Abstract
Objectives
To describe head computed tomography (CT) utilization and the diagnostic yield of acute intracranial pathology among adult survivors of non-traumatic in-hospital cardiac arrest (IHCA), and to identify factors associated with obtaining CT.
Methods
We conducted a retrospective cohort study of adults with non-traumatic IHCA who achieved return of spontaneous circulation (ROSC) at a tertiary academic hospital between January 2019 and December 2024. Clinical characteristics, arrest variables, and radiologic findings were abstracted from the electronic medical record and institutional cardiac arrest registry. Acute intracranial pathology was categorized descriptively and included intracranial hemorrhage, hypoxic–ischemic brain injury (HIBI)–related cerebral edema (with or without sulcal or basilar cistern effacement), or other acute structural abnormalities. Multivariable logistic regression was used to evaluate predictors of CT utilization. Survival and neurological outcomes were assessed as exploratory, hypothesis-generating analyses.
Results
Among 525 IHCA survivors, 89 (17%) underwent head CT. CT recipients were younger and more likely to have cerebrovascular disease or arrest in the emergency department. Intracranial hemorrhage was identified in 17% of scanned patients, while HIBI-related cerebral edema was present in 26%, with sulcal or cisternal effacement in 20% and 11%, respectively. CT utilization was not independently associated with survival or a favorable neurological outcome.
Conclusion
Head CT after IHCA was used selectively but demonstrated a high diagnostic yield. The principal contribution of this study is the characterization of current imaging practices and the clinical profile of patients who undergo CT after IHCA. Further work is needed to define which patients may benefit most from early neuroimaging and whether imaging meaningfully alters management or decision-making.
Keywords: Head CT, In-hospital cardiac arrest, Post-cardiac arrest care, Intracerebral hemorrhage
Introduction
Early neuroimaging is frequently considered after cardiac arrest to evaluate for intracranial hemorrhage (ICH), hypoxic–ischemic brain injury (HIBI)–related cerebral edema, or other structural causes of sudden collapse.1, 2 Because cardiac arrest is a cause, not a consequence, of HIBI-related edema, neuroimaging is most often used to evaluate etiologies or complications after ROSC rather than to explain the arrest itself.3 Although head computed tomography (CT) is well studied in out-of-hospital cardiac arrest (OHCA), its diagnostic yield and clinical utility in non-traumatic in-hospital cardiac arrest (IHCA) remain poorly defined.1, 4 Importantly, most prior studies have focused on the prevalence of post-arrest neurologic injury rather than on which IHCA patients undergo imaging and how imaging is selectively applied in real-world practice.1, 2, 4 IHCA differs substantially from OHCA with respect to monitored status, etiologic heterogeneity, comorbidity burden, and arrest circumstances, all of which may influence imaging decisions.5, 6, 7
Recent guideline updates, including the 2025 American Heart Association Post–Cardiac Arrest Care Guidelines, note that CT may be reasonable after ROSC to investigate reversible causes or complications, but acknowledge that the available evidence is limited and largely focused on OHCA.8 Imaging decisions for IHCA may differ due to distinct clinical contexts and etiologic mechanisms.9, 10 Understanding current CT utilization patterns and their associated diagnostic yield is therefore essential for contextualizing post-arrest neuroimaging practices.
Accordingly, the primary objective was to describe head CT utilization and the spectrum of acute intracranial findings among adult survivors of non-traumatic IHCA. Secondarily, we sought to identify patient-, arrest-, and system-level factors associated with obtaining CT, recognizing survival and neurological outcomes as exploratory analyses subject to substantial selection bias.
Methods
Study design
We conducted a retrospective observational cohort study of adults with non-traumatic IHCA who achieved ROSC between January 2019 and December 2024. The study adhered to STROBE guidelines and was approved by the Institutional Review Board, with informed consent waived due to minimal risk.
Setting and participants
The study was performed in a 1,400-bed tertiary academic hospital with a 24-hour emergency department (ED). All adult IHCA events were screened. Cardiac arrests occurring within the ED were classified as IHCA, consistent with Utstein definitions.11 Exclusions included traumatic arrest, age <15 years, out-of-hospital arrest before arrival, and failure to achieve sustained ROSC. All included patients had complete survival and neurological outcome data.
