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Routier L, Edalati M, Querné L, Dorion J, Ghostine-Ramadan G, Wallois F, Moghimi S, Bourel-Ponchel E. Negative central activity in extremely preterm newborns: EEG characterization and relationship with brain injuries and neurodevelopmental outcome. Clin Neurophysiol 2024; 163:236-243. [PMID: 38810567 DOI: 10.1016/j.clinph.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 01/19/2024] [Accepted: 04/05/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVE To characterize Negative Central Activity (NCA), an overlooked electroencephalographic activity of preterm newborns and investigate its relationship with brain injuries, dysfunction, and neurodevelopmental outcome. METHODS 109 preterm infants (23-28 weeks) were retrospectively included. NCA were selected at the negative peak on EEG. Individual averaged NCA were automatically characterized. Brain structural data were collected from cranial ultrasounds (cUS). The neurodevelopmental outcome at two years of age was assessed by the Denver Developmental Screening Test-II. RESULTS Thirty-six (33%) children showed NCA: 6,721 NCA were selected, a median of 75 (interquartile range, 25/157.3) per EEG. NCA showed a triphasic morphology, with a mean amplitude and duration of the negative component of 24.6-40.0 µV and 222.7-257.3 ms. The presence of NCA on EEG was associated with higher intraventricular haemorrhage (IVH) grade on the first (P = 0.016) and worst neonatal cUS (P < 0.001) and poorer neurodevelopmental outcome (P < 0.001). CONCLUSIONS NCA is an abnormal EEG feature of extremely preterm newborns that may correspond to the functional neural impact of a vascular pathology. SIGNIFICANCE The NCA relationships with an adverse outcome and the presence/severity of IVH argue for considering NCA in the assessment of pathological processes in the developing brain network and for early outcome prediction.
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Affiliation(s)
- Laura Routier
- INSERM UMR 1105, Research Group on Multimodal Analysis of Brain Function, University of Picardie Jules Verne, rue René Laennec, 80054 Amiens Cedex, France; Pediatric Neurophysiology Unit, Amiens-Picardie University Hospital, 1 rue du Professeur Christian Cabrol, 80054 Amiens Cedex, France.
| | - Mohammadreza Edalati
- INSERM UMR 1105, Research Group on Multimodal Analysis of Brain Function, University of Picardie Jules Verne, rue René Laennec, 80054 Amiens Cedex, France
| | - Laurent Querné
- INSERM UMR 1105, Research Group on Multimodal Analysis of Brain Function, University of Picardie Jules Verne, rue René Laennec, 80054 Amiens Cedex, France; Department of Pediatric Neurology, Amiens-Picardie University Hospital, 1 rue du Professeur Christian Cabrol, 80054 Amiens Cedex, France
| | - Julie Dorion
- INSERM UMR 1105, Research Group on Multimodal Analysis of Brain Function, University of Picardie Jules Verne, rue René Laennec, 80054 Amiens Cedex, France
| | - Ghida Ghostine-Ramadan
- INSERM UMR 1105, Research Group on Multimodal Analysis of Brain Function, University of Picardie Jules Verne, rue René Laennec, 80054 Amiens Cedex, France; Neonatal Intensive Care Unit, Amiens-Picardie University Medical Center, Amiens Cedex, France
| | - Fabrice Wallois
- INSERM UMR 1105, Research Group on Multimodal Analysis of Brain Function, University of Picardie Jules Verne, rue René Laennec, 80054 Amiens Cedex, France; Pediatric Neurophysiology Unit, Amiens-Picardie University Hospital, 1 rue du Professeur Christian Cabrol, 80054 Amiens Cedex, France
| | - Sahar Moghimi
- INSERM UMR 1105, Research Group on Multimodal Analysis of Brain Function, University of Picardie Jules Verne, rue René Laennec, 80054 Amiens Cedex, France
| | - Emilie Bourel-Ponchel
- INSERM UMR 1105, Research Group on Multimodal Analysis of Brain Function, University of Picardie Jules Verne, rue René Laennec, 80054 Amiens Cedex, France; Pediatric Neurophysiology Unit, Amiens-Picardie University Hospital, 1 rue du Professeur Christian Cabrol, 80054 Amiens Cedex, France
