Search Results (6)

Brain swelling after cardiac arrest may affect brain ventricular volume. This study aimed to investigate the prognostic implications of ventricular volume on early thin-slice brain computed tomography (CT) after cardiac arrest. We measured the gray-to-white matter ratio (GWR) and the characteristics and volumes of the lateral, third, and fourth ventricles. The primary outcome was a poor 6-month neurological outcome. Of the 166 patients, 115 had a poor outcome. The fourth ventricle was significantly smaller in the poor outcome group (0.58 cm³ [95% CI, 0.43–0.80]) than in the good outcome group (0.74 cm³ [95% CI, 0.68–0.99], p < 0.001). Ventricular characteristics and other ventricular volumes did not differ between outcome groups. The area under the curve for the fourth ventricular volume was 0.68, comparable to 0.69 for GWR. Lower GWR (<1.09) and lower fourth ventricular volume (<0.41 cm³) predicted poor outcomes with 100% specificity and sensitivities of 8.7% (95% CI, 4.2–15.4) and 20.9% (95% CI, 13.9–29.4), respectively. Combining these measures improved the sensitivity to 25.2% (95% CI, 17.6–34.2). After adjusting for covariates, the fourth ventricular volume was independently associated with neurologic outcome. A marked decrease in fourth ventricular volume, with concomitant hypoattenuation on CT scans, more accurately predicted outcomes. Full article

We investigated prognostic strategies for predicting good outcomes in the early stage of post-cardiac-arrest care using multiple prognostic tests that are available until 24 h after the return of spontaneous circulation (ROSC). A retrospective analysis was conducted on 138 out-of-hospital cardiac-arrest patients who underwent prognostic tests, including the gray–white-matter ratio (GWR-BG), the Glasgow Coma Scale motor (GCS-M) score before sedative administration, and the neuron-specific enolase (NSE) level measured at 24 h after the ROSC. We investigated the prognostic performances of the tests as single predictors and in various combination strategies. Classification and regression-tree analysis were used to provide a reliable model for the risk stratification. Out of all the patients, 55 (44.0%) had good outcomes. The NSE level showed the highest prognostic performance as a single prognostic test and provided improved specificities (>70%) and sensitivities (>98%) when used in combination strategies. Low NSE levels (≤32.1 ng/mL) and high GCS-M (≥4) scores identified good outcomes without misclassification. The overall accuracy for good outcomes was 81.8%. In comatose patients with low NSE levels or high GCS-M scores, the premature withdrawal of life-sustaining therapy should be avoided, thereby complying with the formal prognostication-strategy algorithm after at least 72 h from the ROSC. Full article

We analyzed the prognostic performance of optic nerve sheath diameter (ONSD) on thin-slice (0.6 mm) brain computed tomography (CT) reconstruction images as compared to routine-slice (4 mm) images. We conducted a retrospective analysis of brain CT images taken within 2 h after cardiac arrest. The maximal ONSD (mONSD) and optic nerve sheath area (ONSA) were measured on thin-slice images, and the routine ONSD (rONSD) and gray-to-white matter ratio (GWR) were measured on routine-slice images. We analyzed their area under the receiver operator characteristic curve (AUC) and the cutoff values for predicting a poor 6-month neurological outcome (a cerebral performance category score of 3–5). Of the 159 patients analyzed, 113 patients had a poor outcome. There was no significant difference in rONSD between the outcome groups (p = 0.116). Compared to rONSD, mONSD (AUC 0.62, 95% CI: 0.54–0.70) and the ONSA (AUC 0.63, 95% CI: 0.55–0.70) showed better prognostic performance and had higher sensitivities to determine a poor outcome (mONSD, 20.4% [95% CI, 13.4–29.0]; ONSA, 16.8% [95% CI, 10.4–25.0]; rONSD, 7.1% [95% CI, 3.1–13.5]), with specificity of 95.7% (95% CI, 85.2–99.5). A combined cutoff value obtained by both the mONSD and GWR improved the sensitivity (31.0% [95% CI, 22.6–40.4]) of determining a poor outcome, while maintaining a high specificity. In conclusion, rONSD was clinically irrelevant, but the mONSD had an increased sensitivity in cutoff having acceptable specificity. Combination of the mONSD and GWR had an improved prognostic performance in these patients. Full article

