Elsevier

Resuscitation

Volume 57, Issue 3, June 2003, Pages 287-297
Resuscitation

Cardiac arrest: long-term cognitive and imaging analysis

https://doi.org/10.1016/S0300-9572(03)00033-9Get rights and content

Abstract

Background: Neurological and cognitive sequelae resulting from cardiac arrest (CA), despite their potential personal and social impact, are usually not considered as major outcome measures in long-term analysis of survivors. The aim of this study is to analyze the contribution of neuropsychological testing and cerebral imaging to the development of a long-term classification of neurological impairment. Patients and methods: A total of 19 patients admitted over a 3 years period in an eight-bed intensive care unit of a tertiary care hospital with a diagnosis of CA were alive and attended a 6-month follow-up consultation. Eleven of these patients agreed to participate in this study carried out between 1 and 3 years after CA. Patients were classified using the Cerebral Performance Categories (CPC), neurological examination, detailed cognitive testing and computerized tomography (CT) scan with qualitative and quantitative imaging analysis. Results: Six of the 11 patients had good cerebral performance. Verbal and visuo-spatial short-term memory scores were associated with CPC. All patients with at least moderate cerebral disability had abnormal verbal memory test results compared with only one survivor with CPC 1; visuo-spatial short-term memory was abnormal in four moderately affected survivors and normal in those with CPC 1. The bicaudate ratio evaluated in the CT scan was correlated with the verbal memory score while the III ventricle diameter correlated with the executive functions score, suggesting involvement of different brain areas in these functions. Conclusions: Neuropsychological and CT scan measurements are proxy measures of long-term impairment of CA survivors, providing a dichotomized global evaluation of CA survivors in close agreement with CPC.

Sumàrio

Contexto: As sequelas neurológicas e cognitivas resultantes de paragem cardı́aca (CA) não são habitualmente consideradas como resultados de avaliação major nas análises de sobreviventes de longo prazo, apesar do seu potencial impacto pessoal e social O objectivo deste estudo é analisar a contribuição de testes neuropsicológicos e de imagem cerebral no desenvolvimento de uma classificação de disfunção neurológica a longo prazo. Doentes e métodos: Um total de 19 doentes com diagnóstico de PC admitidos ao longo de 3 anos numa unidade de cuidados intensivos de 8 camas de um hospital terciário foram avaliados uma consulta de follow-up durante 6meses. Onze destes doentes concordaram em participar neste estudo efectuado depois num perı́odo entre 1 e 3 anos após a PC. Os doentes foram classificados utilizando a Cerebral Performance Categories (CPC), o exame neurológico, testes cognitivos detalhados e tomografia computorizada (TAC) com análise de imagem qualitativa e quantitativa. Resultados: Seis dos onze doentes tinham bom desempenho cerebral. Os resultados da memória verbal e visuo-espacial de curto prazo estavam associados à CPC. Todos os doentes com disfunção cerebral pelo menos moderada tiveram resultados de testes de memória verbal anormais comparados com apenas um sobrevivente com CPC1; a memória visuo-espacial de curto prazo estava anormal em 4 doentes moderadamente afectados e normal nos que tinham CPC1. A razão bicaudada avaliada na TAC foi correlacionada com os resultados da memória verbal enquanto o diâmetro do III ventrı́culo correlacionava-se com os resultados das funções executivas, sugerindo envolvimento de diferentes áreas cerebrais nestas funções. Conclusões: As avaliações neuropsicológicas e por TAC são medidas directivas para disfunção a longo prazo de sobreviventes de PC, fornecendo uma avaliação dicotomizada global dos sobreviventes de PC e concordantes com a CPC.

Resumen

Antecedentes: Secuelas neurológicas y cognitivas resultantes después de un paro cardı́aco (CA), a pesar de su potencial impacto personal y social, usualmente no son consideradas como medidas mayores de resultado en el análisis de sobrevivientes a largo plazo. El objetivo de este estudio es analizar la contribución de pruebas neurosicológicas y de la imagenologı́a cerebral al desarrollo de una clasificación de déficit neurológico a largo plazo. Pacientes y métodos: Un total de 19 pacientes admitidos con el diagnóstico de paro cardı́aco, en una unidad de tratamiento intensivo de 8 camas de un hospital de cuidados terciarios en un perı́odo de 3 años, que estaban vivos y que asisten a una consulta de seguimiento a los 6 meses. Once de estos pacientes aceptaron participar en este estudio llevado a cabo entre uno y tres años después del paro cardı́aco. Los pacientes fueron clasificados usando las categorı́as de desempeño cerebral(CPC), examen neurológico, evaluación cognitiva detallada y tomografı́a computarizada de cerebro (CT) con análisis cualitativo y cuantitativo de imágenes. Resultados: Seis de los once pacientes tenı́an un buen desempeño cerebral. Los puntajes de memoria verbal y visuo-espacial de corto plazo se asociaron con el CPC. Todos los pacientes con discapacidad cerebral al menos moderada tenı́an resultados alterados en los exámenes de memoria verbal comparados con el único sobreviviente con CPC 1; la memoria visuo-espacial de corto plazo fue anormal en 4 sobrevivientes moderadamente afectados y normal en aquellos con CPC 1. La relación bicaudado/ edad evaluada en el CT se correlacionó con el puntaje de memoria verbal mientras que el diámetro del III ventrı́culo se correlacionó con el puntaje de las funciones ejecutivas, sugiriendo compromiso de diferentes áreas en estas funciones. Conclusiones: mediciones neurosicológicas y de CT son poderosas medidas de déficit neurológico a largo plazo para sobrevivientes de paro cardı́aco, proporcionando una evaluación global dicotomizada de los sobrevivientes de paro cardı́aco en concordancia estrecha con las categorı́as de desempeño cerebral.

