Neurologic Outcomes and Postresuscitation Care of Patients With Myoclonus Following Cardiac Arrest*

Seder, David B.; Sunde, Kjetil; Rubertsson, Sten; Mooney, M.; Stammet, Pascal; Riker, Richard R.; Kern, Karl B.; Unger, Barbara; Cronberg, Tobias; Dziodzio, John; Nielsen, Niklas

doi:10.1097/ccm.0000000000000880

Cited by 124 publications

(110 citation statements)

References 44 publications

(21 reference statements)

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“…Coming to clinical prognosticators, lack of corneal reflexes had the lowest false positive prediction of poor outcome (0 %); the false positive rate regarding occurrence of myoclonus was 14 %, especially if a normal voltage was observed, broadly confirming other recent observations [12,13]; false positivity for the lack motor response was identical, also in line with previous reports [12]. Finally, the authors propose a two-step approach for outcome prognosis, starting with EEG at 24 h and completing it with corneal reflexes at 72 h. This is a single-center analysis performed in an environment with the highest expertise for cEEG interpretation, potentially limiting its generalizability; the poor outcome rate of 71 % is higher than that in other recent series [5,12], but outcome assessment at discharge might have underestimated the recovery of some patients, especially for those in the inhomogeneous category of GOS (or CPC) = 3.…”

supporting

confidence: 75%

EEG for outcome prediction after cardiac arrest: when the quest for optimization needs standardization

Rossetti

2015

Intensive Care Med

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Early outcome prognostication of comatose patients following cardiac arrest represents a daunting task; several clinical, biochemical, radiological, and neurophysiological parameters have been intensively evaluated recently, in the context of growing popularity of targeted temperature management or therapeutic hypothermia (TH) in the last decade [1,2]. Among these potential predictors, EEG represents a relatively cheap, noninvasive tool available at the bedside, but the assessment of its exact role has to deal with the influence of timing, lingering pharmacological sedation, temperature, and not least the expertise of interpreters and the sometimes confusing taxonomy of the findings.In this issue, Dr. Sivaraju and colleagues report their effort to assess the prognostic significance of continuous EEG (cEEG) data in 100 patients treated with TH at 32-34°C [3]. They reviewed all EEG recordings in the form of 5-min extracts taken at predefined intervals from the acute event (6, 12, 24, 48, and 72 h). Blinded to patients' identity and outcome, they applied the recently published standardized American Clinical Neurophysiology Society (ACNS) critical care EEG terminology [4], correlating their data with those of other clinical investigations.The principal findings are that suppression-burst at any time (but not a discontinuous recording), and a low voltage (\20 lV) background after 24 h, have a false positive rate of 0 % for poor prognosis, defined as a Glasgow outcome scale (GOS) of 1-3 at hospital discharge, suggesting that in this cohort assessment at 24 h heralds the best prognostic value, despite the probable concomitant use of sedation (mostly midazolam, further details not given) and TH. As the authors acknowledge, other groups have reported different results regarding the temporal dynamics of evolution of the cEEG [5]; furthermore, the ACNS terminology puts a threshold between suppression-burst and discontinuous background at 50 % of relative suppression, which could prove tricky to label with certainty in specific borderline situations (in other words: EEG signals represent a continuous, not a discrete variable).Conversely, normal voltage ([20 lV) at any time is related to a good outcome in 71 % of patients, confirming earlier data along the same lines [6]. Considering the delicacy in reliably deciding upon a voltage amplitude around 20 lV in some patients [7], other groups concentrated rather on background reactivity to stimuli, which if present during TH has been reported to herald good prognosis in as much as 86 % [8], while lack of reactivity portended a poor prognosis in a much higher rate (99 % in [9]). This last figure contrasts with a predictive value of 86 % in this study (it was, however, not indicated when reactivity was assessed), pinpointing the lack of standardization of its testing (in this series with auditory and peripheral painful stimuli; in the aforementioned papers applying also vigorous pressure to the nipples) and its scoring [7,10]. In the same context, identical bursts, recently report...

