Practice Parameter: Prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review) [RETIRED]

Wijdicks, Eelco F. M.; Hijdra, A.; Young, G. Bryan; Bassetti, Claudio; Wiebe, Samuel

doi:10.1212/01.wnl.0000227183.21314.cd

Cited by 1,160 publications

(944 citation statements)

References 76 publications

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“…Prior to TTM, the “gold standard” for early prediction of neurologic outcomes was the 2006 American Academy of Neurology practice parameter, comprising 6 physical examination and diagnostic test findings on post‐arrest days 1 to 3, each with reported positive predictive value (PPV) of 100% for poor neurologic outcome 10. However, validity in the TTM population has been repeatedly questioned because of decreased individual and composite PPV 11, 12, 13.…”

Section: Introductionmentioning

confidence: 99%

C‐GRApH : A Validated Scoring System for Early Stratification of Neurologic Outcome After Out‐of‐Hospital Cardiac Arrest Treated With Targeted Temperature Management

Kiehl

Parker

Matar

et al. 2017

JAHA

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BackgroundOut‐of‐hospital cardiac arrest (OHCA) results in significant morbidity and mortality, primarily from neurologic injury. Predicting neurologic outcome early post‐OHCA remains difficult in patients receiving targeted temperature management.Methods and ResultsRetrospective analysis was performed on consecutive OHCA patients receiving targeted temperature management (32–34°C) for 24 hours at a tertiary‐care center from 2008 to 2012 (development cohort, n=122). The primary outcome was favorable neurologic outcome at hospital discharge, defined as cerebral performance category 1 to 2 (poor 3–5). Patient demographics, pre‐OHCA diagnoses, and initial laboratory studies post‐resuscitation were compared between favorable and poor neurologic outcomes with multivariable logistic regression used to develop a simple scoring system (C‐GRApH). The C‐GRApH score ranges 0 to 5 using equally weighted variables: (C): coronary artery disease, known pre‐OHCA; (G): glucose ≥200 mg/dL; (R): rhythm of arrest not ventricular tachycardia/fibrillation; (A): age >45; (pH): arterial pH ≤7.0. A validation cohort (n=344) included subsequent patients from the initial site (n=72) and an external quaternary‐care health system (n=272) from 2012 to 2014. The c‐statistic for predicting neurologic outcome was 0.82 (0.74–0.90, P<0.001) in the development cohort and 0.81 (0.76–0.87, P<0.001) in the validation cohort. When subdivided by C‐GRApH score, similar rates of favorable neurologic outcome were seen in both cohorts, 70% each for low (0–1, n=60), 22% versus 19% for medium (2–3, n=307), and 0% versus 2% for high (4–5, n=99) C‐GRApH scores in the development and validation cohorts, respectively.Conclusions C‐GRApH stratifies neurologic outcomes following OHCA in patients receiving targeted temperature management (32–34°C) using objective data available at hospital presentation, identifying patient subsets with disproportionally favorable (C‐GRApH ≤1) and poor (C‐GRApH ≥4) prognoses.

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Section: Introductionmentioning

confidence: 99%

C‐GRApH : A Validated Scoring System for Early Stratification of Neurologic Outcome After Out‐of‐Hospital Cardiac Arrest Treated With Targeted Temperature Management

Kiehl

Parker

Matar

et al. 2017

JAHA

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“…This discrepancy might be caused by the presence of variable anoxic/hypoxic damage to the architecture of brain motor pathways in PHM patients. This damage may pave the way for a variety of mechanisms in which cortical generalized PHM can occur 3, 7, 33. For example, in some cases, a generalized jerk could arise from seizures wherein generalized ictal discharges act as the cortical source of PHM 33, 34.…”

Section: Discussionmentioning

confidence: 99%

“…Generalized PHM has been correlated with poor outcome in PAE and included as prognosticator of poor outcome in the American postanoxic coma guideline 1, 3. It is thought that the CM or SM represents the localization of anoxic brain decay in PHM patients 8, 33, 34, 35.…”

Section: Discussionmentioning

confidence: 99%

“…Myoclonus in the first few days after hypoxic brain damage is in general considered to predict an unfavorable prognosis in patients who remain comatose after cardiopulmonary resuscitation (CPR) 1, 2, 3. The incidence of posthypoxic myoclonus (PHM) in resuscitated patients with postanoxic encephalopathy (PAE) is 19%, and only 9–14% of these patients recover with mild to no cognitive deficits 4, 5, 6…”

Section: Introductionmentioning

confidence: 99%

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The interrelation between clinical presentation and neurophysiology of posthypoxic myoclonus

