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The predictive value of highly malignant EEG patterns after cardiac arrest : evaluation of the ERC-ESICM recommendations

Turella, Sara LU ; Dankiewicz, Josef LU orcid ; Friberg, Hans LU ; Jakobsen, Janus Christian ; Leithner, Christoph ; Levin, Helena LU ; Lilja, Gisela LU ; Moseby-Knappe, Marion LU ; Nielsen, Niklas LU and Rossetti, Andrea O. , et al. (2024) In Intensive Care Medicine 50(1). p.90-102
Abstract

Purpose: The 2021 guidelines endorsed by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) recommend using highly malignant electroencephalogram (EEG) patterns (HMEP; suppression or burst-suppression) at > 24 h after cardiac arrest (CA) in combination with at least one other concordant predictor to prognosticate poor neurological outcome. We evaluated the prognostic accuracy of HMEP in a large multicentre cohort and investigated the added value of absent EEG reactivity. Methods: This is a pre-planned prognostic substudy of the Targeted Temperature Management trial 2. The presence of HMEP and background reactivity to external stimuli on EEG recorded > 24 h after CA was... (More)

Purpose: The 2021 guidelines endorsed by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) recommend using highly malignant electroencephalogram (EEG) patterns (HMEP; suppression or burst-suppression) at > 24 h after cardiac arrest (CA) in combination with at least one other concordant predictor to prognosticate poor neurological outcome. We evaluated the prognostic accuracy of HMEP in a large multicentre cohort and investigated the added value of absent EEG reactivity. Methods: This is a pre-planned prognostic substudy of the Targeted Temperature Management trial 2. The presence of HMEP and background reactivity to external stimuli on EEG recorded > 24 h after CA was prospectively reported. Poor outcome was measured at 6 months and defined as a modified Rankin Scale score of 4–6. Prognostication was multimodal, and withdrawal of life-sustaining therapy (WLST) was not allowed before 96 h after CA. Results: 845 patients at 59 sites were included. Of these, 579 (69%) had poor outcome, including 304 (36%) with WLST due to poor neurological prognosis. EEG was recorded at a median of 71 h (interquartile range [IQR] 52–93) after CA. HMEP at > 24 h from CA had 50% [95% confidence interval [CI] 46–54] sensitivity and 93% [90–96] specificity to predict poor outcome. Specificity was similar (93%) in 541 patients without WLST. When HMEP were unreactive, specificity improved to 97% [94–99] (p = 0.008). Conclusion: The specificity of the ERC-ESICM-recommended EEG patterns for predicting poor outcome after CA exceeds 90% but is lower than in previous studies, suggesting that large-scale implementation may reduce their accuracy. Combining HMEP with an unreactive EEG background significantly improved specificity. As in other prognostication studies, a self-fulfilling prophecy bias may have contributed to observed results.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Brain injury, Cardiac arrest, Coma, EEG, Outcome, Prognosis
in
Intensive Care Medicine
volume
50
issue
1
pages
90 - 102
publisher
Springer Science and Business Media B.V.
external identifiers
  • scopus:85181448610
  • pmid:38172300
ISSN
0342-4642
DOI
10.1007/s00134-023-07280-9
language
English
LU publication?
yes
id
d2ba2054-fb76-44eb-8b1b-aab3f115794c
date added to LUP
2024-02-07 13:39:42
date last changed
2025-08-14 13:07:51
@article{d2ba2054-fb76-44eb-8b1b-aab3f115794c,
  abstract     = {{<p>Purpose: The 2021 guidelines endorsed by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) recommend using highly malignant electroencephalogram (EEG) patterns (HMEP; suppression or burst-suppression) at &gt; 24 h after cardiac arrest (CA) in combination with at least one other concordant predictor to prognosticate poor neurological outcome. We evaluated the prognostic accuracy of HMEP in a large multicentre cohort and investigated the added value of absent EEG reactivity. Methods: This is a pre-planned prognostic substudy of the Targeted Temperature Management trial 2. The presence of HMEP and background reactivity to external stimuli on EEG recorded &gt; 24 h after CA was prospectively reported. Poor outcome was measured at 6 months and defined as a modified Rankin Scale score of 4–6. Prognostication was multimodal, and withdrawal of life-sustaining therapy (WLST) was not allowed before 96 h after CA. Results: 845 patients at 59 sites were included. Of these, 579 (69%) had poor outcome, including 304 (36%) with WLST due to poor neurological prognosis. EEG was recorded at a median of 71 h (interquartile range [IQR] 52–93) after CA. HMEP at &gt; 24 h from CA had 50% [95% confidence interval [CI] 46–54] sensitivity and 93% [90–96] specificity to predict poor outcome. Specificity was similar (93%) in 541 patients without WLST. When HMEP were unreactive, specificity improved to 97% [94–99] (p = 0.008). Conclusion: The specificity of the ERC-ESICM-recommended EEG patterns for predicting poor outcome after CA exceeds 90% but is lower than in previous studies, suggesting that large-scale implementation may reduce their accuracy. Combining HMEP with an unreactive EEG background significantly improved specificity. As in other prognostication studies, a self-fulfilling prophecy bias may have contributed to observed results.</p>}},
  author       = {{Turella, Sara and Dankiewicz, Josef and Friberg, Hans and Jakobsen, Janus Christian and Leithner, Christoph and Levin, Helena and Lilja, Gisela and Moseby-Knappe, Marion and Nielsen, Niklas and Rossetti, Andrea O. and Sandroni, Claudio and Zubler, Frédéric and Cronberg, Tobias and Westhall, Erik}},
  issn         = {{0342-4642}},
  keywords     = {{Brain injury; Cardiac arrest; Coma; EEG; Outcome; Prognosis}},
  language     = {{eng}},
  number       = {{1}},
  pages        = {{90--102}},
  publisher    = {{Springer Science and Business Media B.V.}},
  series       = {{Intensive Care Medicine}},
  title        = {{The predictive value of highly malignant EEG patterns after cardiac arrest : evaluation of the ERC-ESICM recommendations}},
  url          = {{http://dx.doi.org/10.1007/s00134-023-07280-9}},
  doi          = {{10.1007/s00134-023-07280-9}},
  volume       = {{50}},
  year         = {{2024}},
}