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Aim: Magnetic Resonance Imaging (MRI) is an important prognostic tool in cardiac arrest (CA) survivors given its sensitivity for detecting hypoxic-ischemic brain injury (HIBI), however, it is limited by poorly defined objective thresholds. To address this limitation, we evaluated a qualitative MRI score for predicting neurological outcome in CA survivors., Methods: Adult comatose CA survivors who underwent MRI were retrospectively identified at a single academic medical center. Two blinded neurointensivists qualitatively scored HIBI amongst 12 MRI brain regions. Scores were summated to form four distinct score groups: cortex, deep grey nuclei (DGN), cortex-DGN combined, and total (cortex, DGN, brainstem, and cerebellum). Poor neurological outcome was defined as Cerebral Performance Category (CPC) score 3-5 at hospital discharge. Inter-rater reliability was tested using intra-class correlation (ICC) and discrimination of poor neurological outcome assessed using area under the receiver operating curve (AUC)., Results: Our cohort included 219 patients with median time to MRI of 96 (IQR 81-110) hours. ICC (95% CI) was good to excellent across all MRI scores: cortex 0.92 (0.89-0.94), DGN 0.88 (0.80-0.92), cortex-DGN 0.94 (0.92-0.95), and total 0.93 (0.91-0.95). AUC (95% CI) for poor outcome was good across all MRI scores: cortex 0.84 (0.78-0.90), DGN 0.83 (0.77-0.89), cortex-DGN 0.83 (0.77-0.89), and total 0.83 (0.77-0.88)., Conclusion: A simplified, qualitative MRI score had excellent reliability and good discrimination for poor neurologic outcome. Further work is necessary to externally validate our findings in an independent, ideally prospective, cohort., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: “Dr. Tripodis receives research support from the NIH and the AMA. Dr. Greer receives research funding in the form of a grant to Boston Medical Center to conduct the INTREPID study as co-PI, including reimbursed travel to present results at major conferences. In unrelated support, Dr. Greer receives research support from NIH/NINDS, as well as personal compensation as Editor-in-Chief for Seminars in Neurology, royalties for several books, as well as medical-legal expert work.”., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background and Objectives: Brain death (BD) occurs in 9-24% of successfully resuscitated out-of-hospital cardiac arrests (OHCA). To predict BD after OHCA, we developed a novel brain death risk (BDR) score., Methods: We identified independent predictors of BD after OHCA in a retrospective, single academic center cohort between 2011 and 2021. The BDR score ranges from 0 to 7 points and includes: non-shockable rhythm (1 point), drug overdose as etiology of arrest (1 point), evidence of grey-white differentiation loss or sulcal effacement on head computed tomography (CT) radiology report within 24 hours of arrest (2 points), Full-Outline-Of-UnResponsiveness (FOUR) score of 0 (2 points), FOUR score 1-5 (1 point), and age <45 years (1 point). We internally validated the BDR score using k-fold cross validation (k = 8) and externally validated the score at an independent academic center. The main outcome was BD., Results: The development cohort included 362OHCA patients, of whom 18% (N = 58) experienced BD. Internal validation provided an area under the receiving operator characteristic curve (AUC) (95% CI) of 0.931 (0.905-0.957). In the validation cohort, 19.8% (N = 17) experienced BD. The AUC (95% CI) was 0.849 (0.765-0.933). In both cohorts, a BDR score >4 was the optimal cut off (sensitivity 0.903 and 0.882, specificity 0.830 and 0.652, in the development and validation cohorts respectively)., Discussion: The BDR score identifies those at highest risk for BD after OHCA. Our data suggest that a BDR score >4 is the optimal cut off., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Aim: Early, accurate outcome prediction after out-of-hospital cardiac arrest (OHCA) is critical for clinical decision-making and resource allocation. We sought to validate the revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia (rCAST) score in a United States cohort and compare its prognostic performance to the Pittsburgh Cardiac Arrest Category (PCAC) and Full Outline of UnResponsiveness (FOUR) scores., Methods: This is a single-center, retrospective study of OHCA patients admitted between January 2014-August 2022. Area under the receiver operating curve (AUC) was computed for each score for predicting poor neurologic outcome at discharge and in-hospital mortality. We compared the scores' predictive abilities via Delong's test., Results: Of 505 OHCA patients with all scores available, the medians [IQR] for rCAST, PCAC, and FOUR scores were 9.5 [6.0, 11.5], 4 [3, 4], and 2 [0, 5], respectively. The AUC [95% confidence interval] of the rCAST, PCAC, and FOUR scores for predicting poor neurologic outcome were 0.815 [0.763-0.867], 0.753 [0.697-0.809], and 0.841 [0.796-0.886], respectively. The AUC [95% confidence interval] of the rCAST, PCAC, and FOUR scores for predicting mortality were 0.799 [0.751-0.847], 0.723 [0.673-0.773], and 0.813 [0.770-0.855], respectively. The rCAST score was superior to the PCAC score for predicting mortality (p = 0.017). The FOUR score was superior to the PCAC score