Factors Affecting Prognosis in Hypoxic Encephalopathy Patients Followed-up in Intensive Care Unit

Abstract

Objectives: Hypoxic encephalopathy (HE) after cardiac arrest is a clinical condition that can cause severe neurological sequelae and death. It is important to determine the prognosis in patients with HE for follow up and developing future treatments in the long term. Our aim was to investigate the effects of age, gender, hypothermia, lesion site in brain magnetic resonance imaging (MRI), seizure and electroencephalography (EEG) findings on prognosis in patients with the diagnosis of HE. Materials and Methods: The data of the adult intensive care unit was evaluated retrospectively. A total of 194 patients with HE were included into the study. One hundred and eighteen (60.8%) of the patients were male and 76 (39.2%) were female. The survivors and those who died were identified. Hypothermia therapy, brain MRI findings (cortical and/or subcortical lesion), presence of seizures (myoclonic, generalized, focal) and EEG findings (epileptic activity, status, generalized slowing) were recorded. Results: The mean age was 59.46±1.71 (18-89). Seventy-six (39.2%) patients underwent hypothermia. One hundred and seven (55.2%) patients died. The rate of exitus in elderly patients was significantly higher (p<0.01). The brain MRI of 88 patients showed hypoxic lesions (cortical in 8 patients, subcortical in 21 patients, cortical + subcortical lesion in 59 patients). The survival rate of the patients with cortical or subcortical pathology is significantly higher than patients with both pathology (p<0.01). As a result of multiple regression analysis, a 1-year increase in age, increased the risk of death by 4%, while the presence of pathological findings in both areas in brain MRI increased the risk of death by 2.62 times. There was no significant difference of gender, hypothermia, seizures and pathological EEG findings on survival (p>0.05). Conclusion: Approximately half of the patients included in our study died. The survival rate of the elderly patients and the patients with multiple lesions in brain MRI was low.

Keywords

• Hypoxic Encephalopathy
• Prognosis
• Intensive Care Unit

Yoğun Bakımda Takip Edilen Hipoksik Ensefalopati Hastalarında Prognozu Etkileyen Faktörler

Abstract

Amaç: Kardiyak arrest sonrasında gelişen hipoksik ensefalopati (HE) ciddi nörolojik sekel ve ölüme neden olabilen bir klinik tablodur. HE’li hastalarda prognozu belirlemek, takip ve uzun vadede geliştirilecek tedaviler açısından önemlidir. Bu çalışmada amacımız HE tanısı almış hastalarda yaş, cinsiyet, hipotermi uygulamasının, beyin manyetik rezonans görüntüleme de (MRG) lezyon yerinin, epileptik nöbet varlığının ve elektroensefalografi (EEG) bulgularının prognoz üzerine etkilerini araştırmaktır. Gereç ve Yöntem: Erişkin yoğun bakım ünitesi hasta kayıtları retrospektif olarak incelendi. HE tanısı almış 194 hasta çalışmaya dahil edildi. Hastaların 118’i erkek (%60,8), 76’sı (%39,2) kadındı. Sağ kalanlar ve eksitus olanlar belirlendi. Hipotermi uygulananlar, beyin MRG bulguları (kortikal ve/veya subkortikal lezyon), epileptik nöbet varlığı (miyoklonik, jeneralize, fokal) ve EEG bulguları (epileptik aktivite, status, jeneralize yavaşlama) kaydedildi. Bulgular: Yaş ortalaması 59,46±1,71 (18-89) idi. Yetmiş altı (%39,2) hastaya hipotermi uygulandı. Yüz yedi (%55,2) hasta eksitus oldu. Yaşlı hastaların eksitus olma oranı anlamlı olarak daha yüksekti (p<0,01). Seksen sekiz hastanın beyin MRG’sinde hipoksik etkilenme (8 hastada kortikal, 21 hastada subkortikal, 59 hastada kortikal + subkortikal lezyon) görüldü. Beyin MRG’de kortikal veya subkortikal patoloji bulunanların taburcu olma oranı, her ikisinde patoloji bulunan hastalarınkine göre anlamlı düzeyde daha yüksekti (p<0,01). Çoklu regresyon analizi sonucunda yaşın 1 yıl artması ölüm riskini %4 arttırırken, beyin MRG’de her iki alanda patolojik bulgu olması ölüm riskini 2,62 kat arttırmaktaydı. Cinsiyet, hipotermi tedavisi, epileptik nöbet varlığı ve EEG’de patoloji olma durumu ile sağkalım arasında anlamlı fark yoktu (p>0,05). Sonuç: Çalışmamıza dahil edilen hastaların yaklaşık yarısı eksitus olmuştur. Yaşlı ve beyin MRG’de multiple lezyonu olanların sağkalım oranı düşüktür.

