Clinical paper| Volume 164, P12-19, July 2021

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Prognostic value of brainstem auditory and visual evoked potentials in cardiac arrest patients with targeted temperature management



      We analysed the prognostic value of somatosensory, brainstem auditory and visual evoked potentials (SSEPs, BAEPs and VEPs, respectively) for outcome prediction in cardiac arrest patients with targeted temperature management (TTM) and assessed whether BAEP and VEP measurements conferred added value to SSEP measurements.


      Cases with SSEPs and VEPs or BAEPs were reviewed in a TTM registry. We focused on whether the following responses were clearly discernible: N20 for SSEPs, V for BAEPs, and P100 for VEPs. Each type of evoked potential was classified as absent, present or indeterminable. Neurological outcomes after 6 months were dichotomized as good (Cerebral Performance Category [CPC] 1–2) or poor (CPC 3–5).


      From 185 patients, 185 SSEPs, 172 BAEPs and 178 VEPs were included. None of the patients with a good outcome had absent SSEP, BAEP or VEP responses. Absent SSEP, BAEP and VEP responses yielded sensitivities of 42.3% (95% confidence interval [CI], 33.7–51.3%), 9.4% (95% CI, 4.6–16.7%) and 54.4% (95% CI, 46.0–62.5%) for poor outcomes, respectively. For the overall cohort, the addition of VEP measurements improved the sensitivities of single SSEP measurements (65.8% [95% CI, 57.7–73.3%] versus 36.2% [95% CI, 28.6–44.4%] and multimodal prognostication using SSEPs, brainstem reflex and brain computed tomography (75.7% [95% CI, 68.0–82.3%] versus 60.5% [95% CI, 52.3–68.4%]).


      The prognostic value of VEPs was comparable to that of SSEPs, but the use of BAEPs was limited due to their low sensitivity. Additional VEP measurements can reduce prognostic uncertainty.


