Elsevier

Resuscitation

Volume 181, December 2022, Pages 297-303
Resuscitation

Clinical paper
Risk factors for development of cerebral edema following cardiac arrest

https://doi.org/10.1016/j.resuscitation.2022.10.013Get rights and content

Abstract

Background

Cerebral edema following cardiac arrest is a well-known complication of resuscitation and portends a poor outcome. We identified predictors of post-cardiac arrest cerebral edema and tested the association of cerebral edema with discharge outcome.

Methods

We performed a retrospective chart review including patients admitted at a single center between January 2015–March 2020 following resuscitation from in-hospital and out-of-hospital cardiac arrest who had head computed tomography imaging. Our primary outcome was moderate-to-severe cerebral edema, which we defined as loss of grey-white differentiation with effacement of the basal and ambient cisterns and radiographic evidence of uncal herniation. We used logistic regression to test associations of demographic information, clinical predictors and comorbidities with moderate-severe cerebral edema.

Results

We identified 727 patients who met the inclusion criteria, of whom 102 had moderate-to-severe cerebral edema. We identified six independent predictors of moderate-to-severe cerebral edema: younger age, prolonged arrest duration, pulseless electrical activity/asystole as initial rhythm, unwitnessed cardiac arrest, hyperglycemia on admission, and lower Glasgow coma score on presentation. Of patients with moderate-to-severe cerebral edema, 2% survived to discharge, 56% had withdrawal of life-sustaining therapies and 42% progressed to death by neurological criteria.

Conclusions

Our study identified several risk factors associated with the development of cerebral edema following cardiac arrest. Further studies are needed to determine the benefits of early interventions in these high-risk patients.

Introduction

Over 600,000 individuals in the United States suffer cardiac arrest (CA) annually.1, 2 Most patients resuscitated from CA are initially comatose from neuronal injury, of whom some develop cerebral edema.3 Cerebral edema is observed as early as 1 h following CA, may become prominent 24 h following return of spontaneous circulation (ROSC) and is a predictor of poor neurological outcomes.4, 5, 6, 7 Severe cerebral edema may result in death by neurological criteria, withdrawal of life-sustaining therapies (WLST) for perceived poor neurological prognosis, and/or contribute to secondary brain injury.8, 9, 10, 11, 12 We identified factors associated with the development of moderate-to-severe cerebral edema after resuscitation from CA and secondarily quantified the association of edema with outcomes at hospital discharge.

Section snippets

Study design and participants

We performed a retrospective cohort study including patients resuscitated from in-and out-of-hospital CA between January 2015 and March 2020 at a single academic medical center. Our Institutional Review Board approved this study. We included all patients who survived to hospital care and underwent computed tomographic (CT) imaging of the head at any point after ROSC. We excluded those with other neurological conditions that could potentially cause cerebral edema, such as ischemic stroke,

Results

Of 1354 patients screened, 727 (54 %) had confirmed CA with at least one head CT acquired and were included in analysis. Of these, 102 (14 %) had moderate-to-severe cerebral edema. Demographic and clinical features are described in Table 1. Median time from collapse to CT used in analysis did not differ between groups (median 36 [IQR 10–72] vs 22 [IQR 6–72] hours, p = 0.5735), but GWR from a random subset of patients (12 %) differed between both groups (median 0.97 [IQR 0.90–1.02] vs median

Discussion

Cerebral edema is a well-known consequence of CA and is associated with poor outcome. Edema is observed in 2–34 % of patients following OHCA, with great variability based on the inclusion criteria, timing of imaging in relation to CA and the duration of CPR.4, 14 The clinical pathophysiology of hypoxic-ischemic brain injury involves a cascade of events leading to neuronal cell death, with primary injury from cessation of blood flow during CA and secondary injury from reperfusion.15 Cerebral

Conclusion

In our study, moderate-to-severe cerebral edema was more common in those who were younger, had PEA/asystole, prolonged arrest duration, unwitnessed CA, hyperglycemic and had a lower GCS score. There was a high rate of withdrawal of life-sustaining therapies in patients with moderate-to-severe cerebral edema. Although, more research needs to be done to identify if improved resuscitation algorithms could reduce or prevent the development of cerebral edema, our study provides insights on high-risk

CRediT authorship contribution statement

Archana Hinduja: Conceptualization, Investigation, Writing – review & editing. Yevgeniya Gokun: Writing – review & editing. Elochukwu Ibekwe: . Blake Senay: Writing – review & editing. Jonathan Elmer: Writing – review & editing, Supervision.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationship that could have appeared to influence the work reported in this paper.

Acknowledgements

None.

References (40)

  • R.G. Pirrallo et al.

    Effect of an inspiratory impedance threshold device on hemodynamics during conventional manual cardiopulmonary resuscitation

    Resuscitation

    (2005)
  • R.V. Anderson et al.

    Hyperglycemia increases cerebral intracellular acidosis during circulatory arrest

    Ann Thorac Surg

    (1992)
  • Z.L. Fuller et al.

    University of Pittsburgh Post-Cardiac Arrest S. Recovery among post-arrest patients with mild-to-moderate cerebral edema

    Resuscitation

    (2021)
  • S.H. Kim et al.

    Time to reach target glucose level and outcome after cardiac arrest patients treated with therapeutic hypothermia

    J Crit Care

    (2015)
  • K. Nadolny et al.

    Glasgow Coma Scale score of more than four on admission predicts in-hospital survival in patients after out-of-hospital cardiac arrest

    Am J Emerg Med

    (2021)
  • K.B. Sondergaard et al.

    Out-of-hospital cardiac arrest: 30-day survival and 1-year risk of anoxic brain damage or nursing home admission according to consciousness status at hospital arrival

    Resuscitation

    (2020)
  • M. Breil et al.

    Randomised study of hypertonic saline infusion during resuscitation from out-of-hospital cardiac arrest

    Resuscitation

    (2012)
  • S.S. Virani et al.

    Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

    Circulation

    (2021)
  • A.R. Panchal et al.

    Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

    Circulation

    (2020)
  • R.G. Geocadin et al.

    Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement From the American Heart Association

    Circulation

    (2019)
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