Skip to main content
Key Specialties
Anesthesiology Cardiology Dermatology Diabetology Endocrinology Gastroenterology General Medicine Geriatrics Hematology Infectious Diseases Internal Medicine Nephrology Neurology Obstetrics and Gynecology Oncology Ophthalmology Pediatrics Psychiatry Radiology Respiratory Medicine Rheumatology Surgery Urology
Congress Coverage
ASH 2024 Annual Meeting 2024 ESMO Congress 2024 ERS Congress 2024 EASD Congress 2024 ESC Congress 2024 EAN Congress 2024 ASCO Annual Meeting 2024 ACC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote series | Spotlight on menopause

Menopause can have a significant impact on the body, with effects ranging beyond the endocrine and reproductive systems. Learn about the systemic effects of menopause, so you can help patients in your clinics through the transition.

Published: Thursday 12th December 2024
ADVANCED SEARCH
Log in
Top
Intensive Care Medicine
Published in:

Open Access 03-01-2024 | Electroencephalography | Original

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

Authors: Sara Turella, Josef Dankiewicz, Hans Friberg, Janus Christian Jakobsen, Christoph Leithner, Helena Levin, Gisela Lilja, Marion Moseby-Knappe, Niklas Nielsen, Andrea O. Rossetti, Claudio Sandroni, Frédéric Zubler, Tobias Cronberg, Erik Westhall, the TTM2-trial investigators

