• Patrick J Coppler, Jonathan Elmer, Ankur A Doshi, Francis X Guyette, Masashi Okubo, Cecelia Ratay, Adam N Frisch, Alexis Steinberg, Alexandra Weissman, Valerie Arias, Byron C Drumheller, Katharyn L Flickinger, John Faro, Mark Schmidhofer, Zachary J Rhinehart, Barinder S Hansra, Joanna Fong-Isariyawongse, Niravkumar Barot, Maria E Baldwin, Murat KaynarAADepartment of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, USA., Joseph M Darby, Lori A Shutter, Joseph Mettenburg, Clifton W Callaway, and University of Pittsburgh Post Cardiac Arrest Service.
• Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
• Resuscitation. 2023 Jul 1; 188: 109823109823.

BackgroundPatients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration.MethodsWe identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression.ResultsWe included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time.ConclusionsBrain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.Copyright © 2023. Published by Elsevier B.V.

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