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Abstract
Objective: Therapeutic hypothermia (TH) is a recommended treatment for survivors of cardiac arrest. Prognostication is complicated since sedation and muscle relaxation are used and established indicators of a poor prognosis are lacking. This prospective, observational study describes the pattern of commonly used prognostic markers in a hypothermia-treated cohort of cardiac arrest patients with prolonged coma.
Methods: Among 111 consecutive patients, 19 died, 58 recovered, and 34 were in coma 3 days after normothermia (4.5 days after cardiac arrest), defined as prolonged coma. All patients were monitored with continuous amplitude-integrated EEG and repeated samples of neuron-specific enolase (NSE) were collected. In patients with prolonged coma, somatosensory evoked potentials (SSEP) and brain MRI were performed. A postmortem brain investigation was undertaken in patients who died.
Results: Six of the 17 patients (35%) with NSE levels <33 μg/L at 48 hours regained the capacity to obey verbal commands. By contrast, all 17 patients with NSE levels >33 failed to recover consciousness. In the >33 NSE group, all 10 studied with MRI had extensive brain injury on diffusion-weighted images, 12/16 lacked cortical responses on SSEP, and all 6 who underwent autopsy had extensive severe histologic damage. NSE levels also correlated with EEG pattern, but less uniformly, since 11/17 with NSE <33 had an electrographic status epilepticus (ESE), only one of whom recovered. A continuous EEG pattern correlated to NSE <33 and awakening.
Conclusions: NSE correlates well with other markers of ischemic brain injury. In patients with no other signs of brain injury, postanoxic ESE may explain a poor outcome.
GLOSSARY
- aEEG=
- amplitude-integrated EEG monitoring;
- CA=
- cardiac arrest;
- CPC=
- Cerebral Performance Categories Scale;
- DWI=
- diffusion-weighted image;
- ESE=
- electrographic status epilepticus;
- GCS-M=
- motor response to pain according to Glasgow Coma Scale;
- ICU=
- intensive care unit;
- IQR=
- interquartile range;
- NSE=
- neuron-specific enolase;
- ROC=
- receiver operating characteristic;
- SB=
- suppression burst;
- SSEP=
- somatosensory evoked potential;
- TH=
- therapeutic hypothermia
Footnotes
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Study funding: Supported by ALF (Academic Learning and Research grants), Lund University Medical Faculty, to Håkan Widner and Hans Friberg; Regional Research Support, Region Skåne, Skåne University Hospital, to Håkan Widner, Hans Friberg, Malin Rundgren, and Tobias Cronberg; Swedish Research Council (#84, Ingmar Rosén); and Laerdal Foundation to Hans Friberg.
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Editorial, page 614
- Received December 3, 2010.
- Accepted March 2, 2011.
- Copyright © 2011 by AAN Enterprises, Inc.
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- Neuron-specific enolase correlates with other prognostic markers after cardiac arrest
- High false positive rate of NSE in patients treated with hypothermia after cardiac arrest
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