Prognosis In Cardiac Arrest Survivors Research Articles

Quantitative analysis of apparent diffusion coefficients to predict neurological prognosis in cardiac arrest survivors: an observational derivation and internal–external validation study

BackgroundThis study aimed to validate apparent diffusion coefficient (ADC) values and thresholds to predict poor neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors by quantitatively analysing the ADC values via brain magnetic resonance imaging (MRI).MethodsThis observational study used prospectively collected data from two tertiary academic hospitals. The derivation cohort comprised 70% of the patients randomly selected from one hospital, whereas the internal validation cohort comprised the remaining 30%. The external validation cohort used the data from another hospital, and the MRI data were restricted to scans conducted at 3 T within 72–96 h after an OHCA experience. We analysed the percentage of brain volume below a specific ADC value at 50-step intervals ranging from 200 to 1200 × 10–6 mm2/s, identifying thresholds that differentiate between good and poor outcomes. Poor neurological outcomes were defined as cerebral performance categories 3–5, 6 months after experiencing an OHCA.ResultsA total of 448 brain MRI scans were evaluated, including a derivation cohort (n = 224) and internal/external validation cohorts (n = 96/128, respectively). The proportion of brain volume with ADC values below 450, 500, 550, 600, and 650 × 10–6 mm2/s demonstrated good to excellent performance in predicting poor neurological outcomes in the derivation group (area under the curve [AUC] 0.89–0.91), and there were no statistically significant differences in performances among the derivation, internal validation, and external validation groups (all P > 0.5). Among these, the proportion of brain volume with an ADC below 600 × 10–6 mm2/s predicted a poor outcome with a 0% false-positive rate (FPR) and 76% (95% confidence interval [CI] 68–83) sensitivity at a threshold of > 13.2% in the derivation cohort. In both the internal and external validation cohorts, when using the same threshold, a specificity of 100% corresponded to sensitivities of 71% (95% CI 58–81) and 78% (95% CI 66–87), respectively.ConclusionsIn this validation study, by consistently restricting the MRI types and timing during quantitative analysis of ADC values in brain MRI, we observed high reproducibility and sensitivity at a 0% FPR. Prospective multicentre studies are necessary to validate these findings.

The Differences of CPR duration between Shockable and Nonshockable Rhythms in Predicting the Benefit of Target Temperature Management.

Among cardiac arrest (CA) survivors, whether the combination of duration of cardiopulmonary resuscitation (CPR) and shockable/nonshockable rhythms during resuscitation can help predict the benefit of targeted temperature management (TTM) remains un-investigated. This multicenter retrospective cohort study enrolled 479 nontraumatic adult CA survivors with TTM and CPR duration < 60 min during January 2014 to June 2019 from the Taiwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) registry. The differences of CPR duration between shockable and nonshockable rhythms in predicting outcomes in the studied population was evaluated. We observed that 205 patients (42.8%) survived to hospital discharge and 100 patients (20.9%) presented favorable neurological outcomes at discharge. The enrolled patients were further re-classified into four groups according to shockable/nonshockable rhythms and CPR duration. Patients with shockable rhythms and shorter CPR duration had better survival-to-discharge (adjusted odds ratio [OR] = 2.729, 95% confidence interval [CI] = 1.384-5.383, P = 0.004) and neurological recovery (adjusted OR = 9.029, 95%CI = 3.263-24.983, P < 0.001) than did those with nonshockable rhythms and longer CPR duration. The CPR duration for predicting outcomes differs between CA patients with shockable and nonshockable rhythms. The combination of shockable/nonshockable rhythms and CPR duration may help predict the prognosis in CA survivors undergoing TTM.

