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Prediction of good functional outcome decreases diagnostic uncertainty in unconscious survivors after out-of-hospital cardiac arrest

Lagebrant, Alice LU orcid ; Sandroni, Claudio ; Nolan, Jerry P ; Bělohlávek, Jan ; Cariou, Alain ; Carrai, Riccardo ; Dankiewicz, Josef LU orcid ; Grejs, Anders Morten ; Grippo, Antonello and Hassager, Christian , et al. (2025) In Resuscitation 214. p.1-10
Abstract

PURPOSE: To explore modifications of the 2021 European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM) guideline algorithm for neuroprognostication after cardiac arrest to improve its prognostic accuracy.

METHODS: Post-hoc analysis of four prospective multicentre studies (TTM, TTM2, KORHN and ProNeCA). We raised the Glasgow Coma Scale motor (GCS-M) inclusion threshold at 72 h after cardiac arrest from the current GCS-M < 4 to GCS-M < 6 (all unconscious patients). Secondly, we included good outcome predictors (GCS-M 4-5, neuron-specific enolase < 17 µg/L, benign electroencephalography patterns ≤ 72 h post-arrest and normal magnetic resonance imaging at 72-168 h post-arrest) in the algorithm.... (More)

PURPOSE: To explore modifications of the 2021 European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM) guideline algorithm for neuroprognostication after cardiac arrest to improve its prognostic accuracy.

METHODS: Post-hoc analysis of four prospective multicentre studies (TTM, TTM2, KORHN and ProNeCA). We raised the Glasgow Coma Scale motor (GCS-M) inclusion threshold at 72 h after cardiac arrest from the current GCS-M < 4 to GCS-M < 6 (all unconscious patients). Secondly, we included good outcome predictors (GCS-M 4-5, neuron-specific enolase < 17 µg/L, benign electroencephalography patterns ≤ 72 h post-arrest and normal magnetic resonance imaging at 72-168 h post-arrest) in the algorithm. Functional outcome was assessed dichotomously at six months, including modified Rankin Scale 0-3, Cerebral Performance Category 1-2 or Glasgow Outcome Scale 4-5 (no symptoms to moderate disability) as good outcome.

RESULTS: We analysed 3,388 patients, of whom 2,079 had GCS-M < 4 at ≥ 72 h. Of the 874 patients identified by the 2021 ERC/ESICM poor outcome criteria, 870 had poor functional outcome (specificity: 99.6% [95%CI 99.0-99.9]). Using the GCS-M < 6 threshold, 366 more patients entered the algorithm (N = 2,445). Seven more patients with poor outcomes were identified, with close to identical specificity. Good outcome predictors thereafter identified 673 patients with potential recovery, of whom 411 (61%) had a good functional outcome at six months. With the updated algorithm, the number of prognosticated patients with an indeterminate prognosis decreased from 1,205/2,079 (58%) to 891/2,445 (36%).

CONCLUSION: Raising the GCS-M inclusion threshold and adding favourable predictors to the 2021 ERC/ESICM prognostication algorithm reduced prognostic uncertainty without increasing falsely pessimistic predictions.

