Prognostic Value of Computed Tomography Score in Patients After Extracorporeal Cardiopulmonary Resuscitation

Jeong-Am Ryu; Young Hwan Lee; Chi Ryang Chung; Yang Hyun Cho; Kiick Sung; Kyeongman Jeon; Gee Young Suh; Taek Kyu Park; Joo Myung Lee; Minjung Kathy Chae; Jeong-Ho Hong; Sei Hee Lee; Hyoung Soo Kim; Jeong Hoon Yang

Disclosures

Crit Care. 2018;22(323)

Background

Neurological outcome is an important issue in patients who survive cardiac arrest. In these survivors, several predictors of neurological outcomes, such as physical examination, several biomarkers, and electrophysiologic studies, have been reported.^[1,2] Brain imaging might also be helpful for predicting neurological outcomes after cardiac arrest.^[3,4] Acute hypoxic-ischemic injury might be manifested by loss of gray-white matter discrimination, brain swelling, or low-density lesions on brain computed tomography (CT).^[5,6] However, these changes in brain CT are likely to be subjective and difficult to quantify.^[7] The Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is a widely used screening tool that provides a framework for quantifying the extent of ischemic hypodensity or hypoattenuation in the middle cerebral arterial (MCA) territory.^[8] In the setting of conventional cardiopulmonary resuscitation (CPR), ASPECTS with some modifications has been found to be useful to predict neurological outcomes of post-cardiac arrest patients.^[9,10] However, whether ASPECTS might be helpful to systemically estimate neurological outcomes of survivors after extracorporeal cardiopulmonary resuscitation (ECPR) has not been reported. Therefore, the objective of this study was to investigate whether ASPECTS with some modifications could be used to predict neurological outcomes of patients after ECPR.

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Crit Care. 2018;22(323) © 2018 BioMed Central, Ltd.
Copyright to this article is held by the author(s), licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original citation.

Table 1. Scoring system of modified ASPECTS
	Side		Scoring
Vascular territories	Right	Left
ACA lower (A1)	1	1	2
ACA upper (A2)	1	1	2
MCA (ASPECTS and ASPECTS-b)			20
MCA as per ASPECTS (C, caudate; I, insula; L, lentiform nucleus; IC, internal capsule; MCA, M1-M6)	0–10	0–10
PCA lower (P1)	1	1	2
PCA upper (P2)	1	1	2
Cerebellum (CL)	1	1	2
Brainstem (B)	1		1
Total score			31

Abbreviations: ACA Anterior cerebral artery, ASPECTS Alberta Stroke Program Early CT Score, MCAMiddle cerebral artery, PCA Posterior cerebral artery

Table 2. Baseline characteristics of patients
	Good neurological outcome (n = 19)	Poor neurological outcome (n = 39)	P Value
Age, yr, median (IQR)	50.0 (32.0–54.5)	54.0 (45.0–61.0)	0.136
Gender, male, n (%)	15 (78.9)	29 (74.4)	0.955
Body mass index, kg/m²	23.1 (21.6–25.8)	25.5 (22.4–28.3)	0.064
Medical history, n (%)
Diabetes mellitus	3 (15.8)	15 (38.5)	0.147
Hypertension	6 (31.6)	18 (46.2)	0.439
Malignancy	1 (5.3)	5 (12.8)	0.669
Dyslipidemia	1 (5.3)	6 (15.4)	0.496
Current smoker	6 (31.6)	14 (35.9)	0.976
Previous myocardial infarction	0 (0)	6 (15.4)	0.178
Targeted temperature management, n (%)			0.928
Arctic Sun®	11 (57.9)	24 (61.5)
Cooling pad	2 (10.5)	3 (7.7)
Initial Glasgow Coma Scale score, median (IQR)	3.0 (3.0–3.0)	3.0 (3.0–3.0)	0.208
Laboratory data on admission
Initial lactate, mmol/L	12.4 (10.1–15.1)	8.8 (7.3–13.3)	0.071
Hemoglobin before ECMO, g/dl	15.0 (12.6–15.5)	13.2 (11.3–14.8)	0.099
Hemoglobin after ECMO, g/dl	11.1 (9.8–12.4)	12.1 (9.7–13.1)	0.449
Total bilirubin, mg/dl	0.7 (0.3–0.9)	0.8 (0.5–1.1)	0.210
Blood urea nitrogen, mg/dl	15.0 (10.6–18.0)	15.5 (13.0–23.5)	0.223
Creatinine, mg/dl	1.1 (1.0–1.3)	1.2 (1.0–1.7)	0.292
Bicarbonate, IU/L	11.7 (10.3–17.9)	17.7 (13.2–20.9)	0.121

