Neurocrit Care (2023) 38:129–137

https://doi.org/10.1007/s12028-022-01570-8

ORIGINAL WORK

The SLANT Score Predicts Poor Neurologic

Outcome in Comatose Survivors of Cardiac
Arrest: An External Validation Using a
Retrospective Cohort
Trevor G. Luck1, Katherine Locke1, Benjamin C. Sherman1, Matthew Vibbert2, Sara Hefton2
and Syed Omar Shah2*

© 2022 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society

Abstract
Background: Hypoxic brain injury is the leading cause of death in comatose patients following resuscitation from
cardiac arrest. Neurological outcome can be difficult to prognosticate following resuscitation, and goals of care
discussions are often informed by multiple prognostic tools. One tool that has shown promise is the SLANT score,
which encompasses five metrics including initial nonshockable rhythm, leukocyte count after targeted temperature
management, total adrenaline dose during resuscitation, lack of bystander cardiopulmonary resuscitation, and time
to return of spontaneous circulation. This cohort study aimed to provide an external validation of this score by using a
database of comatose cardiac arrest survivors from our institution.
Methods: We retrospectively queried our database of cardiac arrest survivors, selecting for patients with coma,
sustained return of spontaneous circulation, and use of targeted temperature management to have a comparable
sample to the index study. We calculated SLANT scores for each patient and separated them into risk levels, both
according to the original study and according to a Youden index analysis. The primary outcome was poor neurologic
outcome (defined by a cerebral performance category score of 3 or greater at discharge), and the secondary outcome
was in-hospital mortality. Univariable and multivariable analyses, as well as a receiver operator characteristic curve,
were used to assess the SLANT score for independent predictability and diagnostic accuracy for poor outcomes.
Results: We demonstrate significant association between a SLANT group with increased risk and poor neurologic
outcome on univariable (p = 0.005) and multivariable analysis (odds ratio 1.162, 95% confidence interval 1.003–1.346,
p = 0.046). A receiver operating characteristic analysis indicates that SLANT scoring is a fair prognostic test for poor
neurologic outcome (area under the curve 0.708, 95% confidence interval 0.536–0.879, p = 0.024). Among this cohort,
the most frequent SLANT elements were initial nonshockable rhythm (84.5%) and total adrenaline dose ≥ 5 mg
(63.9%). There was no significant association between SLANT score and in-hospital mortality (p = 0.064).
Conclusions: The SLANT score may independently predict poor neurologic outcome but not in-hospital mortality.
Including the SLANT score as part of a multimodal approach may improve our ability to accurately prognosticate
comatose survivors of cardiac arrest.

