Degree of neurological recovery as a function of initial neuron-specific enolase levels and electroencephalographic patterns in survivors of cardiac arrest: a bicentric study

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INTRODUCTION: The relationship between early markers of brain injury (biomarkers and EEG patterns) and the subsequent degree of neurological recovery in cardiac arrest survivors at 3 months has received little attention. We aimed to examine this relationship and describe patients who survived despite having initial unfavorable NSE levels and EEG patterns. METHODS: Cohort study analysing two prospective registries (CHUV Lausanne, Switzerland; Cochin Hospital, France). We included comatose patients after cardiac arrest who had at least one serum NSE at 48 h and an EEG ≥ 24 h. NSE was classified as < 17 µg/L, 17 ≤ NSE < 41 µg/L, 41 ≤ NSE ≤ 60 µg/L or > 60 µg/L. EEG was classified as highly malignant, malignant or benign. The primary outcome was the level of neurological recovery at 3 months according to the Cerebral Performance Category (CPC) scale. NSE and EEG were compared between the CPC groups. We also assessed the number of patients with a CPC 1 or 2 and either an NSE > 60 µg/L or a highly malignant EEG. RESULTS: Between 2017 and 2024, 966 comatose patients were included. The NSE level ranges at 48 h differed significantly across the CPC groups, higher values being associated with poorer functional outcomes; this significant difference was also notable in survivors (CPC1 vs CPC2 vs CPC3) (p < 0.001). EEG patterns were also significantly different across CPC groups: the more severe the EEG pattern, the worse the functional outcome (p < 0.001). Regarding false-positive prediction of unfavorable outcome, NSE > 60 µg/L was found in 2/176 patients (1.2 %) who reached CPC 1 (maximum at 79.5 µg/L) and 3/138 patients (2.2 %) who reached CPC 2 at follow up (maximum at 68 µg/L); none of them had other markers of unfavorable outcome. No patients with CPC 1 or 2 had a highly malignant EEG. CONCLUSION: This large bicentric study found a progressive worsening of neurological outcomes at 3 months with higher NSE levels or deteriorating EEG patterns. Thus, both NSE and EEG may be valuable for predicting cognitive impairments in survivors. Only a few patients with favorable outcome had NSE levels > 60 µg/L, and none of them had other markers of unfavorable outcome.

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