Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review

Claudio Sandroni, Massimo Antonelli, Sonia D'Arrigo, Cacciola 1 Sofia, W E Hoedemaekers 4 Cornelia, J A Kamps 5 Marlijn, Oddo 6 Mauro, S Taccone 7 Fabio, Di Rocco 8 Arianna, J A Meijer 9 Frederick, Westhall 10 Erik, Soar 11 Jasmeet, P Nolan 12 Jerry, Tobias Cronberg

Research output: Contribution to journalArticle


Purpose: To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3-5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA). Methods: PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013-April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. Results: Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2-5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors. Conclusion: In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169). Keywords: Cardiac arrest; Clinical examination; Coma; Computed tomography; Diffusion magnetic resonance imaging; Neuron-specific enolase; Prognosis; Somatosensory-evoked potentials.
Original languageEnglish
Pages (from-to)1803-1851
Number of pages49
JournalIntensive Care Medicine
Publication statusPublished - 2020


  • Cardiac arrest
  • Clinical examination
  • Coma
  • Computed tomography
  • Diffusion magnetic resonance imaging
  • Neuron-specific enolase
  • Prognosis
  • Somatosensory-evoked potentials.


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