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) 

In This Article

Results

Baseline Characteristics and Clinical Outcomes

The median age of patients was 52 years (IQR, 37–58 years). Of 58 patients, 44 (75.9%) were males. A cardiac cause of arrest was verified in 49 (84.5%) patients. Thirty-one (53.4%) patients experienced cardiac arrest in the hospital, and 27 (46.6%) patients had cardiac arrest in an out-of-hospital setting. The median time from arrest to ECMO pump-on was 47.5 minutes (IQR, 29.0–63.0 minutes). Targeted temperature management was performed in 40 (69.0%) patients using surface cooling devices. Only one patient had ROSC during cannulation. Baseline characteristics of ECPR patients are presented in Table 2. Characteristics of cardiac arrest are shown in Table 3. There were no significant differences in baseline or arrest-related characteristics between the two neurological outcome groups. Successful ECMO weaning was achieved in 35 (60.3%) patients. Survival to discharge was identified in 25 (43.1%) patients. Of these 25 survivors, 19 (32.8%) had good neurological outcomes (CPC score of 1 or 2) (Figure 1).

Brain CT Findings

In this study, interrater reliabilities of CT scores were excellent. ICCs of ASPECTS, ASPECTS-b, and mASPECTS were 0.918 (95% CI, 0.865–0.950), 0.918 (95% CI, 0.866–0.951), and 0.915 (95% CI, 0.860–0.949), respectively. CT scores of ASPECTS, ASPECTS-b, and mASPECTS in the poor neurological outcome group were significantly lower than those in the good neurological outcome group (all p < 0.001) (Table 4, Figure 3a). In ROC curve analysis for the prediction of poor neurological outcome, the C-statistic of ASPECTS was 0.812 (95% CI, 0.688–0.902). A cutoff ≤ 3 had a sensitivity of 59.0% (95% CI, 42.1–74.4%) and a specificity of 100% (95% CI, 82.4–100%). The C-statistic of ASPECTS-b was 0.818 (95% CI, 0.694–0.907). A cutoff ≤ 14 had a sensitivity of 66.7% (95% CI, 49.8–80.9%) and a specificity of 94.7% (95% CI, 74.0–99.9%). The C-statistic of mASPECTS was 0.922 (95% CI, 0.821–0.976). A cutoff ≤ 25 had a sensitivity of 84.6% (95% CI, 69.5–94.1%) and a specificity of 89.5% (95% CI, 66.9–98.7%). The predictive performance of mASPECTS for poor neurological outcome was better than that of ASPECTS or ASPECTS-b (p = 0.004 and p = 0.003, respectively). Among three regions (cortex, subcortex/basal ganglia, and brainstem/cerebellum) for mASPECTS, the score of cortex had the best predictive performance for poor neurological outcome after ECPR (Figure 3b).

Figure 3.

ROC curves for the prediction of poor neurological outcome using ASPECTS, ASPECTS-b, and mASPECTS (a), as well as three regions of mASPECTS (b). ASPECTS Alberta Stroke Program Early Computed Tomography Score, ASPECTS-b Bilateral ASPECTS, mASPECTS Modified ASPECTS, BG Basal ganglia, B Brainstem, CL Cerebellum

There were only ten patients for whom follow-up CT scans were performed within 7 days (three good neurological outcomes and seven poor neurological outcomes) during ECMO support. Four patients had lower CT scores than previous scans, and another six patients had the same scores as for previous scans. All four patients who had lower CT scores than on previous scans had poor neurological outcomes.

Portable EEG was performed in 30 patients within 7 days after ECPR. Continuous slow (36.7%) and background suppression (23.3%) were the most common EEG findings. One-half of patients received continuous intravenous sedatives during EEG monitoring. Therefore, EEG findings might have reflected the use of sedatives as well as hypoxic brain injury. All patients who had well-known malignant EEG patterns such as electrocerebral inactivity, burst suppression, or generalized periodic epileptiform discharges had poor neurological outcomes. The EEG findings are shown in Additional File 1.

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