Introduction

The progressive improvement of emergency healthcare has increased the percentage of cardiac arrest (CA) survivors. Nevertheless, there are about 30–50% of patients that remain with different degrees of anoxic encephalopathy and with diverse levels of impairment in daily life activities [1]. Although the ultimate goal of cardiopulmonary resuscitation (CPR) is to return the patient to a pre-arrest functional level for a sustained period of time [2], [3], evaluation of outcome after CA focuses mainly on survival, less emphasis being given to other outcome measures.

Although cognitive impairment, particularly memory dysfunction, has been reported in about 20–50% [4], [5], [6] of CPR survivors, there are few long-term analyses of neuropsychological sequelae and their impact on cognitive and mood dysfunction of patients, families and society [7], [8], [9], [10].

Neurological and neuropsychological outcomes influence health related quality of life (HR-QOL), a multivariate concept progressively more used in the outcome analysis of CA [3]. Even so, HR-QOL is probably not the best measurement to analyze personal and social impact of cognitive dysfunction due to brain anoxia, as higher cognitive impairment and mood changes can lead to an underscoring of difficulties by the patient [10]. Currently recommended neurological outcomes in the Utstein reporting style [11], [12], [13] focus on Cerebral Performance Categories (CPC) defined in a 1–5 scale with 1, being good cerebral performance and 5, brain death. Although CPC classification is easy to use, it does not detail sufficiently higher cognitive function impairment. For example grade 3: ‘includes a wide range of cerebral abnormalities from independent existence to paralysis and able to communicate minimally’. There could be important social and personal differences among patients classified as CPC 1: ‘good cerebral performance’ and as CPC 2: ‘moderate cerebral disability’. In this latter group, patients must be conscious and have sufficient cerebral function for part-time work in a sheltered environment or the independent activities of daily life, but they can present important neurological deficits such as hemiplegia, ataxia, dysarthria, dysphagia, seizures and permanent memory or mental changes.

Notwithstanding the widely known neurophysiologic abnormalities caused by brain anoxia, there is still much uncertainty about the mechanisms of neuroplasticity following cerebral anoxia in humans [14] and the cognitive rehabilitation potential.

This study has two main objectives: (i) to evaluate the extension and cognitive dysfunction characteristics of CA survivors from our ongoing program of evaluation of HR-QOL; (ii) to analyze the contribution of neuropsychological testing and cerebral imaging to the development of a long-term classification of neurological impairment.

Section snippets

Subjects and procedure

All the nineteen CA adult patients admitted to an eight-bed medical/surgical (ICU) of a tertiary care hospital from April 1997 to December 2000, alive at 6 months after ICU discharge attended a follow-up interview [15]. Eleven of these patients lived in the geographical area of the hospital and agreed to participate in a more extensive evaluation. Patient and family interviews, neurological examination, cognitive testing and computerized tomography (CT) scan were performed in all patients. CA

Global evaluation and interrater reliability

The reliability of classification was assessed considering the CT scan, the neurological examination, the CPC and the neuropsychological overall performance.

Considering a dichotomous classification (joining affected or considerably affected patients), for nine out of the 11 patients there was complete agreement (Table 1). In patient 1M there was lack of agreement on the classification of CPC, considered as affected by two examiners and not affected by other examiner. In the eldest patient

Discussion

The neurological examination, neuropsychological testing and brain CT scan measurements assessed in 11 patients observed between 1 and 3 years after CA were in close agreement, indicating a good overall performance in six of these patients.

With reference to the prognostic value of CA variables at admission, the GCS score 3 days after CA was associated with cognitive outcome evaluated on average 22 months after CA. Four of the five remaining patients presented an abnormal GCS score and all

Acknowledgements

We thank Minal Honavar, for her review of the manuscript.

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