for predicting poor neurological outcome (p < 0.001) and mortality (p < 0.001)., Conclusion: The rCAST score can reliably predict poor outcome in a United States cohort of OHCA patients regardless of TTM status and outperforms the PCAC score., Competing Interests: Declaration of Competing Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Assessment of brain injury severity is critically important after survival from cardiac arrest (CA). Recent advances in low-field MRI technology have permitted the acquisition of clinically useful bedside brain imaging. Our objective was to deploy a novel approach for evaluating brain injury after CA in critically ill patients at high risk for adverse neurological outcome., Methods: This retrospective, single center study involved review of all consecutive portable MRIs performed as part of clinical care for CA patients between September 2020 and January 2022. Portable MR images were retrospectively reviewed by a blinded board-certified neuroradiologist (S.P.). Fluid-inversion recovery (FLAIR) signal intensities were measured in select regions of interest., Results: We performed 22 low-field MRI examinations in 19 patients resuscitated from CA (68.4% male, mean [standard deviation] age, 51.8 [13.1] years). Twelve patients (63.2%) had findings consistent with HIBI on conventional neuroimaging radiology report. Low-field MRI detected findings consistent with HIBI in all of these patients. Low-field MRI was acquired at a median (interquartile range) of 78 (40-136) hours post-arrest. Quantitatively, we measured FLAIR signal intensity in three regions of interest, which were higher amongst patients with confirmed HIBI. Low-field MRI was completed in all patients without disruption of intensive care unit equipment monitoring and no safety events occurred., Conclusion: In a critically ill CA population in whom MR imaging is often not feasible, low-field MRI can be deployed at the bedside to identify HIBI. Low-field MRI provides an opportunity to evaluate the time-dependent nature of MRI findings in CA survivors., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Rachel Beekman reports no disclosures. Anna Crawford reports no disclosures. Mercy H. Mazurek reports no disclosures. Anjali M. Prabhat reports no disclosures. Isha R. Chavva reports no disclosures. Nethra Parasuram reports no disclosures. Noah Kim reports no disclosures. Dr. Jennifer A. Kim reports no disclosures. Dr. Nils Petersen reports no disclosures. Dr. Adam de Havenon reports no disclosures. Dr. Akhil Khosla reports no disclosures. Dr. Shyoko Honiden reports no disclosures. Dr. P. Elliott Miller reports no disclosures. Dr. Charles Wira reports no disclosures. Dr. James Daley reports no disclosures. Dr. Seyedmehdi Payabvash reports no disclosures. Dr. David M. Greer reports no disclosures. Dr. Emily J. Gilmore reports no disclosures. Dr. W. Taylor Kimberly receives grants from the NIH and AHA to support his work with portable MRI. Dr. Kevin N. Sheth receives support from the Collaborative Science Award (American Heart Association), National Institutes of Health Supplement Grant (U01NS106513-S1), and Hyperfine Research, Inc. research grant for his work with portable MRI., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: Neuroprognostication guidelines suggest that early head computed tomography (HCT) might be useful in the evaluation of cardiac arrest (CA) patients following return of spontaneous circulation. We aimed to determine the impact of early HCT, performed within the first 6 h following CA, on decision-making following resuscitation., Methods: We identified a cohort of initially unconscious post-CA patients at a tertiary care academic medical center from 2012 to 2017. Variables pertaining to demographics, CA details, post-CA care, including neuroimaging and neurophysiologic testing, were abstracted retrospectively from the electronic medical records. Changes in management resulting from HCT findings were recorded. Blinded board-certified neurointensivists adjudicated HCT findings related to hypoxic-ischemic brain injury (HIBI) burden. The gray-white matter ratio (GWR) was also calculated., Results: Of 302 patients, 182 (60.2%) underwent HCT within six hours of CA (early HCT group). Approximately 1 in 4 early HCTs were abnormal (most commonly HIBI changes; 78.7%, n = 37), which resulted in a change in management in nearly half of cases (46.8%, n = 22). The most common changes in management were de-escalation in care [including transition to do not resuscitate status), withholding targeted temperature management, and withdrawal of life sustaining therapy (WLST)]. In cases with radiographic HIBI, mean [standard deviation] GWR was lower (1.20 [0.10] vs 1.30 [0.09], P < 0.001) and progression to brain death was higher (44.4% vs 2.9%; P < 0.001). The inter-rater reliability (IRR) of early HCT to determine presence of HIBI between radiology and three neurointensivists had a wide range (κ 0.13-0.66)., Conclusion: Early HCT identified abnormalities in 25% of cases and frequently influenced therapeutic decisions. Neuroimaging interpretation discrepancies between radiology and neurointensivists are common and agreement on severity of HIBI on early HCT is poor (k 0.11)., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Purpose: To assess the performance