Neurologic outcome after cardiac arrest: What you see at hospital discharge may or may not be what you get


Neurologic outcome after cardiac arrest: What you see at hospital discharge may or may not be what you get

 Matthew P. Kirschen, Alexis A. Topjian, Robert A. Berg


Only 6–14% of children survive to hospital discharge following out-of-hospital cardiac arrests (OHCA) in developed countries., , , , , , ,  The reported rate of favorable neurologic outcomes among survivors varies widely from 38 to 91%., , , , , , ,  Differences in favorable neurologic outcome may be related to differences in bystander CPR rates, quality of CPR, termination/withdrawal of technologic support, and/or the definition of favorable neurologic outcome. The neurologic outcome is typically reported as a crude qualitative assessment of neurologic functioning based on the Utstein-style recommended Pediatric Cerebral Performance Category (PCPC) or the Glasgow-Pittsburgh Cerebral Performance Category., , , 

In this issue of Resuscitation, Michiels and colleagues report the long-term neurologic status of children who survived OHCA from January 1976 to December 2007. They retrospectively determined the PCPC score of 91 children based on chart review of the “history and physical examination” at the time of hospital discharge from their OHCA and then again after subsequent hospital admissions or clinic visits. We applaud the efforts of the investigators for undertaking this challenging and laborious task. Children in this study were followed a median 4 years after hospital discharge. Encouragingly, 94% of children with a favorable neurologic status at hospital discharge, defined as a PCPC of 1 or 2 (normal or mild disability), maintained a favorable status at long-term follow-up. Similarly, 92% of children with an unfavorable neurologic status at discharge, defined as PCPC 3, 4 or 5 (moderate disability, severe disability, coma or vegetative state) either maintained an unfavorable neurologic status (38%) or died (54%). While these data partially reaffirm the commonly held belief that neurologic status after resuscitation from cardiac arrest does not appreciably change after hospital discharge, the most intriguing aspect of these results are the small percentage of children whose neurologic status declined or improved over time. Given the retrospective nature of these data and the imprecision of the PCPC score, this percentage may be an underestimate of the number of children who experienced more subtle changes in their neurocognitive or neurobehavioral functioning over time.

Interestingly, many patients transitioned to better neurologic status over time and some to worse. Eleven children had improved neurologic function over the years, and three transitioned from a severe disability category (PCPC 4) to a favorable neurologic status (PCPC 1 or 2). These observations suggest that some children whose initial neurologic assessment indicates a moderate to severe brain injury may be able to recover significant neurologic function. Four children who were categorized as having a favorable neurologic outcome had a decline in their neurologic status, and two transitioned into an unfavorable category. This may be due to the phenomena that some deficits become evident as children mature and fail to meet developmental or scholastic expectations or that morbidities worsen over time. Transitions in each direction highlight the challenges and imprecisions in predicting long-term neurologic abilities at the time of hospital discharge following an OHCA.

Limitations of the data include: information was obtained by retrospective chart review, lack of information on baseline neurologic status, differences in the emergency medical systems and ICU care provided over the last 40 years, and shortcomings inherent in using the PCPC scale as the measure of neurologic function. The PCPC, as acknowledged by the authors, is a gross and somewhat subjective scale of neurologic functioning, especially when determined by retrospective chart review. The PCPC scores of 1 and 2 were considered favorable outcomes in this study, but each PCPC grouping may encompass a fairly wide range of neurologic and functional status.,  In addition, a patient with pre-existing brain injury and neurologic impairments resulting in a PCPC ?3 at baseline cannot be expected to attain a PCPC score of 1 or 2 at hospital discharge despite an excellent resuscitation with return to baseline neurologic and functional status. Therefore, many studies include patients with no change in PCPC score as “favorable neurologic outcome.”

The broad range of normal developmental stages in childhood further complicates neurologic status assignment on scales like the PCPC, especially for young children. This lack of precision of the PCPC has been evaluated by comparing the scale to more specific neuropsychological tests. While the mean PCPC scores are associated with the means from standardized psychometric tests of neurologic functioning, the variability of the neuropsychological measures within each PCPC category is quite large.