*Correspondence: syed.shah@jefferson.edu
2
Division of Neurocritical Care, Department of Neurosurgery, Jefferson
Hospital for Neuroscience, Thomas Jefferson University, 909 Walnut Street,
3rd Floor, Philadelphia, PA 19107, USA
Full list of author information is available at the end of the article
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Keywords: Neurocritical care, External validation, Prognostic scoring system, Cardiac arrest, Neuroprognostication,
SLANT score
Introduction
Hypoxic Brain Injury
Hypoxic ischemic brain injury (HIBI) is the primary
determinant of neurologic outcome after resuscitation
from out-of-hospital cardiac arrest (OHCA) [1, 2]. Given
that HIBI outcomes have not improved significantly over
the last 20 years [1, 3, 4], this area is a critical target for
systematic prognostication to inform clinicians and
patient families alike. Certainty in the evidence of neu-
rological prognostication studies is typically low because
of biases that limit the internal validity of these stud-
ies, as has been highlighted in systematic review [5–8].
One recent metric that has shown some promise is the
SLANT risk stratification scoring system described by
Chen et al. [9].
Current neuroprognostication standards consists of
multiple disparate methods with no single linking metric,
leading to a complex system that varies among hospital
systems [10]. Among these are electrophysiology, imag-
ing modalities, chemical biomarkers, and physical exami-
nation, but none may be standardized as a simple, easily
calculated scoring system [10, 11]. Therefore, there may
be benefit from including a score that is calculable from
readily available elements of patient data and may be eas-
ily used. Created in 2021 by Chen et al. [9], the SLANT
score fulfills these criteria, with most of its elements
consisting of routinely recorded factors and biomark-
ers, and demonstrates a standardized application. Most
interestingly, the SLANT score considers injury factors
that are not traditionally used in prognostication. By add-
ing a simple scoring system to an extensive multimodal
approach, there may be a significant improvement in our
reliability to accurately prognosticate comatose patients
of cardiac arrest.
The SLANT Score
Each letter of the acronym “SLANT” stands for a crite-
rion on which patients are scored, with cumulative scores
yielding a risk stratification (Supplementary Table 1).
These criteria are (1) Initial nonshockable rhythm, (2)
Leukocytosis/leukopenia within 24 h after completion of
targeted temperature management (TTM), (3) Adrena-
line dose exceeding 5 mg during resuscitation, (4) Lack
of onlooker cardiopulmonary resuscitation, and (5) Time
of resuscitation exceeding 20 min [9]. Each criterion is a
Boolean operator assigned a scoring value depending on
the presence or absence of the described factor. After the
addition of each score, a patient may be stratified into
one of three risk groups for poor neurologic status at dis-
charge and in-hospital mortality.
Internal validation of the scoring system was prom-
ising, showing a statistically significant association
between risk group assignment and both neurologic
status at discharge and in-hospital mortality [9]. How-
ever, as stated by the American Heart Association, vari-
ous systematic reviews consistently find biases that limit
internally validated prognostication scores for HIBI out-
comes [5–8]. Therefore, the need for the external valida-
tion of prognostic scoring systems is particularly pressing
for those that predict HIBI outcomes following cardiac
resuscitation [5, 12].
The purpose of our study is to meet this need by ret-
rospectively reviewing patient data and assigning SLANT
score values, and then comparing scores to patient out-
comes. Although Chen et al. [9] did use data from mul-
tiple centers, their data were not independent because
they were consistently reviewed by the same researchers
assessing each cohort. There is yet to be an independent,
external validation of this scoring system. By adding our
data, we can contribute to a full validation with a differ-
ent geographic location and independent review. There-
fore, our goal is to externally validate the SLANT score as
an accurate risk stratification system.
Methods
Study Design and Patient Selection
This study is a retrospective cohort analysis of data col-
lected from comatose survivors of cardiac arrest at our
institution. After obtaining approval from our institu-
tional review board, we collected data through electronic
medical record review of 149 adults who experienced
coma following survival of cardiac arrest during May
2019 through January 2021. Inclusion and exclusion
criteria for this study are detailed in Fig. 1. Inclusion
criteria were age of at least 18 years old, cardiac arrest
(both out of the hospital and in the hospital) with sub-
sequent coma (unresponsiveness or Glasgow Coma
Scale [GCS] of 8 or less), sustained return of spontane-
ous circulation (> 20 min), and TTM (both therapeutic
hypothermia and active normothermia). Exclusion crite-
ria were no TTM treatment and missing outcomes data
(both neurological outcome and mortality). Following
these criteria, 41 patients were excluded for an analysis
of 108 patients. In accordance with the original pub-
lished analysis, SLANT scores were calculated and each
patient was allocated into moderate-risk (score of 0–7),