Evolution toward brain death (BD) in out-of-hospital cardiac arrest patients with targeted temperature management (TTM) provides opportunities for organ donation. However, knowledge regarding BD in these patients is limited. We retrospectively analyzed the TTM registry of one hospital where life-sustaining therapy was not withdrawn. In-hospital death patients were categorized into BD and non-BD groups. We explored the process of evolution toward BD and its predictors by comparing the serial measurements of clinical variables and the results of various prognostic tests between the two groups. Of the 121 patients who died before hospital discharge, 19 patients (15.7%) developed BD at a median of 6 (interquartile range, 5.0–7.0) days after cardiac arrest. Four patients with pupillary light reflexes at 48 h eventually developed BD. The area under the curves of the gray-to-white matter ratio (GWR) on early brain computed tomography images and the level of S100 calcium-binding protein B (S100B) at 72 h were 0.67 (95% CI, 0.55–0.77) and 0.70 (95% CI, 0.55–0.83), respectively. In conclusion, approximately one-sixth of all in-hospital deaths were diagnosed with BD at a median of 6 days after cardiac arrest. The use of GWR and serial S100B measurements may help to screen potential BD. Full article

Cardiopulmonary resuscitation (CPR) successfully restores systemic circulation approximately 50% of the time; however, many successfully restored patients have severe neurologic damage. In adults, the gray matter to white matter attenuation ratio (GWR) in brain computed tomography (CT) correlates with the neurologic outcome. However, in children, the clinical significance of GWR still remains unclear. The aim of this study was to evaluate the clinical characteristics of children who underwent CPR for cardiac arrest according to the survival and to demonstrate the differentiation of grey/white matter by Hounsfield units of brain CT and to characterize the attenuations of grey and white matters. Methods: This is a retrospective single-center study. We enrolled those who underwent brain CT within 24 h after return of spontaneous circulation (ROSC) from January 2005 to June 2018. Brain CTs were taken within 24 h of ROSC. We measured the attenuation of grey and white matter in Hounsfield units and calculated GWR. They were compared with healthy controls. Patients were analyzed as follows: survivors vs. non-survivors and better neurologic outcome vs. worse neurologic outcome. Results: Among 100 pediatric patients who had CPR, 56 met inclusion criteria. There were 24 patients who survived and 32 non-survivors. Our study revealed that the incidence of seizure, duration of CPR, and instances of hypothermia were significantly different between survivors and non-survivors. In both survivors and non-survivors, the attenuation of the caudate nucleus, putamen, GWR-basal ganglia, and average GWR were significantly different from controls. In regression analyses, the medial cortex and average GWR were the significant variables to predict survival, and the receiver operating curves revealed areas under curve of 0.733 and 0.666, respectively. Also, the medial cortex 1 was the only variable that predicted the neurologic outcome. Conclusions: There was some predictive survival value of GWR and medial cortex at the centrum semiovale level in early brain CT within 24 h after cardiac arrest. Although we could not find the predictive value of GWR in the neurologic outcome of pediatric patients, we found that the absolute attenuation of the medial cortex was low in patients with worse neurologic outcomes. Further prospective, multicenter studies are needed to determine the predictive value of GWR and the medial cortex. Full article

Introduction: Early prediction of long-term outcomes in patients resuscitated after cardiac arrest (CA) is still challenging. Guidelines suggested a multimodal approach combining multiple predictors. We evaluated whether the combination of the electroencephalography (EEG) reactivity, somatosensory evoked potentials (SSEPs) cortical complex and Gray to White matter ratio (GWR) on brain computed tomography (CT) at different temperatures could predict survival and good outcome at hospital discharge and six months after the event. Methods: We performed a retrospective cohort study including consecutive adult, non-traumatic patients resuscitated from out-of-hospital CA who remained comatose on admission to our intensive care unit from 2013 to 2017. We acquired SSEPs and EEGs during the treatment at 36 °C and after rewarming at 37 °C, Gray to white matter ratio (GWR) was calculated on the brain computed tomography scan performed within six hours of the hospital admission. We primarily hypothesized that SSEP was associated with favor-able functional outcome at distance and secondarily that SSEP provides independent information from EEG and CT. Outcomes were evaluated using the Cerebral Performance Category (CPC) scale at six months from discharge. Results: Of 171 resuscitated patients, 75 were excluded due to missing data or uninterpretable neurophysiological findings. EEG reactivity at 37 °C has been shown the best single predictor of good out-come (AUC 0.803) while N20P25 was the best single predictor for survival at each time point. (AUC 0.775 at discharge and AUC 0.747 at six months follow up). The predictive value of a model including EEG reactivity, average GWR, and SSEP N20P25 amplitude was superior (AUC 0.841 for survival and 0.920 for good out-come) to any combination of two tests or any single test. Conclusions: Our study, in which life-sustaining treatments were never suspended, suggests SSEP cortical complex N20P25, after normothermia and off sedation, is a reliable predictor for survival at any time. When SSEP cortical complex N20P25 is added into a model with GWR average and EEG reactivity, the predictivity for good outcome and survival at distance is superior than each single test alone. Full article