Resuscitation 85 (2014) e65–e66
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Long-term functional outcome of cardiac arrest survivors
GOSe evolution 8 7
Sir,
0300-9572/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2013.12.034
GOSe scores
6
Cardiac arrest (CA) survivors may experience hypoxic brain injury leading to cognitive impairment,1–3 the most frequent disabilities affect memory and executive functions.2,4 The long-term prognosis of post anoxic encephalopathy is difficult to predict during the first month.5,6 Although cognitive impairment can be difficult to diagnose, they can affect daily activities, social life and quality of life.7 However, if the patient has only light to moderate impairment after CA, they are not usually referred to a neurological rehabilitation specialist. We think that such referral and neuropsychological treatment may be necessary. Temporal evolution of the disability suggests that progress occurs for several months or a year after the onset.8 We therefore conducted a prospective study in survivors of CA to assess their long-term functional outcome. All consecutive patients with a Glasgow Coma Scale score ≥ 12 within the first week after CA onset between 01/01/2009 and 05/31/2010 were included. Neurological clinical exam (MMSE) and cerebral magnetic resonance imaging (MRI) were performed within the first week. Functional outcome was assessed using the extended Glasgow Outcome Scale (GOSe) at 3 months, one and 3 years.9 Eighteen patients were screened and 15 were included (followup not possible in the remaining 3). Of the 15 patients included, 12 were male and 3 female, with a mean [range] age at CA onset of 44 [15–63] years. All but one (a child) had full-time professional activities at the time of CA. No flow duration ranged from 0 to 16 min (duration unknown in 3 cases). All patients had therapeutic hypothermia and woke up within 48 h after re-warming. The cause of CA was myocardial infarction for 10 patients, primary (idiopathic) ventricular fibrillation in 4 and pulmonary embolism in 1. All MRIs (performed after a median [IQR] of 17 [7–20] days after CA) were normal except in one patient. This particular patient, MRI showed hypersignals of the caudate and lenticular nuclei compatible with post anoxic injury. At 3 months, all patients had cognitive and/or behavioural complaints; four were inpatients in a neurological rehabilitation unit and ten were referred to neuropsychological rehabilitation. Four patients had mild cognitive complaints but none reported complete return to premorbid functioning. At one year, three patients reported a return to premorbid functioning and all 3 had returned to work. At one year, all but 2 had an improvement of their GOSe, this improvement being increased or maintained at 3 years (data were not available for 7 patients at 3 years) (Fig. 1). Most patients (73%) had not returned to work after one year, partly because of cognitive and behavioural disorders, whereas 8 (50%) had returned to work by 3 years.
5 4 3 2 1
3 months
12 months
36 months
Time
Fig. 1. GOSe scores for 15 patients at three months, one year and three years (7 patients).
Our results confirm the need for referral to neurological rehabilitation if there is mild to moderate neuropsychological impairment following cerebral anoxia.10 Systematic follow-up of survivors of CA to investigate the presence of such disabilities remains to be determined. Conflict of interest statement The authors report no conflict of interest. References 1. Mateen FJ, Josephs KA, Trenerry MR, et al. Long-term cognitive outcomes following out-of-hospital cardiac arrest: a population-based study. Neurology 2011;77:1438–45. 2. Peskine A, Rosso C, Picq C, Caron E, Pradat-Diehl P. Neurological sequelae after cerebral anoxia. Brain Inj 2010;24:755–61. 3. Xiong W, Hoesch RE, Geocadin RG. Post-cardiac arrest encephalopathy. Semin Neurol 2011;31:216–25. 4. Lim C, Alexander MP, LaFleche G, Schnyer DM, Verfaellie M. The neurological and cognitive sequelae of cardiac arrest. Neurology 2004;63:1774–8. 5. Bisschops LL, van Alfen N, Bons S, van der Hoeven JG, Hoedemaekers CW. Predictors of poor neurologic outcome in patients after cardiac arrest treated with hypothermia: a retrospective study. Resuscitation 2011;82:696–701. 6. Benjamin S. Therapeutic hypothermia after cardiac arrest. Circulation 2013;127:244–50. 7. Moulaert VR, Verbunt JA, van Heugten CM, Wade DT. Cognitive impairments in survivors of out-of-hospital cardiac arrest: a systematic review. Resuscitation 2009;80:297–305. 8. Shah MK, Al-Adawi S, Dorvlo AS, Burke DT. Functional outcomes following anoxic brain injury: a comparison with traumatic brain injury. Brain Inj 2004;18:111–7. 9. Wilson JT, Pettigrew LE, Teasdale GM. Structured interviews for the Glasgow outcome Scale and the Extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma 1998;15:573–85. 10. Cronberg T, Lilja G, Rundgren M, Friberg H, Widner H. Long-term neurological outcome after cardiac arrest and therapeutic hypothermia. Resuscitation 2009;80:1119–23.