2019-2021 TJUH
Cardiac Arrest
Database (n=149)
Excluded (n=41)
• No TTM (n=38)
• Missing Outcomes
Data (n=3)
Allocated into Good
and Poor Neurologic
Status
(n=108)
Good Neurologic Poor Neurologic
Status (n=11) Status (n=97)
Fig. 1 Patient Selection. TJUH, Thomas Jefferson University Hospital,
TTM, targeted temperature management
high-risk (score of 8–14), and very-high-risk groups
(score of 15–21), as well as a binary grouping of mod-
erate risk (score of 0–8) and higher risk (score of 9–21)
[9]. Standard patient demographics and characteristics
of cardiac arrest and resuscitation and physical examina-
tion findings (first neurological examination after arrest
and neurological examination within 72 h post-TMM)
were collected. Anoxic imaging findings, laboratory data
(neuron-specific enolase [NSE]), and neurophysiology
studies (electroencephalography [EEG], bilateral N20
on somatosensory evoked potentials [SSEP]) during the
course of patient admission were also collected. Because
this was an external validation of a previously published
study, the matching primary outcome of interest was
poor neurologic outcome defined as a cerebral perfor-
mance category score of 3 or greater at discharge. This
indicates greater than or equal to severe disability with
dependence on others for activities of daily living. The
secondary outcome was in-hospital mortality.
Statistical Analysis: Univariable
All calculations and statistics were performed by using
SPSS, version 28.0 (IBM Corp, Armonk, NY). Normality
was assessed by using the Shapiro-Wilks test. Continuous
variables are expressed as means and standard deviations
or as medians and interquartile ranges (IQRs), as appro-
priate, whereas categorical variables are expressed as
frequencies and proportions. Univariable analyses were
done by using the χ2 test or Fisher’s exact test for cat-
egorical variables, as appropriate, and the independent
samples t-test or Mann–Whitney U-test for continuous
131
variables, as appropriate. To assess the relationship
between increasing risk group level and the primary out-
comes, the Cochrane Armitage trend test was used in
accordance with the original study [9]. The SLANT score
risk model was assessed by constructing a receiver opera-
tor characteristic curve for the primary outcome, with
predictive performance assessed by area under the curve
(AUC) calculation as well as asymptotic p value. Optimal
cutoff point was determined by computing an index of
Youden’s J Statistic. All tests were considered statistically
significant at a p value of less than 0.05.
Statistical Analysis: Multivariable
To assess predictiveness of the SLANT score for poor
neurologic outcome in relation to other factors, all poten-
tial confounders with a univariable p value less than 0.2
and less than 10% missing values were included in a back-
ward conditional logistic regression analysis. This analy-
sis included OHCA status, pupillary and corneal reflex
absence post-TTM, any malignant findings on long-term
EEG monitoring (including seizure, status epilepticus,
myoclonic status epilepticus, periodic discharges, and
burst suppression), the Acute Physiology and Chronic
Health Evaluation (APACHE) II admission risk score,
rearrest in the hospital, and anoxic injury findings on
computed tomography (CT) scan. Because the original
authors state this score is intended for post-TTM prog-
nostication rather than prognostication on admission,
physical examination elements within 72 h post-TTM
were included and other time points were omitted. Wit-
nessed cardiac arrest status was omitted because OHCA
status was believed to overlap in nuance. Percutaneous
coronary intervention was omitted as per the original
authors’ analysis and reasoning [9].
Results
Patient Demographics
The average age of this cohort was 57.4 ± 15.2 years old
(Table 1). A total of 64.8% were men, with the most prev-
alent ethnic groups represented being White (44.4%) and
African American (44.4%). Median APACHE II score on
admission was 33 with an IQR of 28–38. Eleven patients
had good neurologic outcome and 97 had poor neuro-
logic outcome. The mortality rate was 66.7% (Supple-
mentary Table 3), with the most common causes of death
being withdrawal of care (72.9%) followed by brain death
(11.4%) or cardiovascular collapse (11.4%). A total of 108
patients were included in the study.
Characteristics of Cardiac Arrest
The most common cause of arrest was from cardiac etiol-
ogy (41.5%), followed by pulmonary etiology (26.4%) and
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Table 1 Patient characteristics by neurologic outcome

Parameter Total (N=108) Good neurologic status Poor neurologic status p value
(n=11) (n=97)