IQR Interquartile range, ECMO Extracorporeal membrane oxygenation

Table 3. Characteristics of patients with cardiac arrest and procedure
	Good neurological outcome (n = 19)	Poor neurological outcome (n = 39)	P Value
Type of cardiac arrest, n (%)			0.451
Out-of-hospital cardiac arrest	7 (36.8)	20 (51.3)
In-hospital cardiac arrest	12 (63.2)	19 (48.7)
Bystander-witnessed cardiac arrest, n (%)	19 (100.0)	35 (89.7)	0.371
Bystander-performed CPR, n (%)	15 (78.9)	30 (76.9)	0.999
First monitored rhythm, n (%)			0.474
Asystole	2 (11.8)	10 (26.3)
Pulseless electrical activity	6 (35.3)	12 (31.6)
Shockable rhythm (VT or VF)	9 (52.9)	16 (42.1)
Defibrillation, n (%)	11 (61.1)	18 (47.4)	0.500
Arrest to ECMO pump-on time, min, median (IQR)	47.0 (19.0–55.0)	48.0 (34.5–65.0)	0.359
Location of ECMO insertion, n(%)			0.594
Intensive care unit	3 (15.8)	7 (17.9)
Catheterization room	7 (36.8)	19 (48.7)
Emergency room	9 (47.4)	12 (30.8)
Other	0 (0)	1 (2.6)
Cardiac cause of arrest, n (%)			0.156
Ischemic	6 (37.5)	21 (63.6)
Nonischemic	10 (62.5)	12 (36.4)

Abbreviations: CPR Cardiopulmonary resuscitation, VT Ventricular tachycardia, VF Ventricular fibrillation, ECMO Extracorporeal membrane oxygenation, IQR Interquartile range

Table 4. mASPECTS and ASPECTS-b according to neurological outcomes
	Good neurological outcome (n = 19)	Poor neurological outcome (n = 39)	P Value
ASPECTS (range 0–10)	9.0 (7.5–10.0)	1.0 (0–8.0)	< 0.001
ASPECTS-b^a (range 0–20)	19.0 (16.0–20.0)	6.0 (0–17.5)	< 0.001
mASPECTS^b (range 0–31)	29.0 (27.0–31.0)	9.0 (0–25.0)	< 0.001
Cortex (range 0–20)	20.0 (18.5–20.0)	4.0 (0–14.0)	< 0.001
Subcortex/basal ganglia (range 0–8)	8.0 (6.0–8.0)	0 (0–8.0)	0.001
Brainstem/cerebellum (range 0–3)	3.0 (3.0–3.0)	0 (0–3.0)	< 0.001

ASPECTS Alberta Stroke Program Early Computed Tomography Score
^aASPECTS-b; ASPECTS-b is extended to both sides from the original ASPECTS protocol
^bmASPECTS, modified ASPECT; similar to ASPECTS-b (bilateral ASPECTS), each middle cerebral artery territory had 0–10 points. Anterior cerebral artery and posterior cerebral artery territories had 2 points, corresponding to upper and lower levels of each territory. The brainstem and each cerebellar hemisphere had 1 point

Supplementary Table 1. The findings of portable electroencephalography (EEG) within 7 days after extracorporeal cardiopulmonary resuscitation.
	Good neurological outcome (n = 11)	Poor neurological outcome (n = 19)	p value
EEG findings — no. of patients (%)			0.005
Continuous slow	9 (81.8)	2 (10.5)
Background suppression	2 (18.2)	5 (26.3)
Electrocerebral inactivity	0 (0)	8 (42.1)
Burst suppression	0 (0)	1 (5.3)
Generalized periodic epileptiform discharges	0 (0)	2 (10.5)
Ictal EEG	0 (0)	1 (5.3)

Authors and Disclosures

Jeong-Am Ryu^1,2†, Young Hwan Lee^3†, Chi Ryang Chung¹, Yang Hyun Cho⁴, Kiick Sung⁴, Kyeongman Jeon^1,5, Gee Young Suh^1,5, Taek Kyu Park⁶, Joo Myung Lee⁶, Minjung Kathy Chae⁷, Jeong-Ho Hong⁸, Sei Hee Lee⁹, Hyoung Soo Kim¹⁰ and Jeong Hoon Yang^1,6*

¹Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea. ²Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. ³Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea. ⁴Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. ⁵Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. ⁶Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. ⁷Department of Emergency Medicine, Ajou University School of Medicine, Suwon, South Korea. ⁸Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea. ⁹Department of Emergency Medicine, Hallym University Medical Center, Anyang, South Korea. ¹⁰Department of Thoracic and Cardiova
^†Jeong-Am Ryu and Young Hwan Lee contributed equally to this work.

* Correspondence
jhysmc@gmail.com

Authors' contributions
JAR participated in study design, data collection, drafting of the manuscript, and the statistical analysis. YHL participated in study design, data collection, drafting of the manuscript, and the statistical analysis. CRC participated in the statistical analysis and helped to draft the manuscript. YHC participated in study design, performed the statistical analysis, and drafted the manuscript. KS participated in the statistical analysis and helped to draft the manuscript. KJ participated in study design and coordination. GYS participated in study design and coordination and helped to draft the manuscript. TKP participated in study design and drafting of the manuscript. JML participated in the statistical analysis and helped to draft the manuscript. MKC participated in study conception and design, data collection, and drafting of the manuscript. JHH participated in study design and coordination. SHL participated in the statistical analysis and helped to draft the manuscript. HSK participated in the statistical analysis and helped to draft the manuscript. JHY participated in study conception and design, data collection, and drafting of the manuscript. All authors read and approved the final manuscript.

Competing interests
The authors declare that they have no competing interests.

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Prognostic Value of Computed Tomography Score in Patients After Extracorporeal Cardiopulmonary Resuscitation

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