of neuroprognostic guidelines proposed by the American Academy of Neurology (AAN), European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM), and American Heart Association (AHA) in predicting outcomes of patients who remain unconscious after cardiac arrest., Methods: We retrospectively identified a cohort of unconscious post-cardiac arrest patients at a single tertiary care centre from 2011 to 2017 and reviewed hospital records for clinical, radiographic, electrophysiologic, and biochemical findings. Outcomes at discharge and 6 months post-arrest were abstracted and dichotomized as good (Cerebral Performance Category (CPC) scores of 1-2) versus poor (CPC 3-5). Outcomes predicted by current guidelines were compared to actual outcomes, with false positive rate (FPR) used as a measure of predictive value., Results: Of 226 patients, 36% survived to discharge, including 24 with good outcomes; 52% had withdrawal of life-sustaining therapies (WLST) during hospitalization. The AAN guideline yielded discharge and 6-month FPR of 8% and 15%, respectively. In contrast, the ERC/ESICM had a FPR of 0% at both discharge and 6 months. The AHA predictors had variable specificities, with diffuse hypoxic-ischaemic injury on MRI performing especially poorly (FPR 12%) at both discharge and 6 months., Conclusions: Though each guideline had components that performed well, only the ERC/ESICM guideline yielded a 0% FPR. Amongst the AAN and AHA guidelines, false positives emerged more readily at 6 months, reflective of continuing recovery after discharge, even in a cohort inevitably biased by WLST. Further assessment of predictive modalities is needed to improve neuroprognostic accuracy., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Data pertaining to clinical characteristics and outcomes of cardiac arrest (CA) due to drug overdose (ODCA) are limited. We hypothesized that patients with ODCA would have binary outcomes (brain death or functional recovery) compared to patients in whom CA was due to another etiology., Methods: We performed a retrospective analysis of CA cases from a single academic institution from 2012 to 2017. ODCA cases were ascertained by admission notes strongly suggestive of OD or positive toxicology screens not explained by medication administration. Clinical characteristics and outcomes were extracted from medical records, and regression modeling was used to compare ODCA and non-ODCA patients., Results: Of the 300 CA cases in this analysis, 28 (9%) were attributed to drug overdose, with opioids accounting for 54%. ODCA patients were younger, had fewer comorbidities, were less likely to have witnessed arrests or bystander cardiopulmonary resuscitation, and had longer downtimes. Inpatient mortality did not differ between cohorts (79% ODCA, 73% non-ODCA, p = 0.66), but ODCA was associated with higher rates of brain death (43%, 6%, p < 0.001). Of patients who survived to discharge, there was no difference in the likelihood of favorable neurological recovery, defined as Cerebral Performance Category score of 1-2 (7%, 7%, p = 1.00) or modified Rankin Scale score of 0-3 (7%, 9%, p = 1.00)., Conclusions: Despite similar neurological recovery and survival rates to hospital discharge, ODCA patients were more likely than non-ODCA patients to progress to brain death. Larger prospective studies analyzing ODCA are needed to better understand potential treatment options and prognostic tools in this cohort., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To systematically examine the electro-clinical characteristics of post anoxic myoclonus (PAM) and their prognostic implications in comatose cardiac arrest (CA) survivors., Methods: Fifty-nine CA survivors who developed myoclonus within 72 h of arrest and underwent continuous EEG monitoring were included in the study. Retrospective chart review was performed for all relevant clinical variables including time of PAM onset ("early onset" when within 24 h) and semiology (multi-focal, facial/ocular, whole body and limbs only). EEG findings including background, reactivity, epileptiform patterns and EEG correlate to myoclonus were reviewed at 6, 12, 24, 48 and 72 h after the return of spontaneous circulation (ROSC). Outcome was categorized as either with recovery of consciousness (Cerebral Performance Category (CPC) 1-3) or without recovery of consciousness (CPC 4-5) at the time of discharge., Results: Seven of the 59 patients (11.9%) regained consciousness, including 6/51 (11.8%) with early onset PAM. Patients with recovery of consciousness had shorter time to ROSC, and were more likely to have preserved brainstem reflexes and normal voltage background at all times. No patient with suppression burst or low voltage background (N = 52) at any point regained consciousness. In the subset where precise electro-clinical correlation was possible, all (5/5) those with recovery of consciousness had multi-focal myoclonus and most (4/5) had midline-maximal spikes over a continuous background. No patient with any other semiology (N = 21) regained consciousness., Conclusions: Early onset PAM is not always associated with lack of recovery of consciousness. EEG can help discriminate between patients who may or may not regain consciousness by the time of hospital discharge., (Copyright © 2018 Elsevier B.V. All rights reserved.)