Variables and outcome
Clinical data were extracted from the electronic medical record and the institutional cardiac arrest registry maintained by the hospital’s resuscitation committee. The registry is populated through retrospective chart abstraction by trained clinical research personnel using standardized variable definitions, with periodic data quality checks. Cardiac arrest variables included hospital location, time of day, initial rhythm, and CPR duration. Pre-arrest interventions (oxygen, mechanical ventilation, vasoactive support) were also recorded.
There is no institutional protocol mandating head CT after IHCA. Decisions to obtain CT were made at the discretion of the treating clinical team (ED, ICU, or primary inpatient service).
Clinical characteristics, comorbidities, arrest variables, and pre-arrest interventions were collected. Cerebrovascular disease was defined as a documented history of ischemic stroke, intracerebral hemorrhage, or other diagnosed cerebrovascular pathology. For patients undergoing head CT, all head CTs obtained after ROSC within 7 days during the index hospitalization were included, and the time from ROSC to imaging was recorded. Radiologic findings were abstracted from final attending radiologist reports generated as part of routine clinical care. Radiologists were not involved in the study and were unaware of the study objectives. Investigators did not reinterpret the imaging; they reported the findings.
Hypoxic–ischemic/anoxic brain injury (HIBI)–related cerebral edema was defined radiographically by loss of gray–white differentiation, and/or cerebral edema, with sulcal and/or basilar cistern effacement recorded as severity markers rather than distinct disease entities.12 These features were permitted to co-occur and were not mutually exclusive.12
Primary neurogenic causes (e.g., acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage) were abstracted based on the radiology report as clinically significant acute findings. Incidental or non–arrest-related findings were recorded when noted by radiology but were not felt to plausibly explain the arrest based on the treating team’s documentation.
Subarachnoid hemorrhage diagnoses were based on routine radiology interpretation; we acknowledge that severe cerebral edema may produce a pseudosubarachnoid appearance and that confirmatory vascular imaging or MRI was not systematically available to adjudicate equivocal cases.
The primary outcome was the descriptive diagnostic yield of CT. Secondary outcomes included survival to hospital discharge and a favorable neurological outcome at hospital discharge, defined as having a Cerebral Performance Category (CPC) of 1–2.
Statistical analysis
We included all eligible adult IHCA survivors during the study period; therefore, no a priori sample size estimation was performed. Results are presented as effect estimates with 95% confidence intervals.
Baseline demographic, clinical, arrest-related, and resuscitation characteristics were summarized for the overall cohort and stratified by head CT utilization (CT vs no CT). Continuous variables were assessed for normality and are presented as mean ± standard deviation (SD) for approximately normally distributed data or median with interquartile range (IQR) for non-normally distributed data. Categorical variables are reported as counts and percentages.
Group comparisons were performed for descriptive purposes only. Continuous variables were compared using the independent t-test or Wilcoxon rank-sum test, as appropriate, and categorical variables were compared using the χ2 test or Fisher’s exact test when expected cell counts were small.
Multivariable logistic regression with head CT utilization as the dependent variable was performed to characterize patient, arrest, and resuscitation features associated with obtaining imaging after ROSC, thereby describing contemporary practice patterns and clinical selection for head CT. STATA version 16 was used for the data analysis.
Results
Baseline characteristics
Among 525 eligible IHCA survivors (Fig. 1), the mean age was 66.8 ± 15.3 years, and 58% were male (Table 1). Eighty-nine patients (17%) underwent head CT. CT recipients were younger (63.2 vs 67.5 years, p = 0.015) and more likely to have cerebrovascular disease (25% vs 10%, p < 0.001) or chronic heart failure (16% vs 9%, p = 0.035). Arrests in the ED were more common among CT patients (45% vs 22%, p < 0.001). Pre-arrest use of vasoactive agents was significantly less frequent in the CT group (9% vs 28%; p < 0.001). Unadjusted survival to discharge was higher in CT patients (51% vs 40%, p = 0.043), whereas favorable neurological outcomes were similar (24% vs 25%; p = 0.78).
Fig. 1.
Study flow.
Table 1.
