Search

The management of patients in shock or arrest is a critical aspect of emergency medicine and critical care. Rapid and accurate assessment is paramount in determining the underlying causes and initiating timely interventions. This article provides a summary of essential ultrasound protocols for the critically ill patient including the extended focused assessment with sonography for trauma (EFAST), rapid ultrasound for shock and hypotension (RUSH), and sonography in hypotension and cardiac arrest in the emergency department (SHoC-ED)., Competing Interests: Disclosure Dr J. Rosario has no financial disclosures. Dr J. Lin has no financial disclosures. Dr N. Saltarelli has no financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Thoracic computed tomography scans (CT) are used by several study groups to investigate the circulatory structures (heart and vessels) located behind the pressure point for chest compressions. Yet, it remains unclear how the positioning of these structures is influenced by factors such as intubation, the respiratory cycle and arm positioning., Methods: We retrospectively analyzed data of adult patients with in- or out-of-hospital cardiac arrest who underwent thoracic CT imaging within one year before or up to six months after arrest. A region of interest (ROI) behind the pressure point was defined. The largest structure within this region was defined as "leading circulatory structure", which was the primary outcome. Airway status (intubated versus spontaneous breathing), respiratory cycle (inspiration, expiration, resting expiratory position), and arm position (up over the head versus down beside the trunk) served as covariates in an ordinal regression model., Results: Among 500 initially screened patients, 411 (82.2 %) were included in the analysis. There was a significant association between the arm position and the leading circulatory structure behind the pressure point. However, no association was found with airway status or respiratory cycle. The most frequently identified leading circulatory structure was the left atrium (arms up: 41.8 %, down: 50.7 %), followed by the ascending aorta (up: 23.8 % vs. down: 16.7 %). The left ventricle was the leading structure in only one case (0.2 %, arms down)., Conclusion: This study shows that arm position is significantly associated with the leading circulatory structure behind the pressure point for chest compressions in cardiac arrest., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Abstract: Pediatric cardiac arrest is a rare but time-critical event that poses significant challenges to health care providers. Initiation of point-of-care ultrasound (POCUS) early in resuscitation can help optimize the location of chest compressions, identify inadequate compressions, evaluate for sonographic pulse, and help direct management. Although several algorithms currently exist to incorporate POCUS into adult cardiac arrest, none, to our knowledge, currently exist for the pediatric population. We propose a novel protocol for POCUS use as an adjunct to existing standard-of-care measures in pediatric cardiac arrest, which we call the Pediatric Ultrasound for Life-Supporting Efforts protocol., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Long-term cognitive impairment is common in cardiac arrest survivors. Screening to identify patients at risk is recommended. Functional magnetic resonance brain imaging (fMRI) holds potential to contribute to prediction of cognitive outcomes. In this study, we investigated the possible value of early changes in resting-state networks for predicting short and long-term cognitive functioning of cardiac arrest survivors. We performed a prospective multicenter cohort study in cardiac arrest survivors in three Dutch hospitals. Resting-state fMRI scans were acquired within a month after cardiac arrest. We primarily focused on functional connectivity within the default-mode network (DMN) and salience network (SN), and additionally explored functional connectivity in seven other networks. Cognitive outcome was measured using the Montreal Cognitive Assessment (MoCA) during hospital admission and at 3 and 12 months, and by neuropsychological examination (NPE) at 12 months. We tested mixed effects models to evaluate the value of connectivity within the networks for predicting global cognitive outcomes at the three time points, and long-term cognitive outcomes in the memory, attention, and executive functioning domains. We included 80 patients (age 60 ± 11 years, 72 (90%) male). MoCA scores increased significantly between hospital admission and 3 months (ΔMoCA hospital-3M  = 2.89, p < 0.01), but not between 3 and 12 months (ΔMoCA 3M-12M  = 0.38, p = 0.52). Connectivity within the DMN, SN, and dorsal attention network (DAN) was positively related to global cognitive functioning during hospital admission (β DMN  = 0.85, p = 0.03; β SN  = 1.48, p < 0.01; β DAN  = 0.96, p = 0.01), but not at 3 and 12 months. Network connectivity was also unrelated to long-term memory, attention, or executive functioning. Resting-state functional connectivity in the DMN, SN, and DAN measured in the first month after cardiac arrest is related to short-term global, but not long-term global or domain-specific cognitive performance of survivors. These results do not support the value of functional connectivity within these RSNs for prediction of long-term cognitive performance after cardiac arrest., (© 2024 The Author(s). Human Brain Mapping published by Wiley Periodicals LLC.)

Cardiac arrest is a hyper-acute condition with a high mortality that requires rapid diagnostics and treatment. As such, point-of-care ultrasound (POCUS) has become a valuable tool in the assessment of these patients. While transthoracic echocardiography (TTE) is the more conventional modality used to find reversible causes of cardiac arrest, transoesophageal echocardiography (TOE) has been increasingly utilised due to its superior image quality, continuous imaging, and ability to be operated away from the patient's chest. TOE also has a number of applications in the aftermath of cardiac arrest, such as during the initiation of extracorporeal cardiopulmonary resuscitation (ECPR) and the subsequent monitoring of extracorporeal membranous oxygenation (ECMO). As TOE has evolved, multiple variations have been developed with different utilities. In this article, we will review the evidence supporting the use of TOE in cardiac arrest and where the different forms of TOE can be applied to evaluate the cardiac arrest patient in a timely and accurate manner., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Purpose: We aimed to predict the neurological prognosis of cardiac arrest (CA) patients using quantitative imaging biomarkers extracted from brain computed tomography images., Methods: We retrospectively enrolled 86 CA patients (good prognosis, 32; poor prognosis, 54) who were treated at three hospitals between 2017 and 2019. We then extracted 1131 quantitative imaging biomarkers from whole-brain and local volumes of interest in the computed tomography images of the patients. The data were split into training and test sets containing 60 and 26 samples, respectively, and the training set was used to select representative quantitative imaging biomarkers for classification. In univariate analysis, the classification was evaluated using the p-value of the Brunner-Munzel test and area under the receiver operating characteristic curve (AUC) for the test set. In multivariate analysis, machine learning models reflecting nonlinear and complex relations were trained, and they were evaluated using the AUC on the test set., Results: The best performance provided p = 0.009 (<0.01) and an AUC of 0.775 (95% confidence interval, 0.590-0.960) for the univariate analysis and an AUCof0.813 (95% confidence interval, 0.640-0.985) for the multivariate analysis. Overall, the gray level with the maximum gradient in the histogram of the three-dimensionally low-pass-filtered image was an important feature for prediction across the analyses., Conclusions: Quantitative imaging biomarkers can be used in neurological prognosis prediction for CA patients. Relevant biomarkers may contribute to protocolized computed tomography image acquisition to ensure proper decision support in acute care., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Associazione Italiana di Fisica Medica e Sanitaria. Published by Elsevier Ltd. All rights reserved.)

