperature management. ObjectivesThis study investigated the role of NSE as a prognostic marker of outcome after out-of-hospital cardiac arrest (OHCA) in a contemporary setting. MethodsA total of 686 patients hospitalized after OHCA were randomized to targeted temperature management at either 33°C or 36°C. NSE levels were assessed in blood samples obtained 24, 48, and 72 h after return of spontaneous circulation. The primary outcome was neurological outcome at 6 months using the cerebral performance category score. ResultsNSE was a robust predictor of neurological outcome in a baseline variable-adjusted model, and target temperature did not significantly affect NSE values. Median NSE values were 18 ng/ml versus 35 ng/ml, 15 ng/ml versus 61 ng/ml, and 12 ng/ml versus 54 ng/ml for good versus poor outcome at 24, 48, and 72 h, respectively (p < 0.001). At 48 and 72 h, NSE predicted neurological outcome with areas under the receiver-operating curve of 0.85 and 0.86, respectively. High NSE cutoff values with false positive rates ≤5% and tight 95% confidence intervals were able to reliably predict outcome. ConclusionsHigh, serial NSE values are strong predictors of poor outcome after OHCA. Targeted temperature management at 33°C or 36°C does not significantly affect NSE levels. (Target Temperature Management After Cardiac Arrest [TTM]; NCT01020916)

Predictors of neurological outcomes after successful extracorporeal cardiopulmonary resuscitation.

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) refers to use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary arrest. Although ECPR can increase survival rates after cardiac arrest, it can also result in poor post-resuscitation neurological status. Thus, we investigated predictors of good neurological outcomes after successful ECPR.MethodsA total of 227 patients underwent ECPR from May 2004 to June 2013 at Samsung Medical Center. Successful ECPR was defined as survival more than 24 hours after ECPR. Neurological outcomes were assessed at discharge using the Glasgow-Pittsburgh Cerebral Performance Categories scale (CPC). CPC 1 and 2 were classified as good and CPC 3 to 5 were classified as poor neurological outcomes. Excluded were 22 patients who did not survive more than 24 hours after ECPR and 90 patients who died from unknown causes or causes other than brain death or whose neurological status could not be assessed at discharge. Multiple logistic regression analysis was used to identify independent predictors of neurological outcomes.ResultsIncluded were 115 patients with a mean age of 58 (range 45–66) years and 80 men (70%). Cardiopulmonary resuscitation (CPR) was performed at non-hospital sites for 19 (17%) patients and bystander CPR was performed in 9 of 19 cases (47%). Cardiac etiology was verified in 74 (64%) patients and therapeutic hypothermia was performed in 9 patients (8%); 68 (59%) had good neurological outcomes and 47 (41%) did not and 24 patients died from brain death. Neurological outcomes were affected by hemoglobin levels before ECMO (P = 0.02), serum lactic acid (P < 0.001) before ECMO insertion, and interval from cardiac arrest to ECMO (P = 0.04).ConclusionsLow hemoglobin or high serum lactic acid levels before ECMO, and prolonged interval from cardiac arrest to ECMO predicted poor neurological outcomes after successful ECPR. Early institution of ECMO and a low threshold for blood transfusion might improve neurological outcomes for patients who survive ECPR.

Impact of tumor histology on resectability and neurological outcome in primary intramedullary spinal cord tumors: a single-center experience with 102 patients.

Surgical outcomes for intramedullary spinal cord tumors are affected by many variables including tumor histology and preoperative neurological function. To analyze the impact of tumor histology on neurological outcome in primary intramedullary spinal cord tumors. A retrospective review of 102 consecutive patients with intramedullary spinal cord tumors treated at a single institution between January 1998 and March 2009. Ependymomas were the most common tumors with 55 (53.9%), followed by 21 astrocytomas (20.6%), 12 hemangioblastomas (11.8%), and 14 miscellaneous tumors (13.7%). Gross total resection was achieved in 50 ependymomas (90.9%), 3 astrocytomas (14.3%), 11 hemangioblastomas (91.7%), and 12 miscellaneous tumors (85.7%). At a mean follow-up of 41.8 months (range, 1-132 months), we observed recurrences in 4 ependymoma cases (7.3%), 10 astrocytoma cases (47.6%), 1 miscellaneous tumor case (7.1%), and no recurrence in hemangioblastoma cases. When analyzed by tumor location, there was no difference in neurological outcomes (P = .66). At the time of their last follow-up visit, 11 patients (20%) with an ependymoma improved, 38 (69%) remained the same, and 6 (10.9%) worsened. In patients with an astrocytoma, 1 (4.8%) improved, 10 (47.6%) remained the same, and 10 (47.6%) worsened. One patient (8.3%) with a hemangioblastoma improved and 11 (91.7%) remained the same. No patient with a hemangioblastoma worsened. In the miscellaneous tumor group, 2 (14.3%) improved, 10 (71.4%) remained the same, and 2 (14.3%) worsened. Preoperative neurological status (P = .02), tumor histology (P = .005), and extent of resection (P < .0001) were all predictive of functional neurological outcomes. Tumor histology is the most important predictor of neurological outcome after surgical resection because it predicts resectability and recurrence.