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. 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.

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Conflict of interest statement

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

Figures

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Fig. 1
Flow chart of study inclusion
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