Abstract: An 83-year-old man with multiple myeloma and history of coronary artery disease and ischemic cardiomyopathy experienced cardiac arrest during the 18 F-FDG PET/CT examination. The patient had not yet been treated for multiple myeloma. The PET/CT demonstrated focal FDG uptake about the left anterior descending coronary artery. Diffuse intense FDG uptake in the liver and less than normal uptake in other organs of usual FDG distribution were also present, likely due to altered hemodynamics and heart failure in the setting of an acute coronary syndrome., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care., Recent Findings: POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care., Summary: POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Early identification of the severity of hypoxic-ischemic brain injury (HIBI) after cardiac arrest can be used to help plan appropriate subsequent therapy. We evaluated whether conductivity of cerebral tissue measured using magnetic resonance-based conductivity imaging (MRCI), which provides contrast derived from the concentration and mobility of ions within the imaged tissue, can reflect the severity of HIBI in the early hours after cardiac arrest., Methods: Fourteen minipigs were resuscitated after 5 min or 12 min of untreated cardiac arrest. MRCI was performed at baseline and at 1 h and 3.5 h after return of spontaneous circulation (ROSC)., Results: In both groups, the conductivity of cerebral tissue significantly increased at 1 h after ROSC compared with that at baseline (P = 0.031 and 0.016 in the 5-min and 12-min groups, respectively). The increase was greater in the 12-min group, resulting in significantly higher conductivity values in the 12-min group (P = 0.030). At 3.5 h after ROSC, the conductivity of cerebral tissue in the 12-min group remained increased (P = 0.022), whereas that in the 5-min group returned to its baseline level., Conclusions: The conductivity of cerebral tissue was increased in the first hours after ROSC, and the increase was more prominent and lasted longer in the 12-min group than in the 5-min group. Our findings suggest the promising potential of MRCI as a tool to estimate the severity of HIBI in the early hours after cardiac arrest., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Early prediction of the recovery of consciousness in comatose cardiac arrest patients remains challenging. We prospectively studied task-relevant fMRI responses in 19 comatose cardiac arrest patients and five healthy controls to assess the fMRI's utility for neuroprognostication. Tasks involved instrumental music listening, forward and backward language listening, and motor imagery. Task-specific reference images were created from group-level fMRI responses from the healthy controls. Dice scores measured the overlap of individual subject-level fMRI responses with the reference images. Task-relevant responsiveness index (Rindex) was calculated as the maximum Dice score across the four tasks. Correlation analyses showed that increased Dice scores were significantly associated with arousal recovery ( P < 0.05 ) and emergence from the minimally conscious state (EMCS) by one year ( P < 0.001 ) for all tasks except motor imagery. Greater Rindex was significantly correlated with improved arousal recovery (P = 0.002) and consciousness (P = 0.001). For patients who survived to discharge ( n = 6 ), the Rindex's sensitivity was 75% for predicting EMCS (n = 4). Task-based fMRI holds promise for detecting covert consciousness in comatose cardiac arrest patients, but further studies are needed to confirm these findings. Caution is necessary when interpreting the absence of task-relevant fMRI responses as a surrogate for inevitable poor neurological prognosis., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Point-of-care ultrasound (POCUS) holds immense potential to manage critically deteriorating infants within the neonatal intensive care unit (NICU) and is increasingly used in neonatal clinical practice worldwide. Recent ultrasound-based protocols such as the Sonographic Assessment of liFe-threatening Emergencies-Revised (SAFE-R) and Crashing Neonate Protocol (CNP) offer step-by-step guidance for diagnosing and addressing reversible causes of cardiorespiratory collapse. Traditionally, pulseless electrical activity (PEA) has been diagnosed solely based on absent pulses on clinical examination, disregarding myocardial activity. However, integrating POCUS into resuscitation unveils the concept of pseudo-PEA, where cardiac motion activity is observed visually on the ultrasound but fails to generate a detectable pulse due to inadequate cardiac output. Paradoxically, existing neonatal resuscitation protocols lack directives for identifying and effectively leveraging pseudo-PEA insights in infants, limiting their potential to enhance outcomes. Pseudo-PEA is extensively described in adult literature owing to routine POCUS use in resuscitation. This review article comprehensively evaluates the adult pseudo-PEA literature to glean insights adaptable to neonatal care. Additionally, we propose a simple strategy to integrate POCUS during neonatal resuscitation, especially in infants who do not respond to routine measures., Conclusion: Pseudo-PDA is a newly recognized diagnosis in infants with the use of POCUS during resuscitation. This article highlights the importance of cross-disciplinary learning in tackling emerging challenges within neonatal medicine., What Is Known: • Point-of-Care ultrasound (POCUS) benefits adult cardiac arrest management, particularly in distinguishing true Pulseless Electrical Activity (PEA) from pseudo-PEA. • Pseudo-PEA is when myocardial motion can be seen on ultrasound but fails to generate palpable pulses or sustain circulation despite evident cardiac electrical activity., What Is New: • Discuss recognition and management of pseudo-PEA in infants. • A proposed algorithm to integrate POCUS into active neonatal cardiopulmonary resuscitation (CPR) procedures., (© 2023. The Author(s).)