Zijl

Beudel

Jong

et al. 2018

Ann Clin Transl Neurol

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ObjectivePosthypoxic myoclonus (PHM) in the first few days after resuscitation can be divided clinically into generalized and focal (uni‐ and multifocal) subtypes. The former is associated with a subcortical origin and poor prognosis in patients with postanoxic encephalopathy (PAE), and the latter with a cortical origin and better prognosis. However, use of PHM as prognosticator in PAE is hampered by the modest objectivity in its clinical assessment. Therefore, we aimed to obtain the anatomical origin of PHM with use of neurophysiological investigations, and relate these to its clinical presentation.MethodsThis study included 20 patients (56 ± 18 y/o, 68% M, 2 survived, 1 excluded) with EEG‐EMG‐video recording. Three neurologists classified PHM into generalized or focal PHM. Anatomical origin (cortical/subcortical) was assessed with basic and advanced neurophysiology (Jerk‐Locked Back Averaging, coherence analysis).ResultsClinically assessed origin of PHM did not match the result obtained with neurophysiology: cortical PHM was more likely present in generalized than in focal PHM. In addition, some cases demonstrated co‐occurrence of cortical and subcortical myoclonus. Patients that recovered from PAE had cortical myoclonus (1 generalized, 1 focal).InterpretationHypoxic damage to variable cortical and subcortical areas in the brain may lead to mixed and varying clinical manifestations of myoclonus that differ of those patients with myoclonus generally encountered in the outpatient clinic. The current clinical classification of PHM is not adequately refined to play a pivotal role in guiding treatment decisions to withdraw care. Our neurophysiological characterization of PHM provides specific parameters to be used in designing future comprehensive studies addressing the potential role of PHM as prognosticator in PAE.

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“…The chance of neurologically intact survival from cardiac arrest remains low despite significant advances in clinical care, including cardiopulmonary resuscitation (CPR) and treatment with therapeutic hypothermia. Less than half of those with return to spontaneous circulation survive to hospital discharge and 20%–30% of the survivors are neurologically devastated (Bisschops et al., 2011; Wijdicks et al., 2006). Seizures have been reported in 10%–12% of the survivors and have been shown to be an independent risk factor for mortality (Arnoldus & Lammers, 1995; Celesia, Grigg, & Ross, 1988; Fugate et al., 2010; Harper & Wilkes, 1991; Hui et al., 2005; Kawai, Thapalia, & Verma, 2011; Krumholz, Stern, & Weiss, 1988; Mani et al., 2012; Rabinstein & Wijdicks, 2012; Rossetti et al., 2007; Wijdicks, Parisi, & Sharbrough, 1994; Young, Jordan, & Doig, 1996).…”

Section: Introductionmentioning

confidence: 99%

Occurrence of overt seizures in comatose survivor patients treated with targeted temperature

et al. 2017

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BackgroundUnconscious patients after out‐of‐hospital cardiac arrest have a high risk of death. Therapeutic hypothermia is recommended by international resuscitation guidelines in order to attenuate secondary destructive physiological processes such as reperfusion injury, apoptosis, and cerebral edema. The target temperature to reach ranges between 32 and 34°C for at least 24 hr. Hypothermia can induce metabolic disturbances. There are some reports in the literature indicating the presence of seizures during targeted temperature management. On the other hand, postanoxic seizures are a sign of unfavorable neurological outcome. The purpose of this study was to evaluate the occurrence of overt seizures in comatose survivor patients treated with targeted temperature in respect to overt seizures in a normal temperature group of comatose patients.MethodsThis was a retrospective study of unconscious adults post cardiopulmonary resuscitation, hospitalized in the intensive care unit during the years 2008–2015. The patients were divided into two groups: those treated with hypothermia and those with normal body temperature. Both groups were evaluated for the appearance of overt seizures during their hospitalization which was the primary outcome of the study.ResultsThe data of 88 consecutive unconscious patients after out‐of‐hospital cardiac arrest were collected. Twenty‐six patients were treated with targeted temperature (32–34°C) and 62 patients with normal temperature. In the hypothermic group, 6 (23%) patients developed overt seizures during hospitalization compared to 11 (17%) in the normothermic group. The mortality rate was similar in both groups, 16 (61%) in the hypothermic group and 38 (61%) in the conservative group. According to the present study, overt seizures were more common in the group treated with hypothermia.

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Practice Parameter: Prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review) [RETIRED]

Cited by 1,160 publications

References 76 publications

C‐GRApH : A Validated Scoring System for Early Stratification of Neurologic Outcome After Out‐of‐Hospital Cardiac Arrest Treated With Targeted Temperature Management

C‐GRApH : A Validated Scoring System for Early Stratification of Neurologic Outcome After Out‐of‐Hospital Cardiac Arrest Treated With Targeted Temperature Management

The interrelation between clinical presentation and neurophysiology of posthypoxic myoclonus

Occurrence of overt seizures in comatose survivor patients treated with targeted temperature

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