Neuroprognostication is one of the most controversial and sensitive examinations in the field of neurology. Neuroprognostication after cardiac arrest is a particularly important evaluation to complete as it is closely tied to the pathology of cardiac arrest and the time to return of spontaneous circulation (ROSC). With the improvement in healthcare, there are more survivors of cardiac arrest. These survivors have variable outcomes, and often, a difficult prognosis to interpret based on their clinical presentation with hypoxic brain injury. Many patients experience moderate to severe neurological impairment in the form of severe cognitive disability or persistent vegetative state. Withdrawal of life-sustaining measures inevitably leads to death, thus propagating neuroprognostication as a controversial tool used to guide these difficult decisions. Thorough evaluation and tests are required for prognostication, with new guidelines consistently being updated. The non-exhaustive list of tests includes pupillary light response, neurological motor response, computed tomography of the brain, magnetic resonance imaging of the brain, electro-encephalogram, somatosensory evoked potentials, and more. Testing variables and outcomes are also dependent on the patient’s clinical picture, including potential hypothermic status. Overall, neuroprognostication after cardiac arrest holds great value in guiding clinical decision-making with the help of physical exam skills, updated algorithmic decision-making guidelines, and technology.
References
[1]
Lacerte, M., Hays Shapshak, A. and Mesfin, F.B. (2024) Hypoxic Brain Injury. StatPearls Publishing.
[2]
Federal Communications Commission (2024) Cognitive Disabilities. https://www.fcc.gov/cognitive-disabilities
[3]
Fordyce, C.B., Kramer, A.H., Ainsworth, C., Christenson, J., Hunter, G., Kromm, J., et al. (2023) Neuroprognostication in the Post Cardiac Arrest Patient: A Canadian Cardiovascular Society Position Statement. Canadian Journal of Cardiology, 39, 366-380. https://doi.org/10.1016/j.cjca.2022.12.014
[4]
Elmer, J., Torres, C., Aufderheide, T.P., Austin, M.A., Callaway, C.W., Golan, E., etal. (2016) Association of Early Withdrawal of Life-Sustaining Therapy for Perceived Neurological Prognosis with Mortality after Cardiac Arrest. Resuscitation, 102, 127-135. https://doi.org/10.1016/j.resuscitation.2016.01.016
[5]
Rydvall, A. and Lynöe, N. (2008) Withholding and Withdrawing Life-Sustaining Treatment: A Comparative Study of the Ethical Reasoning of Physicians and the General Public. Critical Care, 12, R13. https://doi.org/10.1186/cc6786
[6]
Sandroni, C., Skrifvars, M.B. and Taccone, F.S. (2023) Brain Monitoring after Cardiac Arrest. Current Opinion in Critical Care, 29, 68-74. https://doi.org/10.1097/mcc.0000000000001023
[7]
Patel, K. and Hipskind, J.E. (2023) Cardiac Arrest. StatPearls Publishing.
[8]
Sekhon, M.S., Ainslie, P.N. and Griesdale, D.E. (2017) Clinical Pathophysiology of Hypoxic Ischemic Brain Injury after Cardiac Arrest: A “Two-Hit” Model. Critical Care, 21, Article No. 90. https://doi.org/10.1186/s13054-017-1670-9
[9]
Adigun, R., Basit, H. and Murray, J. (2023) Cell Liquefactive Necrosis. StatPearls Publishing.
[10]
Elmer, J. and Callaway, C.W. (2019) The Brain after Cardiac Arrest. Seminars in Neurology, 37, 19-24. https://doi.org/10.1055/s-0036-1597833
[11]
Hirschberg, R. and Giacino, J.T. (2011) The Vegetative and Minimally Conscious States: Diagnosis, Prognosis and Treatment. Neurologic Clinics, 29, 773-786. https://doi.org/10.1016/j.ncl.2011.07.009
[12]
Laureys, S., Celesia, G.G., Cohadon, F., Lavrijsen, J., León-Carrión, J., Sannita, W.G., et al. (2010) Unresponsive Wakefulness Syndrome: A New Name for the Vegetative State or Apallic Syndrome. BMC Medicine, 8, Article No. 68. https://doi.org/10.1186/1741-7015-8-68
[13]
Posner, J.B., Saper, C.B., Schiff, N. and Plum, F. (2008). Plum and Posner’s Diagnosis of Stupor and Coma. Oxford University Press. https://doi.org/10.1093/med/9780195321319.001.0001
[14]
Giacino, J.T., Schnakers, C., Rodriguez-Moreno, D., Kalmar, K., Schiff, N. and Hirsch, J. (2009) Behavioral Assessment in Patients with Disorders of Consciousness: Gold Standard or Fool’s Gold? In: Progress in Brain Research, Elsevier, 33-48. https://doi.org/10.1016/s0079-6123(09)17704-x
[15]
Giacino, J.T. and Kalmar, K. (2005) Diagnostic and Prognostic Guidelines for the Vegwive and Minimally Conscious States. Neuropsychological Rehabilitation, 15, 166-174. https://doi.org/10.1080/09602010443000498
[16]
Giacino, J.T., Kalmar, K. and Whyte, J. (2004) The JFK Coma Recovery Scale-Revised: Measurement Characteristics and Diagnostic Utility11no Commercial Party Having a Direct Financial Interest in the Results of the Research Supporting This Article Has or Will Confer a Benefit upon the Authors or upon Any Organization with Which the Authors Are Associated. Archives of Physical Medicine and Rehabilitation, 85, 2020-2029. https://doi.org/10.1016/j.apmr.2004.02.033
[17]
Deng, R., Liu, Y.C., Li, J.Q., Xu, J. and Chen, G. (2020) The Role of Carbon Dioxide in Acute Brain Injury. Brain Circulation, 6, 199‑208.
