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From the Division of Critical Care Neurology (E.F.M.W.), Mayo Clinic College of Medicine, Rochester, MN; Department of Neurology (A.H.), Academic Medical Center, University of Amsterdam, The Netherlands; Department of Clinical Neurological Sciences (G.B.Y.), University of Western Ontario, London, Ontario, Canada; Department of Neurology (C.L.B.), University Hospital Zurich, Switzerland; Department of Clinical Neurosciences (S.W.), University of Calgary, Alberta, Canada.
Address correspondence and reprint requests to the American Academy of Neurology, 1080 Montreal Avenue, Saint Paul, MN 55116; e-mail: guidelines{at}aan.com
Objective: To systematically review outcomes in comatose survivors after cardiac arrest and cardiopulmonary resuscitation (CPR).
Methods: The authors analyzed studies (1966 to 2006) that explored predictors of death or unconsciousness after 1 month or unconsciousness or severe disability after 6 months.
Results: The authors identified four class I studies, three class II studies, and five class III studies on clinical findings and circumstances. The indicators of poor outcome after CPR are absent pupillary light response or corneal reflexes, and extensor or no motor response to pain after 3 days of observation (level A), and myoclonus status epilepticus (level B). Prognosis cannot be based on circumstances of CPR (level B) or elevated body temperature (level C). The authors identified one class I, one class II, and nine class III studies on electrophysiology. Bilateral absent cortical responses on somatosensory evoked potential studies recorded 3 days after CPR predicted poor outcome (level B). Burst suppression or generalized epileptiform discharges on EEG predicted poor outcomes but with insufficient prognostic accuracy (level C). The authors identified one class I, 11 class III, and three class IV studies on biochemical markers. Serum neuron-specific enolase higher than 33 µg/L predicted poor outcome (level B). Ten class IV studies on brain monitoring and neuroimaging did not provide data to support or refute usefulness in prognostication (level U).
Conclusion: Pupillary light response, corneal reflexes, motor responses to pain, myoclonus status epilepticus, serum neuron-specific enolase, and somatosensory evoked potential studies can reliably assist in accurately predicting poor outcome in comatose patients after cardiopulmonary resuscitation for cardiac arrest.
Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of Contents for the July 25 issue to find the title link for this article.
Approved by the Quality Standards Subcommittee on January 28, 2006; by the Practice Committee on April 27, 2006; and by the AAN Board of Directors on May 4, 2006.
Disclosure: The authors report no conflicts of interest.
Received March 3, 2006. Accepted in final form April 26, 2006.
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