Department of Neurology, Yale University School of Medicine, LLCI 912, 15 York Street, New Haven, CT 06520, USA.
Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
Nat Rev Neurol. 2014 Apr;10(4):190-203. doi: 10.1038/nrneurol.2014.36. Epub 2014 Mar 11.
Neurological prognostication after cardiac arrest has always been challenging, and has become even more so since the advent of therapeutic hypothermia (TH) in the early 2000s. Studies in this field are prone to substantial biases--most importantly, the self-fulfilling prophecy of early withdrawal of life-sustaining therapies--and physicians must be aware of these limitations when evaluating individual patients. TH mandates sedation and prolongs drug metabolism, and delayed neuronal recovery is possible after cardiac arrest with or without hypothermia treatment; thus, the clinician must allow an adequate observation period to assess for delayed recovery. Exciting advances have been made in clinical evaluation, electrophysiology, chemical biomarkers and neuroimaging, providing insights into the underlying pathophysiological mechanisms of injury, as well as prognosis. Some clinical features, such as pupillary reactivity, continue to provide robust information about prognosis, and EEG patterns, such as reactivity and continuity, seem promising as prognostic indicators. Evoked potential information is likely to remain a reliable prognostic tool in TH-treated patients, whereas traditional serum biomarkers, such as neuron-specific enolase, may be less reliable. Advanced neuroimaging techniques, particularly those utilizing MRI, hold great promise for the future. Clinicians should continue to use all the available tools to provide accurate prognostic advice to patients after cardiac arrest.
心脏骤停后的神经预后一直是一个挑战，自 21 世纪初治疗性低温（TH）问世以来，这一挑战变得更加严峻。该领域的研究容易受到较大的偏倚影响——最重要的是，尽早停止生命支持治疗的自我实现预言——医生在评估个体患者时必须意识到这些局限性。TH 需要镇静并延长药物代谢，并且心脏骤停后无论是否进行低温治疗都可能出现神经元延迟恢复；因此，临床医生必须允许足够的观察期来评估延迟恢复。在临床评估、电生理学、化学生物标志物和神经影像学方面取得了令人兴奋的进展，为损伤的潜在病理生理机制以及预后提供了深入了解。一些临床特征，如瞳孔反应性，继续为预后提供可靠信息，而脑电图模式，如反应性和连续性，似乎是有前途的预后指标。诱发电位信息可能仍然是治疗性低温患者中可靠的预后工具，而传统的血清生物标志物，如神经元特异性烯醇化酶，可能不太可靠。先进的神经影像学技术，特别是利用 MRI 的技术，具有广阔的前景。临床医生应继续使用所有可用的工具，为心脏骤停后的患者提供准确的预后建议。