Keywords

• Hipoksik Ensefalopati
• Prognoz
• Yoğun Bakım Ünitesi

Ethical Statement

Medipol Üniversitesi Tıp Fakültesi’nden onay alınmıştır (10840098-604.01.01-E53715).

References

1. 1. Levy DE, Caronna JJ, Singer BH, et al. Predicting outcome from hypoxicischemic coma. JAMA. 1985;253:1420-1426.
2. 2. Lemiale V, Dumas F, Mongardon N, et al. Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort. Intensive Care Med. 2013;39:1972-1980.
3. 3. Wijdicks EF, Hijdra A, Young GB, et al. Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;67:203-210.
4. 4. Nolan JP, Laver SR, Welch CA, et al. Anaesthesia. Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysisof the ICNARC Case Mix Programme Database. 2007;62:1207-1216.
5. 5. Maynard C, Longstreth WT Jr, Nichol G, et al. Effect of prehospital induction of mild hypothermia on 3-month neurological status and 1-year survival among adults with cardiac arrest: long-term follow-up of a randomized, clinical trial. J Am Heart Assoc. 2015;4:e001693.
6. 6. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346:549-556.
7. 7. Topcuoglu MA, Oguz KK, Buyukserbetci G, et al. Prognostic value of magnetic resonance imaging in post-resuscitation encephalopathy. Intern Med. 2009;48:1635-1645.
8. 8. Lybeck A, Friberg H, Aneman A, et al. TTM-trial Investigators. Prognostic significance of clinical seizures after cardiac arrest and target temperature management. Resuscitation. 2017;114:146-151.

