Prognostic values of gray matter to white matter ratios on early brain computed tomography in adult comatose patients after out-of-hospital cardiac arrest of cardiac etiology

doi:10.1016/j.resuscitation.2015.07.027

Resuscitation

Volume 96, November 2015, Pages 46-52

https://doi.org/10.1016/j.resuscitation.2015.07.027 Get rights and content

Abstract

Aim of the study

Previous studies found that the gray matter to white matter ratio (GWR) on brain computed tomography (CT) could be used to predict poor outcomes in cardiac arrest survivors. However, these studies have included cardiac arrests of both cardiac and non-cardiac etiologies. We sought to evaluate if the GWR on brain CT can help to predict poor outcomes after out-of-hospital cardiac arrest (OHCA) of cardiac etiology.

Methods

Using a multicenter retrospective registry of adult cardiac arrest survivors treated with therapeutic hypothermia, we identified survivors of OHCA of cardiac etiology who underwent brain CT within 24 h after successful resuscitation. Gray and white matter attenuations were measured, and the GWRs were calculated as in previous studies. The prognostic values of the GWRs were analyzed, and a logistic regression analysis was performed to determine the contribution of the GWR in predicting poor outcomes (Cerebral Performance Category 3–5).

Results

of 283 included patients, 140 had good outcomes and 143 had poor outcomes. Although the GWRs could predict poor outcomes with statistical significance, the sensitivities were remarkably low (3.5% to 5.6%) at cutoff values with 100% specificity. No significant difference in predictive performance was found between the primary predictive model, containing independent poor outcome predictors, and the primary predictive model combined with the GWR.

Conclusion

In a cohort of comatose adults after OHCA of cardiac etiology, the GWR demonstrated poor predictive performance and was not helpful in predicting poor outcomes.

Introduction

Although recent advances in post-cardiac arrest care have been revolutionary for cardiac arrest survivors,1, 2 45–70% of the survivors still suffer from severe neurologic deficits or die from brain injury.3, 4, 5 Thus, early methods to accurately predict patient outcomes would be useful in making therapeutic decisions and titrating therapy. Various parameters have been used for prognostication in comatose cardiac arrest survivors.6, 7, 8 However, accurate outcome prediction remains difficult, particularly within 24 h of cardiac arrest.

Brain computed tomography (CT) is frequently performed early following restoration of spontaneous circulation (ROSC) to exclude primary brain injury that could result in cardiac arrest and coma. Cerebral edema, a marker of brain injury associated with cardiac arrest, is seen as a loss of gray matter to white matter differentiation on brain CT images. Several previous studies found that gray matter to white matter ratio (GWR), calculated by dividing densities of gray matter by those of white matter, was significantly lower in cardiac arrest survivors with poor outcome relative to patients with good outcome, and thus that decreased GWR could predict poor outcome in cardiac arrest patients.9, 10, 11, 12, 13, 14 Scheel et al.¹⁵ evaluated the prognostic performance of GWR in 98 cardiac arrest survivors, and found a strong association of a low GWR with poor outcome. However, the ability of the GWR to predict outcomes in comatose patients after out-of-hospital cardiac arrest (OHCA) of cardiac etiology needs to be reassessed. Outcomes after OHCA of non-cardiac etiology are generally poor compared to OHCA of cardiac etiology.16, 17, 18 However, previous studies have included cardiac arrests of both etiologies, and did not consider etiology-based differences.9, 10, 11, 12, 13, 14, 15 For example, in the study by Scheel et al.,¹⁵ the arrest etiology was cardiac only in 53% of included subjects.

In this study, we sought to evaluate if the GWR on brain CT could help predict poor outcomes in adult comatose patients after OHCA of cardiac etiology.

Section snippets

Data source and population

This was a retrospective observational study using data from the Korean Hypothermia Network (KORHN) retrospective registry, which is a web-based, multicenter registry collection of data from adult (≥18 years) comatose OHCA survivors treated with therapeutic hypothermia (TH).¹⁹ Twenty-four hospitals throughout the Republic of Korea participated in the registry. The Institutional Review Board of each institution approved the study protocol before data collection. Informed consent was waived

Patients demographics

Of 930 patients with cardiac arrest in the registry, 564 were classified as OHCA of cardiac etiology. Of these 564 patients, 319 underwent brain CT scan within 24 h after ROSC. We excluded 21 patients with inadequate CT images for cerebral density measurements (poor quality, artifact) and 15 whose CT scans indicated previous surgery, infarction, or severe cerebral atrophy. Thus, 283 patients were included in this study. The clinical characteristics of these patients are summarized in Table 1.

Discussion

In this cohort of comatose adult patients after OHCA of cardiac etiology, GWRs on brain CT were significantly associated with outcomes. However, the GWRs demonstrated poor predictive value (AUC of 0.571 to 0.621), and the contribution of GWRs was not helpful in predicting poor outcomes.

Previous studies have indicated that the GWR from brain CT is a useful tool for predicting poor outcomes in comatose cardiac arrest survivors.10, 11, 12, 13 Choi et al.¹⁰ showed in 28 comatose cardiac arrest

Conclusions

In this study, the GWR could predict poor outcomes with statistical significance. However, given its poor predictive value, the GWR from early brain CT does not seem sufficiently useful as a predictor of poor outcomes in comatose adult patients after OHCA of cardiac etiology.

Conflict of interest statement

The authors have no conflict of interest.

Acknowledgements

We thank all the KORHN investigators and their hospitals for their participation in this study.

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^☆: A Spanish translated version of the summary of this article appears as the Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.07.027.

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Clinical paperPrognostic values of gray matter to white matter ratios on early brain computed tomography in adult comatose patients after out-of-hospital cardiac arrest of cardiac etiology☆

Abstract

Aim of the study

Methods

Results

Conclusion

Introduction

Section snippets

Data source and population

Patients demographics

Discussion

Conclusions

Conflict of interest statement

Acknowledgements

Resuscitation

Resuscitation

Resuscitation

Resuscitation

J Am Coll Cardiol

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Circulation

Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia

N Engl J Med

Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest

N Engl J Med

Targeted temperature management at 33 °C versus 36 °C after cardiac arrest

N Engl J Med

Changes in neuron-specific enolase are more suitable than its absolute serum levels for the prediction of neurologic outcome in hypothermia-treated patients with out-of-hospital cardiac arrest

Neurocrit Care

Clinical outcome after a reactive hypothermic EEG following cardiac arrest

Neurocrit Care

Quantitative analysis of the loss of distinction between gray and white matter in comatose patients after cardiac arrest

Stroke

Clinical paper
Prognostic values of gray matter to white matter ratios on early brain computed tomography in adult comatose patients after out-of-hospital cardiac arrest of cardiac etiology☆