Recently, Suominen and colleagues evaluated long-term neurocognitive outcomes in a small cohort of children a median of 8 years after OHCA due to drowning. Most of the children (8/11) categorized as normal (POPC 1) at hospital discharge had normal IQ tests at follow-up; however, 3/11 had ongoing memory or executive function impairments. Of the four children with a POPC of 2 at hospital discharge, one was normal, two had minor cognitive deficits, and one had major neurologic impairments. Of the five patients with POPC ?3 at hospital discharge, one improved to minor neurologic dysfunction, but the other four continued to have the major neurologic dysfunction exhibited at hospital discharge. In addition, van Zellem and colleagues described long-term neurologic outcomes of 43 children with OHCA or in-hospital cardiac arrest. They found deficits in IQ with a mean score of 87.3 with deficiencies mainly in visual motor processing and memory.

The study by Michiels and colleagues provides some comfort about the long-term neurologic outcome of children who survive to discharge with favorable neurologic outcomes following OHCA, but simultaneously raises concerns. Contrary to commonly held beliefs, neurologic functioning can, and does, change over time. With this new information, we now have the responsibility to more clearly define the long-term functional, neurocognitive, neurobehavioral and health-related quality of life profiles of these children, and to identify and characterize those who improve beyond our early expectations., ,  What you see on hospital discharge is not always what you get.

Conflict of interest statement

None of the authors have any conflicts of interest to disclose.


  1. Atkins, D.L., Everson-Stewart, S., Sears, G.K. et al. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest.Circulation20091191484–1491
  2. Deasy, C., Bernard, S.A., Cameron, P. et al. Epidemiology of paediatric out-of-hospital cardiac arrest in Melbourne, Australia. Resuscitation2010811095–1100
  3. Donoghue, A.J., Nadkarni, V., Berg, R.A. et al. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med200546512–522
  4. Lopez-Herce, J., Garcia, C., Rodriguez-Nunez, A. et al. Long-term outcome of paediatric cardiorespiratory arrest in Spain. Resuscitation20056479–85
  5. Tijssen, J.A., Prince, D.K., Morrison, L.J. et al. Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest. Resuscitation2015941–7
  6. Topjian, A.A., Berg, R.A., and Nadkarni, V.M. Pediatric cardiopulmonary resuscitation: advances in science, techniques, and outcomes. Pediatrics20081221086–1098
  7. Gelberg, J., Stromsoe, A., Hollenberg, J. et al. Improving survival and neurologic function for younger age groups after out-of-hospital cardiac arrest in sweden: a 20-year comparison. Pediatr Crit Care Med201516750–757
  8. Nitta, M., Iwami, T., Kitamura, T. et al. Age-specific differences in outcomes after out-of-hospital cardiac arrests. Pediatrics2011128e812–e820
  9. Fiser, D.H. Assessing the outcome of pediatric intensive care. J Pediatr199212168–74
  10. Jacobs, I., Nadkarni, V., Bahr, J. et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa). Resuscitation200463233–249
  11. Cummins, R.O., Chamberlain, D.A., Abramson, N.S. et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council.Circulation199184960–975
  12. Becker, L.B., Aufderheide, T.P., Geocadin, R.G. et al. Primary outcomes for resuscitation science studies: a consensus statement from the American Heart Association. Circulation20111242158–2177
  13. Michiels, E.A., Quan, L., Dumas, F., and Rea, T. Long-term neurologic outcomes following pediatric out-of-hospitalcardiac arrest. Resuscitation2016;
  14. Pollack, M.M., Holubkov, R., Funai, T. et al. Relationship between the functional status scale and the pediatric overall performance category and pediatric cerebral performance category scales. JAMA Pediatr2014168671–676
  15. Fiser, D.H., Long, N., Roberson, P.K., Hefley, G., Zolten, K., and Brodie-Fowler, M. Relationship of pediatric overall performance category and pediatric cerebral performance category scores at pediatric intensive care unit discharge with outcome measures collected at hospital discharge and 1- and 6-month follow-up assessments. Crit Care Med2000282616–2620
  16. Suominen, P.K., Sutinen, N., Valle, S., Olkkola, K.T., and Lonnqvist, T. Neurocognitive long term follow-up study on drowned children. Resuscitation2014851059–1064
  17. van Zellem, L., Buysse, C., Madderom, M. et al. Long-term neuropsychological outcomes in children and adolescents after cardiac arrest. Intensive Care Med2015411057–1066
  18. van Zellem, L., Utens, E.M., Legerstee, J.S. et al. Cardiac arrest in children: long-term health status and health-related quality of life. Pediatr Crit Care Med201516693–702