Abstract 9724: Variance of the Intracranial Pressure Over Time and Relationship With Neurologic Prognosis in Cardiac Arrest Survivors Who Underwent Targeted Temperature Management

Introduction: Increased intracranial pressure (ICP) is one of the most serious post-cardiac arrest (CA) complications, and is associated with poor outcomes. However, only a few studies have described the changes in ICP over time according to neurologic outcomes during targeted temperature management (TTM) after CA. We aimed to investigate the changes in the ICP over time and neurologic prognosis in out-of-hospital cardiac arrest (OHCA) survivors who received TTM. Methods: This retrospective single-center study included OHCA survivors who underwent TTM between May 2018 and December 2020. ICP was measured immediately after the return of spontaneous circulation (ROSC) (Day 1), and after 24 h (Day 2), 48 h (Day 3), and 72 h (Day 4) by connecting a lumbar drain. The neurologic outcome was determined 3 months after the ROSC, and the Cerebral Performance Category (CPC) was dichotomized into good (CPC 1-2) and poor (CPC 3-5) outcomes. Results: We included 91 patients (males, 67; 74%); of whom 51 (56%) had a poor outcome. The ICP was significantly higher in the poor outcome group at each time point, except for Day 4. Moreover, the peak ICP levels were also higher in the poor outcome group (17.0 vs. 14.8; P = 0.002). The change in ICP levels was highest between Day 2 and Day 3 in the good outcome group, but between Day 1 and Day 2 in the poor outcome group. However, there was no difference in the total ICP change between the poor and good outcome groups (3.00 vs 3.09; P = 0.52). Using receiver operating characteristic analyses, the optimal cutoff values of the ICP levels for the prediction of poor outcomes were determined as: day 1, &gt; 11.8; day 2, &gt; 14.0; day 3, &gt; 15.0; and day 4, &gt; 14.8. Conclusions: All OHCA survivors who received TTM had an elevated ICP, regardless of the neurologic prognosis. However, peak ICP levels and the change in the ICP level on the first day after the ROSC was significantly higher in the poor outcome group. A prospective, multi-center study is required to confirm these results.

Serum proteomic analysis of novel predictive serum proteins for neurological prognosis following cardiac arrest.

Early prognostication of neurological outcome in comatose patients after cardiac arrest (CA) is vital for clinicians when assessing the survival time of sufferers and formulating appropriate treatment strategies to avoid the withdrawal of life‐sustaining treatment (WLST) from patients. However, there is still a lack of sensitive and specific serum biomarkers for early and accurate identification of these patients. Using an isobaric tag for relative and absolute quantitation (iTRAQ)‐based proteomic approach, we discovered 55 differentially expressed proteins, with 39 up‐regulated secreted serum proteins and 16 down‐regulated secreted serum proteins between three comatose CA survivors with good versus poor neurological recovery. Then, four proteins were selected and were validated via an enzyme‐linked immunosorbent assay (ELISA) approach in a larger‐scale sample containing 32 good neurological outcome patients and 46 poor neurological outcome patients, and it was confirmed that serum angiotensinogen (AGT) and alpha‐1‐antitrypsin (SERPINA1) were associated with neurological function and prognosis in CA survivors. A prognostic risk score was developed and calculated using a linear and logistic regression model based on a combination of AGT, SERPINA1 and neuron‐specific enolase (NSE) with an area under the curve of 0.865 (P < .001), and the prognostic risk score was positively correlated with the CPC value (R = 0.708, P < .001). We propose that the results of the risk score assessment not only reveal changes in biomarkers during neurological recovery but also assist in enhancing current therapeutic strategies for comatose CA survivors.

Abstract 23: The Usefulness of Neuron-Specific Enolase in Cerebrospinal Fluid to Predict Neurological Prognosis in Cardiac Arrest Survivors Who Underwent Target Temperature Management: A Prospective Observational Study

