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.

Scarpino, M., Lolli, F., Lanzo, G., Carrai, R., Spalletti, M., Valzania, F., Lombardi, M., Audenino, D., Celani, M. G., Marrelli, A., Contardi, S., Peris, A., Amantini, A., Grippo, A., Sandroni, C., 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, <<RESUSCITATION>>, 2021; 160 (3): 158-167. [doi:10.1016/j.resuscitation.2020.12.003] [http://hdl.handle.net/10807/171082]

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

Sandroni, Claudio
Ultimo
2021

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.
2021
Inglese
Scarpino, M., Lolli, F., Lanzo, G., Carrai, R., Spalletti, M., Valzania, F., Lombardi, M., Audenino, D., Celani, M. G., Marrelli, A., Contardi, S., Peris, A., Amantini, A., Grippo, A., Sandroni, C., 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, <<RESUSCITATION>>, 2021; 160 (3): 158-167. [doi:10.1016/j.resuscitation.2020.12.003] [http://hdl.handle.net/10807/171082]
File in questo prodotto:
Non ci sono file associati a questo prodotto.

I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.

Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/10807/171082
Citazioni
  • ???jsp.display-item.citation.pmc??? 7
  • Scopus 23
  • ???jsp.display-item.citation.isi??? 21
social impact