Does a combination of ≥2 abnormal tests vs. the ERC-ESICM stepwise algorithm improve prediction of poor neurological outcome after cardiac arrest? A post-hoc analysis of the ProNeCA multicentre study

Claudio Sandroni, Maenia Scarpino, Francesco Lolli, Giovanni Lanzo, Riccardo Carrai, Maddalena Spalletti, Franco Valzania, Maria Lombardi, Daniela Audenino, Maria Grazia Celani, Alfonso Marrelli, Sara Contardi, Adriano Peris, Aldo Amantini, Antonello Grippo

Research output: Contribution to journalArticle

5 Citations (Scopus)

Abstract

Background: Bilaterally absent pupillary light reflexes (PLR) or N20 waves of short-latency evoked potentials (SSEPs) are recommended by the 2015 ERC-ESICM guidelines as robust, first-line predictors of poor neurological outcome after cardiac arrest. However, recent evidence shows that the false positive rates (FPRs) of these tests may be higher than previously reported. We investigated if testing accuracy is improved when combining PLR/SSEPs with malignant electroencephalogram (EEG), oedema on brain computed tomography (CT), or early status myoclonus (SM). Methods: Post-hoc analysis of ProNeCA multicentre prognostication study. We compared the prognostic accuracy of the ERC-ESICM prognostication strategy vs. that of a new strategy combining ≥2 abnormal results from any of PLR, SSEPs, EEG, CT and SM. We also investigated if using alternative classifications for abnormal SSEPs (absent-pathological vs. bilaterally-absent N20) or malignant EEG (ACNS-defined suppression or burst-suppression vs. unreactive burst-suppression or status epilepticus) improved test sensitivity. Results: We assessed 210 adult comatose resuscitated patients of whom 164 (78%) had poor neurological outcome (CPC 3–5) at six months. FPRs and sensitivities of the ≥2 abnormal test strategy vs. the ERC-ESICM algorithm were 0[0−8]% vs. 7 [1–18]% and 49[41−57]% vs. 63[56−71]%, respectively (p < .0001). Using alternative SSEP/EEG definitions increased the number of patients with ≥2 concordant test results and the sensitivity of both strategies (67[59−74]% and 54[46−61]% respectively), with no loss of specificity. Conclusions: In comatose resuscitated patients, a prognostication strategy combining ≥2 among PLR, SSEPs, EEG, CT and SM was more specific than the 2015 ERC-ESICM prognostication algorithm for predicting 6-month poor neurological outcome.
Original languageEnglish
Pages (from-to)158-167
Number of pages10
JournalResuscitation
Volume160
DOIs
Publication statusPublished - 2021

Keywords

  • Cardiac arrest
  • Coma
  • Prognosis

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