SLANT score, median (IQR) 12.0 (8–15) 8.0 (4–12) 12.0 (8–15) 0.040*a
Age, mean ± SD 57.4±15.2 55.6±18.3 57.6±14.9 0.724
Sex, n (%) 0.562
Male 70 (64.8%) 8 (72.7%) 62 (63.9%)
Female 38 (35.2%) 3 (27.3%) 25 (36.1%)
Cardiac arrest Circumstances
OHCA 70 (64.8%) 5 (45.5%) 65 (67.0%) 0.156
Witnessed 84 (77.8%) 11 (100%) 73 (77.8%) 0.061
Defibrillation attempts 36 (34.3%) 4 (36.4%) 32 (34.0%) 0.981
Cause of arrest 0.807
Cardiac 44 (41.5%) 4 (36.4%) 40 (42.1%)
Pulmonary 28 (26.4%) 3 (26.3%) 25 (26.3%)
Trauma 2 (1.9%) 0 2 (2.1%)
Drug overdose 17 (16.0%) 1 (9.1%) 16 (16.8%)
Asphyxia 6 (5.7%) 1 (9.1%) 5 (5.3%)
Other 9 (8.5%) 2 (18.2%) 7 (7.4%)
First monitored Rhythm 0.372
Sinus 0 0
VT 5 (4.7%) 1 (9.1%) 4 (4.2%)
VF 13 (12.1%) 3 (27.3%) 10 (10.4%)
PEA 59 (55.1%) 4 (36.4%) 55 (57.3%)
Asystole 25 (23.4%) 2 (18.2%) 23 (24.0%)
Other 5 (4.7%) 1 (9.1%) 4 (4.2%)
Rearrest in hospital 15 (14.2%) 0 15 (15.8%) 0.155
APACHE II Admission score, Median (IQR) 33 (28-32) 32 (28-35) 33 (27-40) 0.193a
First neurological examination, n (%)
Pupillary 68 (64.2%) 8 (72.7%) 60 (63.2%) 0.531
Corneal 40 (40.8%) 7 (63.6%) 33 (37.9%) 0.102
GCS after arrest,  Median (IQR) 3 (3–5) 5 (3–7) 3 (3–5) 0.083a
Post-TTM neurological examination, n (%)
Pupillary 72 (77.4%) 11 (100%) 61 (74.4%) 0.056
Corneal 55 (61.1%) 8 (80.0%) 47 (58.8%) 0.194
Post-TTM GCS, median, (IQR) (n=93) 3 (3–6) 7 (6–8) 3 (3–5) <0.001a
Anoxia on imaging
CT scan (n=104) 51 (49.0%) 1 (9.1%) 50 (53.8%) 0.005*
MRI FLAIR (n=55) 44 (80.0%) 3 (50.0%) 41 (83.7%) 0.052
MRI DWI (n=55) 43 (78.2%) 4 (66.7%) 39 (79.6%) 0.469
Malignant EEG (n=104) 92 (88.5%) 8 (72.7%) 84 (90.3%) 0.084
N20 absent on SSEP (n=52) 33 (63.5%) 0 33 (73.3%) <0.001*
<0.001b
NSE >56.8 ng/mL (n=64) 33 (51.6%) 24 (42.1%) 33 (57.9%) 0.004*
0.004b
Hours from arrest to diagnostic tests, median (IQR)
CT head (n=104) 3 (1–8) 3 (1–9) 3 (1–8) 0.554
MRI brain (n=55) 141 (119–165) 162.5 (143–207.5) 130 (117–164) 0.072
SSEP (n=52) 114 (99.25–140) 111 (104–158) 115 (99–140) 0.846
NSE (n=64) 101.5 (82–125) 88 (83–108) 108 (80–125.5) 0.784
APACHE Acute Physiology and Chronic Health Evaluation, CT Computed tomography, DWI Diffusion-Weighted Imaging, EEG electroencephalography, FLAIR Fluid
Attenuated Inversion Recovery, GCS Glasgow Coma Scale, IQR Interquartile range, MRI Magnetic resonance imaging, NSE Neuron-specific enolase, PEA Pulseless
Electrical Activity, OHCA Out of hospital cardiac arrest, SD Standard deviation, SSEP Somatosensory Evoked Potential, TTM Targeted temperature management, VF
Ventricular Fibrillation, VT Ventricular Tachycardia

