VALIDITY OF THE ADJUNCTIVE USE OF BEDSIDE NONINVASIVE CLINICAL EXAMINATION AND TRANSCRANIAL DOPPLER ULTRASOUND IN OUTCOME PREDICTION AFTER CARDIAC ARREST

Abstract

Background: Neurological recovery after resuscitation from cardiac arrest (CA) can be potentially evaluated by
clinical examination. The aim of the present study was to validate the adjunctive use of transcranial Doppler (TCD)
ultrasound and the clinical examination for guiding outcome prediction within 72 hr after cardiopulmonary resuscitation
(CPR). Methods: 45 adult patients (mean age 51 ±12 yr) successfully resuscitated from CA were prospectively
included in this study. Clinical examination including (Glasgow coma scale (GCS)- motor score, pupil and corneal
reflexes) were carried out after CPR and 24hr, 48hr and 72hr later. Mean cerebral blood flow velocity (MFV) and
pulsatility index (PI) were assessed using TCD ultrasound at the same previous time points. The patients were followed
up for 28 days and then were retrospectively classified into two groups according to cerebral performance category
scale (CPC). Group I (CPC1-2) of good outcome and group II (CPC 3-5) of poor outcome. Results: 28.9% of patients
developed good outcome (CPC1-2) while, 71.1% developed poor outcome (CPC3-5). The number of patients with GCS
– motor score  3 or absent pupil or corneal reflexes was decreased over time until 72 hr in group I in comparison to
group II. MFV values were low after CPR in both groups , but increased significantly in group I in comparison to
group II over time until 72 hr. Also PI mean values were high after CPR in both groups. However, these values
decreased significantly over time until 72 hr in group I in parallel to increase in MFV in comparison to group II. At
72hr after CPR, clinical examination (GCS - motor score  3, absent pupil and corneal reflexes) was +ve predictor of
poor outcome of 92.6% with sensitivity of 78.1% , specificity of 84.6% and accuracy of 80%. TCD ultrasound
measurement (MFV and PI) at 72 hr was +ve predictor of poor outcome of 96.4% with sensitivity of 84.4%, specificity
of 92.3% and accuracy of 86.7%. The combination of clinical examination and TCD measurement raised the percentage
of +ve prediction of poor outcome after 72 hr of CPR to 100% with sensitivity of 90.6%, specificity of 100% and
accuracy of 93.3%. Conclusion: The adjunctive use of bedside, noninvasive clinical examinations and TCD ultrasound
after 72 hr of CPR can potentially achieve more accurate prediction of poor outcome after CA rather than the use of
single modality alone.
Keywords: clinical examination, transcranial Doppler, prediction, outcome, cardiac arrest
INTRODUCTION
espite the advances in cardiopulmonary
resuscitation (CPR) practices, the outcome of
most cardiac arrest (CA) cases remains poor(1).
Patients successfully resuscitated from CA are at
high risk of death or being neurologically
devastated survivors.
Although numerous researches concerning
outcome prediction after CA have been performed,
limited degree of accuracy of early prognostication
still exist(2, 3).
Several parameters (somatosensory evoked
potential "SSEP", electroencephalography "EEG"
and biochemical markers) have been studied to
predict outcome after CA. SSEP is considered one
of the most reliable prognostic tests(1, 2). However,
it requires advanced neurological training, can be
interpreted only in specialized centers and is
influenced by electric field in intensive care(2).
Burst suppression or generalized
epileptiform waves on EEG have insufficient
prognostic accuracy of predicting poor outcome(1).
Furthermore, the need for expertise and its
susceptibility to effect of many