Published in: Intensive Care Medicine | Issue 1/2024

Login to get access

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 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.
Appendix
Available only for authorised users
Literature
1.
Lemiale V, Dumas F, Mongardon N, Giovanetti O, Charpentier J, Chiche JD, Carli P, Mira JP, Nolan J, Cariou A (2013) Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort. Intensive Care Med 39:1972–1980CrossRefPubMed
2.
Sandroni C, Cronberg T, Sekhon M (2021) Brain injury after cardiac arrest: pathophysiology, treatment, and prognosis. Intensive Care Med 47:1393–1414CrossRefPubMedPubMedCentral
3.
Laver S, Farrow C, Turner D, Nolan J (2004) Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med 30:2126–2128CrossRefPubMed
4.
Dragancea I, Wise MP, Al-Subaie N, Cranshaw J, Friberg H, Glover G, Pellis T, Rylance R, Walden A, Nielsen N, Cronberg T, investigators TTMt, (2017) Protocol-driven neurological prognostication and withdrawal of life-sustaining therapy after cardiac arrest and targeted temperature management. Resuscitation 117:50–57CrossRefPubMed
5.
Friberg H, Cronberg T, Dunser MW, Duranteau J, Horn J, Oddo M (2015) Survey on current practices for neurological prognostication after cardiac arrest. Resuscitation 90:158–162CrossRefPubMed
6.
Nolan JP, Sandroni C, Bottiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J (2021) European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 47:369–421CrossRefPubMedPubMedCentral
7.
Hirsch LJ, Fong MWK, Leitinger M, LaRoche SM, Beniczky S, Abend NS, Lee JW, Wusthoff CJ, Hahn CD, Westover MB, Gerard EE, Herman ST, Haider HA, Osman G, Rodriguez-Ruiz A, Maciel CB, Gilmore EJ, Fernandez A, Rosenthal ES, Claassen J, Husain AM, Yoo JY, So EL, Kaplan PW, Nuwer MR, van Putten M, Sutter R, Drislane FW, Trinka E, Gaspard N (2021) American Clinical Neurophysiology Society’s Standardized Critical Care EEG Terminology: 2021 Version. J Clin Neurophysiol 38:1–29CrossRefPubMedPubMedCentral
8.
Westhall E, Rossetti AO, van Rootselaar AF, Wesenberg Kjaer T, Horn J, Ullen S, Friberg H, Nielsen N, Rosen I, Aneman A, Erlinge D, Gasche Y, Hassager C, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wetterslev J, Wise MP, Cronberg T, investigators TT-t, (2016) Standardized EEG interpretation accurately predicts prognosis after cardiac arrest. Neurology 86:1482–1490CrossRefPubMedPubMedCentral
9.
Sandroni C, D’Arrigo S, Cacciola S, Hoedemaekers CWE, Kamps MJA, Oddo M, Taccone FS, Di Rocco A, Meijer FJA, Westhall E, Antonelli M, Soar J, Nolan JP, Cronberg T (2020) Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med 46:1803–1851CrossRefPubMedPubMedCentral
10.
Soar J, Berg KM, Andersen LW, Bottiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D’Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CWE, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O’Neil BJ, Otto Q, de Paiva EF, Parr MJA, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP, Adult Advanced Life Support C (2020) Adult advanced life support: 2020 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 156:A80–A119CrossRefPubMedPubMedCentral
11.
Dankiewicz J, Cronberg T, Lilja G, Jakobsen JC, Levin H, Ullen S, Rylander C, Wise MP, Oddo M, Cariou A, Belohlavek J, Hovdenes J, Saxena M, Kirkegaard H, Young PJ, Pelosi P, Storm C, Taccone FS, Joannidis M, Callaway C, Eastwood GM, Morgan MPG, Nordberg P, Erlinge D, Nichol AD, Chew MS, Hollenberg J, Thomas M, Bewley J, Sweet K, Grejs AM, Christensen S, Haenggi M, Levis A, Lundin A, During J, Schmidbauer S, Keeble TR, Karamasis GV, Schrag C, Faessler E, Smid O, Otahal M, Maggiorini M, Wendel Garcia PD, Jaubert P, Cole JM, Solar M, Borgquist O, Leithner C, Abed-Maillard S, Navarra L, Annborn M, Unden J, Brunetti I, Awad A, McGuigan P, Bjorkholt Olsen R, Cassina T, Vignon P, Langeland H, Lange T, Friberg H, Nielsen N, Investigators TTMT (2021) Hypothermia versus normothermia after out-of-hospital cardiac arrest. N Engl J Med 384:2283–2294CrossRefPubMed
12.
Dankiewicz J, Cronberg T, Lilja G, Jakobsen JC, Belohlavek J, Callaway C, Cariou A, Eastwood G, Erlinge D, Hovdenes J, Joannidis M, Kirkegaard H, Kuiper M, Levin H, Morgan MPG, Nichol AD, Nordberg P, Oddo M, Pelosi P, Rylander C, Saxena M, Storm C, Taccone F, Ullen S, Wise MP, Young P, Friberg H, Nielsen N (2019) Targeted hypothermia versus targeted Normothermia after out-of-hospital cardiac arrest (TTM2): A randomized clinical trial-Rationale and design. Am Heart J 217:23–31CrossRefPubMed