Cardiac arrest is a common cause of death annually mainly due to postcardiac arrest syndrome that leads to multiple organ global hypoxia and dysfunction after resuscitation. The ability to quantify vasculature changes and tissue oxygenation is crucial to adapt patient treatment in order to minimize major outcomes after resuscitation. For the first time, we applied high-resolution ultrasound associated with photoacoustic imaging (PAI) to track neurovascular oxygenation and cardiac function trajectories in a murine model of cardiac arrest and resuscitation. We report the preservation of brain oxygenation is greater compared to that in peripheral tissues during the arrest. Furthermore, distinct patterns of cerebral oxygen decay may relate to the support of vital brain functions. In addition, we followed trajectories of cerebral perfusion and cardiac function longitudinally after induced cardiac arrest and resuscitation. Volumetric cerebral oxygen saturation (sO2) decreased 24 h postarrest, but these levels rebounded at one week. However, systolic and diastolic cardiac dysfunction persisted throughout and correlated with cerebral hypoxia. Pathophysiologic biomarker trends, identified via cerebral PAI in preclinical models, could provide new insights into understanding the pathophysiology of cardiac arrest and resuscitation.

Point-of-care ultrasound (POCUS) is an expanding noninvasive diagnostic modality used for the management of patients in multiple intensive care and pediatric specialties. POCUS is used to assess cardiac activity and pathology, pulmonary disease, intravascular volume status, intra-abdominal processes, procedural guidance including vascular access, lumbar puncture, thoracentesis, paracentesis, and pericardiocentesis. POCUS has also been used to determine anterograde flow following circulatory arrest when organ donation after circulatory death is being considered. Published guidelines exist from multiple medical societies including the recent guidelines for the use of POCUS in neonatology for diagnostic and procedural purposes., Competing Interests: Dr. Su received funding from Stanford University School of Medicine, Children’s Hospital of Philadelphia, and the University of Texas Health Science Center at San Antonio; he disclosed that he has had a past relationship with Children’s Hospital and Medical Center, Omaha. Dr. Nakagawa received author royalties from Wolters-Kluwer and UpToDate. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

While transesophageal echocardiography (TEE) has traditionally been used in perioperative care, there is growing evidence supporting point of care ultrasound (POCUS) for the anesthesiologist in guiding patient care. It is a quick way to non-invasively evaluate hemodynamically unstable patients and ascertain their state of shock, determine volume status, and guide resuscitation in cardiac arrest. In addition, through use of POCUS, the anesthesiologist is able to identify signs of chronic heart disease to provide a more tailored and safer approach to perioperative care., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of patients in cardiac arrest. It can help identify possible causes of cardiac arrest like tamponade and pulmonary embolism, which can guide therapy. US can also yield prognostic information, with lack of cardiac activity being highly specific for failure to achieve return of spontaneous circulation. US may also be used to aid in procedural guidance. Recently, focused transesophageal echocardiography has been used in the emergency department setting., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose of Review: Many patients who survive a cardiac arrest have a disorder of consciousness in the period after resuscitation, and prediction of long-term neurologic outcome requires multimodal assessments. Brain imaging with computed tomography (CT) and MRI is a key component. We aim to provide an overview of the types of neuroimaging available and their uses and limitations., Recent Findings: Recent studies have evaluated qualitative and quantitative techniques to analyze and interpret CT and MRI to predict both good and poor outcomes. Qualitative interpretation of CT and MRI is widely available but is limited by low inter-rater reliability and lack of specificity around which findings have the highest correlation with outcome. Quantitative analysis of CT (gray-white ratio) and MRI (amount of brain tissue with an apparent diffusion coefficient below certain thresholds) hold promise, though additional research is needed to standardize the approach., Summary: Brain imaging is important for evaluating the extent of neurologic injury after cardiac arrest. Future work should focus on addressing previous methodological limitations and standardizing approaches to qualitative and quantitative imaging analysis. Novel imaging techniques are being developed and new analytical methods are being applied to advance the field., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Transesophageal echocardiography (TEE) is an emerging tool that can aid emergency physicians in treating patients in cardiac arrest and undifferentiated shock. TEE can aid in diagnosis, resuscitation, identify cardiac rhythms, guide chest compression vectors, and shorten sonographic pulse checks. This study evaluated the proportion of patients who underwent a change in their resuscitation management as a result of emergency department resuscitative TEE., Methods: This was a single-centre case series of 25 patients who underwent ED resuscitative TEE from 2015 to 2019. The objective of this study is to evaluate the feasibility and clinical impact of resuscitative TEE in critically ill patients in the emergency department. Data including changes in working diagnosis, complications, patient disposition, and survival to hospital discharge were also collected., Results: 25 patients (median age 71, 40% female) underwent ED resuscitative TEE. All patients were intubated prior to probe insertion and adequate TEE views were obtained for every patient. The most common indications for resuscitative TEE were cardiac arrest (64%) and undifferentiated shock (28%). Resuscitation management changed in 76% (N = 19) and working diagnosis changed in 76% (N = 19) of patients. Ten patients died in the ED, 15 were admitted to hospital, and eight survived to hospital discharge. There were no immediate complications (0/15) and two delayed complications (2/15), both of which were minor gastrointestinal bleeding., Conclusions: The use of ED resuscitative TEE is a practical modality that provides useful diagnostic and therapeutic information for critically ill patients in the emergency department, with an excellent rate of adequate cardiac visualization, and a low complication rate., (© 2023. The Author(s).)

