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Multicenter Study
. 2023 Jun 1;6(6):e2320713.
doi: 10.1001/jamanetworkopen.2023.20713.

Assessment of Brain Magnetic Resonance and Spectroscopy Imaging Findings and Outcomes After Pediatric Cardiac Arrest

Ericka L Fink  1   2   3 , Patrick M Kochanek  1   2   3 , Sue R Beers  4 , Robert R S B Clark  1   2   3 , Rachel P Berger  2   3 , Hülya Bayir  1   2   3 , Alexis A Topjian  5 , Christopher Newth  6 , Craig Press  5 , Aline B Maddux  7 , Frederick Willyerd  8 , Elizabeth A Hunt  9 , Ashley Siems  9 , Melissa G Chung  10 , Lincoln Smith  11 , Leslie Doughty  12 , J Wesley Diddle  13 , Jason Patregnani  13 , Juan Piantino  14 , Karen Hallermeier Walson  15 , Binod Balakrishnan  16 , Michael T Meyer  16 , Stuart Friess  17 , Jose Pineda  18 , David Maloney  1 , Pamela Rubin  1 , Tamara L Haller  19 , Amery Treble-Barna  20 , Chunyan Wang  19 , Vince Lee  21 , Jessica L Wisnowski  22 , Subramanian Subramanian  21 , Srikala Narayanan  21 , Stefan Blüml  22 , Anthony Fabio  19 , Ashok Panigrahy  21 ; POCCA Investigators
Collaborators, Affiliations
Multicenter Study

Assessment of Brain Magnetic Resonance and Spectroscopy Imaging Findings and Outcomes After Pediatric Cardiac Arrest

Ericka L Fink et al. JAMA Netw Open. .

Abstract

Importance: Morbidity and mortality after pediatric cardiac arrest are chiefly due to hypoxic-ischemic brain injury. Brain features seen on magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) after arrest may identify injury and aid in outcome assessments.

Objective: To analyze the association of brain lesions seen on T2-weighted MRI and diffusion-weighted imaging and N-acetylaspartate (NAA) and lactate concentrations seen on MRS with 1-year outcomes after pediatric cardiac arrest.

Design, setting, and participants: This multicenter cohort study took place in pediatric intensive care units at 14 US hospitals between May 16, 2017, and August 19, 2020. Children aged 48 hours to 17 years who were resuscitated from in-hospital or out-of-hospital cardiac arrest and who had a clinical brain MRI or MRS performed within 14 days postarrest were included in the study. Data were analyzed from January 2022 to February 2023.

Exposure: Brain MRI or MRS.

Main outcomes and measures: The primary outcome was an unfavorable outcome (either death or survival with a Vineland Adaptive Behavior Scales, Third Edition, score of <70) at 1 year after cardiac arrest. MRI brain lesions were scored according to region and severity (0 = none, 1 = mild, 2 = moderate, 3 = severe) by 2 blinded pediatric neuroradiologists. MRI Injury Score was a sum of T2-weighted and diffusion-weighted imaging lesions in gray and white matter (maximum score, 34). MRS lactate and NAA concentrations in the basal ganglia, thalamus, and occipital-parietal white and gray matter were quantified. Logistic regression was performed to determine the association of MRI and MRS features with patient outcomes.

Results: A total of 98 children, including 66 children who underwent brain MRI (median [IQR] age, 1.0 [0.0-3.0] years; 28 girls [42.4%]; 46 White children [69.7%]) and 32 children who underwent brain MRS (median [IQR] age, 1.0 [0.0-9.5] years; 13 girls [40.6%]; 21 White children [65.6%]) were included in the study. In the MRI group, 23 children (34.8%) had an unfavorable outcome, and in the MRS group, 12 children (37.5%) had an unfavorable outcome. MRI Injury Scores were higher among children with an unfavorable outcome (median [IQR] score, 22 [7-32]) than children with a favorable outcome (median [IQR] score, 1 [0-8]). Increased lactate and decreased NAA in all 4 regions of interest were associated with an unfavorable outcome. In a multivariable logistic regression adjusted for clinical characteristics, increased MRI Injury Score (odds ratio, 1.12; 95% CI, 1.04-1.20) was associated with an unfavorable outcome.

Conclusions and relevance: In this cohort study of children with cardiac arrest, brain features seen on MRI and MRS performed within 2 weeks after arrest were associated with 1-year outcomes, suggesting the utility of these imaging modalities to identify injury and assess outcomes.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Fink reported receiving grants from the Neurocritical Care Society and personal fees from the American Board of Pediatrics while serving as a subboard member outside the submitted work. Dr Kochanek reported holding a patent for the 8 628 512 B2 Method of Inducing EPR Following Cardiopulmonary Arrest, a pending patent (Application 15/573006) for a Method to Improve Neurologic Outcomes in Temperature Managed Patients; serving as an expert witness on several cases over the past 36 months; receiving honoraria for numerous lectures at national meetings and/or as a guest professor at various institutions of higher education; and receiving stipends for editing or authoring books and/or chapters outside the submitted work. Dr. Berger reported having patents pending for angle biosensors and biomarkers in infant brain injury outside the submitted work. Dr Topjian reported receiving grants from the National Institutes of Health (NIH) and Marinus Pharmaceuticals outside the submitted work. Dr Press reported receiving grants and personal fees from Marinus Pharmaceuticals outside the submitted work. Dr Maddux reported receiving grants from the NIH and NIH/National Institute of Child Health and Human Development (K23HD096018) outside the submitted work. Dr Willyerd reported receiving grants from the University of Pittsburgh Medical Center outside the submitted work. Dr Hunt reported receiving grants from the NIH, American Heart Association, and Inspire Pharmaceuticals; personal fees from ZOLL Medical Corporation, The CRO Academy, LLC, and Resuscitate Our Lives, LLC; serving as a consultant and speaker to hospitals; and holding a patent for ETCO2 simulator licensed to ZOLL Medical Corporation outside the submitted work. Dr Piantino reported receiving personal fees from Applied Cognition and serving as a member of the Scientific Advisory Board outside the submitted work. Dr Pineda reported receiving grants from the NIH outside the submitted work. No other disclosures were reported.

Figures

Figure.
Figure.. Magnetic Resonance Spectroscopy (MRS) of N-Acetylaspartate and Lactate Concentrations by 1-Year Outcome in 4 Regions of Interest
Panel A shows MRS N-acetylaspartate concentrations, and panel B shows MRS lactate concentrations in 4 different regions of the brain at 1 year. Diamonds denote means, lines within boxes denote medians, tops and bottoms of boxes denote IQRs, error bars denote 95% CIs, and circles denote outliers. IU indicates institutional units; VABS, Vineland Adaptive Behavioral Scale. aDenotes a significant difference (P < .05) between unfavorable vs favorable outcomes at 1 year.
See this image and copyright information in PMC

References

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