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

Research output: Contribution to journalReview article


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).


  • 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
External organisations
  • Policlinico Universitario Agostino Gemelli
  • Catholic University of the Sacred Heart
  • Radboud Institute for Health Sciences
  • Catharina Hospital
  • University of Lausanne
  • Free University of Brussels (ULB)
  • Sapienza University of Rome
  • Skåne University Hospital
  • Royal United Hospital, Bath
  • Southmead Hospital
Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Anesthesiology and Intensive Care


  • Cardiac arrest, Clinical examination, Coma, Computed tomography, Diffusion magnetic resonance imaging, Neuron-specific enolase, Prognosis, Somatosensory-evoked potentials
Original languageEnglish
Pages (from-to)1803-1851
Number of pages49
JournalIntensive Care Medicine
Issue number10
Publication statusPublished - 2020
Publication categoryResearch