Prognostic value of continuous EEG monitoring during therapeutic hypothermia after cardiac arrest
Andrea O Rossetti, Luis A Urbano, Frederik Delodder, Peter W Kaplan, Mauro Oddo, Andrea O Rossetti, Luis A Urbano, Frederik Delodder, Peter W Kaplan, Mauro Oddo
Abstract
Introduction: Continuous EEG (cEEG) is increasingly used to monitor brain function in neuro-ICU patients. However, its value in patients with coma after cardiac arrest (CA), particularly in the setting of therapeutic hypothermia (TH), is only beginning to be elucidated. The aim of this study was to examine whether cEEG performed during TH may predict outcome.
Methods: From April 2009 to April 2010, we prospectively studied 34 consecutive comatose patients treated with TH after CA who were monitored with cEEG, initiated during hypothermia and maintained after rewarming. EEG background reactivity to painful stimulation was tested. We analyzed the association between cEEG findings and neurologic outcome, assessed at 2 months with the Glasgow-Pittsburgh Cerebral Performance Categories (CPC).
Results: Continuous EEG recording was started 12 ± 6 hours after CA and lasted 30 ± 11 hours. Nonreactive cEEG background (12 of 15 (75%) among nonsurvivors versus none of 19 (0) survivors; P < 0.001) and prolonged discontinuous "burst-suppression" activity (11 of 15 (73%) versus none of 19; P < 0.001) were significantly associated with mortality. EEG seizures with absent background reactivity also differed significantly (seven of 15 (47%) versus none of 12 (0); P = 0.001). In patients with nonreactive background or seizures/epileptiform discharges on cEEG, no improvement was seen after TH. Nonreactive cEEG background during TH had a positive predictive value of 100% (95% confidence interval (CI), 74 to 100%) and a false-positive rate of 0 (95% CI, 0 to 18%) for mortality. All survivors had cEEG background reactivity, and the majority of them (14 (74%) of 19) had a favorable outcome (CPC 1 or 2).
Conclusions: Continuous EEG monitoring showing a nonreactive or discontinuous background during TH is strongly associated with unfavorable outcome in patients with coma after CA. These data warrant larger studies to confirm the value of continuous EEG monitoring in predicting prognosis after CA and TH.
Figures
References
- Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346:549–556. doi: 10.1056/NEJMoa012689.
- ECC Committee, Subcommittees and Task Forces of the American Heart Association. American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005;112:IV1–IV203.
- Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346:557–563. doi: 10.1056/NEJMoa003289.
- Young GB. Clinical practice: neurologic prognosis after cardiac arrest. N Engl J Med. 2009;361:605–611. doi: 10.1056/NEJMcp0903466.
- Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;67:203–210. doi: 10.1212/.
- Rossetti AO, Oddo M, Logroscino G, Kaplan PW. Prognostication after cardiac arrest and hypothermia: a prospective study. Ann Neurol. 2010;67:301–307.
- Al Thenayan E, Savard M, Sharpe M, Norton L, Young B. Predictors of poor neurologic outcome after induced mild hypothermia following cardiac arrest. Neurology. 2008;71:1535–1537. doi: 10.1212/01.wnl.0000334205.81148.31.
- Friedman D, Claassen J, Hirsch LJ. Continuous electroencephalogram monitoring in the intensive care unit. Anesth Analg. 2009;109:506–523. doi: 10.1213/ane.0b013e3181a9d8b5.
- Rossetti AO, Oddo M. The neuro-ICU patient and electroencephalography paroxysms: if and when to treat. Curr Opin Crit Care. 2010;16:105–109. doi: 10.1097/MCC.0b013e3283374b5b.
- Abend NS, Topjian A, Ichord R, Herman ST, Helfaer M, Donnelly M, Nadkarni V, Dlugos DJ, Clancy RR. Electroencephalographic monitoring during hypothermia after pediatric cardiac arrest. Neurology. 2009;72:1931–1940. doi: 10.1212/WNL.0b013e3181a82687.
- Legriel S, Bruneel F, Sediri H, Hilly J, Abbosh N, Lagarrigue MH, Troche G, Guezennec P, Pico F, Bedos JP. Early EEG monitoring for detecting postanoxic status epilepticus during therapeutic hypothermia: a pilot study. Neurocrit Care. 2009;11:338–344. doi: 10.1007/s12028-009-9246-4.
- Oddo M, Ribordy V, Feihl F, Rossetti AO, Schaller MD, Chiolero R, Liaudet L. Early predictors of outcome in comatose survivors of ventricular fibrillation and non-ventricular fibrillation cardiac arrest treated with hypothermia: a prospective study. Crit Care Med. 2008;36:2296–2301. doi: 10.1097/CCM.0b013e3181802599.
- Rossetti AO, Logroscino G, Liaudet L, Ruffieux C, Ribordy V, Schaller MD, Despland PA, Oddo M. Status epilepticus: an independent outcome predictor after cerebral anoxia. Neurology. 2007;69:255–260. doi: 10.1212/01.wnl.0000265819.36639.e0.
- Rossetti AO, Oddo M, Liaudet L, Kaplan PW. Predictors of awakening from postanoxic status epilepticus after therapeutic hypothermia. Neurology. 2009;72:744–749. doi: 10.1212/01.wnl.0000343006.60851.62.
- Booth CM, Boone RH, Tomlinson G, Detsky AS. Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest. JAMA. 2004;291:870–879. doi: 10.1001/jama.291.7.870.
- Bassetti C, Bomio F, Mathis J, Hess CW. Early prognosis in coma after cardiac arrest: a prospective clinical, electrophysiological, and biochemical study of 60 patients. J Neurol Neurosurg Psychiatry. 1996;61:610–615. doi: 10.1136/jnnp.61.6.610.
- Zandbergen EG, Hijdra A, Koelman JH, Hart AA, Vos PE, Verbeek MM, de Haan RJ. Prediction of poor outcome within the first 3 days of postanoxic coma. Neurology. 2006;66:62–68. doi: 10.1212/01.wnl.0000191308.22233.88.
- Rundgren M, Rosen I, Friberg H. Amplitude-integrated EEG (aEEG) predicts outcome after cardiac arrest and induced hypothermia. Intensive Care Med. 2006;32:836–842. doi: 10.1007/s00134-006-0178-6.
- Wennervirta JE, Ermes MJ, Tiainen SM, Salmi TK, Hynninen MS, Sarkela MO, Hynynen MJ, Stenman UH, Viertio-Oja HE, Saastamoinen KP, Pettilä VY, Vakkuri AP. Hypothermia-treated cardiac arrest patients with good neurological outcome differ early in quantitative variables of EEG suppression and epileptiform activity. Crit Care Med. 2009;37:2427–2435. doi: 10.1097/CCM.0b013e3181a0ff84.
Source: PubMed