Does Combining Biomarkers and Brain Images Provide Improved Prognostic Predictive Performance for Out-Of-Hospital Cardiac Arrest Survivors before Target Temperature Management?

Abstract

We examined whether combining biomarkers measurements and brain images early after the return of spontaneous circulation improves prognostic performance compared with the use of either biomarkers or brain images for patients with cardiac arrest following target temperature management (TTM). This retrospective observational study involved comatose out-of-hospital cardiac arrest survivors. We analyzed neuron-specific enolase levels in serum (NSE) or cerebrospinal fluid (CSF), grey-to-white matter ratio by brain computed tomography, presence of high signal intensity (HSI) in diffusion-weighted imaging (DWI), and voxel-based apparent diffusion coefficient (ADC). Of the 58 patients, 33 (56.9%) had poor neurologic outcomes. CSF NSE levels showed better prognostic performance (area under the curve (AUC) 0.873, 95% confidence interval (CI) 0.749–0.950) than serum NSE levels (AUC 0.792, 95% CI 0.644–0.888). HSI in DWI showed the best prognostic performance (AUC 0.833, 95% CI 0.711–0.919). Combining CSF NSE levels and HSI in DWI had better prognostic performance (AUC 0.925, 95% CI 0.813–0.981) than each individual method, followed by the combination of serum NSE levels and HSI on DWI and that of CSF NSE levels and the percentage of voxels of ADC (AUC 0.901, 95% CI 0.792–0.965; AUC 0.849, 95% CI 0.717–0.935, respectively). Combining CSF/serum NSE levels and HSI in DWI before TTM improved the prognostic performance compared to either each individual method or other combinations.

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

“…Its thresholds for 0% FPR for poor outcome were ≤ 726 × 10 −6 mm 2 /s within 48 h from ROSC and ≤ 627 × 10 −6 mm 2 /s between 48 h and 7 days from ROSC, respectively. In this and another study [115], the percentage of brain volume with a low ADC (defined as an ADC value ≤ 400 × 10 −6 mm 2 /s) was assessed at a median of 3 h from ROSC [115], or within 48 h and between 48 h and 7 days from ROSC [84]. Thresholds for 0% FPR of the percentage of low-ADC brain volume were 4.3%, 2.5%, and 1.66%, respectively.…”

“…However, there is no universal consensus on the best technique to assess reduced ADC within the brain after HIBI. In the four studies assessing ADC included in our review [79,84,97,115], three methods for ADC measurement were described: the mean global or regional ADC value of the brain [79,84], the proportion of voxels with low ADC [84,97,115], and the maximum size of the MRI clusters with minimum ADC [79]. In all these studies, ADC thresholds for 0% FPR were identified, often with sensitivities above 50%.…”

“…In most studies included in our review, cytotoxic oedema was detected within 1-2 h after ROSC using brain CT and within 2-3 days after ROSC using DWI/ADC. However, in other studies [78,115], MRI was performed at a median of 3 h after ROSC. In a study not included in our review [168] changes on DWI MRI predicted poor neurological outcome within 6 h from ROSC.…”

The Usefulness of Quantitative Analysis of Blood-Brain Barrier Disruption Measured Using Contrast-Enhanced Magnetic Resonance Imaging to Predict Neurological Prognosis in Out-of-Hospital Cardiac Arrest Survivors: A Preliminary Study

“…In addition, Son et al’s recent study showing poor neurological outcome using DWI-MRI conducted before TTM after ROSC reported a high signal intensity in 22 of 33 (66.7%) patients [ 8 ]. One previous study reported that, while DWI is not noticeable in most patients with transient ischemic attack, BBB interruptions may exist.…”

“…Current prognostication guidelines suggest performing brain magnetic resonance imaging (MRI) 2–5 days after ROSC [ 5 ]. However, recent evidence has shown that MRI is better than brain CT at predicting neurological outcome within 3 h after ROSC [ 6 , 7 , 8 ].…”