Cerebral Infarction Observed on Brain MRI in Unconscious Out-of-Hospital Cardiac Arrest Survivors: A Pilot Study

Abstract

Background

Cumulative evidence regarding the use of brain magnetic resonance imaging (MRI) for predicting prognosis of unconscious out-of-hospital cardiac arrest (OHCA) survivors treated with targeted temperature management (TTM) is available. Theoretically, these patients are at a high risk of developing cerebral infarction. However, there is a paucity of reports regarding the characteristics of cerebral infarction in this population. Thus, we performed a pilot study to identify the characteristics and risk factors of cerebral infarction and to evaluate whether this infarction is associated with clinical outcomes.

Methods

A single-center, retrospective, registry-based cohort study was conducted at Severance Hospital, a tertiary center. Unconscious OHCA survivors were registered and treated with TTM between September 2011 and December 2015. We included patients who underwent brain MRI in the first week after the return of spontaneous circulation. We excluded patients who underwent any endovascular interventions to focus on “procedure-unrelated” cerebral infarctions. We assessed hypoxic–ischemic encephalopathy (HIE) and procedure-unrelated cerebral infarction separately on MRI. Patients were categorized into the following groups based on MRI findings: HIE (−)/infarction (−), infarction-only, and HIE (+) groups. Conventional vascular risk factors showing p < 0.05 in univariate analyses were entered into multivariate logistic regression. We also evaluated if the presence of this procedure-unrelated cerebral infarction lesion or HIE was associated with a poor clinical outcome at discharge, defined as a cerebral performance category of 3–5.

Results

Among 71 unconscious OHCA survivors who completed TTM, underwent MRI, and who did not undergo endovascular interventions, 14 (19.7%) patients had procedure-unrelated cerebral infarction based on MRI. Advancing age [odds ratio (OR) 1.11] and atrial fibrillation (OR 5.78) were independently associated with the occurrence of procedure-unrelated cerebral infarction (both p < 0.05). There were more patients with poor clinical outcomes at discharge in the HIE (+) group (88.1%) than in the infarction-only (30.0%) or HIE (−)/infarction (−) group (15.8%) (p < 0.001). HIE (+) (OR 38.69, p < 0.001) was independently associated with poor clinical outcomes at discharge, whereas infarction-only was not (p > 0.05), compared to HIE (−)/infarction (−).

Conclusions

In this pilot study, procedure-unrelated cerebral infarction was noted in approximately one-fifth of unconscious OHCA survivors who were treated with TTM and underwent MRI. Older age and atrial fibrillation might be associated with the occurrence of procedure-unrelated cerebral infarction, and cerebral infarction was not considered to be associated with clinical outcomes at discharge. Considering that the strict exclusion criteria in this pilot study resulted in a highly selected sample with a relatively small size, further work is needed to verify our findings.

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Data Availability

The datasets for this manuscript are not publicly available because of protection for personal information. Requests to access the datasets should be directed to KC (zhau@yuhs.ac; zhau@naver.com).

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Acknowledgements

KC was supported by a faculty research grant from Yonsei University College of Medicine 6-2018-0092.

Funding

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Authors

Contributions

MB participated in the study design, collection and analysis of data, interpretation of results, and drafted and finalized the manuscript. KHC participated in the study design, interpretation of results, and reviewed and provided the final approval of the version to be published. CO participated in the statistical analysis and revision of critical points in the manuscript. YC participated in the study design and collection of data. KMK participated in the collection of data. SSA participated in the analysis of neuroimaging data. DS provided substantial contribution to the study conception and design. JHH, YSP, JW, YSK, and JK participated in the collection of data and reviewed the manuscript.

Corresponding author

Correspondence to Kyoo Ho Cho.

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Conflict of interest

The authors declare that the research was conducted in the absence of any personal, commercial, or financial relationships that could potentially be construed as a conflict of interest.

Ethical Approval

The study was approved by the institutional review board of Severance Hospital, Yonsei University Health System. Informed consent was waived owing to the retrospective nature of the study.

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Baik, M., Kim, K.M., Oh, C. et al. Cerebral Infarction Observed on Brain MRI in Unconscious Out-of-Hospital Cardiac Arrest Survivors: A Pilot Study. Neurocrit Care (2020). https://doi.org/10.1007/s12028-020-00990-8

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Keywords

  • Out-of-hospital cardiac arrest
  • Induced hypothermia
  • Cerebral infarction
  • Hypoxia–ischemia, brain
  • Prognosis