Study Objective: This study explored femoral arterial Doppler during active cardiopulmonary resuscitation (CPR) to identify and characterize the resumptions of cardiac activity without stopping CPR., Methods: This was a proof-of-concept study exploring arterial Doppler during cardiac arrest. Patients in cardiac arrest undergoing active CPR were prospectively enrolled. Arterial Doppler of the common femoral artery was recorded during CPR and during pauses in CPR. CPR-induced arterial tracings and native cardiac-induced tracings were analyzed for rate and peak systolic velocity. Cardiac activity on echocardiogram during pause in CPR was classified as "absent," "disorganized," or "organized." Descriptive data and survival are presented as mean and 95% confidence intervals (CI), as well as sensitivity and specificity of Doppler during active CPR in detecting native cardiac pulsations., Results: Sixteen patients with 48 paired Doppler recordings during active CPR, pause in CPR, and associated echocardiogram were enrolled. Native cardiac-induced tracings were visible during 39.6% of pauses in CPR (19 of 48) and during 18.8% of the periods of active CPR (9 of 48). Arterial pulsations were more frequently visualized with organized contractions by echocardiogram (10 of 14, 71%) than disorganized contractions (9 of 22, 41%). Arterial Doppler was 100% specific and 50% sensitive in detecting organized cardiac activity during active CPR. Patients with visible native cardiac pulsations during active CPR demonstrated 0% mortality compared with 67% mortality without visible arterial pulsations., Conclusion: Arterial Doppler tracings may identify the resumption of native cardiac activity during active CPR; however, more research is needed., (Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Predicting poor neurological outcomes after resuscitation is important for planning treatment strategies. We constructed an explainable artificial intelligence-based prognostic model using head computed tomography (CT) scans taken immediately within 3 h of resuscitation from cardiac arrest and compared its predictive accuracy with that of previous methods using gray-to-white matter ratio (GWR). We included 321 consecutive patients admitted to our institution after resuscitation for out-of-hospital cardiopulmonary arrest with circulation resumption over 6 years. A machine learning model using head CT images with transfer learning was used to predict the neurological outcomes at 1 month. These predictions were compared with the predictions of GWR for multiple regions of interest in head CT using receiver operating characteristic (ROC)-area under curve (AUC) and precision recall (PR)-AUC. The regions of focus were visualized using a heatmap. Both methods had similar ROC-AUCs, but the machine learning model had a higher PR-AUC (0.73 vs. 0.58). The machine learning-focused area of interest for classification was the boundary between gray and white matter, which overlapped with the area of focus when diagnosing hypoxic- ischemic brain injury. The machine learning model for predicting poor outcomes had superior accuracy to conventional methods and could help optimize treatment., (© 2023. The Author(s).)

Background and Purpose: MR imaging of the brain provides unbiased neuroanatomic evaluation of brain injury and is useful for neurologic prognostication following cardiac arrest. Regional analysis of diffusion imaging may provide additional prognostic value and help reveal the neuroanatomic underpinnings of coma recovery. The purpose of this study was to evaluate global, regional, and voxelwise differences in diffusion-weighted MR imaging signal in patients in a coma after cardiac arrest., Materials and Methods: We retrospectively analyzed diffusion MR imaging data from 81 subjects who were comatose for >48 hours following cardiac arrest. Poor outcome was defined as the inability to follow simple commands at any point during hospitalization. ADC differences between groups were evaluated across the whole brain, locally by using voxelwise analysis and regionally by using ROI-based principal component analysis., Results: Subjects with poor outcome had more severe brain injury as measured by lower average whole-brain ADC (740 [SD, 102] × 10 -6 mm 2 /s versus 833 [SD, 23] × 10 -6 mm 2 /s, P  < .001) and larger average volumes of tissue with ADC below 650 × 10 -6 mm s /s (464 [SD, 469] mL versus 62 [SD, 51] mL, P  < .001). Voxelwise analysis showed lower ADC in the bilateral parieto-occipital areas and perirolandic cortices for the poor outcome group. ROI-based principal component analysis showed an association between lower ADC in parieto-occipital regions and poor outcome., Conclusions: Brain injury affecting the parieto-occipital region measured with quantitative ADC analysis was associated with poor outcomes after cardiac arrest. These results suggest that injury to specific brain regions may influence coma recovery., (© 2023 by American Journal of Neuroradiology.)

Purpose: Amniotic fluid embolism (AFE) is a leading cause of obstetrical cardiac arrest and maternal morbidity. The pathogenesis of hemodynamic collapse is thought to be from right ventricular (RV) failure; however, there is a paucity of data documenting echocardiography findings in this population. We undertook a systematic review of the literature to evaluate the echocardiography findings in patients with AFE., Sources: We retrieved all case reports and case series reporting AFE in Embase and MEDLINE from inception to 20 November 2021. Studies reporting AFE diagnosed by fulfilling at least one of three different proposed AFE criteria and echocardiography findings during hospitalization were included. Patient and echocardiographic data were retrieved, and univariate logistic regression analysis was performed for outcomes of interest. Bias was assessed using the Joanna Briggs Institute clinical appraisal tool for case series., Principal Findings: Eighty publications reporting on 84 patients were included in the final review. Fifty-five out of 82 patients with data (67%) showed RV dysfunction, including 11/82 (13%) with biventricular dysfunction; 14/82 (17%) had normal systolic function. No data on RV or left ventricular function were reported for two patients. The presence of RV dysfunction on echocardiography was associated with cardiac arrest (odds ratio [OR], 3.66; 95% confidence interval [CI], 1.39 to 9.67; P = 0.009), and a composite risk of cardiac arrest, maternal death or use of extracorporeal membrane oxygenation (OR, 3.86; 95% CI, 1.43 to 10.4; P = 0.007). A low risk of bias was observed in 15/84 (18%) cases., Conclusions: Right ventricular dysfunction on echocardiography is a common finding in AFE and is associated with a high risk of cardiac arrest. The finding of RV dysfunction on echocardiography may help diagnose AFE and help triage the highest risk patients with AFE., Study Registration: PROSPERO (CRD42021271323); registered 1 September 2021., (© 2022. Canadian Anesthesiologists' Society.)

Background: Cardiac arrest (CA) is associated with worse outcomes in patients with cardiogenic shock (CS). To better understand the contribution of CA on CS, we evaluated transthoracic echocardiography (TTE) parameters in CS patients with and without CA., Methods: We retrospectively identified CS patients with a TTE performed near cardiac intensive care unit admission between 2007 to 2018. We compared TTE measurements of left ventricular (LV) and right ventricular (RV) function in patients with and without CA. The primary outcome was all-cause in-hospital mortality, as determined using multivariable logistic regression., Results: We included 1085 patients, 35% of whom had CA. Median age was 70 years and 37% were females. CA patients had higher severity of illness, more invasive mechanical ventilation and greater vasopressor/inotrope use. In-hospital mortality was 31% and was higher in CA patients (45% vs. 23%, p <0.001). Although LV ejection fraction (LVEF) was similar (35% vs. 37%, p = 0.05), CA patients had lower cardiac index, mitral valve E wave peak velocity, E/A ratio and E/e' ratio. TTE variables that were associated with hospital mortality varied, among patients with CA, these included measures of RV pressure and function and among patients without CA, these included parameters reflecting LV systolic function., Conclusions: Doppler assessments of RV systolic dysfunction were the strongest TTE predictors of hospital mortality in CS patients with CA, unlike CS patients without CA in whom LV systolic function was more important. This emphasizes the importance of RV assessment for mortality risk stratification after CA.

