CT signs of mass effect and oedema most consistently preceded death by neurological criteria

Design

Systematic review and meta-analysis of prognostic studies

Population

18 studies (9,070 patients); 4 pooled (1,738) after stroke or cardiac arrest

Primary outcome

Progression to death by neurological criteria

Effect

Stroke, severe mass effect on CT: OR 3.14 (1.98–4.96); post-arrest grey-white ratio MD −0.15

This systematic review and meta-analysis looked for predictors of progression to death by neurological criteria after non-traumatic acute brain injury, such as stroke or hypoxic injury after cardiac arrest. It identified 18 studies with about 9,070 patients, but only four (1,738 patients) had comparable enough data to pool.

In stroke cohorts, CT signs of severe intracranial mass effect were associated with about three times the odds of progression (pooled OR 3.14, 95% CI 1.98–4.96, no heterogeneity). After cardiac arrest, a lower grey-white matter ratio on CT was associated with progression (mean difference −0.15), with substantial heterogeneity.

The evidence base is thin, as the authors note. Its practical use is in anticipating which patients may progress, so that families can be prepared and, where appropriate, organ donation conversations can be started in time — not in making early prognostic decisions from one scan.

• In comatose patients after stroke or cardiac arrest, note CT features of mass effect, effacement and loss of grey-white differentiation.
• Patients with these features need closer neurological observation for signs of progression, including loss of brainstem reflexes.
• Begin early, honest conversations with families when imaging suggests severe injury.
• Notify the regional organ donation team early where local protocols allow, rather than after progression.

Why it matters

Recognising which patients may progress allows families and donation teams to be prepared rather than surprised.

Don't overread it

Pooled from four small studies; it cannot be used to predict death by neurological criteria in an individual patient.

The statistics, in plain English

An odds ratio of 3.14 means roughly three times the odds of progression with severe mass effect on CT. The pooled estimate comes from only two small stroke cohorts, so its size is uncertain even though the interval excludes 1.0.

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