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Prognosis After Cardiac Arrest: The Additional Value of DWI and FLAIR to EEG

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Abstract

Background

Despite application of the multimodal European Resuscitation Council and European Society of Intensive Care Medicine algorithm, neurological prognosis of patients who remain comatose after cardiac arrest remains uncertain in a large group of patients. In this study, we investigate the additional predictive value of visual and quantitative brain magnetic resonance imaging (MRI) to electroencephalography (EEG) for outcome estimation of comatose patients after cardiac arrest.

Methods

We performed a prospective multicenter cohort study in patients after cardiac arrest submitted in a comatose state to the intensive care unit of two Dutch hospitals. Continuous EEG was recorded during the first 3 days and MRI was performed at 3 ± 1 days after cardiac arrest. EEG at 24 h and ischemic damage in 21 predefined brain regions on diffusion weighted imaging and fluid-attenuated inversion recovery on a scale from 0 to 4 were related to outcome. Quantitative MRI analyses included mean apparent diffusion coefficient (ADC) and percentage of brain volume with ADC < 450 × 10−6 mm2/s, < 550 × 10−6 mm2/s, and < 650 × 10−6 mm2/s. Poor outcome was defined as a Cerebral Performance Category score of 3–5 at 6 months.

Results

We included 50 patients, of whom 20 (40%) demonstrated poor outcome. Visual EEG assessment correctly identified 3 (15%) with poor outcome and 15 (50%) with good outcome. Visual grading of MRI identified 13 (65%) with poor outcome and 25 (89%) with good outcome. ADC analysis identified 11 (55%) with poor outcome and 3 (11%) with good outcome. EEG and MRI combined could predict poor outcome in 16 (80%) patients at 100% specificity, and good outcome in 24 (80%) at 63% specificity. Ischemic damage was most prominent in the cortical gray matter (75% vs. 7%) and deep gray nuclei (45% vs. 3%) in patients with poor versus good outcome.

Conclusions

Magnetic resonance imaging is complementary with EEG for the prediction of poor and good outcome of patients after cardiac arrest who are comatose at admission.

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Acknowledgements

The authors thank Ruud van Kaam, technical physician at the intensive care unit (ICU) of the Radboudumc, Yvonne Teitink, and Helene Vogelensang, research nurses of the ICU at the Rijnstate Hospital, together with the staff of the ICU, radiology, and clinical neurophysiology departments, for constructive assistance in obtaining informed consent and performing electroencephalography measurements and magnetic resonance imaging examinations.

Funding

HMK is funded by the Rijnstate-Radboud promotion fund. CJMK is supported by a clinical established investigator grant of the Dutch Heart Foundation (Grant Number 2012T077) and an ASPASIA grant from The Netherlands Organization for Health Research and Development, ZonMw (Grant Number 015008048). JH is supported by a clinical established investigator grant of the Dutch Heart Foundation (Grant Number 2018T070).

Author information

Author notes

  1. Cornelia W. E. Hoedemaekers and Jeannette Hofmeijer have contributed equally to this publication.

Authors and Affiliations

  1. Department of Neurology, Rijnstate Hospital, P.O. box 9555, 6800 TA, Arnhem, The Netherlands

    Hanneke M. Keijzer, Marlous M. L. H. Verhulst & Jeannette Hofmeijer

  2. Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands

    Hanneke M. Keijzer & Catharina J. M. Klijn

  3. Department of Clinical Neurophysiology, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands

    Marlous M. L. H. Verhulst & Jeannette Hofmeijer

  4. Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands

    Frederick J. A. Meijer

  5. Department of Radiology, Rijnstate Hospital, Arnhem, The Netherlands

    Bart A. R. Tonino

  6. Department of Intensive Care Medicine, Rijnstate Hospital, Arnhem, The Netherlands

    Frank H. Bosch

  7. Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands

    Cornelia W. E. Hoedemaekers

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  1. Hanneke M. Keijzer
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Contributions

Conception and design of study and analyses: HMK, MMLHV, FJAM, CWEH, CJMK, and JH. Data collection: HMK, MMLHV, FHB, and CWEH. Data analyses: HMK, MMLHV, FJAM, BART, and JH. Writing of the article (first draft): HMK. Revising of the article: HMK, MMLHV, FJAM, BART, FHB, CWEH, CJMK, and JH. All authors approve of the final manuscript.

Corresponding author

Correspondence to Hanneke M. Keijzer.

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Conflicts of interest

The authors report no conflict of interest.

Ethical approval/informed consent

The study is conducted in accordance with ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The study was approved by the Committee on Research Involving Human Subjects region Arnhem-Nijmegen.

Clinical trial registration

ClinicalTrials.gov: NCT03308305

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Keijzer, H.M., Verhulst, M.M.L.H., Meijer, F.J.A. et al. Prognosis After Cardiac Arrest: The Additional Value of DWI and FLAIR to EEG. Neurocrit Care 37, 302–313 (2022). https://doi.org/10.1007/s12028-022-01498-z

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  • DOI: https://doi.org/10.1007/s12028-022-01498-z

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