Use of Magnetic Resonance Imaging in Neuroprognostication After Pediatric Cardiac Arrest: Survey of Current Practices

Piantino, Juan; Ruzas, Christopher M.; Press, Craig A.; Subramanian, Subramanian; Balakrishnan, Binod; Panigrahy, Ashok; Pettersson, David; Maloney, John; Vossough, Arastoo; Topjian, Alexis; Kirschen, Matthew; Doughty, Lesley; Chung, Melissa G.; Maloney, David G.; Haller, Tamara; Fabio, Anthony; Fink, Ericka L.

doi:10.1016/j.pediatrneurol.2022.06.011

Cited by 4 publications

(4 citation statements)

References 29 publications

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“…Our 2016–2020 experience shows variable approaches to timing of prognostication and heterogeneity in the use of neurodiagnostic tools, as observed nationally in a 2020 survey study (23). A minority of patients underwent brain MR images, a commonly used neuroimaging modality for aiding in prognostication after adult cardiac arrest (24).…”

Section: Discussionmentioning

confidence: 81%

“…Across Europe, in a 2019 survey, there was high variability in perceived practice by neurologists and intensivists regarding WLST after pediatric brain injury (4), and practices in the United States likely suffer from this same problem, underscoring the need for standardized approaches to methodology and timing of neurologic prognostication. Our 2016-2020 experience shows variable approaches to timing of prognostication and heterogeneity in the use of neurodiagnostic tools, as observed nationally in a 2020 survey study (23). A minority of patients underwent brain MR images, a commonly used neuroimaging modality for aiding in prognostication after adult cardiac arrest (24).…”

Section: What This Study Meansmentioning

confidence: 99%

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Mortality and Timing of Withdrawal of Life-Sustaining Therapies After Out-of-Hospital Cardiac Arrest: Two-Center Retrospective Pediatric Cohort Study*

Vassar,

Mehta,

Epps

et al. 2023

Pediatric Critical Care Medicine

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Objectives: Pediatric out-of-hospital cardiac arrest (OHCA) is associated with substantial morbidity and mortality. Limited data exist to guide timing and method of neurologic prognostication after pediatric OHCA, making counseling on withdrawal of life-sustaining therapies (WLSTs) challenging. This study investigates the timing and mode of death after pediatric OHCA and factors associated with mortality. Additionally, this study explores delayed recovery after comatose examination on day 3 postarrest. Design: This is a retrospective, observational study based on data collected from hospital databases and chart reviews. Setting: Data collection occurred in two pediatric academic hospitals between January 1, 2016, and December 31, 2020. Patients: Patients were identified from available databases and electronic medical record queries for the International Classification of Diseases, 10th Edition (ICD-10) code I46.9 (Cardiac Arrest). Patient inclusion criteria included age range greater than or equal to 48 hours to less than 18 years, OHCA within 24 hours of admission, greater than or equal to 1 min of cardiopulmonary resuscitation, and return-of-spontaneous circulation for greater than or equal to 20 min. Interventions: None. Measurements and Main Results: One hundred thirty-five children (65% male) with a median age of 3 years (interquartile range 0.6–11.8) met inclusion criteria. Overall, 63 of 135 patients (47%) died before hospital discharge, including 34 of 63 patients (54%) after WLST. Among these, 20 of 34 patients underwent WLST less than or equal to 3 days postarrest, including 10 of 34 patients who underwent WLST within 1 day. WLST occurred because of poor perceived neurologic prognosis in all cases, although 7 of 34 also had poor perceived systemic prognosis. Delayed neurologic recovery from coma on day 3 postarrest was observed in 7 of 72 children (10%) who ultimately survived to discharge. Conclusions: In our two centers between 2016 and 2020, more than half the deaths after pediatric OHCA occurred after WLST, and a majority of WLST occurred within 3 days postarrest. Additional research is warranted to determine optimal timing and predictors of neurologic prognosis after pediatric OHCA to better inform families during goals of care discussions.

