Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review

Abstract

Purpose: To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3-5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA). Methods: PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013-April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. Results: Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2-5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors. Conclusion: In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169

Postcardiac Arrest Neuroprognostication Practices: A Survey of Brazilian Physicians

“…The presence of status myoclonus may be more specific ( 2 ), but the associated electrophysiology is critical, as patients with persistent myoclonus but distinct EEG patterns have achieved a good outcome ( 17 , 18 ). In contrast, pupillary and corneal reflexes boast strong evidence in support of their utility, as their false-positive rates are reportedly low though nonzero at 72-hour postarrest or postrewarming ( 2 , 3 , 19 ). In our cohort, pupillary reflexes were most commonly assessed using light with the naked eye; however, studies have demonstrated greater specificity and interrater reliability through use of automated pupillometry ( 20 , 21 ).…”

“…In contrast, SSEP and NSE testings were less accessible and less frequently used. SSEP was still considered highly important, mirroring its high reliability in the literature ( 14 , 15 , 19 ); however, the majority reported never using this modality, likely due to its unavailability. NSE testing was regarded as less important—perhaps a reflection of its unavailability as well as its more tenuous evidence base, particularly as optimal cutoff levels remain controversial and are assay-dependent ( 28 ).…”

Which Target Temperature for Post-Anoxic Brain Injury? A Systematic Review from “Real Life” Studies

“…The most severe complication of sudden cardiac death is hypoxic-ischemic brain injury (HIBI) [ 1 ]; most patients admitted to an intensive care unit (ICU) after resuscitation from either out-of-hospital (OHCA) or in-hospital cardiac arrest (IHCA) are comatose and about two-thirds of them will eventually die before hospital discharge because of irreversible brain damage [ 2 ]. Moreover, severe cognitive dysfunction can affect up to 20% of cardiac arrest survivors with favorable neurological recovery [ 3 ] and potential neuroprotective therapies remains one of the most relevant strategies in this setting [ 4 ].…”

Serum neurofilament light chain as outcome marker for intensive care unit patients

“…Moreover, it helps to provide correct information for patients’ relatives, and, in case of a scarcity of resources, to allocate resources appropriately. A recent study showed that in case of resuscitation from out-of-hospital cardiac arrest more than 80% of patients admitted to an ICU have hypoxic–ischemic brain injury and about two-thirds of them die from withdrawal of life-sustaining treatment due to a predicted poor neurological outcome [ 8 ].…”