Table 1 (continued)
*
Indicates p < 0.05
a
Mann–Whitney U-test
b
Fisher’s exact test, used in addition to χ2 test with small sample size
Table 2 SLANT score factors
Parameter Score Total (N = 108) Survivor (n = 36) Nonsurvivor (n = 72) Good neuro-
assigned
Initial nonshockable rhythm 8 89 (82.4%)
Post TTM leukocyte count < 4 or > 12 4 46 (42.6%)
Total adrenaline dose ≥ 5 mg 4 72 (66.7%)
Lack of onlooker CPR 2 59 (54.6%)
Duration time of resuscitation ≥ 20 min 3 42 (38.9%)
CPR Cardiopulmonary resuscitation, TTM Targeted temperature management
drug overdose (16.0%) (Table 1). Most arrests were wit-
nessed (77.8%) and occurred out of the hospital (64.8%),
with the majority having an initial nonshockable rhythm
(82.4%). Of all arrests, 10.6% underwent percutaneous
coronary intervention, and 14.2% of patients rearrested
during admission. Median GCS on admission was 3 (IQR
3–5), which persisted for most of the sample following
TTM (median 3, IQR 3–6). APACHE II score on admis-
sion did not have a statistically significant difference in
poor versus favorable neurologic outcome (p = 0.193).
Neurologic Examination
On the first neurologic examination during admission,
patients with poor neurologic outcome did not have sta-
tistically significant differences in presence of corneal
reflexes (p = 0.102), pupillary reflexes (p = 0.531), or ini-
tial GCS (p = 0.083) (Table 1). On post-TTM neurologic
examination, patients with poor neurologic outcome did
not have a statistically significant difference in presence
of corneal and pupillary reflexes (p = 0.194 and p = 0.056,
respectively) but did see a significant change in GCS
(p < 0.001).
Other Imaging, Laboratory, and Neurophysiology Tests
Patients with poor neurologic outcome were more likely
to have anoxic injury findings on CT scan per radiologist
report (53.8% vs. 9.1%, p = 0.008, n = 104), more likely to
have NSE levels above an upper limit of 56.8 ng/mL [13]
(57.9% vs. 0%, p = 0.004, n = 64), and less likely to have
N20 present on somatosensory evoked potential neuro-
physiology (26.7% vs. 100%, p < 0.001, n = 52) (Table 1).
There was no significant difference in malignant EEG
findings (90.3% vs. 72.7%, p = 0.084, n = 104). Magnetic
resonance imaging per radiologist report had more
anoxic findings on diffusion-weighted imaging (DWI)
133
Poor neuro-
logic status logic status
(n = 11) (n = 97)
28 (77.8%) 61 (84.7%) 7 (63.6%) 82 (84.5%)
20 (55.6%) 26 (36.1%) 7 (63.6%) 39 (40.2%)
28 (77.8%) 44 (61.1%) 10 (90.9%) 62 (63.9%)
21 (58.3%) 38 (52.8%) 4 (36.4%) 55 (56.7%)
31 (43.1%) 11 (30.6%) 2 (18.2%) 40 (41.2%)
but not fluid attenuation inversion recovery (FLAIR)
sequences (p = 0.469 and p = 0.052, respectively, n = 55).
The timing from cardiac arrest to imaging and neuro-
physiology results are detailed at the end of Table 1.
There were no significant differences in timing of tests for
neurologic prognosis.
SLANT Score External Validation
Of the five SLANT factors, the most common factor was
presence of initial nonshockable rhythm (82.4%; Table 2).
As outlined in Table 1, SLANT scores were significantly
higher for poor neurologic outcome (12, IQR 8–15 vs.
8, IQR 4–12, p = 0.04) but not for in-hospital mortality
(p = 0.085). Cochrane Armitage trend test demonstrated
that three-tier risk stratification by SLANT score did
not have a statistically significant trend to predict poor
neurological outcome at discharge (p = 0.088) and did
not significantly predict in-hospital mortality (p = 0.272)
(Table 3). At a threshold of 9 based on the Youden’s J Sta-
tistic [14] (Supplementary Table 2), when these groups
were instead made binary, χ2 test demonstrated a signifi-
cant difference for poor neurological outcome (p = 0.005)
with 95.7% of patients being above this threshold, exhib-
iting poor neurologic outcome. This new cutoff did not,
however, demonstrate a significant difference for in-hos-
pital mortality (p = 0.064).
At this threshold of interest based on the Youden
index analysis, the SLANT score predicted poor neuro-
logic outcome at discharge with a sensitivity of 69.1%, a
specificity of 72.7%, positive likelihood ratio of 2.53, and
negative likelihood ratio of 0.43 (Fig. 2). The asymptotic p
value was 0.024 and the AUC was 0.708 (95% CI 0.536–
0.879), indicating statistically significant and reliable
diagnostic accuracy. We also assessed the SLANT score
for a cutoff at which sensitivity and positive predictive
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Table 3 SLANT scores and risk stratification