13.
Lilja G, Nielsen N, Ullen S, Blennow Nordstrom E, Dankiewicz J, Friberg H, Heimburg K, Jakobsen JC, Levin H, Callaway C, Cariou A, Eastwood GM, Helbok R, Hovdenes J, Kirkegaard H, Leithner C, Morgan MPG, Nordberg P, Oddo M, Pelosi P, Rylander C, Saxena M, Taccone FS, Siranec M, Wise MP, Young PJ, Cronberg T (2020) Protocol for outcome reporting and follow-up in the Targeted Hypothermia versus Targeted Normothermia after Out-of-Hospital Cardiac Arrest trial (TTM2). Resuscitation 150:104–112CrossRefPubMed
14.
Rajajee V, Muehlschlegel S, Wartenberg KE, Alexander SA, Busl KM, Chou SHY, Creutzfeldt CJ, Fontaine GV, Fried H, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Montellano F, Sakowitz OW, Weimar C, Westermaier T, Varelas PN (2023) Guidelines for neuroprognostication in comatose adult survivors of cardiac arrest. Neurocrit Care 38:533–563CrossRefPubMedPubMedCentral
15.
Westhall E, Rosen I, Rossetti AO, van Rootselaar AF, Wesenberg Kjaer T, Friberg H, Horn J, Nielsen N, Ullen S, Cronberg T (2015) Interrater variability of EEG interpretation in comatose cardiac arrest patients. Clin Neurophysiol 126:2397–2404CrossRefPubMed
16.
Backman S, Cronberg T, Friberg H, Ullen S, Horn J, Kjaergaard J, Hassager C, Wanscher M, Nielsen N, Westhall E (2018) Highly malignant routine EEG predicts poor prognosis after cardiac arrest in the Target Temperature Management trial. Resuscitation 131:24–28CrossRefPubMed
17.
Rossetti AO, Tovar Quiroga DF, Juan E, Novy J, White RD, Ben-Hamouda N, Britton JW, Oddo M, Rabinstein AA (2017) Electroencephalography predicts poor and good outcomes after cardiac arrest: a two-center study. Crit Care Med 45:e674–e682CrossRefPubMed
18.
Duez CHV, Johnsen B, Ebbesen MQ, Kvaloy MB, Grejs AM, Jeppesen AN, Soreide E, Nielsen JF, Kirkegaard H (2019) Post resuscitation prognostication by EEG in 24 vs 48 h of targeted temperature management. Resuscitation 135:145–152CrossRefPubMed
19.
Doerrfuss JI, Kowski AB, Holtkamp M, Thinius M, Leithner C, Storm C (2021) Prognostic value of “late” electroencephalography recordings in patients with cardiopulmonal resuscitation after cardiac arrest. J Neurol 268:4248–4257CrossRefPubMedPubMedCentral
20.
Bongiovanni F, Romagnosi F, Barbella G, Di Rocco A, Rossetti AO, Taccone FS, Sandroni C, Oddo M (2020) Standardized EEG analysis to reduce the uncertainty of outcome prognostication after cardiac arrest. Intensive Care Med 46:963–972CrossRefPubMed
21.
Scarpino M, Lolli F, Lanzo G, Carrai R, Spalletti M, Valzania F, Lombardi M, Audenino D, Celani MG, Marrelli A, Contardi S, Peris A, Amantini A, Sandroni C, Grippo A, ProNe CASG (2019) Neurophysiology and neuroimaging accurately predict poor neurological outcome within 24 hours after cardiac arrest: The ProNeCA prospective multicentre prognostication study. Resuscitation 143:115–123CrossRefPubMed
22.
Elmer J, Rittenberger JC (2019) Quantitative EEG after cardiac arrest: New insights from an old technology. Resuscitation 142:184–185CrossRefPubMed
23.
Admiraal MM, van Rootselaar AF, Hofmeijer J, Hoedemaekers CWE, van Kaam CR, Keijzer HM, van Putten M, Schultz MJ, Horn J (2019) Electroencephalographic reactivity as predictor of neurological outcome in postanoxic coma: A multicenter prospective cohort study. Ann Neurol 86:17–27CrossRefPubMedPubMedCentral
24.
Caporro M, Rossetti AO, Seiler A, Kustermann T, Nguepnjo Nguissi NA, Pfeiffer C, Zimmermann R, Haenggi M, Oddo M, De Lucia M, Zubler F (2019) Electromyographic reactivity measured with scalp-EEG contributes to prognostication after cardiac arrest. Resuscitation 138:146–152CrossRefPubMed
25.
26.
Admiraal MM, Horn J, Hofmeijer J, Hoedemaekers CWE, van Kaam CR, Keijzer HM, van Putten M, Schultz MJ, van Rootselaar AF (2020) EEG reactivity testing for prediction of good outcome in patients after cardiac arrest. Neurology 95:e653–e661CrossRefPubMed
27.
Drohan CM, Cardi AI, Rittenberger JC, Popescu A, Callaway CW, Baldwin ME, Elmer J (2018) Effect of sedation on quantitative electroencephalography after cardiac arrest. Resuscitation 124:132–137CrossRefPubMed
28.
Ruijter BJ, van Putten M, van den Bergh WM, Tromp SC, Hofmeijer J (2019) Propofol does not affect the reliability of early EEG for outcome prediction of comatose patients after cardiac arrest. Clin Neurophysiol 130:1263–1270CrossRefPubMed
29.
