Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Jan;50(1):90-102.
doi: 10.1007/s00134-023-07280-9. Epub 2024 Jan 3.

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

Sara Turella  1 , Josef Dankiewicz  2 , Hans Friberg  3 , Janus Christian Jakobsen  4   5 , Christoph Leithner  6 , Helena Levin  7 , Gisela Lilja  8   9 , Marion Moseby-Knappe  10 , Niklas Nielsen  11 , Andrea O Rossetti  12 , Claudio Sandroni  1 , Frédéric Zubler  13 , Tobias Cronberg  8 , Erik Westhall  14 ; TTM2-trial investigators
Collaborators, Affiliations

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

Sara Turella et al. Intensive Care Med. 2024 Jan.

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.

Keywords: Brain injury; Cardiac arrest; Coma; EEG; Outcome; Prognosis.

PubMed Disclaimer

Conflict of interest statement

CS is Associate Editor of Intensive Care Medicine. All the other authors report no disclosures relevant to this manuscript.

Figures

Fig. 1
Fig. 1
Flow chart of study inclusion
See this image and copyright information in PMC

References

    1. Lemiale V, Dumas F, Mongardon N, Giovanetti O, Charpentier J, Chiche JD, Carli P, Mira JP, Nolan J, Cariou A. Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort. Intensive Care Med. 2013;39:1972–1980. doi: 10.1007/s00134-013-3043-4. - DOI - PubMed
    1. Sandroni C, Cronberg T, Sekhon M. Brain injury after cardiac arrest: pathophysiology, treatment, and prognosis. Intensive Care Med. 2021;47:1393–1414. doi: 10.1007/s00134-021-06548-2. - DOI - PMC - PubMed
    1. Laver S, Farrow C, Turner D, Nolan J. Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med. 2004;30:2126–2128. doi: 10.1007/s00134-004-2425-z. - DOI - PubMed
    1. 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, Protocol-driven neurological prognostication and withdrawal of life-sustaining therapy after cardiac arrest and targeted temperature management. Resuscitation. 2017;117:50–57. doi: 10.1016/j.resuscitation.2017.05.014. - DOI - PubMed
    1. Friberg H, Cronberg T, Dunser MW, Duranteau J, Horn J, Oddo M. Survey on current practices for neurological prognostication after cardiac arrest. Resuscitation. 2015;90:158–162. doi: 10.1016/j.resuscitation.2015.01.018. - DOI - PubMed