Predicting Outcome With Diffusion-Weighted Imaging in Cardiac Arrest Patients Receiving Hypothermia Therapy: Multicenter Retrospective Cohort Study.
OBJECTIVE
Many comatose patients following cardiac arrest have ischemic brain injury. Diffusion-weighted imaging is a sensitive tool to identify hypoxic-ischemic brain injury. The accurate prediction of the prognosis for comatose cardiac arrest survivors has been challenging, and thus, a multimodal approach, combining diffusion-weighted image findings, could be feasible. The aim of this study was to assess regional brain injury on diffusion-weighted imaging and to test the potential association with its neurologic outcome in patients treated with target temperature management after out-of-hospital cardiac arrest.


METHODS
A multicenter, registry-based, retrospective cohort study was conducted using cases from 24 hospitals across South Korea. Of the 930 adult (≥18 yr) nontraumatic out-of-hospital cardiac arrest patients treated with target temperature management between January 2007 and December 2012 at these hospitals, we included the patients who underwent brain diffusion-weighted imaging in the first week after cardiac arrest. The brain regions examined included the four cerebral lobes, basal ganglia-thalamus, brain stem, and cerebellum. Imaging results were compared between a good neurologic outcome, defined as a cerebral performance category score of 1 or 2, and a poor neurologic outcome (cerebral performance category score≥3).


RESULTS
Poor neurologic outcome occurred in 118 of the 172 patients analyzed (68.6%). Positive diffusion-weighted image findings, defined as any regional brain injury lesion in diffusion-weighted imaging, were present in 106 patients. Positive diffusion-weighted image findings had 93% sensitivity, 86% specificity, 76% positive predictive value, and 96% negative predictive value for a poor neurologic outcome. The poor outcome group had higher numbers of affected brain lesions than the good outcome group (3.8±1.9 vs 0.1±0.6; p<0.01). By multivariate analysis, positive diffusion-weighted image findings (odds ratio, 58.2; 95% CI, 13.29-254.91) and lack of a shockable rhythm (odds ratio, 0.13; 95% CI, 0.03-0.57) were associated with a poor neurologic outcome.


CONCLUSIONS
Diffusion-weighted imaging allows reliable prediction of poor neurologic outcome in comatose patients treated with target temperature management after out-of-hospital cardiac arrest. Further prospective validation study will be required to generalize this result.
1Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea. 2Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea. 3Department of Emergency Medicine, Ewha University College of Medicine, Seoul, Korea. 4Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea. 5Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Korea. 6Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea. 7Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
Seung Mok
SM
Ryoo
Sang-Beom
SB
Jeon
Chang Hwan
CH
Sohn
Shin
S
Ahn
Chul
C
Han
Byung Kook
BK
Lee
Dong Hoon
DH
Lee
Soo Hyun
SH
Kim
Michael W
MW
Donnino
Won Young
WY
Kim
D000328:Adult; D000368:Aged; D019540:Area Under Curve; D016887:Cardiopulmonary Resuscitation / Q000379:methods* / Q000401:mortality; D002423:Cause of Death; D015331:Cohort Studies; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D007036:Hypothermia, Induced / Q000009:adverse effects* / Q000379:methods; D020925:Hypoxia-Ischemia, Brain / Q000209:etiology / Q000473:pathology*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D058687:Out-of-Hospital Cardiac Arrest / Q000401:mortality / Q000628:therapy*; D011237:Predictive Value of Tests; D012042:Registries; D056910:Republic of Korea; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D015996:Survival Rate; D016896:Treatment Outcome