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        • Geocadin R.G.
        • Callaway C.W.
        • Fink E.L.
        • et al.
        Standards for studies of neurological prognostication in comatose survivors of cardiac arrest: a scientific statement from the American Heart Association.
        Circulation. 2019; 140: e517-e542
        • Cronberg T.
        • Kuiper M.
        Withdrawal of life-sustaining therapy after cardiac arrest.
        Semin Neurol. 2017; 37: 81-87
        • Nolan J.P.
        • Soar J.
        • Cariou A.
        • et al.
        European Resuscitation Council and European Society of Intensive Care Medicine guidelines for post-resuscitation care 2015: section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015.
        Resuscitation. 2015; 95: 202-222
        • Sandroni C.
        • Cariou A.
        • Cavallaro F.
        • et al.
        Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine.
        Resuscitation. 2014; 85: 1779-1789
        • Horn J.
        • Tjepkema-Cloostermans M.C.
        Somatosensory evoked potentials in patients with hypoxic-ischemic brain injury.
        Semin Neurol. 2017; 37: 60-65
        • Callaway C.W.
        • Donnino M.W.
        • Fink E.L.
        • et al.
        Part 8: post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2015; 132: S465-82
        • Oh S.H.
        • Park K.N.
        • Choi S.P.
        • et al.
        Prognostic value of somatosensory evoked potential in cardiac arrest patients without withdrawal of life-sustaining therapy.
        Resuscitation. 2020; 150: 154-161
        • Ruijter B.J.
        • Tjepkema-Cloostermans M.C.
        • Tromp S.C.
        • et al.
        Early electroencephalography for outcome prediction of postanoxic coma: a prospective cohort study.
        Ann Neurol. 2019; 86: 203-214
        • Scarpino M.
        • Carrai R.
        • Lolli F.
        • et al.
        Neurophysiology for predicting good and poor neurological outcome at 12 and 72 h after cardiac arrest: the ProNeCA multicentre prospective study.
        Resuscitation. 2020; 147: 95-103
        • Ragazzoni A.
        • Cincotta M.
        • Giovannelli F.
        • et al.
        Clinical neurophysiology of prolonged disorders of consciousness: from diagnostic stimulation to therapeutic neuromodulation.
        Clin Neurophysiol. 2017; 128: 1629-1646
        • Pittet-Metrailler M.P.
        • Almazrooei A.M.
        • Tam E.W.Y.
        Sensory assessment: neurophysiology in neonates and neurodevelopmental outcome.
        Handb Clin Neurol. 2020; 174: 183-203
        • Sandroni C.
        • D’Arrigo S.
        • Cacciola S.
        • et al.
        Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review.
        Intensive Care Med. 2020; 46: 1803-1851
        • André-Obadia N.
        • Zyss J.
        • Gavaret M.
        • et al.
        Recommendations for the use of electroencephalography and evoked potentials in comatose patients.
        Neurophysiol Clin. 2018; 48: 143-169
        • de Biase S.
        • Gigli G.L.
        • Lorenzut S.
        • et al.
        The importance of polysomnography in the evaluation of prolonged disorders of consciousness: sleep recordings more adequately correlate than stimulus-related evoked potentials with patients’ clinical status.
        Sleep Med. 2014; 15: 393-400
        • Oh S.H.
        • Park K.N.
        • Choi S.P.
        • et al.
        Beyond dichotomy: patterns and amplitudes of SSEPs and neurological outcomes after cardiac arrest.
        Crit Care. 2019; 23: 224
        • Oh S.H.
        • Oh J.S.
        • Jung H.H.
        • et al.
        Prognostic value of P25/30 cortical somatosensory evoked potential amplitude after cardiac arrest.
        Crit Care Med. 2020; 48: 1304-1311
        • Kim Y.M.
        • Park K.N.
        • Choi S.P.
        • et al.
        Part 4. Post-cardiac arrest care: 2015 Korean Guidelines for Cardiopulmonary Resuscitation.
        Clin Exp Emerg Med. 2016; 3: S27-S38
        • Kim S.H.
        • Choi S.P.
        • Park K.N.
        • Youn C.S.
        • Oh S.H.
        • Choi S.M.
        Early brain computed tomography findings are associated with outcome in patients treated with therapeutic hypothermia after out-of-hospital cardiac arrest.
        Scand J Trauma Resusc Emerg Med. 2013; 21: 57
        • Tiainen M.
        • Kovala T.T.
        • Takkunen O.S.
        • Roine R.O.
        Somatosensory and brainstem auditory evoked potentials in cardiac arrest patients treated with hypothermia.
        Crit Care Med. 2005; 33: 1736-1740
        • Choi S.P.
        • Park K.N.
        • Wee J.H.
        • et al.
        Can somatosensory and visual evoked potentials predict neurological outcome during targeted temperature management in post cardiac arrest patients?.
        Resuscitation. 2017; 119: 70-75
        • Guérit J.M.
        The usefulness of EEG, exogenous evoked potentials, and cognitive evoked potentials in the acute stage of post-anoxic and post-traumatic coma.
        Acta Neurol Belg. 2000; 100: 229-236
        • Choi S.P.
        • Park K.N.
        • Park H.K.
        • et al.
        Diffusion-weighted magnetic resonance imaging for predicting the clinical outcome of comatose survivors after cardiac arrest: a cohort study.
        Crit Care. 2010; 14: R17
        • Guérit J.M.
        Neuromonitoring in the operating room: why, when, and how to monitor?.
        Electroencephalogr Clin Neurophysiol. 1998; 106: 1-21
        • Guérit J.M.
        Evoked potentials in severe brain injury.
        Prog Brain Res. 2005; 150: 415-426
        • Guérit J.M.
        • de Tourtchaninoff M.
        • Soveges L.
        • Mahieu P.
        The prognostic value of three-modality evoked potentials (TMEPs) in anoxic and traumatic comas.
        Neurophysiol Clin. 1993; 23: 209-226
        • Sakurai A.
        • Kinoshita K.
        • Moriya T.
        • et al.
        Reduced effectiveness of hypothermia in patients lacking the wave V in auditory brainstem responses immediately following resuscitation from cardiac arrest.
        Resuscitation. 2006; 70: 52-58
        • De Santis P.
        • Lamanna I.
        • Mavroudakis N.
        • et al.
        The potential role of auditory evoked potentials to assess prognosis in comatose survivors from cardiac arrest.
        Resuscitation. 2017; 120: 119-124
        • Maia B.
        • Roque R.
        • Amaral-Silva A.
        • Lourenco S.
        • Bento L.
        • Alcantara J.
        Predicting outcome after cardiopulmonary arrest in therapeutic hypothermia patients: clinical, electrophysiological and imaging prognosticators.
        Acta Med Port. 2013; 26: 93-97
        • Huntgeburth M.
        • Adler C.
        • Rosenkranz S.
        • et al.
        Changes in neuron-specific enolase are more suitable than its absolute serum levels for the prediction of neurologic outcome in hypothermia-treated patients with out-of-hospital cardiac arrest.
        Neurocrit Care. 2014; 20: 358-366
        • Guérit J.M.
        • 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
        • Rothstein T.L.
        SSEP retains its value as predictor of poor outcome following cardiac arrest in the era of therapeutic hypothermia.
        Crit Care. 2019; 23: 327
        • Sohmer H.
        • Freeman S.
        • Gafni M.
        • Goitein K.
        The depression of the auditory nerve-brain-stem evoked response in hypoxaemia—mechanism and site of effect.
        Electroencephalogr Clin Neurophysiol. 1986; 64: 334-338
        • Lee E.M.
        • Seok H.Y.
        • Park K.D.
        • Seo D.W.
        Evoked potentials: basic requirements and guidelines for writing reports.
        Ann Clin Neurophysiol. 2018; 20: 18-25