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Greenblatt AS, Beniczky S, Nascimento FA. Pitfalls in scalp EEG: Current obstacles and future directions. Epilepsy Behav 2023; 149:109500. [PMID: 37931388 DOI: 10.1016/j.yebeh.2023.109500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 11/08/2023]
Abstract
Although electroencephalography (EEG) serves a critical role in the evaluation and management of seizure disorders, it is commonly misinterpreted, resulting in avoidable medical, social, and financial burdens to patients and health care systems. Overinterpretation of sharply contoured transient waveforms as being representative of interictal epileptiform abnormalities lies at the core of this problem. However, the magnitude of these errors is amplified by the high prevalence of paroxysmal events exhibited in clinical practice that compel investigation with EEG. Neurology training programs, which vary considerably both in the degree of exposure to EEG and the composition of EEG didactics, have not effectively addressed this widespread issue. Implementation of competency-based curricula in lieu of traditional educational approaches may enhance proficiency in EEG interpretation amongst general neurologists in the absence of formal subspecialty training. Efforts in this regard have led to the development of a systematic, high-fidelity approach to the interpretation of epileptiform discharges that is readily employable across medical centers. Additionally, machine learning techniques hold promise for accelerating accurate and reliable EEG interpretation, particularly in settings where subspecialty interpretive EEG services are not readily available. This review highlights common diagnostic errors in EEG interpretation, limitations in current educational paradigms, and initiatives aimed at resolving these challenges.
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Affiliation(s)
- Adam S Greenblatt
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund and Aarhus University Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Fábio A Nascimento
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.
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Lemus HN, Gururangan K, Fields MC, Jetté N, Bolden D, Yoo JY. Analysis of Electrocorticography in Epileptic Patients With Responsive Neurostimulation Undergoing Scalp Electroencephalography Monitoring. J Clin Neurophysiol 2023; 40:574-581. [PMID: 35294419 DOI: 10.1097/wnp.0000000000000936] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To describe the relationship of electrocorticography events detected by a brain-responsive neurostimulation system (RNS) and their association with ictal and interictal activity detected on simultaneous scalp EEG. METHODS We retrospectively identified patients with drug-resistant epilepsy implanted with RNS who subsequently underwent long-term scalp EEG monitoring. RNS detections were correlated to simultaneous activity recorded on scalp EEG to determine the characteristics of electrocorticography-stored long episodes associated with seizures or other findings on scalp EEG. RESULTS Eleven patients were included with an average of 3.6 days of monitoring. Most RNS detections were of very brief duration (<10 seconds, 92.9%) and received one stimulation therapy (80.8%). A high proportion of long episodes (67.1%) were not identified as electrographic seizures on scalp EEG. Of those ictal-appearing (71.2%) long episodes, 68.2% had seizure correlates. Long episodes associated with seizures on scalp EEG had a longer median duration compared with those without (39.7 vs. 16.8 seconds, P < 0.002) and had broader spread pattern and were of higher amplitude on electrocorticography. Brief potentially ictal rhythmic discharges were the most common EEG findings associated with long episodes that did not have scalp EEG seizure correlates (100% for ictal- and 50% for non-ictal-appearing long episodes). CONCLUSIONS Longer, broader spread and higher amplitude intracranial RNS detections are more likely to manifest as electrographic seizures on scalp EEG. Brief potentially ictal rhythmic discharges may serve as a scalp EEG biomarker of ictal intracranial episodes that are detected as long episodes by the RNS but not identified as electrographic seizures on scalp EEG.