Risk group Total SLANT score (CA trend Mortality, n (% within risk group) Poor neurologic status, n (%
test) (p = 0.272) within risk group) (p = 0.088)

Moderate risk (n = 15) 0–7 9 (60.0) 11(73.3)

High risk (n = 65) 8–14 42 (64.6) 60 (92.3)
Very high risk (n = 28) 15–21 21 (75.0) 26 (92.9)
2
Risk group Total SLANT score (χ test) Mortality, n (% within risk group) Poor neurologic status,
(p = 0.064) n (% within risk group)
(p = 0.005*)

Moderate risk (n = 38) 0–8 21 (55.3) 30 (78.9)

Higher risk (n = 70) 9–21 51 (72.9) 67 (95.7)
CA Cochrane Armitage
*denotes significance

Table 4 Logistic regression analysis for poor neurologic

status
Predictor Odds ratio 95% CI p value

SLANT score 1.162 1.003–1.346 0.046*

Anoxic injury on first CT 8.531 0.991–73.466 0.051
Post-TTM corneal reflex 0.329 0.053–2.051 0.234
Post-TTM pupillary reflex – – 0.999
OHCA 2.781 0.592–13.072 0.195
Admission APACHE II score 1.061 0.944–1.193 0.319
Malignant EEG 1.847 0.223–15.323 0.570
Rearrest in hospital – – 0.999
APACHE Acute Physiology and Chronic Health Evaluation, CI Confidence interval,
CT computed tomography, EEG Electroencephalography, OHCA Out of hospital
cardiac arrest, TTM Targeted temperature management

due to a p value less than 0.20 on univariable analysis,

Fig. 2 Receiver operating characteristic (ROC) curve for poor neuro-
logic outcome (area under the curve 0.708, 95% confidence interval
0.536–0.879, p = 0.024)
value (PPV) would be maximized. At a cutoff of ≥ 2, the
SLANT score predicts poor neurologic outcome with a
sensitivity of 97.9% and a PPV of 90.5%.
Multivariable Analysis
On backward conditional logistic regression analysis,
the SLANT score retained independent predictiveness
for poor neurologic outcome (odds ratio 1.162, 95%
confidence interval [CI] 1.003–1.346, p = 0.046) when
controlled for anoxic injury findings on CT, post-TTM
pupillary and corneal reflexes, OHCA status, APACHE II
score, malignant EEG findings, and rearrest in the hos-
pital (Table 4). These other parameters, while of interest
were not independent predictors of poor neurologic sta-
tus on multivariable analysis.
Discussion
External Validation of SLANT
As described in the Prognosis Research Strategy, a
four-part series detailing a generalizable framework for
researching clinical outcomes, there are several crite-
ria that indicate the reliability of a prognostic scoring
system: the use of a large, high-quality data set; a study
protocol with sound statistical analyses; and validation in
independent data sets obtained from different locations
[15]. Chen et al. [9] attempted to satisfy the first two of
these criteria, albeit with a retrospective, midsized data
set. The third criterion was partially met in their initial
study, as the data set consisted of multisystem collabora-
tion; however, it was not independent.
We found that the SLANT prognostication system
had the most statistically significant predictive power
when used as a binary rather than a three-tiered metric.

