Unresponsive wakefulness or coma after cardiac arrest—A long-term follow-up study

Petzinka, Victor N.; Endisch, Christian; Streitberger, Kaspar Josche; Salih, Farid; Ploner, Christoph J.; Storm, Christian; Nee, Jens; Leithner, Christoph

doi:10.1016/j.resuscitation.2018.07.007

Cited by 27 publications

(22 citation statements)

References 30 publications

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“…8 Nevertheless, reports of late recoveries from prolonged postcardiac arrest coma suggest that recovery of neuronal function can extend over much longer time periods. [11][12][13][14][15][16] The 3 patients with late recovery presented here all remained in coma for more than 2 weeks following cardiac arrest (17, 37, 30 days, respectively; see Fig 1 and Table 1) and yet achieved independent functional outcomes. In 2 patients (Patients 2 and 3), nonmedical reasons (ie, family wishes and logistical limitations of obtaining a legally authorized decision-maker) prohibited withdrawal of lifesustaining therapy; in the third patient (Patient 1), knowledge of the outcomes and clinical profiles of these first 2 patients provided the basis for the prolonged wait period to allow late emergence from coma (see Table 1).…”

Section: Discussionmentioning

confidence: 85%

“…However, following the widespread use of TTM, an increasing number of reports describe unexpected recoveries despite evidence of poor prognostic markers. [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.…”

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confidence: 99%

“…In this context, many studies have identified physiological markers that remain associated with poor prognosis to guide management (eg, loss of brainstem reflexes on exam, burst suppression pattern [BSP] or refractory status epilepticus on electroencephalogram [EEG]). However, following the widespread use of TTM, an increasing number of reports describe unexpected recoveries despite evidence of poor prognostic markers . In addition, a lack of imaging‐based evidence of anoxic cortical or white matter injuries after cardiac arrest may portend better outcomes, even in patients remaining in coma for more than 7 days .…”

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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: Discussionmentioning

confidence: 85%

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confidence: 99%

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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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“…A total of 132 patients were potentially eligible, and 81 were included in the analyses (Figure 1). For 84% of them, aneurysm was treated by coiling within a median (IQR) of 14 h [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. At ICU admission, 56 patients had an M-GCS of 6, among whom 53 had an M-GCS of 6 both at admission and on day 3; three patients worsened within 3 days (two had hydrocephalus requiring EVD and the third was intubated for respiratory disorder; none had re-bleeding or aneurysm treatment complications).…”

Section: Populationmentioning

confidence: 99%

“…For instance, the presence of a cerebral edema on computed tomography (CT) images, graded using the subarachnoid hemorrhage early brain edema score (SEBES), or the extent of fluid attenuation inversion recovery (FLAIR) hypersignals on magnetic resonance imaging, are predictors of long-term disability and DCI occurrence [6,7,14]. Systemic biomarkers have also been evaluated to rate the burden of brain injury, such as the neuron specific enolase (NSE) following cardiac arrest [15,16]. However, in hemorrhagic stroke, astrocytic markers are better biomarkers of the primary hemorrhagic lesion [17][18][19].…”

Section: Introductionmentioning

confidence: 99%

Significance and Diagnostic Accuracy of Early S100B Serum Concentration after Aneurysmal Subarachnoid Hemorrhage

Balança

Ritzenthaler

Gobert

et al. 2020

JCM

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Background: Early brain injuries (EBI) are one of the most important causes of morbidity and mortality after subarachnoid hemorrhage. At admission, a third of patients are unconscious (spontaneously or sedated) and EBI consequences are not evaluable. To date, it is unclear who will still be comatose (with severe EBI) and who will recover (with less severe EBI) once the aneurysm is treated and sedation withdrawn. The objective of the present study was to determine the diagnostic accuracy of S100B levels at hospital admission to identify patients with severe neurological consequences of EBI. Methods: Patients were consecutively included in this prospective blinded observational study. A motor component of the Glasgow coma score under 6 on day 3 was used to define patients with severe neurological consequences of EBI. Results: A total of 81 patients were included: 25 patients were unconscious at admission, 68 were treated by coiling. On day 3, 12 patients had severe consequences of EBI. A maximal S100B value between admission and day 1 had an area under the receiver operating characteristic curve (AUC) of 86.7% to predict severe EBI consequences. In patients with impaired consciousness at admission, the AUC was 88.2%. Conclusion: Early S100B seems to have a good diagnostic value to predict severe EBI. Before claiming the usefulness of S100B as a surrogate marker of EBI severity to start earlier multimodal monitoring, these results must be confirmed in an independent validation cohort.

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Hypoxic-Ischemic Encephalopathy Evaluated by Brain Autopsy and Neuroprognostication After Cardiac Arrest

et al. 2020

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IMPORTANCE Neuroprognostication studies are potentially susceptible to a self-fulfilling prophecy as investigated prognostic parameters may affect withdrawal of life-sustaining therapy.OBJECTIVE To compare the results of prognostic parameters after cardiac arrest (CA) with the histopathologically determined severity of hypoxic-ischemic encephalopathy (HIE) obtained from autopsy results. DESIGN, SETTING, AND PARTICIPANTSIn a retrospective, 3-center cohort study of all patients who died following cardiac arrest during their intensive care unit stay and underwent autopsy between 2003 and 2015, postmortem brain histopathologic findings were compared with post-CA brain computed tomographic imaging, electroencephalographic (EEG) findings, somatosensory-evoked potentials, and serum neuron-specific enolase levels obtained during the intensive care unit stay. Data analysis was conducted from 2015 to 2020. MAIN OUTCOMES AND MEASURESThe severity of HIE was evaluated according to the selective eosinophilic neuronal death (SEND) classification and patients were dichotomized into categories of histopathologically severe and no/mild HIE. RESULTSOf 187 included patients, 117 were men (63%) and median age was 65 (interquartile range, 58-74) years. Severe HIE was found in 114 patients (61%) and no/mild HIE was identified in 73 patients (39%). Severe HIE was found in all 21 patients with bilaterally absent somatosensory-evoked potentials, all 15 patients with gray-white matter ratio less than 1.10 on brain computed tomographic imaging, all 9 patients with suppressed EEG, 15 of 16 patients with burst-suppression EEG, and all 29 patients with neuron-specific enolase levels greater than 67 μg/L more than 48 hours after CA without confounders. Three of 7 patients with generalized periodic discharges on suppressed background and 1 patient with burst-suppression EEG had a SEND 1 score (<30% dead neurons) in the cerebral cortex, but higher SEND scores (>30% dead neurons) in other oxygen-sensitive brain regions. CONCLUSIONS AND RELEVANCEIn this study, histopathologic findings suggested severe HIE after cardiac arrest in patients with bilaterally absent cortical somatosensory-evoked potentials, gray-white matter ratio less than 1.10, highly malignant EEG, and serum neuron-specific enolase concentration greater than 67 μg/L.

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Unresponsive wakefulness or coma after cardiac arrest—A long-term follow-up study

Cited by 27 publications

References 30 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

Significance and Diagnostic Accuracy of Early S100B Serum Concentration after Aneurysmal Subarachnoid Hemorrhage

Hypoxic-Ischemic Encephalopathy Evaluated by Brain Autopsy and Neuroprognostication After Cardiac Arrest

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