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type
Contribution to journal
publication status
published
subject
keywords
Humans, Out-of-Hospital Cardiac Arrest/therapy, Male, Female, Middle Aged, Prognosis, Algorithms, Aged, Prospective Studies, Glasgow Coma Scale, Unconsciousness/etiology, Electroencephalography, Survivors, Uncertainty, Magnetic Resonance Imaging
in
Resuscitation
volume
214
article number
110686
pages
1 - 10
publisher
Elsevier
external identifiers
  • scopus:105009304366
  • pmid:40533052
ISSN
1873-1570
DOI
10.1016/j.resuscitation.2025.110686
language
English
LU publication?
yes
additional info
Copyright © 2025 The Author(s). Published by Elsevier B.V. All rights reserved.
id
1b659dd2-21df-4bf6-af38-5f8c1d53b3da
date added to LUP
2025-09-03 09:28:07
date last changed
2025-10-16 08:33:30
@article{1b659dd2-21df-4bf6-af38-5f8c1d53b3da,
  abstract     = {{<p>PURPOSE: To explore modifications of the 2021 European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM) guideline algorithm for neuroprognostication after cardiac arrest to improve its prognostic accuracy.</p><p>METHODS: Post-hoc analysis of four prospective multicentre studies (TTM, TTM2, KORHN and ProNeCA). We raised the Glasgow Coma Scale motor (GCS-M) inclusion threshold at 72 h after cardiac arrest from the current GCS-M &lt; 4 to GCS-M &lt; 6 (all unconscious patients). Secondly, we included good outcome predictors (GCS-M 4-5, neuron-specific enolase &lt; 17 µg/L, benign electroencephalography patterns ≤ 72 h post-arrest and normal magnetic resonance imaging at 72-168 h post-arrest) in the algorithm. Functional outcome was assessed dichotomously at six months, including modified Rankin Scale 0-3, Cerebral Performance Category 1-2 or Glasgow Outcome Scale 4-5 (no symptoms to moderate disability) as good outcome.</p><p>RESULTS: We analysed 3,388 patients, of whom 2,079 had GCS-M &lt; 4 at ≥ 72 h. Of the 874 patients identified by the 2021 ERC/ESICM poor outcome criteria, 870 had poor functional outcome (specificity: 99.6% [95%CI 99.0-99.9]). Using the GCS-M &lt; 6 threshold, 366 more patients entered the algorithm (N = 2,445). Seven more patients with poor outcomes were identified, with close to identical specificity. Good outcome predictors thereafter identified 673 patients with potential recovery, of whom 411 (61%) had a good functional outcome at six months. With the updated algorithm, the number of prognosticated patients with an indeterminate prognosis decreased from 1,205/2,079 (58%) to 891/2,445 (36%).</p><p>CONCLUSION: Raising the GCS-M inclusion threshold and adding favourable predictors to the 2021 ERC/ESICM prognostication algorithm reduced prognostic uncertainty without increasing falsely pessimistic predictions.</p>}},
  author       = {{Lagebrant, Alice and Sandroni, Claudio and Nolan, Jerry P and Bělohlávek, Jan and Cariou, Alain and Carrai, Riccardo and Dankiewicz, Josef and Grejs, Anders Morten and Grippo, Antonello and Hassager, Christian and Horn, Janneke and Haenggi, Matthias and Jakobsen, Janus C and Keeble, Thomas R and Kirkegaard, Hans and Kjaergaard, Jesper and Kuiper, Michael A and Lee, Byung Kook and Lee, Dong Hun and Levin, Helena and Lilja, Gisela and Lundin, Andreas and Nielsen, Niklas and Oh, Sang Hoon and Park, Kyu Nam and Pellis, Tommaso and Robba, Chiara and Rylander, Christian and Ryu, Seok Jin and Saxena, Manoxj and Scarpino, Maenia and Schrag, Claudia and Stammet, Pascal and Storm, Christian and Taccone, Fabio Silvio and Thomas, Matthew and Westhall, Erik and Wise, Matt P and Youn, Chun Song and Young, Paul and Cronberg, Tobias and Moseby-Knappe, Marion}},
  issn         = {{1873-1570}},
  keywords     = {{Humans; Out-of-Hospital Cardiac Arrest/therapy; Male; Female; Middle Aged; Prognosis; Algorithms; Aged; Prospective Studies; Glasgow Coma Scale; Unconsciousness/etiology; Electroencephalography; Survivors; Uncertainty; Magnetic Resonance Imaging}},
  language     = {{eng}},
  pages        = {{1--10}},
  publisher    = {{Elsevier}},
  series       = {{Resuscitation}},
  title        = {{Prediction of good functional outcome decreases diagnostic uncertainty in unconscious survivors after out-of-hospital cardiac arrest}},
  url          = {{http://dx.doi.org/10.1016/j.resuscitation.2025.110686}},
  doi          = {{10.1016/j.resuscitation.2025.110686}},
  volume       = {{214}},
  year         = {{2025}},
}