When used in this manner, SLANT had moderate pre-
dictive power for neurological status at discharge, with
an AUC of 0.708 (95% CI 0.536–0.879, p = 0.024) com-
pared with the AUC from Chen et al. [9] of 0.852 (95% CI
0.800–0.903, p < 0.001) but still lacked statistical strength
to predict in-hospital mortality. Our threshold of ≥ 9 is
supported by our use of Youden’s index (Supplementary
Fig. 2). It differs from the originally proposed threshold
of ≥ 6.5, however, and we are unaware of any statistical
methods used by Chen et al. [9] that justify this threshold.
When evaluated as a continuous variable in multivariable
regression analysis, the SLANT score retained independ-
ent predictability, with each increment increasing the risk
of poor neurologic outcome by a factor of 16.2%.
Limitations
The discordances between the findings of Chen et al. [9]
and our own may be evidence of internal bias within the
initial study or within our own. The study by Chen et al.
[9] may be influenced by observation bias, and the exclu-
sion of patients who died during TTM may have been
a particularly influential factor in biasing predictions of
in-hospital mortality, even though these were 4.6% of
eligible cases. Another source of potential internal bias
to the initial study may be sampling bias, as the patient
population assessed had a disproportionately high num-
ber of patients with initial shockable rhythm. “Self-ful-
filling prophecy” bias has a tendency to influence many
prognostications studies, as life-sustaining treatment or
resuscitation may be withheld on the basis of prognos-
tic prediction [16]. This factor is a limitation for both the
study by Chen et al. [9] and our own. Retrospective stud-
ies, while having the advantage of analyzing preexisting
databases, are limited to the data and sample size avail-
able, as well as the influence of confounding variables—
pitfalls that may be at play for both our study and the
study by Chen et al. [9].
Other biases in our own results may be from similar
sources as Chen et al. [9], with alternative influences.
Sampling bias may occur from our sample being geo-
graphically limited to the Philadelphia region patient
population and the inclusion of patients who died dur-
ing TTM. Another factor influencing results may be our
inclusion of patients with in-hospital cardiac arrests,
whereas Chen et al. [9] only assessed OHCA patients,
despite the use of multivariable analysis to control for this
factor. Furthermore, a greater proportion of patients in
the study by Chen et al. [9] had initial shockable rhythm,
an indicator of good prognosis, and a greater proportion
of our total patients died in the hospital. Our sample was
also somewhat small for an external validation study. In
total, we only identified 11 patients with good neuro-
logic status. This may have reduced our patient mortality
135
prediction power in the moderate risk stratification. Ulti-
mately, despite these limitations, our results indicate that
post-TTM SLANT score prognostication is a reason-
able method for predicting neurological outcome at dis-
charge. The reliability of SLANT prediction of mortality
requires further external validation.
Comparing SLANT with other Prognosticating Metrics
Prognostication is a crucial element in the delivery of
neurocritical care across all domains [17]. One of the
seminal attempts to systematically evaluate the relation-
ship between clinical signs and neurologic outcome was
by Levy et al. [18] in 1985. These scores came exclusively
from physical examination findings in the 2 weeks fol-
lowing cardiac arrest. With development and utilization
of TTM, however, some of these findings are no longer
regarded as accurate. Namely, the absence of pupillary
reflexes is still recognized as a highly poor prognostica-
tor [17, 18]. More recent studies have continued to use
physical examination findings in addition to ancillary
tests like electrophysiology, neuroimaging [11], and neu-
rologic biomarkers such as NSE [19]. In one such study,
Daubin et al. [20] combined early clinical and EEG find-
ings to predict death or vegetative state with a high PPV
(100%) but low sensitivity (32%) at day 3 following arrest.
Similarly, in another study on magnetic resonance imag-
ing findings, Hirsch et al. [21] developed a cortical scor-
ing system that predicted unfavorable outcome with a
sensitivity of 55–60% and PPV of 100%.
A multimodal approach to prognostication is still rec-
ommended by guidelines and experts [11, 17, 22, 23]. At
our institution, we follow a multimodal algorithm similar
to the ERC ESICM guidelines (as per Nolan et al. [23]),
requiring two or more methods to predict poor progno-
sis. Similar to the aforementioned studies, while our insti-