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Section: Discussionmentioning

confidence: 81%

Section: What This Study Meansmentioning

confidence: 99%

Mortality and Timing of Withdrawal of Life-Sustaining Therapies After Out-of-Hospital Cardiac Arrest: Two-Center Retrospective Pediatric Cohort Study*

Vassar,

Mehta,

Epps

et al. 2023

Pediatric Critical Care Medicine

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“…Brain MRI is commonly used to evaluate hypoxic-ischemic injury following pediatric cardiac arrest, but evidence regarding best practices in terms of sequences and timing postarrest is lacking. 1 , 4 , 24 Lesions on DWI sequences may become apparent as early as a few hours after arrest, peak at 3 to 7 days after arrest, and then may recede. 25 MRS metabolites may offer better stability over time.…”

Section: Discussionmentioning

confidence: 99%

“…Strengths of our study include the multicenter design, individual site training, and harmonizing of MRI and MRS protocols for each center's platform. Clinically, brain MRI is commonly used to evaluate JAMA Network Open | Critical Care Medicine postcardiac arrest as described in an international survey 24 . Nearly one-half of the respondents reported performing a brain MRI for any surviving child and one-third of respondents reported performing a brain MRI for children with newly diagnosed impairment.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Assessment of Brain Magnetic Resonance and Spectroscopy Imaging Findings and Outcomes After Pediatric Cardiac Arrest

et al. 2023

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ImportanceMorbidity and mortality after pediatric cardiac arrest are chiefly due to hypoxic-ischemic brain injury. Brain features seen on magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) after arrest may identify injury and aid in outcome assessments.ObjectiveTo analyze the association of brain lesions seen on T2-weighted MRI and diffusion-weighted imaging and N-acetylaspartate (NAA) and lactate concentrations seen on MRS with 1-year outcomes after pediatric cardiac arrest.Design, Setting, and ParticipantsThis multicenter cohort study took place in pediatric intensive care units at 14 US hospitals between May 16, 2017, and August 19, 2020. Children aged 48 hours to 17 years who were resuscitated from in-hospital or out-of-hospital cardiac arrest and who had a clinical brain MRI or MRS performed within 14 days postarrest were included in the study. Data were analyzed from January 2022 to February 2023.ExposureBrain MRI or MRS.Main Outcomes and MeasuresThe primary outcome was an unfavorable outcome (either death or survival with a Vineland Adaptive Behavior Scales, Third Edition, score of &lt;70) at 1 year after cardiac arrest. MRI brain lesions were scored according to region and severity (0 = none, 1 = mild, 2 = moderate, 3 = severe) by 2 blinded pediatric neuroradiologists. MRI Injury Score was a sum of T2-weighted and diffusion-weighted imaging lesions in gray and white matter (maximum score, 34). MRS lactate and NAA concentrations in the basal ganglia, thalamus, and occipital-parietal white and gray matter were quantified. Logistic regression was performed to determine the association of MRI and MRS features with patient outcomes.ResultsA total of 98 children, including 66 children who underwent brain MRI (median [IQR] age, 1.0 [0.0-3.0] years; 28 girls [42.4%]; 46 White children [69.7%]) and 32 children who underwent brain MRS (median [IQR] age, 1.0 [0.0-9.5] years; 13 girls [40.6%]; 21 White children [65.6%]) were included in the study. In the MRI group, 23 children (34.8%) had an unfavorable outcome, and in the MRS group, 12 children (37.5%) had an unfavorable outcome. MRI Injury Scores were higher among children with an unfavorable outcome (median [IQR] score, 22 [7-32]) than children with a favorable outcome (median [IQR] score, 1 [0-8]). Increased lactate and decreased NAA in all 4 regions of interest were associated with an unfavorable outcome. In a multivariable logistic regression adjusted for clinical characteristics, increased MRI Injury Score (odds ratio, 1.12; 95% CI, 1.04-1.20) was associated with an unfavorable outcome.Conclusions and RelevanceIn this cohort study of children with cardiac arrest, brain features seen on MRI and MRS performed within 2 weeks after arrest were associated with 1-year outcomes, suggesting the utility of these imaging modalities to identify injury and assess outcomes.

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Deep learning in pediatric neuroimaging

Wang,

Wang

et al. 2023

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Use of Magnetic Resonance Imaging in Neuroprognostication After Pediatric Cardiac Arrest: Survey of Current Practices

Cited by 4 publications

References 29 publications

Mortality and Timing of Withdrawal of Life-Sustaining Therapies After Out-of-Hospital Cardiac Arrest: Two-Center Retrospective Pediatric Cohort Study*

Mortality and Timing of Withdrawal of Life-Sustaining Therapies After Out-of-Hospital Cardiac Arrest: Two-Center Retrospective Pediatric Cohort Study*

Assessment of Brain Magnetic Resonance and Spectroscopy Imaging Findings and Outcomes After Pediatric Cardiac Arrest

Deep learning in pediatric neuroimaging

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