Aim: We aimed to investigate the prognostic performance between serum NSE and cerebrospinal fluid (CSF) NSE for 6-month neurologic outcome in OHCA survivors underwent target temperature management (TTM). Hypothesis: We hypothesized that the NSE levels measured in the CSF would affect the change, earlier and more sensitively than serum, according to severity of hypoxic brain damage. Methods: This single-centre prospective observational study included out-of-hospital cardiac arrest (OHCA) patients underwent TTM. NSE levels were assessed in blood and CSF samples obtained immediately (Day 0), and 24 h (Day 1), 48 h (Day 2), and 72 h (Day 3) after return of spontaneous circulation (ROSC). The primary outcome was the 6-month neurological outcome. Results: We enrolled 34 patients (males, 24; 70.6%), 16 (47.1%) had a poor neurologic outcome. CSF NSE and serum NSE values were significantly higher in the poor outcome group compared to the good outcome group at each time point, except for serum Day 0. CSF NSE and serum NSE had area under curve (AUC) of 0.819-0.972 and 0.648-0.920, respectively. CSF NSE prognostic performances were significant higher than serum NSE at Day 1 and showed excellent AUC values (0.969; 95% Confidential Interval [CI] 0.844-0.999) and high sensitivity (93.8%; 95% CI 69.8-99.8) at 100% specificity. Conclusion: We found CSF NSE values were highly predictive and sensitive markers of 6-month poor neurological outcome in OHCA survivors treated with TTM at Day 1 after ROSC. Thus, CSF NSE level at day 1 after ROSC can be a useful early prognosticator in OHCA survivors.

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

AimCerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels increase ahead of serum NSE levels in patients with severe brain injury. We examined the prognostic performance between CSF NSE and serum NSE levels in out-of-cardiac arrest (OHCA) survivors who had undergone target temperature management (TTM). MethodsThis single-centre prospective observational study included OHCA patients who had undergone TTM. NSE levels were assessed in blood and CSF samples obtained immediately (Day 0), and at 24 h (Day 1), 48 h (Day 2), and 72 h (Day 3) after return of spontaneous circulation (ROSC). The primary outcome was the 6-month neurological outcome. ResultsWe enrolled 34 patients (males, 24; 70.6%), and 16 (47.1%) had a poor neurologic outcome. CSF NSE and serum NSE values were significantly higher in the poor outcome group compared to the good outcome group at each time point, except for serum Day 0. CSF NSE and serum NSE had an area under curve (AUC) of 0.819–0.972 and 0.648–0.920, respectively. CSF NSE prognostic performances were significantly higher than serum NSE levels at Day 1 and showed excellent AUC values (0.969; 95% confidence interval [CI] 0.844–0.999) and high sensitivity (93.8%; 95% CI 69.8–99.8) at 100% specificity. ConclusionWe found CSF NSE values were highly predictive and sensitive markers of 6-month poor neurological outcome in OHCA survivors treated with TTM at Day 1 after ROSC. Therefore, CSF NSE levels at day 1 after ROSC can be a useful early prognosticator in OHCA survivors.

Usefulness of Intracranial Pressure and Mean Arterial Pressure for Predicting Neurological Prognosis in Cardiac Arrest Survivors Who Undergo Target Temperature Management.

We aimed to compare the relationship of mean arterial pressure (MAP) and intracranial pressure (ICP) to predict the neurological prognosis in cardiac arrest (CA) survivors. We retrospectively examined out-of-hospital CA patients treated with targeted temperature management. ICP was measured using cerebrospinal fluid (CSF) pressure, whereas MAP was measured as blood pressure monitored through the radial or femoral artery during CSF pressure measurement. Primary outcome was 6-month neurological outcome. Of 92 enrolled patients, the favorable outcome group comprised 31 (34%) patients. The median and interquartile range of MAP were significantly higher and ICP was significantly lower in patients with favorable neurological outcomes than in those with unfavorable neurological outcomes (94.3 mmHg [80.0-105.3] vs. 82.0 mmHg [65.3-96.3], p = 0.021 and 9.4 mmHg [10.8-8.7] vs. 18.8 mmHg [20.0-15.7], p < 0.001, respectively). ICP showed the higher area under the receiver operating characteristic curve (area under curve [AUC] = 0.953, 95% confidence interval [CI] = 0.888-0.986) for neurological outcome prediction. MAP showed the lower AUC (0.648, 95% CI = 0.541-0.744). Higher accurate prognosis was predicted by ICP than MAP, and the prognostic performance was good. Prospective multicenter studies are required to confirm these results.