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Affiliation(s)
- Hernan Nicolas Lemus
- Department of Neurology, Icahn School of Medicine at Mount Sinai Downtown, New York, New York, U.S.A
| | - Kapil Gururangan
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.; and
| | - Madeline Cara Fields
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.; and
| | - Nathalie Jetté
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.; and
| | - Dina Bolden
- Department of Neurology, Icahn School of Medicine at Mount Sinai West, New York, New York, U.S.A
| | - Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.; and
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4
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Guerriero RM, Morrissey MJ, Loe M, Reznikov J, Binkley MM, Ganniger A, Griffith JL, Khanmohammadi S, Rudock R, Guilliams KP, Ching S, Tomko SR. Macroperiodic Oscillations Are Associated With Seizures Following Acquired Brain Injury in Young Children. J Clin Neurophysiol 2022; 39:602-609. [PMID: 33587388 PMCID: PMC8674933 DOI: 10.1097/wnp.0000000000000828] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Seizures occur in 10% to 40% of critically ill children. We describe a phenomenon seen on color density spectral array but not raw EEG associated with seizures and acquired brain injury in pediatric patients. METHODS We reviewed EEGs of 541 children admitted to an intensive care unit between October 2015 and August 2018. We identified 38 children (7%) with a periodic pattern on color density spectral array that oscillates every 2 to 5 minutes and was not apparent on the raw EEG tracing, termed macroperiodic oscillations (MOs). Internal validity measures and interrater agreement were assessed. We compared demographic and clinical data between those with and without MOs. RESULTS Interrater reliability yielded a strong agreement for MOs identification (kappa: 0.778 [0.542-1.000]; P < 0.0001). There was a 76% overlap in the start and stop times of MOs among reviewers. All patients with MOs had seizures as opposed to 22.5% of the general intensive care unit monitoring population ( P < 0.0001). Macroperiodic oscillations occurred before or in the midst of recurrent seizures. Patients with MOs were younger (median of 8 vs. 208 days; P < 0.001), with indications for EEG monitoring more likely to be clinical seizures (42 vs. 16%; P < 0.001) or traumatic brain injury (16 vs. 5%, P < 0.01) and had fewer premorbid neurologic conditions (10.5 vs. 33%; P < 0.01). CONCLUSIONS Macroperiodic oscillations are a slow periodic pattern occurring over a longer time scale than periodic discharges in pediatric intensive care unit patients. This pattern is associated with seizures in young patients with acquired brain injuries.
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Affiliation(s)
- Réjean M. Guerriero
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Michael J. Morrissey
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Maren Loe
- Medical Scientist Training Program, Washington University School of Medicine, Washington University School of Medicine, St. Louis, Missouri, U.S.A
- Department of Electrical and Systems Engineering, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Joseph Reznikov
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Michael M. Binkley
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Alex Ganniger
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jennifer L. Griffith
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Sina Khanmohammadi
- Department of Electrical and Systems Engineering, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Robert Rudock
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Kristin P. Guilliams
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - ShiNung Ching
- Department of Electrical and Systems Engineering, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Stuart R. Tomko
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
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Yoo JY. BIRDs (Brief Potentially Ictal Rhythmic Discharges) watching during EEG monitoring. Front Neurol 2022; 13:966480. [PMID: 36081872 PMCID: PMC9445572 DOI: 10.3389/fneur.2022.966480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Brief Potentially Ictal Rhythmic Discharges (BIRDs), initially described in neonates, have been shown to correlate with increased risk of seizures in both critically ill and non-critically ill adults. In critically ill patients, BIRDs are associated with acute brain injury and worse functional outcomes. In non-critically ill adults, BIRDs are seen in patients with epilepsy with a greater likelihood of having drug resistance. The location of BIRDs seems to better predict the seizure onset zone compared to other interictal epileptiform discharges. The definition of BIRDs includes Paroxysmal Fast Activity (PFA), and they have similar clinical significance regardless of the exact cut-off frequencies. Their potential as a biomarker for seizure activity and seizure onset zone has been suggested. In patients with status epilepticus, BIRDs also resolve or decrease when seizures resolve. Thus, if BIRDs are observed on scalp EEG, more extended EEG monitoring is recommended to estimate their seizure burden and to guide treatment. With the recent addition of BIRDs in the critical care EEG terminology, with future investigations, we may soon be able to reach a consensus about the definition of electrographic seizures and better understand their neurophysiology and clinical significance.
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Abstract
Purpose of this review This review presents current therapy for seizures in the intensive care unit. The reader is provided with recent evidence regarding the use of EEG in determining treatment for acute seizures. Proposed treatment approaches for seizures and status epilepticus are provided. Controversies and complexity of selecting treatments are discussed. Recent findings Critical Care EEG Monitoring Research Consortium analyzed the association of periodic and rhythmic electroencephalographic patterns with seizures and found that lateralized and generalized periodic discharges and lateralized rhythmic delta were associated with increased seizure risk. Applications using modified EEG techniques have demonstrated more rapid feedback to the ICU than was previously possible. Summary Accurate diagnosis and efficient treatment of seizures in the ICU is challenging due to patient factors, complexities of antiepileptic drug therapy, and the required expertise for EEG interpretation. Selection of optimally effective therapy for seizures or status epilepticus depends on multiple factors, making collaboration between neurophysiologists and the ICU team of paramount importance.
