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Cardiac arrest survivors exhibit varying degrees of neurological recovery even in the setting of targeted temperature management (TTM) use, ranging from severe impairments to making a seemingly full return to neurologic baseline function. We sought to explore the feasibility of utilizing a laptop-based neurocognitive battery to identify more subtle cognitive deficits in this population. In a convenience sample of cardiac arrest survivors discharged with a cerebral performance category (CPC) of 1, we evaluated the use of a computerized neurocognitive battery (CNB) in this group compared to a healthy control normative population. The CNB was designed to test 11 specific neurocognitive domains, including such areas as working memory and spatial processing. Testing was scored for both accuracy and speed. In a feasibility convenience sample of 29 cardiac arrest survivors, the mean age was 52.9±16.7 years; 12 patients received postarrest TTM and 17 did not receive TTM. Patients tolerated the battery well and performed at normative levels for both accuracy and speed on most of the 11 domains, but showed reduced accuracy of working memory and speed of spatial memory with large magnitudes (>1 SD), even among those receiving TTM. Across all domains, including those using speed and accuracy, 7 of the 29 subjects (24%) achieved statistically significant scores lower from the normative population in two or more domains. In this population of CPC 1 cardiac arrest survivors, a sensitive neurocognitive battery was feasible and suggests that specific cognitive deficits can be detected compared to a normative population, despite CPC 1 designation. Such testing might allow improved measurement of outcomes following TTM interventions in future trials.

Therapeutic hypothermia or targeted temperature management (TTM) has been shown to improve survival and neurological outcome after cardiac arrest. TTM is not frequently utilized in the postoperative setting because of the concern for exacerbation of bleeding. We present the case of a 65-year-old man who had a cardiac arrest during craniotomy for a brain tumor resection. He was successfully resuscitated from pulseless electrical activity and remained unresponsive. After assessment for postoperative brain hemorrhage, the neurocritical care team initiated TTM. Repeat imaging revealed no additional bleeding. The patient was discharged with a cerebral performance category of 1 to an acute rehabilitation center 11 days following his cardiac arrest. This case highlights the need for further consideration of TTM in the postoperative cardiac arrest population.

The use of therapeutic hypothermia (TH) in the care of patients after resuscitation from sudden cardiac arrest (SCA) has been shown to improve both survival and neurologic outcomes in randomized, controlled trials and a growing number of cohort studies with historical controls. The robust nature of the data supporting postarrest TH is reflected in the wide variety of clinical investigations that have confirmed outcome benefits of similar magnitude. A number of important questions remain surrounding the implementation of postarrest TH, including the timing of cooling induction and how rapidly providers need to initiate cooling therapy. Several investigations have suggested that earlier cooling may maximize the benefit from TH and that, conversely, increasing delays to TH induction may lead to worse patient outcomes. Prehospital initiation of TH has been proposed as a means to address time barriers inherent in out-of-hospital SCA. In this paradigm, emergency medical service (EMS) personnel are able to start cooling therapies immediately after resuscitation, which can then be continued during transport. Newer technologies may provide other opportunities for rapid cooling in the field; however, the risks and benefits of prehospital cooling remain poorly understood. This review will describe the growing literature and future directions pertaining to prehospital induction of TH after SCA.

Urgent coronary angiography following cardiac arrest is an important consideration as part of a therapeutic hypothermia/postresuscitation care bundle. Few data exist to guide the selection of patients who should receive postarrest angiography. This investigation sought to evaluate patient-level variables on initial postarrest presentation and their association with significant coronary lesions on subsequent angiography. Clinical and angiographic data were collected on consecutive postarrest patients from July 2007 to April 2012 who underwent coronary angiography during hospitalization. Univariate and multivariable analyses were performed to determine the relationship between patient characteristics, clinical data, and the outcome measure, defined as the presence of at least one coronary lesion with75% stenosis. Of 527 cardiac arrest patients, 267 achieved return of spontaneous circulation; 106 of these initial survivors received coronary angiography. This cohort had a mean age of 58.1±13.5 years and a survival to discharge of 73/106 (69%), with therapeutic hypothermia utilized in 79/106 (75%) patients. Significant coronary lesions were found on angiography in 68/106 (64%) patients. Multivariable adjusted analysis demonstrated that significant lesions were associated with a prior known history of coronary disease and/or prior myocardial infarction (odds ratio [OR] 6.2, 95% confidence interval [CI] 1.6-24.4, p=0.009), and with initial rhythm of ventricular fibrillation/ventricular tachycardia (OR 2.9, 95% CI 1.1-7.7, p=0.033), but not with hypertension, tobacco use, age, or initial troponin measurements. Prior known history of coronary disease and a shockable arrest rhythm were associated with significant coronary lesions on subsequent angiography. Normal initial troponin values and younger age did not exclude clinically relevant lesions postarrest.