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April 19, 2016; 86 (16) ArticleOpen Access

Standardized EEG interpretation accurately predicts prognosis after cardiac arrest

Erik Westhall, Andrea O. Rossetti, Anne-Fleur van Rootselaar, Troels Wesenberg Kjaer, Janneke Horn, Susann Ullén, Hans Friberg, Niklas Nielsen, Ingmar Rosén, Anders Åneman, David Erlinge, Yvan Gasche, Christian Hassager, Jan Hovdenes, Jesper Kjaergaard, Michael Kuiper, Tommaso Pellis, Pascal Stammet, Michael Wanscher, Jørn Wetterslev, Matt P. Wise, Tobias Cronberg; On behalf of the TTM-trial investigators
First published February 10, 2016, DOI: https://doi.org/10.1212/WNL.0000000000002462
Erik Westhall
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Andrea O. Rossetti
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Anne-Fleur van Rootselaar
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Troels Wesenberg Kjaer
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Janneke Horn
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Susann Ullén
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Hans Friberg
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Niklas Nielsen
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Ingmar Rosén
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Anders Åneman
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David Erlinge
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Yvan Gasche
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Christian Hassager
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Jan Hovdenes
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Jesper Kjaergaard
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Michael Kuiper
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Tommaso Pellis
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Pascal Stammet
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Michael Wanscher
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Jørn Wetterslev
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Matt P. Wise
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Tobias Cronberg
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Citation
Standardized EEG interpretation accurately predicts prognosis after cardiac arrest
Erik Westhall, Andrea O. Rossetti, Anne-Fleur van Rootselaar, Troels Wesenberg Kjaer, Janneke Horn, Susann Ullén, Hans Friberg, Niklas Nielsen, Ingmar Rosén, Anders Åneman, David Erlinge, Yvan Gasche, Christian Hassager, Jan Hovdenes, Jesper Kjaergaard, Michael Kuiper, Tommaso Pellis, Pascal Stammet, Michael Wanscher, Jørn Wetterslev, Matt P. Wise, Tobias Cronberg
Neurology Apr 2016, 86 (16) 1482-1490; DOI: 10.1212/WNL.0000000000002462

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Abstract

Objective: To identify reliable predictors of outcome in comatose patients after cardiac arrest using a single routine EEG and standardized interpretation according to the terminology proposed by the American Clinical Neurophysiology Society.

Methods: In this cohort study, 4 EEG specialists, blinded to outcome, evaluated prospectively recorded EEGs in the Target Temperature Management trial (TTM trial) that randomized patients to 33°C vs 36°C. Routine EEG was performed in patients still comatose after rewarming. EEGs were classified into highly malignant (suppression, suppression with periodic discharges, burst-suppression), malignant (periodic or rhythmic patterns, pathological or nonreactive background), and benign EEG (absence of malignant features). Poor outcome was defined as best Cerebral Performance Category score 3–5 until 180 days.

Results: Eight TTM sites randomized 202 patients. EEGs were recorded in 103 patients at a median 77 hours after cardiac arrest; 37% had a highly malignant EEG and all had a poor outcome (specificity 100%, sensitivity 50%). Any malignant EEG feature had a low specificity to predict poor prognosis (48%) but if 2 malignant EEG features were present specificity increased to 96% (p < 0.001). Specificity and sensitivity were not significantly affected by targeted temperature or sedation. A benign EEG was found in 1% of the patients with a poor outcome.

Conclusions: Highly malignant EEG after rewarming reliably predicted poor outcome in half of patients without false predictions. An isolated finding of a single malignant feature did not predict poor outcome whereas a benign EEG was highly predictive of a good outcome.

GLOSSARY

ACNS=
American Clinical Neurophysiology Society;
CPC=
Cerebral Performance Category scale;
CI=
confidence intervals;
SSEP=
somatosensory evoked potentials;
TTM=
Target Temperature Management;
WLST=
withdrawal of life-sustaining therapy

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. The Article Processing Charge was paid by the Swedish Research Council.

  • Coinvestigators are listed on the Neurology® Web site at Neurology.org.

  • Supplemental data at Neurology.org

  • Editorial, page 1470

  • Received September 7, 2015.
  • Accepted in final form December 1, 2015.
  • © 2016 American Academy of Neurology

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially.

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Letters: Rapid online correspondence

  • Author reply to Dr. Sethi re prognostic value of sleep transients after cardiac arrest
    • Erik Westhall, Physician, Dept of Clinical Sciences, Lund University, Lund, Swedenerik.westhall@med.lu.se
    • Andrea O. Rossetti, Lausanne, Switzerland; Tobias Cronberg, Lund, Sweden
    Submitted May 17, 2016
  • Routine EEG predictors of outcome in comatose patients after cardiac arrest
    • Nitin K. Sethi, Assistant Professor of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center 525 East 68th Street, New York, NY 1006sethinitinmd@hotmail.com
    Submitted May 09, 2016
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