Use of brain diffusion tensor imaging for the prediction of long-term neurological outcomes in patients after cardiac arrest: a multicentre, international, prospective, observational, cohort study

Velly, Lionel; Perlbarg, Vincent; Boulier, Thomas; Adam, Nicolas; Delphine, Sebastien; Luyt, Charles‐Édouard; Battisti, Valentine; Torkomian, Grégory; Arbelot, Charlotte; Chabanne, Russell; Jean, Betty; Perri, Carol Di; Laureys, Steven; Citerio, Giuseppe; Vargiolu, Alessia; Rohaut, Benjamin; Bruder, Nicolas; Girard, Nadine; Silva, Stein; Cottenceau, Vincent; Tourdias, Thomas; Coulon, Olivier; Riou, Bruno; Naccache, Lionel; Gupta, Rajiv; Benali, Habib; Galanaud, Damien; Puybasset, Louis; Constantin, Jean-Michel; Chastre, Jean; Amour, Julien; Vezinet, Corine; Rouby, Jean-Jacques; Raux, Mathieu; Langeron, Olivier; Degos, Vincent; Bolgert, Françis; Weiss, Nicolas; Similowski, Thomas; Demoule, Alexandre; Duguet, Alexandre; Tollard, É.; Veber, Benoît; Lotterie, Jean-Albert; Sanchez-Peña, Paola; Généstal, M.; Patassini, Mirko

doi:10.1016/s1474-4422(18)30027-9

Cited by 142 publications

(138 citation statements)

References 35 publications

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“…66,67 Lastly, ketogenic diet is increasingly used as an effective treatment for refractory seizures in adults, 68 another treatment modality thought to alter metabolic substrate availability even though the basic underlying mechanism is not completely understood. 69,70 Perhaps most importantly, our findings in conjunction with emerging clinical trials of neuroimaging markers of structural integrity in post-cardiac arrest comatose patients 17,18 also support the broad use of structural imaging protocols (including MRIs) in such patients. Lack of neuroimaging evidence for overwhelming neuronal injury in persistently comatose patients should prompt a vigorous attempt to promote brain activation and aggressive treatment of ongoing seizures or other varying persistent functional abnormalities seen after cardiac arrest.…”

Section: Discussionsupporting

confidence: 64%

“…[11][12][13][14][15][16] In addition, a lack of imaging-based evidence of anoxic cortical or white matter injuries after cardiac arrest may portend better outcomes, 17 even in patients remaining in coma for more than 7 days. 18 The poorly characterized physiological protective factors related to TTM 19 suggest the possibility that in comatose post-cardiac arrest patients with wide preservation of cerebral structure, some negative predictive markers may only indicate a sustained abnormal state of global neuronal functions without permanent loss of potential to recover integrative cerebral functions. Collectively, these observations raise the question of whether global dysfunction of large-scale cerebral networks indexed by negative physiological predictive markers (eg, BSP, refractory status epilepticus) may hide a latent capacity for broad functional recovery across the corticothalamic system in patients with prolonged coma after cardiac arrest.…”

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confidence: 99%

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Independent Functional Outcomes after Prolonged Coma following Cardiac Arrest: A Mechanistic Hypothesis

Forgács

Devinsky

Schiff

2020

Annals of Neurology

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Objective Survivors of prolonged (>2 weeks) post–cardiac arrest (CA) coma are expected to remain permanently disabled. We aimed to investigate 3 outlier patients who ultimately achieved independent functional outcomes after prolonged post‐CA coma to identify electroencephalographic (EEG) markers of their recovery potential. For validation purposes, we also aimed to evaluate these markers in an independent cohort of post‐CA patients. Methods We identified 3 patients with late recovery from coma (17–37 days) following CA who recovered to functionally independent behavioral levels. We performed spectral power analyses of available EEGs during prominent burst suppression patterns (BSP) present in all 3 patients. Using identical methods, we also assessed the relationship of intraburst spectral power and outcomes in a prospectively enrolled cohort of post‐CA patients. We performed chart reviews of common clinical, imaging, and EEG prognostic variables and clinical outcomes for all patients. Results All 3 patients with late recovery from coma lacked evidence of overwhelming cortical injury but demonstrated prominent BSP on EEG. Spectral analyses revealed a prominent theta (~4–7Hz) feature dominating the bursts during BSP in these patients. In the prospective cohort, similar intraburst theta spectral features were evident in patients with favorable outcomes; patients with BSP and unfavorable outcomes showed either no features, transient burst features, or decreasing intraburst frequencies with time. Interpretation BSP with theta (~4–7Hz) peak intraburst spectral power after CA may index a recovery potential. We discuss our results in the context of optimizing metabolic substrate availability and stimulating the corticothalamic system during recovery from prolonged post‐CA coma. ANN NEUROL 2020;87:618–632

