Table 4: Medical history of patients with in-hospital or out-of-hospital cardiac arrest
In-hospital(n=8) / Out-of-hospital
(n=12) / Total
(n=20)
Comorbidities (n) / 6 / 2 / 8
Prematurity (< 32 wks) (n) / 2 / 0 / 2
Respiratory disease (n) / 3 / 0 / 3
Acquired cardiac disease (n) / 1 / 1 / 2
Haematologic disease (n) / 1 / 0 / 1
Neurological disease (n) / 2 / 1 / 3
Wks = weeks, n = number
Table 5: Decreased ADC per region and their association with neurological outcome
PCPC / 1-3(n = 5) / 4-6
(n = 8)
Regional ADC Decrease (%):
- Cortex (n = 6)
- WR (n = 6)
- SWM (n = 3)
- BG (n = 12)
- T (n = 10)
- Cerebellum (n = 3)
- Hippocampus (n = 1) / ¯26 [26] (n = 1)
¯28 [20-42] (n = 4)
(n = 0)
¯18 [13-27] (n = 4)
¯20 [13-25] (n = 4)
(n = 0)
(n = 0) / ¯40 [23-55] (n = 5)
¯50 [42-58] (n = 2)
¯43 [37-56](n = 3)
¯30 [16 -45] (n = 8)
¯30 [12-50] (n = 6)
¯48 [40-62] (n = 3)
¯25 [25] (n = 1)
Patients / Day of DWI / Cortex / WR / SCW / C / TC / GB / T / H / PCPC
F / P / T / O / R / ant / post / ant / post
1 / Day 1 / - / - / - / - / - / - / - / - / - / - / - / + / + / - / 6
2 / Day 1 / - / - / + / + / - / - / - / - / - / - / - / + / + / + / 6
3 / Day 2 / - / - / - / + / - / - / - / - / - / - / - / + / - / - / 6
4 / Day 2 / + / - / - / + / - / - / - / - / + / + / - / + / + / - / 6
5 / Day 3 / - / - / - / - / - / + / + / - / - / - / - / + / + / - / 1
6 / Day 3 / + / + / + / + / - / - / - / - / - / - / - / + / + / - / 4
7 / Day 3 / - / - / - / - / - / - / - / - / - / - / - / + / + / - / 1
8 / Day 3 / - / - / - / + / + / - / - / - / + / - / - / + / + / - / 4
9 / Day 4 / - / - / - / - / - / + / + / - / - / - / - / + / - / - / 1
10 / Day 4 / - / - / - / - / - / + / + / - / + / - / - / - / - / - / 2
11 / Day 4 / - / - / - / - / - / + / + / - / - / + / - / + / - / - / 6
12 / Day 5 / - / - / - / - / - / + / + / - / + / + / - / + / + / 6
13 / Day 5 / - / - / - / - / - / - / - / - / - / - / - / - / - / + / 3
14 / Day 6 / - / - / - / - / - / + / + / - / - / - / - / + / + / - / 1
15 / Day 7 / - / - / - / + / - / + / - / - / - / - / - / - / + / - / 3
16 / Day 1 / - / - / - / - / - / - / - / - / - / - / - / - / - / - / 1
17 / Day 2 / - / - / - / - / - / - / - / - / - / - / - / - / - / - / 1
18 / Day 3 / - / - / - / - / - / - / - / - / - / - / - / - / - / - / 1
19 / Day 5 / - / - / - / - / - / - / - / - / - / - / - / - / - / - / 1
20 / Day 5 / - / - / - / - / - / - / - / - / - / - / - / - / - / - / 1
Table 6: Detail of DWI finding in all patients
Patients / Cortex / WR / SCW / C / BG / T / H / Global ADC decrease (%) / PCPC1 / · / · / · / · / ¯45 / ¯19 / · / 32 / 6
2 / ¯23 / · / · / · / ¯21 / ¯50 / ¯25 / 30 / 6
3 / ¯27 / · / · / · / ¯27 / · / · / 27 / 6
4 / ¯55 / · / ¯56 / ¯62 / ¯38 / ¯12 / · / 45 / 6
5 / · / ¯42 / · / · / ¯27 / ¯24 / · / 31 / 1
6 / ¯53 / · / · / · / ¯34 / ¯38 / · / 42 / 4
7 / · / · / · / · / ¯13 / ¯13 / · / 13 / 1
8 / ¯43 / · / ¯43 / · / ¯30 / ¯40 / · / 39 / 4
9 / · / ¯20 / · / · / ¯16 / · / · / 18 / 1
11 / · / ¯42 / · / ¯41 / ¯16 / · / · / 33 / 6
12 / · / ¯58 / ¯37 / ¯40 / ¯30 / ¯23 / · / 38 / 6
14 / · / ¯28 / · / · / ¯18 / ¯25 / · / 24 / 1
15 / ¯26 / ¯24 / · / · / · / ¯20 / · / 23 / 3
Table 7: Detail of ADC value (when decrease) in all patients
Table 8: Detail of Patients with clinical of brainstem dysfunction
PCPC / 1-3(n = 12) / 4-6
(n = 8)
- Reactive Dilated pupils
- Non reactive dilated pupils
- GCS = 3
- Abolition of Corneal reflex
- Abolition of Spontaneous breathing / n = 0
n = 0
n = 0
n = 0
n = 0 / n = 2
n = 1
n = 2
n = 3
n = 1
GCS = Glasgow Coma Scale
Table 9: Demographic, clinical and biological characteristics of patients underwent therapeutic hypothermia
Patient No. 6 / Patient No. 14 / Patient No. 15Age (months) / 185 / 4 / 153
Gender / Male / Male / Female
Aetiology of CA / Hemodynamic / Hypoxic / Hemodynamic
First monitored rhythm / VF / Asystole / TV pulseless
Location of CA / Out of Hospital / In hospital / Out of Hospital
Witnessed arrest / Yes / Yes / Yes
Epinephrine boluses (n) / 0 / 0 / 1
Resuscitation duration (min) / 6 min / 10 min / 20 min
GCS (admission) / 3 / 4 / 7
Temperature, °C (admission) / 36 / 32,1 / 35
pH (admission) / 7,28 / 7,2 / 7,32
Serum Lactate mmol/l (admission) / 2,12 / 4 / 4,14
PELOD Score (admission) / 32 / 32 / 31
Organ dysfunction (admission) / 3 / 3 / 2
EEG (72 h) / Malignant / Benign / Benign
Motor response to pain (72 h) / Absence / Presence / Presence
Pupillary response (72 h) / Presence / Presence / Presence
Status epilepticus / No / No / No
Time to DWI after ROSC (days) / 3 / 5 / 7
PCPC / 4 / 1 / 3
VF/VT = ventricular fibrillation/ventricular tachycardia, GCS = Glasgow coma scale, CA = cardiac arrest, PELOD = Pediatric Logistic Organ Dysfunction, EEG = Electroencephalogram , ROSC = return on spontaneous circulation
Figure 2: Mean (global) value in decreased ADC
Supplementary materiel
This monocentric and retrospective study was reviewed and approved by the local ethics committee of our university hospital