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supporting

confidence: 75%

EEG for outcome prediction after cardiac arrest: when the quest for optimization needs standardization

Rossetti

2015

Intensive Care Med

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“…The incidence of posthypoxic myoclonus (PHM) in resuscitated patients with postanoxic encephalopathy (PAE) is 19%, and only 9–14% of these patients recover with mild to no cognitive deficits 4, 5, 6…”

Section: Introductionmentioning

confidence: 99%

“…The survival of comatose patients with generalized PHM admitted at an intensive care unit (ICU) is reported to be poor (±3%) in comparison with focal PHM patients (±17%) 4, 5. Generalized PHM is associated with a subcortical origin.…”

Section: Introductionmentioning

confidence: 99%

The interrelation between clinical presentation and neurophysiology of posthypoxic myoclonus

Zijl

Beudel

Jong

et al. 2018

Ann Clin Transl Neurol

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ObjectivePosthypoxic myoclonus (PHM) in the first few days after resuscitation can be divided clinically into generalized and focal (uni‐ and multifocal) subtypes. The former is associated with a subcortical origin and poor prognosis in patients with postanoxic encephalopathy (PAE), and the latter with a cortical origin and better prognosis. However, use of PHM as prognosticator in PAE is hampered by the modest objectivity in its clinical assessment. Therefore, we aimed to obtain the anatomical origin of PHM with use of neurophysiological investigations, and relate these to its clinical presentation.MethodsThis study included 20 patients (56 ± 18 y/o, 68% M, 2 survived, 1 excluded) with EEG‐EMG‐video recording. Three neurologists classified PHM into generalized or focal PHM. Anatomical origin (cortical/subcortical) was assessed with basic and advanced neurophysiology (Jerk‐Locked Back Averaging, coherence analysis).ResultsClinically assessed origin of PHM did not match the result obtained with neurophysiology: cortical PHM was more likely present in generalized than in focal PHM. In addition, some cases demonstrated co‐occurrence of cortical and subcortical myoclonus. Patients that recovered from PAE had cortical myoclonus (1 generalized, 1 focal).InterpretationHypoxic damage to variable cortical and subcortical areas in the brain may lead to mixed and varying clinical manifestations of myoclonus that differ of those patients with myoclonus generally encountered in the outpatient clinic. The current clinical classification of PHM is not adequately refined to play a pivotal role in guiding treatment decisions to withdraw care. Our neurophysiological characterization of PHM provides specific parameters to be used in designing future comprehensive studies addressing the potential role of PHM as prognosticator in PAE.

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“…There are several malignant EEG patterns seen in patients after CRA, including burst suppression, nonreactive background, alpha coma, generalized status epilepticus, and lateralized (LPDs) or generalized periodic discharges (GPDs; 4,5,17,24,29,37). Multiple studies have demonstrated that these EEG patterns, as well as others that signify severe brain injury, predict worse outcomes when found in those with PHM after CRA (4,5,21,(24)(25)(26)29).…”

Section: Neurophysiological Studies May Help Differentiate "Benign" Amentioning

confidence: 99%

“…Multiple studies have demonstrated that these EEG patterns, as well as others that signify severe brain injury, predict worse outcomes when found in those with PHM after CRA (4,5,21,(24)(25)(26)29). This was also described in a review by Gupta et al that included 37 articles, of which a number are included in this review (4,11,12,24,27,29, and a number of cases of LAS also described in Freund et al [3]).…”

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confidence: 99%

Myoclonus after Cardiac Arrest: Where Do We Go from Here?

Freund

Kaplan

2017

Epilepsy Curr

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Prognostication after cardiac arrest often depends primarily on neurological function, and characterizing the extent of neurological injury hinges on neurophysiological testing and clinical neurological examination. The presence of early posthypoxic myoclonus (PHM) following cardiac arrest had been invariably associated with poor outcome, but more recent studies have shown that those with early PHM may survive with good neurological function. Electroencephalographic patterns suggestive of severe brain injury may be more valuable than the presence of PHM itself in portending poor functional status, and phenotyping PHM may also be useful in delineating benign and malignant forms. Patients with early PHM should be evaluated similarly to others who suffer cardiac arrest by using a multimodal approach in determining prognosis until further studies are performed that better characterize early PHM subtypes and their outcomes.

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Neurologic Outcomes and Postresuscitation Care of Patients With Myoclonus Following Cardiac Arrest*

Cited by 124 publications

References 44 publications

EEG for outcome prediction after cardiac arrest: when the quest for optimization needs standardization

EEG for outcome prediction after cardiac arrest: when the quest for optimization needs standardization

The interrelation between clinical presentation and neurophysiology of posthypoxic myoclonus

Myoclonus after Cardiac Arrest: Where Do We Go from Here?

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