tutional algorithm has very high specificity, it has shown
to be only 28% sensitive [24]. Thus, finding an approach
with higher sensitivity such as the SLANT score and add-
ing this into the well accepted multimodal approach may
be the key to finding a method that has both high speci-
ficity and high sensitivity. Perhaps the most interesting
perspective of using the SLANT model is that it captures
a set of data that probably vary with severity of initial
injury, such as rhythm type, use of adrenaline, bystander
cardiopulmonary resuscitation, etc. None of the cur-
rent methods widely accepted use this specific data in
neuroprognostication. Recent TTM trials have demon-
strated that patients who have shockable rhythms and
who receive bystander cardiopulmonary resuscitation
do better neurologically but until now, there has been no
useful means to incorporate these items in a standard-
ized manner to help prognosticate [25, 26]. Incorporating
the items within the SLANT score that focus on injury
136
related to the cardiac arrest to an already well accepted
multimodal approach seems to make sense.
Future Development of SLANT
Aside from potential alterations to the component scores
involved in SLANT prognostication, there remain several
steps in solidifying SLANT as a useful tool. First, further
external validation is necessary for mortality predictions
and may be advisable for neurologic outcome predictions.
A prospective review of SLANT prediction would accom-
plish this while avoiding the observation bias which may
have influenced Chen et al. and our own study. Addition-
ally, construction and analysis of a multicenter database
would significantly add to the validity of SLANT prog-
nostication. Once the validity of SLANT scoring has been
confirmed and it is utilized in more widespread clinical
practice, the next step in development requires impact
studies to assess the influence of SLANT prognostica-
tion on clinical decision making, patient outcomes, and
costs [15]. Finally, continual reassessment is necessary
to determine the performance of the SLANT prognos-
tic model, as its effectiveness may wane due to chang-
ing trends in diagnosis and treatment of HIBI, especially
given SLANT’s heavy reliance on TTM. Should such
changes influence the predictive capacity of SLANT in
neuroprognostication, such continual reassessment will
not only aid researchers and clinicians in detecting this
change but will also grant insight as to how the SLANT
model may be most effectively readapted. Lastly, although
SLANT prediction is intended for post-TTM prognosti-
cation, with continued development of this scoring sys-
tem it should be assessed for predictiveness in non-TTM
cohorts to expand its clinical usefulness to other cardiac
arrest patients experiencing HIBI.
Conclusions
Our external validation of the SLANT score demon-
strated a receiver operator characteristic for the predic-
tion of poor neurologic outcome similar to that from
the study by Chen et al. [9]. Although the SLANT score
significantly predicted poor neurologic outcome at dis-
charge and had similar sensitivity and specificity to the
original study by Chen et al. [9], it did not serve as a
strong predictor of in-hospital mortality in our cohort.
Further validation in larger data sets is needed for this
novel scoring system. This risk score may hold promise
as an additional data point in a multimodal approach to
neuroprognostication.
Supplementary Information
The online version contains supplementary material available at https://​doi.​
org/​10.​1007/​s12028-​022-​01570-8.
Author details
1
Drexel University College of Medicine, Philadelphia, PA, USA. 2 Division
of Neurocritical Care, Department of Neurosurgery, Jefferson Hospital
for Neuroscience, Thomas Jefferson University, 909 Walnut Street, 3rd Floor,
Philadelphia, PA 19107, USA.
Author contributions
Trevor G. Luck: data acquisition and analysis, writing and editing the article.
Katherine Locke: data acquisition, writing and editing the article. Benjamin
Sherman: writing and editing the article. Matthew Vibbert: writing and editing
the article. Sara Hefton: data acquisition, writing and editing the article. Syed
Shah: data acquisition, writing and editing the article. The final manuscript has
been approved by all authors.
Source of support
This work had no source of funding/support.
Conflicts of interest
The authors declare they have no conflict of interest.
Ethical approval/informed consent
This work complies with ethical guidelines and the study was approved by the
Thomas Jefferson Institutional Review Board.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.
Received: 2 March 2022 Accepted: 29 June 2022
Published: 28 July 2022
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