Background and Objectives: Diffusion MRI can quantify the extent of hypoxic-ischemic brain injury after cardiac arrest. Our objective was to determine the association between the adult-derived threshold of apparent diffusion coefficient (ADC) <650 × 10 -6 mm 2 /s in >10% of brain tissue and an unfavorable outcome after pediatric cardiac arrest. Since ADC decreases exponentially as a function of increasing age, we determined the association between (1) having >10% of brain tissue below a novel age-dependent ADC threshold, and (2) age-normalized whole-brain mean ADC and unfavorable outcome., Methods: This was a retrospective study of patients aged ≤18 years who had cardiac arrest and a clinically obtained brain MRI within 7 days. The primary outcome was unfavorable neurologic status at hospital discharge based on the Pediatric Cerebral Performance Category score. ADC images were extracted from 3-direction diffusion imaging. We determined whether each patient had >10% of voxels with an ADC below prespecified thresholds. We computed the whole-brain mean ADC for each patient., Results: One hundred thirty-four patients were analyzed. Patients with ADC <650 × 10 -6 mm 2 /s in >10% of voxels had 15 times higher odds (95% CI 5-65) of an unfavorable outcome compared with patients with ADC <650 × 10 -6 mm 2 /s (area under the receiver operating characteristic curve [AUROC] 0.72 [95% CI 0.63-0.80]). These ADC criteria had a sensitivity and specificity of 0.49 and 0.94, respectively, and positive and negative predictive values of 0.93 and 0.52, respectively, for an unfavorable outcome. The age-dependent ADC threshold that yielded optimal sensitivity and specificity for unfavorable outcomes was <300 × 10 -6 mm 2 /s below each patient's predicted whole-brain mean ADC. The sensitivity, specificity, and positive and negative predictive values for this ADC threshold were 0.53, 0.96, 0.96, and 0.54, respectively (odds ratio [OR] 26.4 [95% CI 7.5-168.3]; AUROC 0.74 [95% CI 0.66-0.83]). Lower age-normalized whole-brain mean ADC was also associated with an unfavorable outcome (OR 0.42 [0.24-0.64], AUROC 0.76 [95% CI 0.66-0.82])., Discussion: Quantitative diffusion thresholds on MRI within 7 days after cardiac arrest were associated with an unfavorable outcome in children. The age-independent ADC threshold was highly specific for predicting an unfavorable outcome. However, the specificity and sensitivity increased when using age-dependent ADC thresholds. Age-dependent ADC thresholds may improve prognostic accuracy and require further investigation in larger cohorts., Classification of Evidence: This study provides Class III evidence that quantitative diffusion-weighted imaging within 7 days postarrest can predict an unfavorable clinical outcome in children., (© 2022 American Academy of Neurology.)

Background: Advances in resuscitation techniques have resulted in more patients surviving cardio-circulatory arrest (CA) and consequently developing hypoxic/anoxic brain damage. The aim of this study is to evaluate the role of PET/CT (Positron Emission Tomography/Computerized Tomography scan) with F-18 FDG (F-18 fluorodeoxyglucose) during the early rehabilitative hospitalization phase in determining the V/C (Vermis/Cerebellar) ratio as a prognostic index to predict patient outcome, as defined by clinical evaluation scales., Methods: This is a single-center retrospective study of 37 consecutive adult patients admitted to the neurorehabilitation center between January 2011 and June 2019. Functional status was measured by the following clinical scales: FIM (Functional Indipendence Measure), LCFS (Levels of Cognitive Functioning Scale), GOS (Glasgow Outcome Scale) and CRS-R (Coma Recovery Scale-Revised). PET/CT with F-18 FDG as a functional imaging technique was used to calculate the V/C ratio as a ratio between the metabolism of the vermis and of the Cerebellar Hemisphere., Results: A statistically significant correlation was observed between the V/C ratio and the delta values (difference between discharge and admission value) for each clinical evaluation scale (Delta FIM: P=0.0014; Delta LCFS P=0.0003). A statistically significant difference was observed between the V/C ratio of patients with LCFS ≥4 that showed an improved outcome (defined as an improvement of at least two points in LCFS), and that of patients with LCFS <4 that did not improve (P=0.0011). A V/C ratio cut-off of 1.5 corresponded with a positive predictive power of 80% and a negative predictive power of 82%; a value <1.5 predicted a better outcome., Conclusions: Clinical evaluation scales when associated with F-18 FDG PET/CT measurement of metabolism, provide a more reliable prognosis. This allows for more focused rehabilitation treatment and better management of family members' expectation.

