Cristal Cristia1, Mai-Lan Ho2, Sean Levy3, Lars W Andersen4, Sarah M Perman5, Tyler Giberson6, Justin D Salciccioli7, Brian Z Saindon8, Michael N Cocchi9, Michael W Donnino10. 1. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States. Electronic address: cristal.cristia@gmail.com. 2. Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, United States. Electronic address: mailanho@yahoo.com. 3. Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States. Electronic address: sdlevy@bidmc.harvard.edu. 4. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark. Electronic address: lwanders@bidmc.harvard.edu. 5. Department of Emergency Medicine, University of Colorado School of Medicine, CO, United States. Electronic address: sarah.perman@ucdenver.edu. 6. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States. Electronic address: t.a.giberson@gmail.com. 7. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States. Electronic address: justin.salciccioli@gmail.com. 8. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States. Electronic address: bsaindon@bu.edu. 9. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Anesthesia Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, United States. Electronic address: mcocchi@bidmc.harvard.edu. 10. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, United States. Electronic address: mdonnino@bidmc.harvard.edu.
Abstract
AIM: Previous studies have examined the association between quantitative head computed tomography (CT) measures of cerebral edema and patient outcomes reporting that a calculated gray matter to white matter attenuation ratio (GWR) of <1.2 indicates a near 100% non-survivable injury post-cardiac arrest. The objective of the current study was to validate whether a GWR <1.2 reliably indicates poor survival post-cardiac arrest. We also sought to determine the inter-rater variability among reviewers, and examine the utility of a novel GWR measurement to facilitate easier practical use. METHODS: We performed a retrospective analysis of post-cardiac arrest patients admitted to a single center from 2008 to 2012. Inclusion criteria were age ≥18 years, non-traumatic arrest, and available CT imaging within 24h after ROSC. Three independent physician reviewers from different specialties measured CT attenuation of pre-specified gray and white matter areas for GWR calculations. RESULTS: Out of 171 consecutive patients, 90 met the study inclusion criteria. Thirteen patients were excluded for technical reasons and/or significant additional pathology, leaving 77 head CT scans for evaluation. Median age was 66 years and 64% were male. In-hospital mortality was 65% and 70% of patients received therapeutic hypothermia. For the validation measurement, the intra-class correlation coefficient was 0.70. In our dataset, a GWR below 1.2 did not accurately predict mortality or poor neurological outcome (sensitivity 0.56-0.62 and specificity 0.63-0.81). A score below 1.1 predicted a near 100% mortality but was not a sensitive metric (sensitivity 0.14-0.20 and specificity 0.96-1.00). Similar results were found for the exploratory model. CONCLUSION: A GWR <1.2 on CT imaging within 24h after cardiac arrest was moderately specific for poor neurologic outcome and mortality. Based on our data, a threshold GWR <1.1 may be a safer cut-off to identify patients with low chance of survival and good neurological outcome. Intra-class correlation among reviewers was moderately good.
AIM: Previous studies have examined the association between quantitative head computed tomography (CT) measures of cerebral edema and patient outcomes reporting that a calculated gray matter to white matter attenuation ratio (GWR) of <1.2 indicates a near 100% non-survivable injury post-cardiac arrest. The objective of the current study was to validate whether a GWR <1.2 reliably indicates poor survival post-cardiac arrest. We also sought to determine the inter-rater variability among reviewers, and examine the utility of a novel GWR measurement to facilitate easier practical use. METHODS: We performed a retrospective analysis of post-cardiac arrestpatients admitted to a single center from 2008 to 2012. Inclusion criteria were age ≥18 years, non-traumatic arrest, and available CT imaging within 24h after ROSC. Three independent physician reviewers from different specialties measured CT attenuation of pre-specified gray and white matter areas for GWR calculations. RESULTS: Out of 171 consecutive patients, 90 met the study inclusion criteria. Thirteen patients were excluded for technical reasons and/or significant additional pathology, leaving 77 head CT scans for evaluation. Median age was 66 years and 64% were male. In-hospital mortality was 65% and 70% of patients received therapeutic hypothermia. For the validation measurement, the intra-class correlation coefficient was 0.70. In our dataset, a GWR below 1.2 did not accurately predict mortality or poor neurological outcome (sensitivity 0.56-0.62 and specificity 0.63-0.81). A score below 1.1 predicted a near 100% mortality but was not a sensitive metric (sensitivity 0.14-0.20 and specificity 0.96-1.00). Similar results were found for the exploratory model. CONCLUSION: A GWR <1.2 on CT imaging within 24h after cardiac arrest was moderately specific for poor neurologic outcome and mortality. Based on our data, a threshold GWR <1.1 may be a safer cut-off to identify patients with low chance of survival and good neurological outcome. Intra-class correlation among reviewers was moderately good.
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