To date, no particular test or combination of tests/findings has a sufficiently high sensitivity and specificity to accurately predict outcome after CA. However, if the aim of a prognostic paradigm is to identify the patients who do poorly, then a test with moderate sensitivity would be acceptable, as long as the specificity is high. In a systematic review of predictors of poor outcome after anoxic coma, Zandbergen identified 3 factors with 100% specificity of poor outcome (defined as death or persistent vegetative state): (i) absence of papillary light reflexes on day 3, (ii) absence of motor response to pain on day 3, and (iii) bilateral absence of cortical SSEP within the first week (37). The estimated false-positive rate was lowest with SSEP, leading the authors to conclude that this was the most useful method to predict poor outcome.

Several principles are suggested by the current literature. First, the best time to assess prognosis after CA is approximately 3 days after the event, by which time a number of predictors emerge and carry greater statistical certainty. Second, loss of brain stem function as assessed by pupillary light responses indicates severe brain damage and poor outcome. Third, if brain stem function is relatively intact, prognosis depends on the extent of cortical injury, which might be best assessed by SSEP. Persistent coma after CA suggests significant brain injury, with a poor prognosis for the majority of patients. Much of the current literature focuses on predictors of poor outcome, and little data is available on factors that can identify with certainty patients who will have a good outcome.

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