Early Prediction of Neurological Outcome after Cardiopulmonary Resuscitation: A Multimodal Approach Combining Neurobiochemical and Electrophysiological Investigations May Provide High Prognostic Certainty in Patients after Cardiac Arrest

Abstract

A reliable and reproducible method for precisely predicting the neurological outcome of patients with hypoxic-ischemic encephalopathy after cardiac arrest is urgently needed in neurological intensive care units. We prospectively investigated the predictive power of serum concentrations of neuron-specific enolase (NSE) and protein S-100B (S-100B) measured on days 1, 2, 3 and 7 as well as somatosensory-evoked potentials (SEPs) recorded within 48 h and on day 7 after cardiopulmonary resuscitation (CPR) in 27 patients (14 females, 13 males; mean age 61.3 ± 17.3 years) with hypoxic-ischemic encephalopathy. During the first 7 days after CPR, median values of NSE and S-100B were increased in patients who remained unconscious after CPR compared to those patients who regained consciousness (significance up to ≤0.001). The best predictor of negative outcome was an NSE cutoff point ≧43 µg/l on day 2; this had a sensitivity of 90.9% and a specificity of 100%. Additional use of S-100B on day 2 did not increase sensitivity, but this could be markedly increased by combining NSE and S-100B on days 1, 3 and 7. SEPs showing bilateral loss of cortical responses identified patients who did not regain consciousness with a specificity of 100%.

Cavernoma of cavernous sinus

“…Serum NSE above 33 g/L proved to be equally accurate, with a prevalence of 60%. An important additional finding, confirming earlier reports, 14,15 was the incomplete overlap of the results of SSEP and NSE. The prevalence of at least one abnormal test result derived from patients in whom both tests were performed was 66%.…”

“…[1][2][3][4][5] With our study, we could make such a comparison, and it is evident that the predictive value of some laboratory tests (SSEP and serum NSE) is superior to that of clinical tests in terms of low false positive rates and high prevalence of abnormal test results. Based on all available evidence, [1][2][3][4][5][14][15][16] confirmed and extended by the current results, we therefore propose the following strategy: Patients who are still unconscious at least 24 hours after an anoxic-ischemic insult undergo SSEP recordings and determination of serum NSE. When N20 is bilaterally absent or serum NSE is Ͼ33 g/L, further treatment will be withheld.…”

Post resuscitation care

“…In einigen anderen Studien [276, 320, 321] konnte aber ein Schwellenwert von 47,6 µg/l nach 24 h, 65,0 µg/l nach 48 h und 90,9 µg/l nach 72 h -jeweils nach ROSC -festgestellt werden [302].…”

Prognostic Value of Venous Blood Ammonia in Patients With Out-of-Hospital Cardiac Arrest

“…26, 27 Elevated levels of S100 (glial protein), the BB fraction of creatine kinase in cerebrospinal fluid or serum, and neurofilament protein have revealed a specificity for poor neurological outcome. 28 The biochemical markers of NSE and S100 at 24-72 h after ROSC have been shown to provide useful predictive neurological information, but these markers have not been used to predict neurological outcome during cardiac arrest or immediately after ROSC. 28 In this study, the venous ammonia level was measured within 1 h of cardiac arrest, and hyperammonemia was associated with poor neurological outcome.…”

“…28 The biochemical markers of NSE and S100 at 24-72 h after ROSC have been shown to provide useful predictive neurological information, but these markers have not been used to predict neurological outcome during cardiac arrest or immediately after ROSC. 28 In this study, the venous ammonia level was measured within 1 h of cardiac arrest, and hyperammonemia was associated with poor neurological outcome. These findings suggest that early measurement of the venous blood ammonia level is useful for predicting neurological outcome in adult patients with out-of-hospital cardiac arrest.…”