[18]
Fischer, D., Edlow, B.L., Giacino, J.T. and Greer, D.M. (2022) Neuroprognostication: A Conceptual Framework. Nature Reviews Neurology, 18, 419-427. https://doi.org/10.1038/s41582-022-00644-7
[19]
Sandroni, C., Cronberg, T. and Sekhon, M. (2021) Brain Injury after Cardiac Arrest: Pathophysiology, Treatment, and Prognosis. Intensive Care Medicine, 47, 1393-1414. https://doi.org/10.1007/s00134-021-06548-2
[20]
Faugeras, F., Rohaut, B., Valente, M., Sitt, J., Demeret, S., Bolgert, F., et al. (2017) Survival and Consciousness Recovery Are Better in the Minimally Conscious State than in the Vegetative State. Brain Injury, 32, 72-77. https://doi.org/10.1080/02699052.2017.1364421
[21]
Westhall, E., Rossetti, A.O., van Rootselaar, A.F., etal. (2017) Electroencephalography for Prognostication after Cardiac Arrest: A Prospective Cohort Study. Neurology, 88, 701‑708.
[22]
Sivaraju, A, Gilmore, E.J., Mundlamuri, R.C., etal. (2015) Influence of Sedative Medications on EEG Background Patterns in Post‑Cardiac‑Arrest Patients. Clinical Neurophysiology, 126, 151‑158.
[23]
Metting, Z., Wilczak, N., de Kruijff, M., etal. (2009) Grey‑to‑White Matter Ratio on CT for Outcome Prediction after Anoxic Brain Injury. Critical Care Medicine, 37, 1179‑1184.
[24]
Hirsch, L.J., Abend, N.S., Arnson, H.A., etal. (2020) Practical Issues in Obtaining MRI in Critically Ill Haemodynamically Unstable Patients. Journal of Neuroimaging, 30, 131‑140.
Iadecola, C. (2013) Pathobiology of the Cerebral Microcirculation after Global Ischaemia. Annals of the New York Academy of Sciences, 1290, 34‑47.
[27]
Fugate, J.E., Wijdicks, E.F.M., White, R.D. and Rabinstein, A.A. (2011) Does Therapeutic Hypothermia Affect Time to Awakening in Cardiac Arrest Survivors? Neurology, 77, 1346-1350. https://doi.org/10.1212/wnl.0b013e318231527d
[28]
Rajajee, V., Muehlschlegel, S., Wartenberg, K.E., Alexander, S.A., Busl, K.M., Chou, S.H.Y., et al. (2023) Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest. Neurocritical Care, 38, 533-563. https://doi.org/10.1007/s12028-023-01688-3
Geocadin, R.G., Callaway, C.W., Fink, E.L., Golan, E., Greer, D.M., Ko, N.U., et al. (2019) Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement from the American Heart Association. Circulation, 140, 517-542. https://doi.org/10.1161/cir.0000000000000702
[31]
Merchant, R.M., Topjian, A.A., Panchal, A.R., Cheng, A., Aziz, K., Berg, K.M., et al. (2020) Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 142, 337-357. https://doi.org/10.1161/cir.0000000000000918
[32]
Mlynash, M., Campbell, D.M., Leproust, E.M., Fischbein, N.J., Bammer, R., Eyngorn, I., et al. (2010) Temporal and Spatial Profile of Brain Diffusion-Weighted MRI after Cardiac Arrest. Stroke, 41, 1665-1672. https://doi.org/10.1161/strokeaha.110.582452
[33]
Hirsch, K.G., Mlynash, M., Eyngorn, I., Pirsaheli, R., Okada, A., Komshian, S., et al. (2015) Multi-Center Study of Diffusion-Weighted Imaging in Coma after Cardiac Arrest. Neurocritical Care, 24, 82-89. https://doi.org/10.1007/s12028-015-0179-9
[34]
Hirsch, K.G., Fischbein, N., Mlynash, M., Kemp, S., Bammer, R., Eyngorn, I., et al. (2020) Prognostic Value of Diffusion-Weighted MRI for Post-Cardiac Arrest Coma. Neurology, 94, 1684-1692. https://doi.org/10.1212/wnl.0000000000009289
[35]
Benghanem, S., Pruvost-Robieux, E., Bouchereau, E., Gavaret, M. and Cariou, A. (2022) Prognostication after Cardiac Arrest: How EEG and Evoked Potentials May Improve the Challenge. Annals of Intensive Care, 12, Article No. 111. https://doi.org/10.1186/s13613-022-01083-9
[36]
Kromm, J., Davenport, A. and Wilcox, M.E. (2024) Neuroprognostication after Cardiac Arrest. Chest Critical Care, 2, Article 100074. https://doi.org/10.1016/j.chstcc.2024.100074
