Doppler sonography of cerebral blood flow for early prognostication after out-of-hospital cardiac arrest: DOTAC study

doi:10.1016/j.resuscitation.2019.05.024

Resuscitation

Volume 141, August 2019, Pages 188-194

https://doi.org/10.1016/j.resuscitation.2019.05.024 Get rights and content

Abstract

Aim

To assess the neurological prognosis of comatose survivors of cardiac arrest by early transcranial Doppler sonography (TCD).

Methods

This was a prospective study performed between May 2016 and October 2017 in a medical intensive care unit (ICU) and a cardiac ICU of a university teaching hospital.

All patients older than 18 years who were successfully resuscitated from an out-of-hospital cardiac arrest (OHCA) with persistent coma after the return of spontaneous circulation (ROSC) were eligible. We excluded patients for whom OHCA was associated with traumatic brain injury, no possibility of TCD measurements, or who were dead before establishing the neurological prognosis.

We measured the pulsatility index (PI) and diastolic flow velocity (DFV) of the right and left middle cerebral arteries within 12 h after ICU admission. The lowest DFV and highest PI values were used for the statistical analysis. The neurological outcome at hospital discharge was evaluated by the cerebral performance category.

Results

Forty-two patients were included in the final analysis: 15 had good and 27 poor neurological outcomes. The PI was higher in the poor outcome (1.49 vs. 1.12, p = 0.01) than good outcome group and the DFV was lower in the poor outcome group (17.3 cm s⁻¹ vs. 26.0 cm s⁻¹; p = 0.01).

Conclusion

Data provided by early TCD after ROSC are associated with neurological outcome. The use of TCD could help guide interventions to improve cerebral perfusion after ROSC in patients resuscitated from OHCA.

Introduction

Out-of-hospital cardiac arrest (OHCA) is a major cause of death and disability, with an incidence rate of 38–55 OHCA per 100,000 person-years worldwide.¹ Despite recent improvements in the management of OHCA, the survival rate at hospital discharge is still below 10%.² Two types of events have been shown to be responsible for the death of patients who survive the initial phase of prehospital care: early reperfusion syndrome, which can induce a refractory state of shock, with death within the first 24 h following admission, and delayed death induced by neurological impairment.³ A retrospective analysis found that more than 60% of such patients died due to neurological injury.⁴ Neurological injury is not only the result of the anoxic period of cardiac arrest, but can also be exacerbated during the post-resuscitation phase due to modifications in cerebral blood flow (CBF).

Transcranial Doppler sonography (TCD) is a non-invasive bedside technique that uses ultrasound to measure cerebrovascular haemodynamics.⁵ The transtemporal measurement of the middle cerebral artery (MCA) pulsatility index (PI) provides a surrogate of cerebral perfusion by recording the velocity of red blood cells circulating in this vessel.⁶ A higher PI is induced by an increase in downstream vascular resistance.⁷ TCD is not currently part of the algorithm recommended in the neurological prognosis strategy for comatose survivors of cardiac arrest.⁸

Based on the hypothesis that impaired CBF in the hours following an OHCA is a marker of ongoing cerebral injury, we assessed the relationship between CBF observed by early TCD examination and neurological outcome at hospital discharge.

Section snippets

Study design

This prospective observational study was conducted between May 2016 and October 2017 in the medical intensive care unit (ICU) and cardiac ICU of a university teaching hospital. The hospital’s ethical committee approved this study (no. 16.34). The ethical committee waived informed consent, as TCD is considered to be observational.

Patient eligibility

All adult patients that were successfully resuscitated from an OHCA with persistent coma after the return of spontaneous circulation (ROSC) were eligible. Exclusion

Study population

During the study period, 88 cardiac-arrest patients resuscitated with ROSC were screened, 36 with in-hospital cardiac arrest and 52 with OHCA (Fig. 1). Among the 52 patients with OHCA, 10 (19.3%) were excluded (two because of the absence of an acoustic window at TCD examination, five because of death before neurological evaluation, and three because >12 h had passed since admission). Finally, 42 patients (80.7%) met the eligibility criteria. The demographic characteristics of the study

Discussion

We found that patients with poor neurological outcomes after OHCA had a lower DFV and higher PI at admission than patients with good neurological outcomes, despite no differences in systemic arterial pressure.

Various studies have provided conflicting results concerning the association between initial TCD values and neurological outcome. Wessels et al.¹⁵ performed serial TCD examinations on various vessels (anterior, middle, and posterior cerebral arteries) during the first 72 h of

Conclusion

Data provided by early TCD examination after ROSC are associated with neurological outcome. The use of TCD could help guide interventions to improve cerebral perfusion after ROSC in patients resuscitated from OHCA.

Conflict of interest statement

All authors have made contribution to the conception of the study, acquisition of data, and analysis of data, and state the absence of conflict of interest in their contribution to this study

Acknowledgements

The authors would like to thank the ICU staff and cardiology department for their participation in the transcranial Doppler measurements and their involvement in allowing the inclusion of patients admitted after OHCA.

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Citation Excerpt :
In the post cardiac arrest patient, transcranial Doppler (TCD) can give information about cerebral haemodynamics and, in the future, may have a role in optimising haemodynamics in these patients.149 Changes in cerebral blood flow can be seen using TCD and this may be a target to for treatment.150–152 However, the technique and interpretations of the images is operator dependent and requires an acoustic window in the patient.
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Clinical paperDoppler sonography of cerebral blood flow for early prognostication after out-of-hospital cardiac arrest: DOTAC study

Abstract

Aim

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Patient eligibility

Study population

Discussion

Conclusion

Conflict of interest statement

Acknowledgements

Resuscitation

Resuscitation

Neurochirurgie

Réanimation

Lancet

Ultrasound Med Biol

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Postcardiac arrest syndrome: from immediate resuscitation to long-term outcome

Ann Intensive Care

Mode of death after admission to an intensive care unit following cardiac arrest

Intensive Care Med

Role of transcranial Doppler in neurocritical care

Crit Care Med

Clinical paper
Doppler sonography of cerebral blood flow for early prognostication after out-of-hospital cardiac arrest: DOTAC study