9. 9. Guérit JM, Amantini A, Amodio P, et al. Consensus on the use of neurophysiological tests in the intensive care unit (ICU): electroencephalogram (EEG), evoked potentials (EP), and electroneuromyography (ENMG). Neurophysiol Clin. 2009;39:71-83.
10. 10. Rabinstein AA, Wijdicks EF. The value of EEG monitoring after cardiac arrest treated with hypothermia. Neurology. 2012;78:774-775.
11. 11. Kizilaslan D. Therapeutic Hypothermia Protocol. ESCIM. https://www.escim. org/research/libraries/ttm-library. Accessed April 2018.
12. 12. Fugate JE. Anoxic-Ischemic Brain Injury. Anoxic-Ischemic Brain Injury. Neurol Clin. 2017;35:601-611.
13. 13. Nolan JP, Neumar RW, Adrie C, et al. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation. 2008;79:350-379.
14. 14. Madl C, Holzer M. Brain function after resuscitation from cardiac arrest. Curr Opin Crit Care. 2004;10:213-217.
15. 15. Zandbergen EG, de Haan RJ, Reitsma JB, et al. Survival and recovery of consciousness in anoxic-ischemic coma after cardiopulmonary resuscitation. Intensive Care Med. 2003;29:1911-1915.
16. 16. Shuvy M, Morrison LJ, Koh M, et al. Rescu Epistry Investigators. Long-term clinical outcomes and predictors for survivors of out-of-hospital cardiac arrest. Resuscitation 2017;112:59-64.
17. 17. Li F, Liu G, Tian X, et al. A novel scoring system to predict the outcomes of adult patients with hypoxic-ischemic encephalopathy. Expert Rev Neurother 2018;18:343-350.
18. 18. Bedell SE, Delbanco TL, Cook EF, et al. Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med 1983;309:569-576.
19. 19. Pell JP, Sirel J, Marsden AK, et al. Sex differences in outcome following community-based cardiopulmonary arrest. Eur Heart J. 2000;21:239-244.
20. 20. Brindley PG, Markland DM, Mayers I, et al. Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ. 2002;167:343-348.
21. 21. Kutsogiannis DJ, Bagshaw SM, Laing B, et al. Predictors of survival after cardiac or respiratory arrest in critical care units. CMAJ. 2011;183:1589-1595.
22. 22. Hirlekar G, Karlsson T, Aune S, et al. Survival and neurological outcome in the elderly after in-hospital cardiac arrest. Resuscitation. 2017;118:101-106.
23. 23. Hackenhaar FS, Medeiros TM, Heemann FM, et al. Therapeutic Hypothermia Reduces Oxidative Damage and Alters Antioxidant Defenses after Cardiac Arrest. Oxid Med Cell Longev. 2017;2017:8704352.
24. 24. Testori C, Sterz F, Behringer W, et al. Mild therapeutic hypothermia is associated with favourable outcome in patients after cardiac arrest with non-shockable rhythms. Resuscitation. 2011;82:1162-1167.
25. 25. Lundbye JB, Rai M, Ramu B, et al. Therapeutic hypothermia is associated with improved neurologic outcome and survival in cardiac arrest survivors of non-shockable rhythms. Resuscitation. 2012;83:202-207.
26. 26. Wibrandt I, Norsted K, Schmidt H, et al. Predictors for outcome among cardiac arrest patients: the importance of initial cardiac arrestrhythm versus time to return of spontaneous circulation, a retrospective cohort study. BMC Emerg Med. 2015;15:3.
27. 27. Bhattacharjee S, Baidya DK, Maitra S. Therapeutic hypothermia after cardiac arrest is not associated with favorable neurologicaloutcome: a meta-analysis. J Clin Anesth. 2016;33:225-232.
28. 28. Loma-Osorio P, Aboal J, Sanz M, et al. Clinical characteristics and vital and functional prognosis of out-of-hospital cardiac arrest survivors admitted to five cardiac intensive care units. Rev Esp Cardiol (Engl Ed). 2013;66:623-628.
29. 29. Leão RN, Ávila P, Cavaco R, et al. Therapeutic hypothermia after cardiac arrest: outcome predictors. Rev Bras Ter Intensiva. 2015;27:322-332.
30. 30. Greer D, Scripko P, Bartscher J, et al. Serial MRI changes in comatose cardiac arrest patients. Neurocrit Care. 2011;14:61-67.
31. 31. Muttikkal TJ, Wintermark M. MRI patterns of global hypoxic-ischemic injury in adults. J Neuroradiol. 2013;40:164-171.
32. 32. Howard RS, Holmes PA, Siddiqui A, et al. Hypoxic-ischaemic brain injury: imaging and neurophysiology abnormalities related to outcome. QJM. 2012;105:551-561.
33. 33. Park JS, Lee SW, Kim H, et al. Efficacy of diffusion-weighted magnetic resonance imaging performed before therapeutic hypothermia in predicting clinical outcome in comatose cardiopulmonary arrest survivors. Resuscitation. 2015;88:132-137.
34. 34. Krumholz A, Stern BJ, Weiss HD. Outcome from coma after cardiopulmonary resuscitation: relation to seizures and myoclonus. Neurology. 1988;38:401-405.
35. 35. Hui AC, Cheng C, Lam A, et al. Prognosis following Postanoxic Myoclonus Status epilepticus. Eur Neurol. 2005;54:10-13.
36. 36. Kongpolprom N, Cholkraisuwat J. Neurological Prognostications for the Therapeutic Hypothermia among Comatose Survivors of Cardiac Arrest. Indian J Crit Care Med. 2018;22:509-518.
37. 37. Poothrikovil RP, Gujjar AR, Al-Asmi A, et al. Predictive Value of Short-Term EEG Recording in Critically ill Adult Patients. Neurodiagn J 2015;55:157-168.
38. 38. Ong C, Gilmore E, Claassen J, et al. Impact of prolonged periodic epileptiformdischarges on coma prognosis. Neurocrit Care. 2012;17:39-44.