Clinical PaperMalignant EEG patterns in cardiac arrest patients treated with targeted temperature management who survive to hospital discharge☆
Introduction
Mild induced hypothermia (IH) became a major therapy for out-of-hospital cardiac arrest (OHCA) attributable to ventricular fibrillation after 2002, and its application expanded to non-shockable rhythms.1, 2 Recent data demonstrate similar outcomes between IH and targeted temperature management (TTM) of 36 °C in the out of hospital VF/VT population.3 Despite the increased survival rates and improved long-term neurological function shown in randomized controlled trials with TTM, identifying which comatose patients will have a favorable outcome remains challenging.1, 2, 4, 5
Malignant EEG patterns (MEPs) such as seizures, status epilepticus (SE), and suppression-burst (SB) are considered predictors of poor neurological function in cardiac arrest.6, 7, 8, 9, 10 For this reason, the American Heart Association guidelines and the American Academy of Neurology practice parameters for prognostication in cardiac arrest consider EEG monitoring a helpful tool for cardiac arrest prognostication.2, 7, 10 However, the prognostic value of EEG monitoring when TTM is utilized has been challenged more recently, as reports of good neurological function despite the presence of MEP have emerged.11
The aim of this study was to identify the incidence of MEPs, SB, and other relevant EEG features in cardiac arrest patients treated with TTM who survive to hospital discharge.
Section snippets
Subjects
All consecutive adult subjects (≥18 years) admitted to a single tertiary care center after being successfully resuscitated from either in-hospital or out-of-hospital cardiac arrest were prospectively enrolled in a quality improvement database from 08/28/2009 to 06/04/2013. Only subjects undergoing IH for cardiac arrest who survived to hospital discharge and had more than 10 h of continuous EEG monitoring were included in this study.
Hypothermia protocol
In our institution, subjects that remain comatose after return
Results
Medical charts from 364 consecutive admissions of 362 subjects presenting with cardiac arrest were screened. Two subjects were admitted after cardiac arrest in two different occasions, and in both cases did not survive the second admission. Subjects who did not survive to hospital discharge (239 subjects), or those who had insufficient EEG monitoring (five subjects) were excluded from the final analysis. Insufficient EEG monitoring occurred due to early clinical improvement in two subjects who
Discussion
In this study, we demonstrated that MEPs and pure SB are commonly seen in cardiac arrest subjects who survive to hospital discharge. Moreover, the presence of MEPs was not correlated with functional outcome. Several subjects with MEPs were discharged to home or rehabilitation, including two subjects with myoclonic status epilepticus.
Epileptiform activity is prevalent in cardiac arrest patients treated with TTM, and these EEG findings are associated with high in-hospital mortality and poor
Conclusion
MEPs and pure SB are common features in EEG recordings of cardiac arrest patients treated with TTM who survive to hospital discharge. The fact that MEPs were not uniformly associated with unfavorable outcomes suggests that EEG data should be interpreted with caution and integrated with a multimodal approach to prognostication. Prospective studies including long-term outcomes are needed to evaluate the role of prolonged EEG monitoring in prognostication of cardiac arrest subjects treated with
Conflict of interest statement
The authors have no conflict of interest to report.
Acknowledgements
The authors thank the Continuous EEG Service and the UPMC Presbyterian Hospital EEG laboratory for their support to this project. We also thank Mr. Yin Zhao for data abstraction. This publication was supported by the National Institutes of Health through Grant Number UL1-TR-000005.
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2009.04.030.