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Published on: April 14, 2023
Multimodal Prediction of Favorable Outcome After Cardiac Arrest: A Cohort Study
Aurélien Vanat1, Jong Woo Lee2, Hisham Elkhider2
1Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
Insights
Predicting favorable outcomes after cardiac arrest (CA) is crucial. A new multimodal score using clinical, EEG, and serum NSE data accurately identifies survivors likely to achieve functional independence within 3 months.
Area of Science:
- Neurology
- Critical Care Medicine
- Neurophysiology
Background:
- Cardiac arrest (CA) prognostication traditionally focuses on predicting unfavorable outcomes.
- Identifying patients likely to achieve favorable neurological recovery after CA is essential for guiding clinical decisions and resource allocation.
Purpose of the Study:
- To identify predictors of favorable neurological outcomes in comatose adults following CA.
- To develop and validate a multimodal prognostic score for early identification of survivors with good functional recovery.
Main Methods:
- Retrospective analysis of prospectively collected data from 499 comatose CA survivors across two academic hospitals.
- Utilized clinical examination (Full Outline of UnResponsiveness [FOUR] score), electroencephalography (EEG), and serum neuron-specific enolase (NSE) levels.
- Developed a multimodal score based on logistic regression and validated its performance using receiver operating characteristic curves and cross-validation.
Main Results:
- A six-component multimodal score was developed, incorporating early EEG characteristics, late EEG reactivity and continuity, peak serum NSE within 48 hours (≤41 µg/L), and FOUR score at 72 hours (≥5).
- A score of ≥4 out of 6 points demonstrated high sensitivity (97.5%) and accuracy (77.5%) in predicting favorable outcomes (Cerebral Performance Category 1-2) at 3 months.
- The score achieved an area under the curve of 0.88 and showed consistent performance in the validation cohort.
Conclusions:
- A novel multimodal prognostic score effectively identifies comatose CA survivors who will achieve functional independence.
- The score integrates readily available clinical, EEG, and biological data within 72 hours post-arrest.
- This tool aids in early prognostication, potentially improving patient management and outcomes after cardiac arrest.
Objectives:
Prognostic guidelines after cardiac arrest (CA) focus on unfavorable outcome prediction; favorable outcome prognostication received less attention. Our aim was to identify favorable outcome predictors and combine them into a multimodal model.
Design:
Retrospective analysis of prospectively collected data (January 2016 to June 2021).
Setting:
Two academic hospitals (Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Brigham and Women's Hospital, Boston, MA).
Patients:
Four hundred ninety-nine consecutive comatose adults admitted after CA.
Interventions:
None.
Measurements And Main Results:
CA variables (initial rhythm, time to return of spontaneous circulation), clinical examination (Full Outline of UnResponsiveness [FOUR] score at 72 hr, early myoclonus), electroencephalography (EEG) (reactivity, continuity, epileptiform features, and prespecified highly malignant patterns), somatosensory-evoked potentials, quantified pupillometry, and serum neuron-specific enolase (NSE) were retrieved. Neurologic outcome was assessed at 3 months using Cerebral Performance Category (CPC); 1 and 2 were considered as favorable outcome. Predictive performance of each variable toward favorable outcomes were calculated, and most discriminant items were combined to obtain a multimodal prognostic score, using multivariable ordinal logistic regression, receiving operator characteristic curves, and cross-validation. Our analysis identified a prognostic score including six modalities (1 point each): 1) early (12-36 hr) EEG not highly malignant, 2) early EEG background reactivity, 3) late (36-72 hr) EEG background reactivity and 4) continuity, 5) peak serum NSE within 48 hours less than or equal to 41 µg/L, and 6) FOUR score greater than or equal to 5 at 72 hours. At greater than or equal to 4 out of 6 points, sensitivity for CPC 1-2 was 97.5% (95% CI, 92.9-99.5%) and accuracy was 77.5% (95% CI, 72.7-81.8%); area under the curve was 0.88 (95% CI, 0.85-0.91). The score showed similar performances in the validation cohort.
Conclusions:
This study describes and externally validates a multimodal score, including clinical, EEG and biological items available within 72 hours, showing a high performance in identifying early comatose CA survivors who will reach functional independence at 3 months.
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