Question 16

List the clinical signs and tests used for neuro-prognostication after cardiac arrest and discuss their limitations.

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College answer

Not available.

Discussion

The question did not ask for "advantages and disadvantages", they only wanted limitations. Thus, a mangled truncated version of summary the table from the neuroprognostication chapter is offered here.

Predictors of Poor Outcome in Comatose Survivors of Cardiac Arrest
Predictive sign or investigation	Limitations and confounding factors
Absent pupillary reflex	Sedation Hypothermia Paralysis Presence of shock Metabolic derangements, eg. acidosis
Absent corneal reflex
Extensor motor response, or worse	High false positive rate (~50%)
Myoclonic status epilepticus	Interpreter-dependent Findings may be subtle Paralysis interferes with interpretation
Somatosensory evoked potentials: absence of the N20 component	N20 responses may disappear on repeat testing. N20 responses may reappear, but this does not suggest a good prognosis.
Burst suppression on EEG	Poor predictive value; cannot be used for prognostication on its own.
Absence of EEG reactivity, or "malignant" EEG pattern	Confounded by sedation and hypothermia
Neuron-specific enolase	NSE may be elevated for reasons other than brain injury; for instance, it may be secreted by neuroendocrine tumours
CT brain	If performed too early, the CT may not demonstrate any findings.
MRI brain	If performed too late, the MRI may not demonstrate any findings.

References

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Scarpino, Maenia, et al. "Neurophysiology and neuroimaging accurately predict poor neurological outcome within 24 hours after cardiac arrest: the ProNeCA prospective multicentre prognostication study." Resuscitation 143 (2019): 115-123.

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Hofmeijer, Jeannette, et al. "Unstandardized treatment of electroencephalographic status epilepticus does not improve outcome of comatose patients after cardiac arrest." Frontiers in neurology 5 (2014): 39.

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