Background: Use of magnetic resonance imaging (MRI) as a tool to aid in neuroprognostication after cardiac arrest (CA) has been described, yet details of specific indications, timing, and sequences are unknown. We aim to define the current practices in use of brain MRI in prognostication after pediatric CA., Methods: A survey was distributed to pediatric institutions participating in three international studies. Survey questions related to center demographics, clinical practice patterns of MRI after CA, neuroimaging resources, and details regarding MRI decision support., Results: Response rate was 31% (44 of 143). Thirty-four percent (15 of 44) of centers have a clinical pathway informing the use of MRI after CA. Fifty percent (22 of 44) of respondents reported that an MRI is obtained in nearly all patients with CA, and 32% (14 of 44) obtain an MRI in those who do not return to baseline neurological status. Poor neurological examination was reported as the most common factor (91% [40 of 44]) determining the timing of the MRI. Conventional sequences (T1, T2, fluid-attenuated inversion recovery, and diffusion-weighted imaging/apparent diffusion coefficient) are routinely used at greater than 97% of centers. Use of advanced imaging techniques (magnetic resonance spectroscopy, diffusion tensor imaging, and functional MRI) were reported by less than half of centers., Conclusions: Conventional brain MRI is a common practice for prognostication after CA. Advanced imaging techniques are used infrequently. The lack of standardized clinical pathways and variability in reported practices support a need for higher-quality evidence regarding the indications, timing, and acquisition protocols of clinical MRI studies., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Despite application of the multimodal European Resuscitation Council and European Society of Intensive Care Medicine algorithm, neurological prognosis of patients who remain comatose after cardiac arrest remains uncertain in a large group of patients. In this study, we investigate the additional predictive value of visual and quantitative brain magnetic resonance imaging (MRI) to electroencephalography (EEG) for outcome estimation of comatose patients after cardiac arrest., Methods: We performed a prospective multicenter cohort study in patients after cardiac arrest submitted in a comatose state to the intensive care unit of two Dutch hospitals. Continuous EEG was recorded during the first 3 days and MRI was performed at 3 ± 1 days after cardiac arrest. EEG at 24 h and ischemic damage in 21 predefined brain regions on diffusion weighted imaging and fluid-attenuated inversion recovery on a scale from 0 to 4 were related to outcome. Quantitative MRI analyses included mean apparent diffusion coefficient (ADC) and percentage of brain volume with ADC < 450 × 10 -6 mm 2 /s, < 550 × 10 -6 mm 2 /s, and < 650 × 10 -6 mm 2 /s. Poor outcome was defined as a Cerebral Performance Category score of 3-5 at 6 months., Results: We included 50 patients, of whom 20 (40%) demonstrated poor outcome. Visual EEG assessment correctly identified 3 (15%) with poor outcome and 15 (50%) with good outcome. Visual grading of MRI identified 13 (65%) with poor outcome and 25 (89%) with good outcome. ADC analysis identified 11 (55%) with poor outcome and 3 (11%) with good outcome. EEG and MRI combined could predict poor outcome in 16 (80%) patients at 100% specificity, and good outcome in 24 (80%) at 63% specificity. Ischemic damage was most prominent in the cortical gray matter (75% vs. 7%) and deep gray nuclei (45% vs. 3%) in patients with poor versus good outcome., Conclusions: Magnetic resonance imaging is complementary with EEG for the prediction of poor and good outcome of patients after cardiac arrest who are comatose at admission., (© 2022. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

The efficacy of ultrasound (US) in real-time differential diagnosis and guiding further treatment decisions has been well demonstrated in prearrest conditions and during resuscitation. Evidence is limited regarding the application of US in postresuscitation care. Most of the patients following resuscitation remain comatose, and the requirement for transportation to other examination rooms increases their risk of injury. US can be performed at the bedside with high accessibility and timeliness without radiation. This narrative review provides an overview of current evidence regarding the application of US in identifying the cause of cardiac arrest (CA), hemodynamic monitoring, and prognostication in postresuscitation care. For identifying the cause of CA, cardiac US is mainly used to detect regional wall motion abnormality. However, postarrest myocardial dysfunction would confound the sonographic findings that a combination of electrocardiograms and biomarkers besides the cardiac US could improve the positive predictive value of coronary artery disease. For hemodynamic monitoring, left ventricular outlet tract velocity time integral has the best performance in predicting fluid responsiveness in conjunction with the passive leg raising test. The RUSH protocol assists in determining the subtypes of shock with high sensitivity and specificity in hypovolemic, cardiogenic, or obstructive shock. Evidence regarding the application of US for prognostication is still limited, and further evaluation should be needed., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

One of the main causes of out-of-hospital cardiac arrest is acute myocardial infarction (AMI). After successful resuscitation from cardiac arrest, approximately 70% of patients die before hospital discharge due to post-resuscitation myocardial and cerebral dysfunction. In experimental models, myocardial dysfunction after cardiac arrest, characterized by an impairment in both left ventricular (LV) systolic and diastolic function, has been described as reversible but very little data are available in cardiac arrest models associated with AMI in pigs. Transthoracic echocardiography is the first-line diagnostic test for the assessment of myocardial dysfunction, structural changes and/or AMI extension. In this pig model of ischemic cardiac arrest, echocardiography was done at baseline and 2-4 and 96 hours after resuscitation. In the acute phase, the examinations are done in anesthetized, mechanically ventilated pigs (weight 39.8 ± 0.6 kg) and ECG is recorded continuously. Mono- and bi-dimensional, Doppler and tissue Doppler recordings are acquired. Aortic and left atrium diameter, end-systolic and end-diastolic left ventricular wall thicknesses, end-diastolic and end-systolic diameters and shortening fraction (SF) are measured. Apical 2-, 3-, 4-, and 5-chamber views are acquired, LV volumes and ejection fraction are calculated. Segmental wall motion analysis is done to detect the localization and estimate the extent of myocardial infarction. Pulsed Wave Doppler echocardiography is used to record trans-mitral flow velocities from a 4-apical chamber view and trans-aortic flow from a 5-chamber view to calculate LV cardiac output (CO) and stroke volume (SV). Tissue Doppler Imaging (TDI) of LV lateral and septal mitral anulus is recorded (TDI septal and lateral s', e', a' velocities). All the recordings and measurements are done according to the recommendations of the American and European Societies of Echocardiography Guidelines.