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Letter to the Editor / Resuscitation 85 (2014) e65–e66
A. Peskine ∗ Department of Physical and Rehabilitation, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
P. Pradat-Diehl Department of Physical and Rehabilitation, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
F. Baronnet Stroke Unit, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
C.E. Luyt Intensive Care Unit, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
E. Bayen Department of Physical and Rehabilitation, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
∗ Corresponding author at: Service de médecine physique et réadaptation, Groupe Hospitalier Pitié – Salpêtrière, 47-83 Boulevard de l’Hôpital, 75651 Paris Cedex 13, France. E-mail addresses: [email protected], [email protected] (A. Peskine)
D. Galanaud Department of Neuroradiology, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
23 December 2013
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Long-term functional outcome of cardiac arrest survivors
GOSe evolution 8 7
Sir,
0300-9572/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2013.12.034
GOSe scores
6
Cardiac arrest (CA) survivors may experience hypoxic brain injury leading to cognitive impairment,1–3 the most frequent disabilities affect memory and executive functions.2,4 The long-term prognosis of post anoxic encephalopathy is difficult to predict during the first month.5,6 Although cognitive impairment can be difficult to diagnose, they can affect daily activities, social life and quality of life.7 However, if the patient has only light to moderate impairment after CA, they are not usually referred to a neurological rehabilitation specialist. We think that such referral and neuropsychological treatment may be necessary. Temporal evolution of the disability suggests that progress occurs for several months or a year after the onset.8 We therefore conducted a prospective study in survivors of CA to assess their long-term functional outcome. All consecutive patients with a Glasgow Coma Scale score ≥ 12 within the first week after CA onset between 01/01/2009 and 05/31/2010 were included. Neurological clinical exam (MMSE) and cerebral magnetic resonance imaging (MRI) were performed within the first week. Functional outcome was assessed using the extended Glasgow Outcome Scale (GOSe) at 3 months, one and 3 years.9 Eighteen patients were screened and 15 were included (followup not possible in the remaining 3). Of the 15 patients included, 12 were male and 3 female, with a mean [range] age at CA onset of 44 [15–63] years. All but one (a child) had full-time professional activities at the time of CA. No flow duration ranged from 0 to 16 min (duration unknown in 3 cases). All patients had therapeutic hypothermia and woke up within 48 h after re-warming. The cause of CA was myocardial infarction for 10 patients, primary (idiopathic) ventricular fibrillation in 4 and pulmonary embolism in 1. All MRIs (performed after a median [IQR] of 17 [7–20] days after CA) were normal except in one patient. This particular patient, MRI showed hypersignals of the caudate and lenticular nuclei compatible with post anoxic injury. At 3 months, all patients had cognitive and/or behavioural complaints; four were inpatients in a neurological rehabilitation unit and ten were referred to neuropsychological rehabilitation. Four patients had mild cognitive complaints but none reported complete return to premorbid functioning. At one year, three patients reported a return to premorbid functioning and all 3 had returned to work. At one year, all but 2 had an improvement of their GOSe, this improvement being increased or maintained at 3 years (data were not available for 7 patients at 3 years) (Fig. 1). Most patients (73%) had not returned to work after one year, partly because of cognitive and behavioural disorders, whereas 8 (50%) had returned to work by 3 years.
5 4 3 2 1
3 months
12 months
36 months
Time
Fig. 1. GOSe scores for 15 patients at three months, one year and three years (7 patients).
Our results confirm the need for referral to neurological rehabilitation if there is mild to moderate neuropsychological impairment following cerebral anoxia.10 Systematic follow-up of survivors of CA to investigate the presence of such disabilities remains to be determined. Conflict of interest statement The authors report no conflict of interest. References 1. Mateen FJ, Josephs KA, Trenerry MR, et al. Long-term cognitive outcomes following out-of-hospital cardiac arrest: a population-based study. Neurology 2011;77:1438–45. 2. Peskine A, Rosso C, Picq C, Caron E, Pradat-Diehl P. Neurological sequelae after cerebral anoxia. Brain Inj 2010;24:755–61. 3. Xiong W, Hoesch RE, Geocadin RG. Post-cardiac arrest encephalopathy. Semin Neurol 2011;31:216–25. 4. Lim C, Alexander MP, LaFleche G, Schnyer DM, Verfaellie M. The neurological and cognitive sequelae of cardiac arrest. Neurology 2004;63:1774–8. 5. Bisschops LL, van Alfen N, Bons S, van der Hoeven JG, Hoedemaekers CW. Predictors of poor neurologic outcome in patients after cardiac arrest treated with hypothermia: a retrospective study. Resuscitation 2011;82:696–701. 6. Benjamin S. Therapeutic hypothermia after cardiac arrest. Circulation 2013;127:244–50. 7. Moulaert VR, Verbunt JA, van Heugten CM, Wade DT. Cognitive impairments in survivors of out-of-hospital cardiac arrest: a systematic review. Resuscitation 2009;80:297–305. 8. Shah MK, Al-Adawi S, Dorvlo AS, Burke DT. Functional outcomes following anoxic brain injury: a comparison with traumatic brain injury. Brain Inj 2004;18:111–7. 9. Wilson JT, Pettigrew LE, Teasdale GM. Structured interviews for the Glasgow outcome Scale and the Extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma 1998;15:573–85. 10. Cronberg T, Lilja G, Rundgren M, Friberg H, Widner H. Long-term neurological outcome after cardiac arrest and therapeutic hypothermia. Resuscitation 2009;80:1119–23.
e66
Letter to the Editor / Resuscitation 85 (2014) e65–e66
A. Peskine ∗ Department of Physical and Rehabilitation, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
P. Pradat-Diehl Department of Physical and Rehabilitation, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
F. Baronnet Stroke Unit, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
C.E. Luyt Intensive Care Unit, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
E. Bayen Department of Physical and Rehabilitation, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
∗ Corresponding author at: Service de médecine physique et réadaptation, Groupe Hospitalier Pitié – Salpêtrière, 47-83 Boulevard de l’Hôpital, 75651 Paris Cedex 13, France. E-mail addresses: [email protected], [email protected] (A. Peskine)
D. Galanaud Department of Neuroradiology, Groupe Hospitalier Pitié – Salpêtrière, Assistance Publique – Hôpitaux de Paris, and Université Paris 6 – Pierre et Marie Curie, Paris, France
23 December 2013