Demographics and baseline characteristics of included patients by head CT utilization.
| Characteristics |
Total (n = 525) |
Head CT scanned (n = 89) |
No head CT scanned (n = 436) |
p-value |
|---|---|---|---|---|
| Age – years, mean ± SD | 66.8 ± 15.3 | 63.2 ± 16.5 | 67.5 ± 15.0 | 0.015 |
| Male sex, n (%) | 302 (57.5) | 47 (52.8) | 255 (58.5) | 0.323 |
| Cardiac arrest on weekend, n (%) | 143 (27.4) | 25 (28.1) | 118 (27.1) | 0.843 |
| Time of cardiac arrest, n (%) | 0.453 | |||
| Day (08:01–16:00) | 213 (40.6) | 37 (41.6) | 176 (40.4) | |
| Evening (16:01–24:00) | 192 (36.6) | 36 (40.5) | 156 (35.8) | |
| Night (00:01–08:00) | 120 (22.9) | 16 (18.0) | 104 (23.9) | |
| Location of cardiac arrest, n (%) | <0.001 | |||
| General wards | 162 (30.9) | 27 (30.3) | 135 (31.0) | |
| Emergency department | 136 (26.0) | 40 (44.9) | 96 (22.1) | |
| Intensive care units | 186 (35.5) | 19 (21.4) | 167 (38.4) | |
| Operating room/recovery room | 5 (1.0) | 0 (0) | 5 (1.2) | |
| Other in-hospital wards | 35 (6.7) | 3 (3.4) | 32 (7.4) | |
| Comorbidities, n (%) | ||||
| Hypertension | 294 (56.0) | 52 (58.4) | 242 (55.5) | 0.613 |
| Diabetes | 181 (34.5) | 29 (32.6) | 152 (34.9) | 0.680 |
| Dyslipidemia | 190 (36.2) | 33 (37.1) | 157 (36.0) | 0.848 |
| Chronic kidney disease | 143 (27.2) | 28 (31.5) | 115 (26.4) | 0.326 |
| Chronic heart failure | 51 (9.7) | 14 (15.7) | 37 (8.5) | 0.035 |
| Coronary artery disease | 92 (17.5) | 19 (21.4) | 73 (16.7) | 0.298 |
| Cerebrovascular disease | 67 (12.8) | 22 (24.7) | 45 (10.3) | <0.001 |
| Dementia | 13 (2.5) | 4 (4.5) | 9 (2.1) | 0.179 |
| Chronic obstructive pulmonary disease | 24 (4.6) | 3 (3.4) | 21 (4.8) | 0.552 |
| Chronic liver disease | 51 (9.7) | 6 (6.7) | 45 (10.3) | 0.299 |
| Pre-arrest bedridden status, n (%) | 148 (28.2) | 26 (29.2) | 122 (28.0) | 0.814 |
| Charlson Comorbidity Index, median (IQR) | 4 (3–6) | 4 (2–6) | 4 (3–6) | 0.497 |
| ESRD on dialysis, n (%) | 77 (14.7) | 12 (13.5) | 65 (14.9) | 0.729 |
| Active malignancy, n (%) | 111 (21.1) | 14 (15.7) | 97 (22.3) | 0.170 |
| Shockable Initial rhythm, n (%) | 104 (20.6) | 17 (19.8) | 87 (20.8) | 0.835 |
| Management before cardiac arrest, n (%) | 0.114 | |||
| None | 191 (36.4) | 41 (46.1) | 150 (34.4) | |
| Oxygen therapy | 106 (20.2) | 15 (16.9) | 91 (20.9) | |
| Ventilation-assisted | 228 (43.4) | 33 (37.1) | 195 (44.7) | |
| Vasoactive agents administered before cardiac arrest, n (%) | 131 (25.0) | 8 (9.0) | 123 (28.2) | <0.001 |
| POCT glucose measured during CPR, n (%) | 200 (38.1) | 45 (50.6) | 155 (35.6) | 0.008 |
| POCT glucose – mg/dL, median (IQR) | 147 (102–199) | 156 (116–220) | 146 (96–197) | 0.119 |
| CPR duration – min, median (IQR) | 6 (3–10) | 6 (4–10) | 6 (3–11) | 0.705 |
Abbreviations: CPR, cardiopulmonary resuscitation; CT, computed tomography; ESRD, end-stage renal disease; IQR, interquartile range; POCT, point-of-care testing; SD, standard deviation.
