Sonya E Zhou1, Carolina B Maciel2, Cora H Ormseth3, Rachel Beekman3, Emily J Gilmore3, David M Greer4. 1. Department of Neurology, Yale University School of Medicine, New Haven, CT, United States. Electronic address: sonya.zhou@yale.edu. 2. Department of Neurology, Yale University School of Medicine, New Haven, CT, United States; Department of Neurology, UF-Health Shands Hospital, University of Florida College of Medicine, Gainesville, FL, United States. 3. Department of Neurology, Yale University School of Medicine, New Haven, CT, United States. 4. Department of Neurology, Yale University School of Medicine, New Haven, CT, United States; Department of Neurology, Boston University School of Medicine, Boston, MA, United States.
Abstract
PURPOSE: To assess the performance of neuroprognostic guidelines proposed by the American Academy of Neurology (AAN), European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM), and American Heart Association (AHA) in predicting outcomes of patients who remain unconscious after cardiac arrest. METHODS: We retrospectively identified a cohort of unconscious post-cardiac arrest patients at a single tertiary care centre from 2011 to 2017 and reviewed hospital records for clinical, radiographic, electrophysiologic, and biochemical findings. Outcomes at discharge and 6 months post-arrest were abstracted and dichotomized as good (Cerebral Performance Category (CPC) scores of 1-2) versus poor (CPC 3-5). Outcomes predicted by current guidelines were compared to actual outcomes, with false positive rate (FPR) used as a measure of predictive value. RESULTS: Of 226 patients, 36% survived to discharge, including 24 with good outcomes; 52% had withdrawal of life-sustaining therapies (WLST) during hospitalization. The AAN guideline yielded discharge and 6-month FPR of 8% and 15%, respectively. In contrast, the ERC/ESICM had a FPR of 0% at both discharge and 6 months. The AHA predictors had variable specificities, with diffuse hypoxic-ischaemic injury on MRI performing especially poorly (FPR 12%) at both discharge and 6 months. CONCLUSIONS: Though each guideline had components that performed well, only the ERC/ESICM guideline yielded a 0% FPR. Amongst the AAN and AHA guidelines, false positives emerged more readily at 6 months, reflective of continuing recovery after discharge, even in a cohort inevitably biased by WLST. Further assessment of predictive modalities is needed to improve neuroprognostic accuracy.
PURPOSE: To assess the performance of neuroprognostic guidelines proposed by the American Academy of Neurology (AAN), European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM), and American Heart Association (AHA) in predicting outcomes of patients who remain unconscious after cardiac arrest. METHODS: We retrospectively identified a cohort of unconscious post-cardiac arrestpatients at a single tertiary care centre from 2011 to 2017 and reviewed hospital records for clinical, radiographic, electrophysiologic, and biochemical findings. Outcomes at discharge and 6 months post-arrest were abstracted and dichotomized as good (Cerebral Performance Category (CPC) scores of 1-2) versus poor (CPC 3-5). Outcomes predicted by current guidelines were compared to actual outcomes, with false positive rate (FPR) used as a measure of predictive value. RESULTS: Of 226 patients, 36% survived to discharge, including 24 with good outcomes; 52% had withdrawal of life-sustaining therapies (WLST) during hospitalization. The AAN guideline yielded discharge and 6-month FPR of 8% and 15%, respectively. In contrast, the ERC/ESICM had a FPR of 0% at both discharge and 6 months. The AHA predictors had variable specificities, with diffuse hypoxic-ischaemic injury on MRI performing especially poorly (FPR 12%) at both discharge and 6 months. CONCLUSIONS: Though each guideline had components that performed well, only the ERC/ESICM guideline yielded a 0% FPR. Amongst the AAN and AHA guidelines, false positives emerged more readily at 6 months, reflective of continuing recovery after discharge, even in a cohort inevitably biased by WLST. Further assessment of predictive modalities is needed to improve neuroprognostic accuracy.
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