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

Figure 1
Figure 1
EEG recording performed during therapeutic hypothermia from one representative patient who had a good outcome (Cerebral Performance Category 1 at 2 months). EEG shows a reactive EEG background activity to sound ("claps"); recording, 30 mm/sec, 10 μV/mm.
Figure 2
Figure 2
EEG recording performed during therapeutic hypothermia from one representative patient who died. EEG shows discontinuous EEG background activity, alternating with generalized, electrical seizures ("seizure-suppression pattern"). EEG was nonreactive to painful stimuli; recording, 20 mm/sec, 10 μV/mm.
Figure 3
Figure 3
Area under the receiver operating characteristic (ROC) curve for mortality prediction of cEEG reactivity (performed during therapeutic hypothermia, blue line) and of somatosensory evoked potentials (SSEPs, performed in normothermic conditions, red line). Continuous EEG yielded better prediction than SSEPs (ROC area, 0.88 versus 0.69; P = 0.006).

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