Predict cardiac death after withdrawal of life-supporting treatment in the neurocritical patients: a neurological score

Guixing Xu, Hua Liu, Donghua Zheng


Background: Accurate prediction the time of death after withdrawal of life-supporting treatment (WLST) in the neurocritical patients is important for donation after cardiac death. We aimed to establish a new neurological scoring system to predict the probability of death within 60 minutes after WLST.

Methods: We retrospectively reviewed the clinical data from a cohort of 231 neurocritical patients from June 2016 to July 2018. The patients were divided into training and external validation sets. In the training set, we used univariate and multivariable logistic regression analyses to assess associations between death within 60 minutes after WLST and these variables. Points attributed to each variable were summed to create a predictive score for cardiac death. We assessed performance of the score using ROC analysis. Finally, we validated the predictive ability of the score in an external validation set.

Results: Multivariable logistic regression analysis showed that absent corneal reflexes, absent cough reflexes, extensor or absent motor response and anisocoric or bilaterally dilated pupil were associated with death within 60 minutes in training set (all p<0.05). The area under curve for the score was 0.839 (95% CI 0.763-0.916) for prediction of death within 60 minutes. A score of 4-6 had a sensitivity of 95.88% and a specificity of 69.05% to predict death within 60 minutes after WSLT. In external validation set, the prevalence of these predictors was similar with training sample.

Conclusions: The neurological score may be useful to predict time of death after WLST in neurocritical patients.


Neurocritical patients, Cardiac death, Prediction, Score system

Full Text:



Peacock SH, Tomlinson AD. Multimodal Neuromonitoring in Neurocritical Care. AACN Adv Crit Care. 2018;29:183-94.

Leblanc G, Boutin A, Shemilt M, Lauzier F, Moore L, Potvin V, et al. Incidence and impact of withdrawal of life-sustaining therapies in clinical trials of severe traumatic brain injury: A systematic review. Clin Trials. 2018;15:398-412.

Mercier E, Boutin A, Shemilt M, Lauzier F, Zarychanski R, Fergusson DA, et al. Predictive value of neuron-specific enolase for prognosis in patients with moderate or severe traumatic brain injury: a systematic review and meta-analysis. CMAJ Open. 2016;4:E371-E82.

Lewis J, Peltier J, Nelson H, Snyder W, Schneider K, Steinberger D, et al. Development of the University of Wisconsin donation After Cardiac Death Evaluation Tool. Prog Transplant. 2003;13:265-73.

Rabinstein AA, Yee AH, Mandrekar J, Fugate JE, de Groot YJ, Kompanje EJ, et al. Prediction of potential for organ donation after cardiac death in patients in neurocritical state:a prospective observational study. Lancet Neurol. 2012;11:414-9.

Suntharalingam C, Sharples L, Dudley C, Bradley JA, Watson CJ. Time to cardiac death after withdrawal of life-sustaining treatment in potential organ donors. Am J Transplant. 2009;9:2157-65.

Weiss MJ, Hornby L, Rochwerg B, van Manen M, Dhanani S, Sivarajan VB, et al. Canadian Guidelines for Controlled Pediatric Donation After Circulatory Determination of Death-Summary Report. Pediatr Crit Care Med. 2017;18:1035-46.

DeVita MA, Brooks MM, Zawistowski C, Rudich S, Daly B, Chaitin E. Donors after cardiac death:validation of identification criteria (DVIC) study for predictors of rapid death. Am J Transplant. 2008;8:432-41.

Yee AH, Rabinstein AA, Thapa P, Mandrekar J, Wijdicks EF. Factors influencing time to death after withdrawal of life support in neurocritical patients. Neurology. 2010;74:1380-5.

Hoffmann M, Lehmann W, Rueger JM, Lefering R, Trauma Registry of the German Society for Trauma S. Introduction of a novel trauma score. J Trauma Acute Care Surg. 2012;73:1607-13.

Hoffmann M, Lefering R, Rueger JM, Kolb JP, Izbicki JR, Ruecker AH, et al. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. Br J Surg. 2012;99 Suppl 1:122-30.

Chamoun RB, Robertson CS, Gopinath SP. Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation. J Neurosurg. 2009;111:683-7.

de Groot YJ, Lingsma HF, Bakker J, Gommers DA, Steyerberg E, Kompanje EJ. External validation of a prognostic model predicting time of death after withdrawal of life support in neurocritical patients. Crit Care Med. 2012;40:233-8.

Wind J, Snoeijs MG, Brugman CA, Vervelde J, Zwaveling J, van Mook WN, et al. Prediction of time of death after withdrawal of life-sustaining treatment in potential donors after cardiac death. Crit Care Med. 2012;40:766-9.

Bakker J, Jansen TC, Lima A, Kompanje EJ. Why opioids and sedatives may prolong life rather than hasten death after ventilator withdrawal in critically ill patients. Am J Hosp Palliat Care. 2008;25:152-4.

Kompanje EJ, van Zuylen L, van der Rijt CC. Morphine is not a sedative and does not shorten life. Arch Intern Med. 2006;166:2047-8.

Chan JD, Treece PD, Engelberg RA, Crowley L, Rubenfeld GD, Steinberg KP, et al. Narcotic and benzodiazepine use after withdrawal of life support:association with time to death? Chest. 2004;126:286-93.