Diffusion and perfusion MRI of the brain in comatose patients treated with mild hypothermia after cardiac arrest: A prospective observational study

Järnum, Hanna; Knutsson, Linda; Rundgren, Malin; Siemund, Roger; Englund, Elisabet; Friberg, Hans; Larsson, Elna‐Marie

doi:10.1016/j.resuscitation.2009.01.004

Cited by 64 publications

(36 citation statements)

References 26 publications

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“…Imaging has a role in these cases, but when and with which modality is still unclear. The greater accuracy of MRI compared to CT, although not statistically significant, demonstrates that MRI should be used more often post arrest, as in some recent studies [3,4].…”

Section: Dear Sirsmentioning

confidence: 79%

The value of motor response versus neuroimaging in predicting outcome post cardiac arrest: a retrospective study

et al. 2010

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Neurologists are often asked about prognosis for recovery after cardiac arrest. However, the role of neuroimaging in prognostication is still unclear. In this analysis, we sought to compare neuroimaging to clinical assessment as a guide to prognosis post cardiac arrest in a tertiary referral hospital.We performed a retrospective study of cases of cardiac arrest admitted to the intensive care unit (ICU) in St. James's Hospital. Data were obtained from the ICU database from May 2005 to October 2008. From this, we reviewed the outcome in each case (Glasgow Outcome Scale (GOS) score of less than 3 or of 3 or greater) and the strength of association (using chi-squared analysis) with three factors-motor response at/before day 3 as on the Glasgow Coma Scale (GCS), non-contrast CT brain result and MRI result. Motor response was graded as normal (6/6 on the GCS) or abnormal (5/6 or less).Over the period studied, 86 patients were identified. Of these, 20 had a GOS of 3 or greater (23.3%).In those with GOS 3 or greater, 60% had a normal motor response by day 3. In those with GOS of less than 3, this figure was only 12% (Fig. 1). In those with a GCS motor score of 2 or less (extension or no response) by day 3, 93% died. However, only 53% of those with a score [ 2 at that point survived to discharge.With regards to neuroimaging, the scans performed varied considerably in terms of timing and findings. Forty three of the 86 patients had a CT brain (50%). Most scans (75%) were done on the day of admission to ICU. Only 16.3% showed evidence of hypoxic ischaemic damage, characterised by diffuse cerebral oedema and loss of sulcal pattern, with or without the presence of low attenuation in the region of the basal ganglia. Other scans were reported as showing non-significant findings, such as old lacunar infarcts (16.3%) and generalised atrophy (26.5%), or were entirely normal (28.6%). Three scans (6.1%) showed focal haemorrhage.MRI scans were performed in 17 of 86 patients (19.8% of total). All scans were done using a standard protocol with T1, T2, FLAIR, DWI and ADC sequences. Scans varied in timing post arrest (range 1-78 days). Thirteen of the scans were done at or before day 10 post arrest. 41.2% of MRIs showed evidence of hypoxic ischaemic damage, characterised by increased signal around the basal ganglia on DWI, and less frequently by associated oedema. 35.3% were felt to have non-significant findings, including old ischaemic changes (11.8%) generalised atrophy (23.5%), or were normal (11.8%). Four scans showed evidence of acute ischaemic events without evidence of hypoxic ischaemic injury (23.5%).Statistical analysis showed that motor score by day 3 post arrest was significantly associated with outcome (p \ 0.002) but that CT result (p = 0.086) and MRI result (p = 0.072) were not (Table 1).Our findings indicate that clinical exam findings are more valuable in prognostication for outcome post cardiac arrest than neuroimaging. The importance of clinical

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Section: Dear Sirsmentioning

confidence: 79%

The value of motor response versus neuroimaging in predicting outcome post cardiac arrest: a retrospective study

et al. 2010

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“…Similar to the other previously discussed studies, this study found that most patients with larger amounts of diffusion changes on MRI did not survive (16 of 20). 65 Of the 8 patients that underwent perfusion imaging, all 4 of the patients who died showed markedly increased perfusion. The hyperperfusion may represent reactive hyperemia that has been associated with diffusion restriction or, alternatively, may be an independent measurement that could be used for prognostication.…”

Section: Neuroimagingmentioning

confidence: 99%

“…The hyperperfusion may represent reactive hyperemia that has been associated with diffusion restriction or, alternatively, may be an independent measurement that could be used for prognostication. 65 Further research is needed before any conclusions can be drawn from the study, and the role of diffusion and perfusion MRI in the setting of TH remains unclear.…”

Section: Neuroimagingmentioning

confidence: 99%

An Update in Postcardiac Arrest Management and Prognosis in the Era of Therapeutic Hypothermia

Cahill

Tirschwell

Khot

2013

The Neurohospitalist

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Prognostication of patients who remain comatose following successful resuscitation after cardiac arrest has long posed a challenge for the consulting neurologist. With increasing rates of early defibrillation, out-of-hospital cardiopulmonary resuscitation, and expanding use of therapeutic hypothermia, prognostication in hypoxic-ischemic encephalopathy has become an increasingly common consult for neurologists. Much of the data we previously relied upon for prognostication were taken from patients who were not treated with therapeutic hypothermia. In this review, we examine useful prognostic tools and markers, including the physical examination, evaluation of myoclonus, electroencephalogram monitoring, somatosensoryevoked potentials, biochemical markers of neuronal injury, and neuroimaging. Neurologists must avoid overly pessimistic prognostic statements regarding survival, awakening from coma, or future quality of life, as such statements may unduly influence decisions regarding the continuation of life-sustaining treatment. Conversely, continuation of aggressive medical management in a patient without any hope of awakening should also be avoided. Thus, an understanding of the utility and the limitations of these prognostic tools in the era of therapeutic hypothermia is essential.

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“…However, not all investigators have found an increased risk of ischemic injury in the watershed/borderzone region (Roine et al, 1993;Wijdicks et al, 2001). There are very few studies providing description of the regions at risk of ischemic injury in the context of cardiac arrest (Fujioka et al, 1994;Jarnum et al, 2009;Mlynash et al, 2010;Singhal et al, 2002;Wijdicks et al, 2001;Wijman et al, 2009). Limited pathology studies in the setting of hypotension related to general anaesthesia showed infarction of cortex, deep grey matter nuclei, and cerebellum but sparing of the hippocampus (Adams et al, 1966;Brierley and Cooper, 1962).…”

Section: Introductionmentioning

confidence: 99%

“…Description of MR findings in the setting of hypoxic ischemic brain injury post-cardiac arrest has used descriptive methodology rather than used systematic approach (Jarnum et al, 2009;Singhal et al, NeuroImage 62 (2012) Wijdicks et al, 2001;Wijman et al, 2009). Recently, we have applied a probabilistic method in mapping the infarct territory related to arterial occlusion (Phan et al, 2005(Phan et al, , 2007(Phan et al, , 2009a(Phan et al, , 2010.…”

Section: Introductionmentioning

confidence: 99%

Application of principal component analysis to study topography of hypoxic–ischemic brain injury

et al. 2012

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Diffusion and perfusion MRI of the brain in comatose patients treated with mild hypothermia after cardiac arrest: A prospective observational study

Cited by 64 publications

References 26 publications

The value of motor response versus neuroimaging in predicting outcome post cardiac arrest: a retrospective study

The value of motor response versus neuroimaging in predicting outcome post cardiac arrest: a retrospective study

An Update in Postcardiac Arrest Management and Prognosis in the Era of Therapeutic Hypothermia

Application of principal component analysis to study topography of hypoxic–ischemic brain injury

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