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Section: Discussionsupporting

confidence: 64%

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confidence: 99%

Independent Functional Outcomes after Prolonged Coma following Cardiac Arrest: A Mechanistic Hypothesis

Forgács

Devinsky

Schiff

2020

Annals of Neurology

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“…If this is not the case, a second step relies on less robust markers, that need to be combined and eventually repeated, such as high serum neuron‐specific enolase, unreactive malignant EEG patterns (status epilecticus or burst‐suppression, the prognostic value of isolated discontinuous or unreactive EEG being less clear) and/or brain imagery showing diffuse anoxic injury (CT or MRI). Recently, the global FA proved to be very accurate in prognosing outcome at 1 year of patients still comatose 7 days after cardiac arrest . In severe TBI, prognosis is more heterogenous and is often delayed by the initial management of high intracranial pressure (sedation, hypothermia, etc).…”

Section: Discussionmentioning

confidence: 99%

Unexpected good outcome in severe cerebral fat embolism syndrome

Hermann

Brisson

Langeron

et al. 2018

Ann Clin Transl Neurol

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In this case study, we report the longitudinal and multimodal follow‐up of a catastrophic initial presentation of cerebral fat embolism syndrome. We show that despite the initial severity, the cognitive outcome was ultimately very good but with a highly nonlinear time‐course and prolonged loss of consciousness (more than 2 months). Repeated clinical assessments and brain‐imaging techniques (electroencephalography, event‐related potential, 18‐Fluoro‐Deoxy‐Glucose‐PET and magnetic resonance imaging) allowed us to monitor and anticipate this dynamic, providing relevant information to guide decision making in front of withdrawal of life‐sustaining therapy discussions. This case illustrates the value of multimodal functional imaging in devastating brain injuries.

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“…Focal lesions in key structures within previously described models of consciousness together with measures related to mass effect of the haemorrhage predict early recovery of consciousness. Both, adding a comprehensive assessment of structural connectivity between these key structures (i.e., using diffusion tensor imaging analysis) [40] as well as quantifying functional connectivity (using functional imaging or EEG markers) may further strengthen the accuracy of this model.…”

Section: Discussionmentioning

confidence: 99%

Deep structural brain lesions associated with consciousness impairment early after haemorrhagic stroke

Rohaut

Doyle

Reynolds

et al. 2018

Preprint

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BackgroundThe significance of deep structural lesions on level of consciousness early after intracerebral haemorrhage (ICH) is largely unknown.MethodsWe studied a consecutive series of patients with spontaneous ICH that underwent MRI within 7 days of the bleed. We assessed consciousness by testing for command following from time of MRI to hospital discharge, and determined 3-months functional outcomes using the Glasgow Outcome Scale-Extended (GOS-E). ICH and oedema volumes, intraventricular haemorrhage (IVH), and midline shift (MLS) were quantified. Presence of blood and oedema in deep brain regions previously implicated in consciousness were assessed. A machine learning approach using logistic regression with elastic net regularization was applied to identify parameters that best predicted consciousness at discharge controlling for confounders.ResultsFrom 158 ICH patients that underwent MRI, 66% (N=105) were conscious and 34% (N=53) unconscious at the time of MRI. Almost half of unconscious patients (49%, N= 26) recovered consciousness by ICU discharge. Focal lesions within subcortical structures predicted persistent impairment of consciousness at discharge together with MLS, IVH, and ICH and oedema volumes (AUC 0.74; 95%-CI 0.73-0.75). Caudate nucleus, midbrain peduncle, and pontine tegmentum were implicated as critical structures. Unconscious patients predicted to recover consciousness had better 3-month functional outcomes than those predicted to remain unconscious (35% vs 0% GOS-E ≥4; p-value=0.02).ConclusionMRI lesions within key subcortical structures together with measures reflecting the mass effect of the haemorrhage (lesion volumes, IVH, MLS) obtained within one week of ICH can help predict early recovery of consciousness and 3-month functional outcome.

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Use of brain diffusion tensor imaging for the prediction of long-term neurological outcomes in patients after cardiac arrest: a multicentre, international, prospective, observational, cohort study

Cited by 142 publications

References 35 publications

Independent Functional Outcomes after Prolonged Coma following Cardiac Arrest: A Mechanistic Hypothesis

Independent Functional Outcomes after Prolonged Coma following Cardiac Arrest: A Mechanistic Hypothesis

Unexpected good outcome in severe cerebral fat embolism syndrome

Deep structural brain lesions associated with consciousness impairment early after haemorrhagic stroke

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