Purpose: The mammalian brain glucose metabolism is tightly and sensitively regulated. An ischemic brain injury caused by cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) affects cerebral function and presumably also glucose metabolism. The majority of patients who survive CA suffer from cognitive deficits and physical disabilities. Toll-like receptor 2 (TLR2) plays a crucial role in inflammatory response in ischemia and reperfusion (I/R). Since deficiency of TLR2 was associated with increased survival after CA-CPR, in this study, glucose metabolism was measured using non-invasive [ 18 F]F-FDG PET-CT imaging before and early after CA-CPR in a mouse model comparing wild-type (WT) and TLR2-deficient (TLR2 -/- ) mice. The investigation will evaluate whether FDG-PET could be useful as an additional methodology in assessing prognosis., Procedures: Two PET-CT scans using 2-deoxy-2-[ 18 F]fluoro-D-glucose ([ 18 F]F-FDG) tracer were carried out to measure dynamic glucose metabolism before and early after CPR. To achieve this, anesthetized and ventilated adult female WT and TLR2 -/- mice were scanned in PET-CT. After recovery from the baseline scan, the same animals underwent 10-min KCL-induced CA followed by CPR. Approximately 90 min after CA, measurements of [ 18 F]F-FDG uptake for 60 min were started. The [ 18 F]F-FDG standardized uptake values (SUVs) were calculated using PMOD-Software on fused FDG-PET-CT images with the included 3D Mirrione-Mouse-Brain-Atlas., Results: The absolute SUV mean of glucose in the whole brain of WT mice was increased about 25.6% after CA-CPR. In contrast, the absolute glucose SUV in the whole brain of TLR2 -/- mice was not significantly different between baseline and measurements post CA-CPR. In comparison, baseline measurements of both mouse strains show a highly significant difference with regard to the absolute glucose SUV in the whole brain. Values of TLR2 -/- mice revealed a 34.6% higher glucose uptake., Conclusions: The altered mouse strains presented a different pattern in glucose uptake under normal and ischemic conditions, whereby the post-ischemic differences in glucose metabolism were associated with the function of key immune factor TLR2. There is evidence for using early FDG-PET-CT as an additional diagnostic tool after resuscitation. Further studies are needed to use PET-CT in predicting neurological outcomes., (© 2021. The Author(s).)

Objectives: We explore the correlation of contrast-enhanced ultrasound (CEUS) parameters to intracranial pressure (ICP) in a porcine experimental model of pediatric cardiac arrest., Methods: Eleven pediatric pigs underwent electrically induced cardiac arrest followed by cardiopulmonary resuscitation. ICP was measured using intracranial bolt monitor and CEUS was monitored through a cranial window. Various CEUS parameters were monitored at baseline, immediately post return of spontaneous circulation (ROSC), 1 hour-post ROSC, and 3 hours post-ROSC., Results: There was significant ICP correlation with wash-out slope assessed by CEUS time intensity curve analysis at immediate post-ROSC. At 3 hours post-ROSC there was also significant negative correlation between ICP and peak enhancement which may be due to the evolution of anoxic injury., Conclusion: The use of CEUS in assessing disruption of cerebral hemodynamics and ICP post cardiac arrest will need future validation and comparison to other imaging modalities. The correlation between CEUS parameters and ICP may be due to the alterations in cerebral autoregulation that result from anoxic brain injury., (© 2021 American Institute of Ultrasound in Medicine.)

The aim of this study was to use dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and diffusion-weighted magnetic resonance imaging (DWI) to measure changes in blood-brain barrier (BBB) permeability and cerebral edema over time in a rat model of asphyxial cardiac arrest (ACA). ACA was established by endotracheal tube clamping. Male rats were randomized into a sham group (n = 5) and three ACA groups (n = 18). After return of spontaneous circulation (ROSC), the rats were randomized to perform DWI and DCE-MRI exam in the 6 h, 24 h and 72 h timepoint (ROSC + 6 h, ROSC + 24 h, and ROSC + 72 h). Results shows that fifteen of 18 animals achieved successful resuscitation in the ACA groups. The average apparent diffusion coefficient(ADC) value of the whole brain in ROSC + 6 h was markedly lower than those of the sham, ROSC + 24 h, and ROSC + 72 h. The aquaporin-4(AQP4) score in ROSC + 6 h was significantly higher than those in the other groups, which were negatively correlated with the ADC values. The ratio of whole brain to masseter muscle of volume transfer constant (rK trans ), tissue interstitium-to-plasma rate constant(rK ep ), and fractional extra-cellular space volume(rV e) in ROSC + 6 h were all significantly higher than those in the sham, ROSC + 24 h, and ROSC + 72 h. The transforming growth factor β1(TGF-β1) and vascular endothelial growth factor A(VEGF-a) scores in ROSC + 6 h were significantly higher than those in the other groups, which were all positively correlated with rK trans and rK ep . In conclusions, brain injury is a frequent complication after CA and resuscitation. DWI and DCE-MRI can quantitatively evaluate brain injury in term of cerebral edema and BBB permeability after successful CPR., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aim: Current multimodal approaches leave approximately half of the comatose patients after cardiac arrest with an indeterminate prognosis. Here we investigated whether early MRI markers of brain network integrity can distinguish between comatose patients with a good versus poor neurological outcome six months later., Methods: We performed a prospective cohort study in 48 patients after cardiac arrest submitted in a comatose state to the Intensive Care Unit of two Dutch hospitals. MRI was performed at three days after cardiac arrest, including resting state functional MRI and diffusion-tensor imaging (DTI). Resting state fMRI was used to quantify functional connectivity within ten resting-state networks, and DTI to assess mean diffusivity (MD) in these same networks. We contrasted two groups of patients, those with good (n = 29, cerebral performance category 1-2) versus poor (n = 19, cerebral performance category 3-5) outcome at six months. Mutual associations between functional connectivity, MD, and clinical outcome were studied., Results: Patients with good outcome show higher within-network functional connectivity (fMRI) and higher MD (DTI) than patients with poor outcome across 8/10 networks, most prominent in the default mode network, salience network, and visual network. While the anatomical distribution of outcome-related changes was similar for functional connectivity and MD, the pattern of inter-individual differences was very different: functional connectivity showed larger inter-individual variability in good versus poor outcome, while the opposite was observed for MD. Exploratory analyses suggested that it is possible to define network-specific cut-off values that could help in outcome prediction: (1) high functional connectivity and high MD, associated with good outcome; (2) low functional connectivity and low MD, associated with poor outcome; (3) low functional connectivity and high MD, associated with uncertain outcome., Discussion: Resting-state functional connectivity and mean diffusivity-three days after cardiac arrest are strongly associated with neurological recovery-six months later in a complementary fashion. The combination of fMRI and MD holds potential to improve prediction of outcome., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Cardiac arrest can cause hypoxic-anoxic ischemic brain injury due to signaling cascades that lead to damaged cell membranes and vital cellular organelles, resulting in cell death in the setting of low or no oxygen. Some brain areas are more prone to damage than others, so patients with hypoxic-anoxic ischemic brain injury present with several outcomes, including reduced level of consciousness or alertness, memory deficits, uncoordinated movements, and seizures. Some patients may have mild deficits, while others may have such severe injury that it can progress to brain death. High-quality cardiopulmonary resuscitation is a proven technique to improve outcome after cardiac arrest, although morbidity and mortality remain high. Induced hypothermia, which involves artificially cooling the body immediately after cardiac arrest, may reduce injury to the brain and improve morbidity and mortality. Neuroprognostication after cardiac arrest is challenging and requires a multimodal approach involving clinical neurologic examinations, brain imaging, electrical studies to assess brain activity, and biomarkers to predict outcome., (© 2020 New York Academy of Sciences.)

