Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review

Claudio Sandroni, Sonia D’Arrigo, Sofia Cacciola, Cornelia W.E. Hoedemaekers, Marlijn J.A. Kamps, Mauro Oddo, Fabio S. Taccone, Arianna Di Rocco, Frederick J.A. Meijer, Erik Westhall, Massimo Antonelli, Jasmeet Soar, Jerry P. Nolan, Tobias Cronberg

Research output: Contribution to journalReview articlepeer-review


Purpose: To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3–5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA). Methods: PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013–April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. Results: Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2–5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors. Conclusion: In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169).

Original languageEnglish
Pages (from-to)1803-1851
Number of pages49
JournalIntensive Care Medicine
Issue number10
Publication statusPublished - Oct 1 2020


  • Cardiac arrest
  • Clinical examination
  • Coma
  • Computed tomography
  • Diffusion magnetic resonance imaging
  • Neuron-specific enolase
  • Prognosis
  • Somatosensory-evoked potentials

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine


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