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Electrocerebral Signature of Cardiac Death

Abstract

Background

Electroencephalography (EEG) findings following cardiovascular collapse in death are uncertain. We aimed to characterize EEG changes immediately preceding and following cardiac death.

Methods

We retrospectively analyzed EEGs of patients who died from cardiac arrest while undergoing standard EEG monitoring in an intensive care unit. Patients with brain death preceding cardiac death were excluded. Three events during fatal cardiovascular failure were investigated: (1) last recorded QRS complex on electrocardiogram (QRS0), (2) cessation of cerebral blood flow (CBF0) estimated as the time that blood pressure and heart rate dropped below set thresholds, and (3) electrocerebral silence on EEG (EEG0). We evaluated EEG spectral power, coherence, and permutation entropy at these time points.

Results

Among 19 patients who died while undergoing EEG monitoring, seven (37%) had a comfort-measures-only status and 18 (95%) had a do-not-resuscitate status in place at the time of death. EEG0 occurred at the time of QRS0 in five patients and after QRS0 in two patients (cohort median − 2.0, interquartile range − 8.0 to 0.0), whereas EEG0 was seen at the time of CBF0 in six patients and following CBF0 in 11 patients (cohort median 2.0 min, interquartile range − 1.5 to 6.0). After CBF0, full-spectrum log power (p < 0.001) and coherence (p < 0.001) decreased on EEG, whereas delta (p = 0.007) and theta (p < 0.001) permutation entropy increased.

Conclusions

Rarely may patients have transient electrocerebral activity following the last recorded QRS (less than 5 min) and estimated cessation of cerebral blood flow. These results may have implications for discussions around cardiopulmonary resuscitation and organ donation.

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Acknowledgments

Thank you to the nurses, attending physicians, fellows, and residents of the Neurological ICU of Columbia University Irving Medical Center for their overall support of this project. We would like to thank Professor Laura Lennihan for her insightful comments regarding the ethical implications of our work and for providing helpful critiques for our paper.

Funding

JC is supported by grant funding from the National Institutes of Health (R01 NS106014 and R03 NS112760), the James McDonnell Foundation, and the Dana Foundation. AA is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under the Miami Clinical and Translational Science Institute KL2 Career Development Award (UL1TR002736). SP is supported by the National Institutes of Health (K01 ES026833).

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Authors and Affiliations

Authors

Contributions

ALM and JC contributed to the design of the study, analysis and writing of the manuscript. AE, KD, and BR contributed to the analysis and writing of the manuscript. AA, WC, CD, KMP, SA, DR, and SP provided helpful edits for the manuscript. JAE, AGV, and LP provided data collection and helpful edits for the manuscript.

Corresponding author

Correspondence to Jan Claassen.

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Conflicts of Interest

JC reports grants from the National Institute of Neurological Disorders and Stroke and the Dana Foundation. He is a minority shareholder at iCE Neurosystems. None of these constitute a conflict of interest to the work presented here. The remaining authors do not have any conflicts of interest.

Ethical approval/informed consent

We confirm adherence to ethical guidelines and indicate ethical approvals (local institutional review board, IRB-AAAL4106) and the use of informed consent, as appropriate. Because this was a retrospective study approved by the local institutional review board at Columbia University, informed consent was waived per section IV of the local institutional review board’s Health Insurance Portability and Accountability Act policy, citing 45 CFR 164.512(i)(1)(iii).

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Supplementary Information

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12028_2021_1233_MOESM1_ESM.tiff

Supplemental Figure 1 Change in full-spectrum EEG features after CBF0. Change in epoch-averaged, full-spectrum EEG features 5 minutes before vs. 5 minutes after CBF0 for patients 1 – 19. Patients are ordered by magnitude of change in global power five minutes before CBF0 vs. five minutes after. For log-power, values between channel locations are interpolated with a linear radial basis function kernel. For coherence, the color of channel-connecting lines encodes coherence change and the color of the channel encodes the average channel coherence. A high-pass threshold was applied to coherence values. Cohort-wide changes in log-power and coherence are statistically significant (p<0.028). (TIFF 2333 kb)

12028_2021_1233_MOESM2_ESM.tiff

Supplemental Figure 2 Raw EEG in a patient with electrocerebral activity on EEG after death declaration. Raw EEG displayed in a bipolar montage at time of (A) non-convulsive status epilepticus (NCSE), (B) cessation of cerebral blood flow (CBF0), (C) start of chest compressions (CC), and (D) end of chest compressions (CC_end). Raw EEG data at each event are shown. Sensitivity is 5 μV/mm, with 60 Hz filter artifacts on. (TIFF 5616 kb)

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Matory, A.L., Alkhachroum, A., Chiu, WT. et al. Electrocerebral Signature of Cardiac Death. Neurocrit Care 35, 853–861 (2021). https://doi.org/10.1007/s12028-021-01233-0

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Keywords

  • Death
  • Encephalography
  • Consciousness
  • Cardiac arrest
  • Brain hypoxia
  • Hypotension