The predictive value of highly malignant EEG patterns after cardiac arrest: evaluation of the ERC-ESICM recommendations.

Turella, S; Dankiewicz, J; Friberg, H; Jakobsen, JC; Leithner, C; Levin, H; Lilja, G; Moseby-Knappe, M; Nielsen, N; Rossetti, AO; Sandroni, C; Zubler, F; Cronberg, T; Westhall, E; TTM2-trial investigators,

The predictive value of highly malignant EEG patterns after cardiac arrest: evaluation of the ERC-ESICM recommendations.

Turella, S Dankiewicz, J Friberg, H Jakobsen, JC Leithner, C Levin, H Lilja, G Moseby-Knappe, M Nielsen, N Rossetti, AO Sandroni, C Zubler, F Cronberg, T Westhall, E TTM2-trial investigators,

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Publisher:: Springer Nature
Publication Type:: Journal Article
Citation:: Intensive Care Med, 2024, 50, (1), pp. 90-102
Issue Date:: 2024-01

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Field	Value	Language
dc.contributor.author	Turella, S
dc.contributor.author	Dankiewicz, J
dc.contributor.author	Friberg, H
dc.contributor.author	Jakobsen, JC
dc.contributor.author	Leithner, C
dc.contributor.author	Levin, H
dc.contributor.author	Lilja, G
dc.contributor.author	Moseby-Knappe, M
dc.contributor.author	Nielsen, N
dc.contributor.author	Rossetti, AO
dc.contributor.author	Sandroni, C
dc.contributor.author	Zubler, F
dc.contributor.author	Cronberg, T
dc.contributor.author	Westhall, E
dc.contributor.author	TTM2-trial investigators,
dc.date.accessioned	2025-07-09T01:35:53Z
dc.date.available	2023-11-14
dc.date.available	2025-07-09T01:35:53Z
dc.date.issued	2024-01
dc.identifier.citation	Intensive Care Med, 2024, 50, (1), pp. 90-102
dc.identifier.issn	0342-4642
dc.identifier.issn	1432-1238
dc.identifier.uri	http://hdl.handle.net/10453/188121
dc.description.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.
dc.format	Print-Electronic
dc.language	eng
dc.publisher	Springer Nature
dc.relation.ispartof	Intensive Care Med
dc.relation.isbasedon	10.1007/s00134-023-07280-9
dc.rights	info:eu-repo/semantics/openAccess
dc.subject	1103 Clinical Sciences, 1117 Public Health and Health Services
dc.subject.classification	Emergency & Critical Care Medicine
dc.subject.classification	3202 Clinical sciences
dc.subject.mesh	Humans
dc.subject.mesh	Cardiopulmonary Resuscitation
dc.subject.mesh	Critical Care
dc.subject.mesh	Electroencephalography
dc.subject.mesh	Heart Arrest
dc.subject.mesh	Hypothermia, Induced
dc.subject.mesh	Prognosis
dc.subject.mesh	Clinical Trials as Topic
dc.subject.mesh	Multicenter Studies as Topic
dc.subject.mesh	Humans
dc.subject.mesh	Heart Arrest
dc.subject.mesh	Electroencephalography
dc.subject.mesh	Prognosis
dc.subject.mesh	Cardiopulmonary Resuscitation
dc.subject.mesh	Critical Care
dc.subject.mesh	Hypothermia, Induced
dc.subject.mesh	Clinical Trials as Topic
dc.subject.mesh	Multicenter Studies as Topic
dc.subject.mesh	Humans
dc.subject.mesh	Cardiopulmonary Resuscitation
dc.subject.mesh	Critical Care
dc.subject.mesh	Electroencephalography
dc.subject.mesh	Heart Arrest
dc.subject.mesh	Hypothermia, Induced
dc.subject.mesh	Prognosis
dc.subject.mesh	Clinical Trials as Topic
dc.subject.mesh	Multicenter Studies as Topic
dc.title	The predictive value of highly malignant EEG patterns after cardiac arrest: evaluation of the ERC-ESICM recommendations.
dc.type	Journal Article
utslib.citation.volume	50
utslib.location.activity	United States
utslib.for	1103 Clinical Sciences
utslib.for	1117 Public Health and Health Services
pubs.organisational-group	University of Technology Sydney
pubs.organisational-group	University of Technology Sydney/Faculty of Health
pubs.organisational-group	University of Technology Sydney/Faculty of Health/School of Nursing and Midwifery
utslib.copyright.status	open_access	*
dc.rights.license	This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0). To view a copy of this license, visit https://creativecommons.org/licenses/by-nc/4.0/
dc.date.updated	2025-07-09T01:35:50Z
pubs.issue	1
pubs.publication-status	Published
pubs.volume	50
utslib.citation.issue	1

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.

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http://hdl.handle.net/10453/188121