Elsevier

Resuscitation

Volume 65, Issue 1, April 2005, Pages 49-55
Resuscitation

Outcome after cardiac arrest: predictive values and limitations of the neuroproteins neuron-specific enolase and protein S-100 and the Glasgow Coma Scale

https://doi.org/10.1016/j.resuscitation.2004.10.011Get rights and content

Abstract

Background and purpose:

Patients resuscitated from cardiac arrest are at risk of subsequent death or poor neurological outcome up to a persistent vegetative state. We investigated the prognostic value of several epidemiological and clinical markers and two neuroproteins, neuron-specific enolase (NSE) and S-100 protein (S-100), in 97 patients undergoing cardiopulmonary resuscitation (CPR) after non-traumatic cardiac arrest between 1998 and 2002.

Results:

52.6% of the patients died, 28.8% survived with severe, moderate or without neurological disorders, and 18.6% remained in a persistent vegetative state. Unconsciousness >48 h after CPR predicted a 60.6-fold (95% CI 14.3287–257.205, p = 0.001) and a Glasgow Coma Scale (GCS) <6 points after 72 h a 11.2-fold (CI 95%, 3.55–36.44, p < 0.001) risk of poor neurological outcome. Serum levels ≥ 65 ng/ml for NSE and ≥ 1.5 μg/l for S-100 increased the risk of death and persistent vegetative state 16.8 (95% CI 2.146–131.520)- and 12.6 (95% CI 1.1093–99.210)-fold, respectively. By combination of the GCS with elevated serum concentrations of both neuroproteins above the cut off levels on third day after CPR a poor neurological outcome was predicted with a specificity of 100%.

Conclusion:

The combination of GCS with the serum levels of both neuroproteins at 72 h after CPR permit a more reliable prediction of outcome in post arrest coma than the single markers alone, independent of the application of anaesthetic agents.

Introduction

The cessation of cerebral perfusion after cardiac arrest leads to global hypoxic-ischaemic brain damage due to death of neuronal and glia cells. This may lead to severe neurological damage, including persistent apallic syndrome in 20–50% of the long-term survivors [1]. The outcome is determined by the extent of brain damage as well as by the underlying disease. The early assessment of the individual cerebral prognosis of these patients should be of major interest in respect of length of stay, extent of intensive care and outcome.

In our study, we assessed clinical neurological findings, epidemiological and reanimation data as well as the predictive value of the two neuroproteins, neuron-specific enolase (NSE) and S-100 protein (S-100), regarding estimation of individual prognosis after cardiopulmonary resuscitation (CPR). Several authors have shown that different cerebral diseases like ischaemic stroke, meningoencephalitis and head injury cause an elevation serum concentration of NSE and S-100 [2], [3]. The serum levels correlated with the extent of brain damage and in some studies with the prognosis of the patients. Cerebral hypoxia also causes death of neuronal cells as well as damage to the blood brain barrier. Therefore, in our study we investigated the prognostic prediction of these neuroproteins in patients with cardiac arrest and global cerebral hypoxia.

Section snippets

Methods

After approval from the local Ethics Committee, we examined, between 1998 and 2002, 97 patients (28 females, 69 males, mean age 63.3 years [range 17–90 years]) after primary successful CPR in a prospective clinical trial. The study protocol is shown in Table 1. We included only patients who arrived at our intensive care unit within 12 h after ROSC and survived for a minimum of 48 h.

The combined endpoint of the study was the degree of cerebral rehabilitation as well as survival 28 days after CPR.

Reference group

In 23 volunteers (9 females, 14 males, mean age 59 [22–90] years) without any neurological disorders, we examined the serum level of NSE and S-100. The mean serum concentration of NSE was 7.74 (±1.82) ng/ml, and the mean serum concentration of S-100 was 0.09 (±0.07) μg/l. Both levels were below the reference limit of 12.5 ng/ml for NSE and 0.1 μg/l for S-100, set by the manufacturer.

Study group

We included 97 successfully resuscitated patients, who suffered from in- and out-of-hospital non-traumatic cardiac

Baseline characteristics

We investigated 97 patients with primary successful resuscitation, who were admitted within 12 h after ROSC to our intensive care unit and survived at least 48 h.

52.6% of the patients died (GOS 1) and 28.9% survived with severe, moderate or without any neurological disabilities (GOS 3–5) during our observation period. Thirty-nine percent of all survivors developed a persistent vegetative state. These results are in agreement with the findings of other authors like Madl et al. [1]. In a group of

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    A Spanish and Portuguese translated version of the Abstract and Keywords of this article appears at 10.1016/j.resuscitation.2004.10.011.

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