CT timing and findings
Median time from ROSC to CT was 4 h (IQR 2–24). 14.6% were scanned within 1 h and 58.4% within 6 h (Table 2). Acute intracranial abnormalities were present in 42.0% of scans.
Table 2.
Head CT timing and diagnostic yield among ROSC patients who underwent head CT (n = 89).
| Parameter | Value |
|---|---|
| (A) Timing | |
| Timing of imaging | |
| Time from ROSC to CT, median [IQR], hours | 4 (2–24) |
| CT performed within 1 h, n (%) | 13 (14.6) |
| CT performed within 6 h, n (%) | 52 (58.4) |
| (B) Acute intracranial findings | |
| 1. Hypoxic-ischemic brain injury (HIBI) spectrum† | |
| Findings | |
| Any HIBI-spectrum feature | 23 (25.8) |
| Diffuse cerebral edema | 23 (25.8) |
| Sulcal effacement, n (%) | 18 (20.2) |
| Basilar cistern effacement, n (%) | 10 (11.2) |
| 2. Primary neurogenic cause | |
| Any intracranial hemorrhage | 15 (16.9) |
| Subarachnoid hemorrhage | 5 (5.6) |
| Subdural hematoma | 7 (7.9) |
| Intraparenchymal hemorrhage | 5 (5.6) |
Abbreviations: CT, computed tomography; IQR, interquartile range; ROSC, return of spontaneous circulation.
Important limitation: Severe cerebral edema may produce a pseudosubarachnoid appearance; confirmatory vascular imaging was not systematically available.
HIBI features may co-occur and are not mutually exclusive.
HIBI-spectrum findings were present in 23 patients (25.8%) and included diffuse cerebral edema (25.8%), with sulcal effacement (20.2%) and basilar cistern effacement (11.2%) recorded as severity markers that could co-occur with other HIBI features (Table 2). Primary neurogenic findings included intracranial hemorrhage in 15 patients (16.9%), comprising subdural hematoma (7.9%), subarachnoid hemorrhage (5.6%), and intraparenchymal hemorrhage (5.6%) (Table 2). Severe cerebral edema can produce a pseudosubarachnoid appearance; confirmatory vascular imaging was not systematically available, and hemorrhage classification was based on the attending radiologist’s interpretation. Hemorrhage acuity and causal attribution (primary cause vs contributor vs incidental) could not be definitively adjudicated from retrospective data.
Patient, arrest, and system factors associated with head CT utilization
In multivariable analysis (Table 3), cerebrovascular disease (aOR 3.63, 95% CI 1.78–7.39), chronic heart failure (aOR 2.73, 95% CI 1.25–5.95), and ED location (aOR 1.95, 95% CI 1.00–3.80) were associated with a higher likelihood of CT. Older age (aOR 0.32, 95% CI 0.18–0.59 for ≥60 years) and pre-arrest vasoactive support (aOR 0.23, 95% CI 0.09–0.57) were strongly associated with decreased CT use.
Table 3.
Patient, arrest, and system factors associated with head CT utilization after return of spontaneous circulation in non-traumatic in-hospital cardiac arrest.
| Variables | Adjusted OR (95% CI) |
|---|---|
| Demographics | |
| Age ≥60 years | 0.32 (0.18–0.59)*** |
| Male sex | 0.80 (0.47–1.35) |
| Pre-arrest bedridden status | 1.35 (0.74–2.44) |
| Comorbidities | |
| Hypertension | 1.01 (0.55–1.84) |
| Diabetes mellitus | 0.82 (0.45–1.49) |
| End-stage renal disease | 1.78 (0.97–3.27) |
| Malignancy | 0.76 (0.37–1.53) |
| Chronic heart failure | 2.73 (1.25–5.95)* |
| Coronary arterial disease | 1.69 (0.88–3.23) |
| Cerebrovascular disease | 3.63 (1.78–7.39)*** |
| Chronic liver disease | 0.78 (0.29–2.11) |
| Arrest characteristics | |
| Initial shockable rhythm | 0.87 (0.45–1.70) |
| CPR duration (min) | 1.01 (0.98–1.04) |
| ICU location | |
| General wards | Ref |
| Emergency department | 1.95 (1.00–3.80)* |
| Intensive care units | 0.69 (0.35–1.36) |
| Operating room | N/A |
| Other in-hospital units | 0.33 (0.07–1.54) |
| Management before cardiac arrest | |
| Ventilation | |
| None | Ref |
| Oxygen therapy | 0.63 (0.29–1.36) |
| Ventilator-assisted | 0.97 (0.51–1.86) |
| Vasoactive agents | 0.23 (0.09–0.57)** |
| System factors | |
| Shift | |
| Day | Ref |
| Evening | 1.04 (0.58–1.88) |
| Night | 0.82 (0.41–1.62) |
| Arrest on the weekend | 1.06 (0.58–1.92) |
Abbreviations: CI, confidence interval; CT, computed tomography; ICU, intensive care unit; ROSC, return of spontaneous circulation.
