Multimodal network connectivity architecture (MOCA) of the brain and its role in the recovery of consciousness in comatose cardiac arrest patients

项目摘要 心血管疾病仍然是美国的主要死亡原因。心脏病死亡率 60- 85%的人被逮捕，而在幸存者中，高达80%的人最初处于昏迷状态。一旦流通 脑损伤的程度是影响脑功能恢复的关键因素。神经系统预后不良 通常导致生命维持疗法（WLST）的撤销和随后的死亡。根据 2015年美国心脏协会指南，最可靠的预后不良诊断策略 仍然是治疗心脏骤停后幸存者的关键知识差距。传统建议 在心脏骤停患者的现代研究中，已经证明神经系统诊断不可靠。新 需要具有改进的准确性的技术来避免来自最终可能 神经功能恢复良好。心脏骤停后最初昏迷的大部分患者将 神经影像学和电生理学都正常，只是在随后的日子里恶化。这可能 表示在发生进行性缺血、凋亡、灌注不足和 脑水肿，最常导致不良结局。我们假设多模式方法， 包括临床、电生理学、生物化学和MRI数据将改善短期 最初昏迷的心脏骤停患者的长期结局，有助于确定最有可能受益的患者 在未来的治疗干预。我们建议进行一项前瞻性观察研究， 心脏骤停患者在停搏后24小时仍然昏迷，或在接受以下治疗的患者中在复温后24小时仍然昏迷 有针对性的温度管理我们的研究主要集中在那些通常最常进行无痛人流的患者身上。 具有挑战性，最有可能从先进的评估工具中受益。我们将系统地 评估这些测试是否可以预测短期的神经恢复和最终的长期 神经学结果我们的第一个目标是确定急性MRI和电生理学是否可以识别 哪些病人最有可能恢复性唤起使用唤醒恢复作为替代指标的好处 长期的结果是，它将较少受到WLST自我实现预言偏差的困扰。其次， 我们将研究亚急性MRI和EEG评估是否与神经学结局相关， 出院、3、6和12个月。

Project Summary Cardiovascular disease remains the leading cause of death in the United States. Mortality rates from cardiac arrest range from 60-85%, and of survivors, up to 80% are initially comatose. Once circulation has been reestablished, the extent of brain injury is a key factor for prognostication. Poor neurologic prognosis commonly leads to the withdrawal of life-sustaining therapies (WLST) and subsequent death. According to the 2015 American Heart Association Guidelines, the most reliable strategy for prognostication of poor outcome remains a key knowledge gap in the treatment of post-cardiac arrest survivors. Traditional recommendations for neurologic prognostication have proven unreliable in modern studies of cardiac arrest patients. New techniques with improved accuracy are needed to avoid premature WLST from patients who may ultimately recover with good neurologic outcome. A large subset of patients initially comatose after cardiac arrest will have normal neuroimaging and electrophysiology, only to deteriorate in the subsequent days. This likely represents a therapeutic window prior to the onset progressive ischemia, apoptosis, hypoperfusion and cerebral edema, which most often leads to poor outcome. We hypothesize that multimodal approaches that include clinical, electrophysiology, biochemical and MRI data will improve prognostication of short-term and long-term outcome in initially comatose cardiac arrest patients, helping to identify those most likely to benefit from therapeutic interventions in the future. We propose to perform a prospective observational study in cardiac arrest patients still comatose 24 hours post-arrest, or 24 hours post-rewarming in those treated with targeted temperature management. Our study focuses on patients for whom prognostication is typically most challenging, and who are most likely to benefit from advanced assessment tools. We will systematically evaluate whether these tests can predict short-term neurological recovery and ultimately long-term neurological outcome. Our first aim is to determine whether acute MRI and electrophysiology can identify which patients are most likely to regain arousal. The benefit of using recovery of arousal as a surrogate marker for long-term outcome is that it will be less plagued by a self-fulfilling prophecy bias from WLST. Secondarily, we will investigate whether subacute MRI and EEG assessments are associated with neurological outcomes at discharge, 3, 6 and 12 months.