A total of 155 children admitted to our PICU department following CA were initially identified from which 22 children had an early DW-MRI. Two of these patients were excluded because of presence of dental material, resulting in misleading interpretation
Therapeutic hypothermia : A standardised protocol for therapeutic hypothermia was used in 3 comatose patients during the second half of the study period. Eligible patients underwent therapeutic hypothermia using an external cooling device for 24 h with a target temperature of 33.0 ± 1°C. Slow rewarming to normal temperature was conducted over eight hours
Neuroimaging:
We used a 1.5-T system (General Electric, Milwaukee, WI, USATM). This study included the following sequences: the axial fast spin-echo T2WIs (4000/1002/2 [TR/TE/NEX] with a 5 mm section thickness and axial DWIs (7000/105.2 [TR/TE], with 5 a mm section thickness, b values of 0 and 1,000 sec/mm2, a 240 × 240 field of view, and a 128 × 128 matrix size. ADC maps were automatically generated by the Functool software (GEMS, Milwaukee, USATM). The DWIs together with the ADC maps were jointly and retrospectively evaluated by two experienced paediatric neuroradiologists blinded to the patients' clinical data. Brain injuries on DWI were categorised into patterns on the basis of the region of injury: normal, cerebral cortical, basal ganglia and thalamus, subcortical white matter, hippocampus, watershed regions, cerebellum and brainstem injury. For patients at risk of delayed myelinisation and/or in the process of myelinisation, images on subcortical white matter were considered abnormal if they were inhomogeneous.
The ADC value of each pixel was constantly displayed on the workstation, with movement of a region of interest (ROI) cursor. ROI sizes were approximately 10 mm² for all regions and were carefully placed by a single analyst who worked in consultation with the neuroradiologist to ensure accurate localisation and consistency of the measurements. DWI/ADC images were considered abnormal in the presence of high signal intensity on DWI and low signal intensity on the corresponding ADC map (cytotoxic oedema), or low iso-intensity or increased signal intensity on DWI and high signal intensity on the ADC map (vasogenic oedema) [33]. Colour scales were used on the ADC maps to visualise the degree of ADC variation. Regions of low ADC exhibited a blue colour; in contrast, regions of high ADC exhibited a red colour. The colour scale on the ADC maps identified the pixel showing the minimum ADC value in each brain region. For each patient, the region of high or low signal on the ADC map was identified. A retrospective quantitative analysis was performed with regional brain ADC measurements compared with subcortical white matter ADC values where there was no injury. A decrease or an increase greater than 10% in ADC measurement was considered to be abnormal. The mean ADC over each imaging slide (known as global ADC) was also calculated thus taking into account all of the affected areas when the ADC was lowered.
For the 3 patients who underwent therapeutic hypothermia, the DW-MRI was performed under normothermia at least 48 h after the end of hypothermia.
Description of the relevant studies which reported neuroimaging finding in comatose patients after anoxic insult:
Wijman et al. in an adult study, determined the ideal time windows for prognostication using DWI (49 to 108 hours after CA) and showed that neuroimaging improved the sensitivity for predicting poor outcome [18].
Alderliesten et al. showed that lower ADCs in the thalamus and basal ganglia at DW-MRI were associated with poor outcome in neonates with hypoxic-ischaemic encephalopathy [21]
Christophe et al. studied the prognostic value of conventional MRI in 40 comatose children after hypoxic insult but not necessarily cardiac arrest and found a strong relationship between MRI abnormalities (watershed zones and grey nuclei) performed in a delay of 3 days and patient outcome “ [27]
Dubowitz et al. reported that generalized/occipital oedema and grey nuclei injuries correlated with poor prognostic outcome when MRI was conducted between 3 and 4 days post-insult in 22 children after near drowning incidents [28]
Fink et al. in an original and first paediatric study conducted in 28 children after CA showed that lesions on basal ganglia and brain lobes were associated with unfavourable outcome [29]. While these findings are certainly of interest, neuroimaging was performed over the course of the first two weeks, which may have led to a pseudonormalisation phenomenon [12] and more importantly, ADC values were not calculated and thus the intensity of cytotoxic oedema was not assessed. Moreover, there was insufficient information regarding clinical and electrophysiological prognostic factors to assume the benefit of DWI in instances where known poor prognostic factors are not present.