p < 0.05.
p < 0.01.
p < 0.001.
Exploratory outcomes by head CT utilization
Targeted temperature management was more commonly initiated among CT recipients (12.5% vs 1.2%; p < 0.001) (Table 4). Unadjusted survival to hospital discharge was higher among CT patients (50.6% vs 39.9%, p = 0.043), whereas a favorable neurological outcome (CPC 1–2 at discharge) was similar between groups (23.6% vs 25.0%, p = 0.780) (Table 4).
Table 4.
Exploratory clinical outcomes by head CT utilization.
| Characteristics |
Total (n = 525) |
Head CT scanned (n = 89) |
No head CT scanned (n = 436) |
p-value |
|---|---|---|---|---|
| TTM initiated, n (%) | 16 (3.1) | 11 (12.5) | 5 (1.2) | <0.001 |
| Survived to hospital discharge, n (%) | 215 (41.0) | 45 (50.6) | 170 (39.9) | 0.043 |
| Favorable neurological outcome (CPC 1–2), n (%) | 130 (24.8) | 21 (23.6) | 109 (25.0) | 0.780 |
Abbreviations: CPC, cerebral performance category; CT, computed tomography; TTM, targeted temperature management.
Discussion
Head CT was used selectively in this IHCA cohort, yet nearly half of the imaged patients had acute intracranial abnormalities, a substantially higher yield than typically reported in OHCA studies.1, 4, 13 Importantly, the principal contribution of this study is not the existence of post-arrest neuroimaging abnormalities per se, but the characterization of contemporary head CT utilization patterns after IHCA and the clinical profile of patients who undergo imaging in routine practice.
The proportion of patients with intracranial hemorrhage (17%) is substantially higher than OHCA-based estimates (3–7%).1, 13 Subdural and subarachnoid hemorrhages predominated, which may reflect enrichment of neurogenic etiologies among patients selected for imaging, a higher burden of underlying cerebrovascular disease, and the higher proportion of arrests occurring in the ED, where undifferentiated presentations and proximity facilitate early CT.1, 14 We removed speculative attribution of hemorrhage to resuscitation-related trauma, as this could not be substantiated from our data. Hemorrhage acuity and causal attribution (primary cause vs contributor vs incidental) could not be definitively adjudicated from retrospective data, and this should be considered when interpreting the high observed hemorrhage frequency. Cerebral edema or anoxic injury was identified in one-quarter of imaged patients, consistent with the recognized burden of hypoxic–ischemic brain injury after arrest.15 We also clarified that sulcal and basilar cistern effacement represent severity markers of HIBI-related edema rather than distinct diagnostic entities and may co-occur with other HIBI features. Although CT is less sensitive than MRI for detecting diffuse injury, its accessibility and speed make it an important early tool.16 We acknowledge that severe cerebral edema can produce a pseudosubarachnoid appearance17; because confirmatory vascular imaging was not systematically available, hemorrhage classification relied on attending radiologist interpretation as part of routine care.