Ruijter BJ, Keijzer HM, Tjepkema-Cloostermans MC, Blans MJ, Beishuizen A, Tromp SC, Scholten E, Horn J, van Rootselaar AF, Admiraal MM, van den Bergh WM, Elting JJ, Foudraine NA, Kornips FHM, van Kranen-Mastenbroek V, Rouhl RPW, Thomeer EC, Moudrous W, Nijhuis FAP, Booij SJ, Hoedemaekers CWE, Doorduin J, Taccone FS, van der Palen J, van Putten M, Hofmeijer J, Investigators T (2022) Treating rhythmic and periodic EEG patterns in comatose survivors of cardiac arrest. N Engl J Med 386:724–734CrossRefPubMed
30.
Stecker MM, Cheung AT, Pochettino A, Kent GP, Patterson T, Weiss SJ, Bavaria JE (2001) Deep hypothermic circulatory arrest: I. Effects of cooling on electroencephalogram and evoked potentials. Ann Thorac Surg 71:14–21CrossRefPubMed
31.
Ruijter BJ, Tjepkema-Cloostermans MC, Tromp SC, van den Bergh WM, Foudraine NA, Kornips FHM, Drost G, Scholten E, Bosch FH, Beishuizen A, van Putten M, Hofmeijer J (2019) Early electroencephalography for outcome prediction of postanoxic coma: a prospective cohort study. Ann Neurol 86:203–214CrossRefPubMedPubMedCentral
32.
33.
May TL, Ruthazer R, Riker RR, Friberg H, Patel N, Soreide E, Hand R, Stammet P, Dupont A, Hirsch KG, Agarwal S, Wanscher MJ, Dankiewicz J, Nielsen N, Seder DB, Kent DM (2019) Early withdrawal of life support after resuscitation from cardiac arrest is common and may result in additional deaths. Resuscitation 139:308–313CrossRefPubMedPubMedCentral
34.
Scarpino M, Carrai R, Lolli F, Lanzo G, Spalletti M, Valzania F, Lombardi M, Audenino D, Contardi S, Celani MG, Marrelli A, Mecarelli O, Minardi C, Minicucci F, Politini L, Vitelli E, Peris A, Amantini A, Sandroni C, Grippo A, ProNe CAsg, (2020) Neurophysiology for predicting good and poor neurological outcome at 12 and 72 h after cardiac arrest: The ProNeCA multicentre prospective study. Resuscitation 147:95–103CrossRefPubMed
35.
Youn CS, Park KN, Kim SH, Lee BK, Cronberg T, Oh SH, Jeung KW, Cho IS, Choi SP, Korean Hypothermia Network I (2022) External validation of the 2020 ERC/ESICM prognostication strategy algorithm after cardiac arrest. Crit Care 26:95CrossRefPubMedPubMedCentral
36.
Paul M, Bougouin W, Geri G, Dumas F, Champigneulle B, Legriel S, Charpentier J, Mira JP, Sandroni C, Cariou A (2016) Delayed awakening after cardiac arrest: prevalence and risk factors in the Parisian registry. Intensive Care Med 42:1128–1136CrossRefPubMed
37.
Giacino JT, Fins JJ, Laureys S, Schiff ND (2014) Disorders of consciousness after acquired brain injury: the state of the science. Nat Rev Neurol 10:99–114CrossRefPubMed
38.
Magliacano A, De Bellis F, Panico F, Sagliano L, Trojano L, Sandroni C, Estraneo A, (2023) Long-term clinical evolution of patients with prolonged disorders of consciousness due to severe anoxic brain injury: A meta-analytic study. Eur J Neurol
39.
Sandroni C, D’Arrigo S, Cacciola S, Hoedemaekers CWE, Westhall E, Kamps MJA, Taccone FS, Poole D, Meijer FJA, Antonelli M, Hirsch KG, Soar J, Nolan JP, Cronberg T (2022) Prediction of good neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med 48:389–413CrossRefPubMedPubMedCentral
Metadata
Title
The predictive value of highly malignant EEG patterns after cardiac arrest: evaluation of the ERC-ESICM recommendations
Authors
Sara Turella
Josef Dankiewicz
Hans Friberg
Janus Christian Jakobsen
Christoph Leithner
Helena Levin
Gisela Lilja
Marion Moseby-Knappe
Niklas Nielsen
Andrea O. Rossetti
Claudio Sandroni
Frédéric Zubler
Tobias Cronberg
Erik Westhall
the TTM2-trial investigators
Publication date
03-01-2024
Publisher
Springer Berlin Heidelberg
Published in
Intensive Care Medicine / Issue 1/2024
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI
https://doi.org/10.1007/s00134-023-07280-9

Other articles of this Issue 1/2024

How environmental impact is considered in economic evaluations of critical care: a scoping review

Phase-3 trial of recombinant human alkaline phosphatase for patients with sepsis-associated acute kidney injury (REVIVAL)

Diagnosis and management of autoimmune diseases in the ICU

Correction: Determinants of fluid use and the association between volume of fluid used and effect of balanced solutions on mortality in critically ill patients: a secondary analysis of the BaSICS trial

  • Correction

Selective digestive tract decontamination in critically ill adults with acute brain injuries: a post hoc analysis of a randomized clinical trial

Determinants of fluid use and the association between volume of fluid used and effect of balanced solutions on mortality in critically ill patients: a secondary analysis of the BaSICS trial