Usefulness of a quantitative analysis of the cerebrospinal fluid volume proportion in brain computed tomography for predicting neurological prognosis in cardiac arrest survivors who undergo target temperature management

PurposeBrain swelling post-cardiac arrest may affect cerebrospinal fluid volume. We aimed to investigate the prognostic performance of the proportion of cerebrospinal fluid volume (pCSFV) using brain computed tomography (CT) in cardiac arrest survivors. Materials and MethodsThis retrospective multicentre study included adult comatose cardiac arrest survivors who underwent brain CT scan prior to target temperature management (TTM) from 2015 to 2016. Grey-to-white matter ratio (GWR) and pCSFV values were calculated. pCSFV analysis was performed using automated quantitative analysis programming. The primary outcome was a 6-month neurological outcome. ResultsOf 251 patients (median age, 57 years), 173 (68.9%) were male, 87 (34.7%) had a shockable rhythm, and 160 (63.7%) had unfavourable neurological outcomes. GWR but not pCSFV was significantly higher in terms of favourable neurological outcomes (p = .015). pCSFV prognostic performances were similar to GWR, and were poor overall, (0.521; 95% confidence interval [CI], 0.446–0.694 vs. 0.515; 95% CI, 0.441–0.589). After adjusting for covariates, pCSFV but not GWR was independently associated with neurological outcome 6 months following cardiac arrest (p = .049). ConclusionpCSFV was independently associated with neurological outcome 6 months following cardiac arrest, however prognostic performance was not good.

Relationship between time related serum albumin concentration, optic nerve sheath diameter, cerebrospinal fluid pressure, and neurological prognosis in cardiac arrest survivors

AimThe optimal time to measure serum albumin concentration (SAC) to predict prognosis in cardiac arrest (CA) survivors has not been elucidated. We aimed to compare the relationships between time-related SAC, optic nerve sheath diameter (ONSD), intracranial pressure (ICP), and neurological prognosis in CA survivors. MethodsWe undertook a retrospective study examining CA patients treated with target temperature management (TTM). ICP was measured using cerebrospinal fluid (CSF) pressure and ONSD was obtained before TTM. SAC was measured repeatedly at 4–6 h intervals from the hospital arrival time. We analysed CSF pressure, ONSD, and minimum SAC (MSAC) separately, or in combination, to predict poor neurological outcome. ResultsOf 83 patients enrolled, the good outcome group comprised 25 (34%) patients. MSAC at 24 h (MSAC24) had a higher area under the receiver operating characteristic curve (AUC) (0.687; 95% confidence interval (CI), 0.668–0.926) than other time points. CSF pressure showed a higher AUC (0.973; 95% CI, 0.911–0.996) than MSAC24 and ONSD (0.677; 95% CI, 0.565–0.776). In contrast to using MSAC24 and ONSD separately, the combination of both modalities resulted in a better AUC, thus improving the prediction of the neurological outcome (0.734; 95% CI, 0.626–0.825) and ICP (0.758; 95% CI, 0.651–0.845) after return of spontaneous circulation (ROSC) from CA. ConclusionA higher ICP was strongly associated with and seemed predictive of poor outcome. Furthermore, the MSAC24/ONSD combination may be a useful predictor of high ICP and poor neurological outcome. Prospective studies should be conducted to confirm these results.

P2758Multimodal approach to the prediction of short- and long-term prognosis in cardiac arrest survivors: results from a prospective registry

P2758Multimodal approach to the prediction of short- and long-term prognosis in cardiac arrest survivors: results from a prospective registry

Long-Latency Sensory-Evoked Responses and Prognosis in Cardiac Arrest Survivors

We read with great interest the recent article published in CHEST (November 2014) by Ben-Hamouda et al.1 Persistent coma after global cerebral ischemia is a serious clinical disorder, and this condition is not rare among patients resuscitated from cardiac arrest. The prospect of neurologic recovery is poor for many patients, and clinicians are often confronted with the question of whether continuing treatment is worthwhile. To answer this question, it is important to know which clinical, neurophysiologic, imaging, and laboratory features determine prognosis.

The benign nature of mild induced therapeutic hypothermia—Induced long QTc

The post cardiac arrest syndrome is a constellation of cardiac, metabolic and neurological dysfunction that adversely affects the prognosis in cardiac arrest survivors. Mild induced therapeutic hypothermia (TH) has been shown to improve neurological recovery and mortality [1]. Although TH can prolong the QT interval, it has not been generally associated with Torsade de pointes (TdP) [2].