Despite its diagnostic value, CT utilization was not independently associated with survival or a favorable neurological outcome. This finding should be interpreted cautiously, given substantial confounding by indication and proximity bias: patients who were hemodynamically stable enough to be transported and those who arrested in the ED may have been more likely to undergo CT, and these same factors are associated with outcomes. This is consistent with previous studies showing that while early CT may clarify etiology or document brain injury, it rarely identifies conditions amenable to immediate intervention.1, 4
Instead, head CT may function primarily to support risk stratification, prognostication, and goals-of-care discussions.1, 18 Additionally, analyses with survival as the outcome are susceptible to immortal time bias, as patients must survive long enough after ROSC to undergo head CT; therefore, CT utilization should be interpreted as a time-dependent marker of early post-ROSC stability rather than as a therapeutic exposure. The strong and expected associations of shockable rhythm, age, malignancy, and pre-arrest functional status with outcomes reinforce the internal validity of our models.
These findings raise the question of whether current imaging practices in IHCA are optimally calibrated. While selective imaging is appropriate, the high rate of abnormalities detected suggests that some clinically relevant diagnoses may remain unrecognized in patients who are not scanned. However, expanding imaging must be balanced against transport risks and the limited therapeutic implications of many findings. We also note the potential for unintended delays to time-sensitive interventions (e.g., coronary angiography/cardiac catheterization), which may carry important clinical consequences and further support a selective, context-driven approach to neuroimaging. Given that the epidemiology of subarachnoid hemorrhage varies geographically, including higher rates reported in some Asian populations,19 the observed hemorrhage frequency in this single-center cohort may not fully generalize to other settings.
Limitations include the retrospective, single-center design; potential selection bias in the selection of patients who underwent CT; possible unmeasured confounders (e.g., severity of hemodynamic instability, sedation, or quality of the neurologic exam); and the inability to determine how CT findings affected management or the timing of withdrawal of life-sustaining therapy. Because imaging was obtained at the clinician's discretion rather than via a standardized protocol, differences between imaged and non-imaged groups likely reflect clinical selection (including perceived futility or an established non-neurologic etiology), limiting the interpretability of outcome comparisons. We also could not reliably capture CT-attributable management changes (e.g., hyperosmolar therapy, ventilatory or blood pressure target adjustments, neurosurgical consultation, or structured goals-of-care transitions), which represents a key direction for future prospective studies. Additionally, data on long-term neurological outcomes (beyond hospital discharge) were unavailable.
Conclusion
In this retrospective cohort of adult survivors of non-traumatic IHCA, head CT was obtained in a minority of patients, yet demonstrated a high diagnostic yield, with acute intracranial abnormalities in 42% and intracranial hemorrhage in 17% of all scans. CT utilization was selective and was independently associated with cerebrovascular disease, chronic heart failure, and ED arrest location, while older age and pre-arrest vasoactive support were associated with a lower likelihood of imaging. Although CT use did not independently improve survival or neurological outcomes, its diagnostic value suggests that current selective practices may overlook clinically relevant pathology. Future research should evaluate whether structured post-IHCA neuroimaging strategies can improve etiologic clarification, inform neuroprotective management or goals-of-care discussions, and better define which patients derive the greatest clinical value from early head CT.
Data sharing
Deidentified individual participant data and statistical code are available upon reasonable request to the corresponding author.
CRediT authorship contribution statement
Wachira Wongtanasarasin: Writing – review & editing, Writing – original draft, Visualization, Validation, Project administration, Methodology, Funding acquisition, Formal analysis, Data curation, Conceptualization. Natcha Meesommit: Writing – review & editing, Investigation, Conceptualization. Phanthira Phukkanan: Writing – review & editing, Investigation, Conceptualization. Purichaya Puwathananon: Writing – review & editing, Investigation, Conceptualization. Metiya Chuajan: Writing – review & editing, Investigation, Conceptualization. Aukkarawit Uttarachon: Writing – review & editing, Investigation, Conceptualization. Daniel K. Nishijima: Writing – review & editing, Visualization, Supervision, Methodology, Conceptualization.
Funding
This study was supported by a grant from the Faculty of Medicine, Chiang Mai University. The APC was also supported by the Faculty of Medicine, Chiang Mai University.
Declaration of competing interest
The authors declare no competing interests. ChatGPT 5.1 and Grammarly were used to check and correct grammatical errors during the writing of this document. We reviewed and edited the content as needed and take full responsibility for the entire content.
Acknowledgments
The authors would like to thank the MERG team for their valuable guidance and insightful comments during manuscript preparation.
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