Objectives: Prognostication of outcome is an essential step in defining therapeutic goals after cardiac arrest. Gray-white-matter ratio obtained from brain CT can predict poor outcome. However, manual placement of regions of interest is a potential source of error and interrater variability. Our objective was to assess the performance of poor outcome prediction by automated quantification of changes in brain CTs after cardiac arrest., Design: Observational, derivation/validation cohort study design. Outcome was determined using the Cerebral Performance Category upon hospital discharge. Poor outcome was defined as death or unresponsive wakefulness syndrome/coma. CTs were automatically decomposed using coregistration with a brain atlas., Setting: ICUs at a large, academic hospital with circulatory arrest center., Patients: We identified 433 cardiac arrest patients from a large previously established database with brain CTs within 10 days after cardiac arrest., Interventions: None., Measurements and Main Results: Five hundred sixteen brain CTs were evaluated (derivation cohort n = 309, validation cohort n = 207). Patients with poor outcome had significantly lower radiodensities in gray matter regions. Automated GWR&#95;si (putamen/posterior limb of internal capsule) was performed with an area under the curve of 0.86 (95%-CI: 0.80-0.93) for CTs taken later than 24 hours after cardiac arrest (similar performance in the validation cohort). Poor outcome (Cerebral Performance Category 4-5) was predicted with a specificity of 100% (95% CI, 87-100%, derivation; 88-100%, validation) at a threshold of less than 1.10 and a sensitivity of 49% (95% CI, 36-58%, derivation) and 38% (95% CI, 27-50%, validation) for CTs later than 24 hours after cardiac arrest. Sensitivity and area under the curve were lower for CTs performed within 24 hours after cardiac arrest., Conclusions: Automated gray-white-matter ratio from brain CT is a promising tool for prediction of poor neurologic outcome after cardiac arrest with high specificity and low-to-moderate sensitivity. Prediction by gray-white-matter ratio at the basal ganglia level performed best. Sensitivity increased considerably for CTs performed later than 24 hours after cardiac arrest., Competing Interests: Dr. Leithner’s institution received funding from Pfizer and Bard Medical; he received funding from Edwards Lifesciences. Dr. Leithner was supported by the Berlin Institute of Health (BIH) clinical fellow program. Dr. Streitberger was supported by the BIH clinician scientist program. Dr. Leithner reports honoraria from Edwards Lifesciences and institutional fees from BD Bard, Zoll, and Bristol Meyer Squibb for lectures outside the submitted work. Dr. Kemmling research collaboration agreement: Siemens healthcare. Dr. Storm has received honoraria for lectures and consulting from BD BARD, Benechill, and Sedana Medical and for lectures from Zoll GmbH. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: This study aimed to assess the prognostic value regarding neurologic outcome of CT neuroimaging based Gray-White-Matter-Ratio measurement in patients after resuscitation from cardiac arrest., Methods: We retrospectively evaluated CT neuroimaging studies of 91 comatose patients resuscitated from cardiac arrest and 46 non-comatose controls. We tested the diagnostic performance of Gray-White-Matter-Ratio compared with established morphologic signs of hypoxic-ischaemic brain injury, e. g. loss of distinction between gray and white matter, and laboratory parameters, i. e. neuron-specific enolase, for the prediction of poor neurologic outcomes after resuscitated cardiac arrest. Primary endpoint was neurologic function assessed with cerebral performance category score 30 days after the index event., Results: Gray-White-Matter-Ratio showed encouraging interobserver variability (ICC 0.670 [95% CI: 0.592-0.741] compared to assessment of established morphologic signs of hypoxic-ischaemic brain injury (Fleiss kappa 0.389 [95% CI: 0.320-0.457]) in CT neuroimaging studies. It correlated with cerebral performance category score with lower Gray-White-Matter-Ratios associated with unfavourable neurologic outcomes. A cut-off of 1.17 derived from the control population predicted unfavourable neurologic outcomes in adult survivors of cardiac arrest with 100% specificity, 50.3% sensitivity, 100% positive predictive value, and 39.3% negative predictive value. Gray-White-Matter-Ratio prognostic power depended on the time interval between circulatory arrest and CT imaging, with increasing sensitivity the later the image acquisition was executed., Conclusions: A reduced Gray-White-Matter-Ratio is a highly specific prognostic marker of poor neurologic outcomes early after resuscitation from cardiac arrest. Sensitivity seems to be dependent on the time interval between circulatory arrest and image acquisition, with limited value within the first 12 h., (© 2021. The Author(s).)

We aimed to explore brain area(s) involved in the generation of ictal asystole (IA) by analyzing the interictal positron emission tomography (PET) metabolism of patients with IA recorded by video-electroencephalography or video-stereo-electroencephalography. We identified in our cohort of focal epilepsy patients who had undergone presurgical evaluation those who had a recorded period of IA of more than 3 s. We investigated the anatomometabolic changes (interictal 18 F-fluorodeoxyglucose PET) of these patients in comparison with (1) healthy subjects with similar age and sex distribution (n = 19) using whole-brain voxel-based analysis (p-voxel < .001, p-cluster < .05, uncorrected) and (2) patients without IA with similar age and seizure onset zone (n = 55). We found 12 patients with IA. Epilepsy was mainly temporal (four right temporal mesial, four bitemporal, two left temporal lateral, one right temporal lateral, and one right temporal "plus"). Seven patients had negative magnetic resonance imaging. Whole-brain statistical analysis of PET imaging was performed at the voxel level, showing that in comparison to healthy subjects and to epileptic patients without IA, a hypometabolism in the right posterior insula characterized epileptic patients with IA. Our study suggests involvement of the right posterior insula-a part of the central autonomic network-in the pathophysiological mechanism of IA., (© 2021 International League Against Epilepsy.)