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 逮捕的比例从60%到85%不等，而幸存者中，高达80%的人最初处于昏迷状态。一旦循环已经完成 重建后，脑损伤程度是判断预后的关键因素。神经系统预后不良 通常会导致生命维持疗法(WLST)的退出和随后的死亡。根据 2015美国心脏协会指南：预测不良结局的最可靠策略 仍然是治疗心脏骤停后幸存者的关键知识缺口。传统推荐 在现代心脏骤停患者的研究中，神经学预测已被证明是不可靠的。新的 需要提高准确性的技术，以避免患者过早进行WLST，最终可能 以良好的神经学结果康复。一大批心脏骤停后最初昏迷的患者将 神经影像和电生理正常，但在接下来的几天里恶化。这很有可能 代表进行性脑缺血、细胞凋亡、低灌注率和 脑水肿，最常导致不良结局。我们假设多式联运方法 包括临床、电生理学、生化和MRI数据将改善短期和 最初昏迷的心脏骤停患者的长期结果，有助于确定最有可能受益的患者 在未来的治疗干预中。我们建议进行一项前瞻性的观察性研究 心脏骤停患者在心脏骤停后24小时仍处于昏迷状态，或在心脏骤停患者复温后24小时仍处于昏迷状态 有针对性的温度管理。我们的研究重点是那些通常预测最多的患者 具有挑战性，最有可能从高级评估工具中受益的人。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恢复 神经学结果。我们的第一个目标是确定急性核磁共振和电生理学是否能 哪些患者最有可能重新唤醒。将觉醒恢复作为替代标记的益处 因为长期结果是，它将不那么受到来自WLST的自我实现的预言偏见的困扰。其次， 我们将调查亚急性MRI和EEG评估是否与神经学结果相关 出院3个月、6个月和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.