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Affiliation(s)
- Jane G Boggs
- Comprehensive Epilepsy Center, Wake Forest University, Winston-Salem, NC USA
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HIRANO T, MIKAMI T, YAMADA S, NAGAHAMA H, ENATSU R, OOKAWA S, AKIYAMA Y, MIKUNI N. Pitfalls of Commonly Used Ischemic and Dementia Models Due to Early Seizure by Carotid Ligation. Neurol Med Chir (Tokyo) 2021; 61:312-320. [PMID: 33790129 PMCID: PMC8120100 DOI: 10.2176/nmc.oa.2020-0365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/09/2020] [Indexed: 11/20/2022] Open
Abstract
While the bilateral common carotid artery (CCA) ligation model is widely used in cerebrovascular disease and dementia studies, it can frequently cause seizures. We examined the validity of seizure as an experimental model of ischemia. Eight-week-old male Wistar and Sprague-Dawley (SD) rats were implanted with electrocorticography (ECoG) electrodes and bilateral CCA ligation was performed and compared to the sham groups. ECoG monitoring was used to confirm the seizure discharge and count the number of spikes in the interictal phase 2 h after ligation, followed by power spectral analysis. Magnetic resonance imaging (MRI) was performed 6 h after bilateral CCA ligation to assess fractional anisotropy (FA), apparent diffusion coefficient (ADC), and cerebral blood flow (CBF) values. Magnetic resonance spectroscopy (MRS) was also performed and the ischemic parameters and electrophysiological changes were compared. The Wistar rat group had significantly higher mortality, frequency of seizures, incidence of non-convulsive seizures, and number of spikes in the interictal period compared to those in the SD rat group. Power spectral analysis showed increased power in the delta band in both Wistar and SD rat groups. MRI, after CCA ligation, showed significantly lower ADC values, lower glutamine and glutamate levels, and higher lactate values in Wistar rats, although there was no difference in FA values. Metabolic and electrophysiological changes after CCA ligation differed according to the rat strain. Wistar rats were prone to increased lactate and decreased glutamine and glutamate levels and the development of status epilepticus. Seizures can affect the results of ischemic experiments.
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Affiliation(s)
- Tsukasa HIRANO
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Takeshi MIKAMI
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Shoto YAMADA
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Hiroshi NAGAHAMA
- Division of Radioisotope Research, Biomedical Research, Education and Instrumentation Center, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Rei ENATSU
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Satoshi OOKAWA
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Yukinori AKIYAMA
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Nobuhiro MIKUNI
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
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Pharmacotherapy for Nonconvulsive Seizures and Nonconvulsive Status Epilepticus. Drugs 2021; 81:749-770. [PMID: 33830480 DOI: 10.1007/s40265-021-01502-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 12/22/2022]
Abstract
Most seizures in critically ill patients are nonconvulsive. A significant number of neurological and medical conditions can be complicated by nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE), with brain infections, hemorrhages, global hypoxia, sepsis, and recent neurosurgery being the most prominent etiologies. Prolonged NCSs and NCSE can lead to adverse neurological outcomes. Early recognition requires a high degree of suspicion and rapid and appropriate duration of continuous electroencephalogram (cEEG) monitoring. Although high quality research evaluating treatment with antiseizure medications and long-term outcome is still lacking, it is probable that expeditious pharmacological management of NCSs and NCSE may prevent refractoriness and further neurological injury. There is limited evidence on pharmacotherapy for NCSs and NCSE, although a few clinical trials encompassing both convulsive and NCSE have demonstrated similar efficacy of different intravenous (IV) antiseizure medications (ASMs), including levetiracetam, valproate, lacosamide and fosphenytoin. The choice of specific ASMs lies on tolerability and safety since critically ill patients frequently have impaired renal and/or hepatic function as well as hematological/hemodynamic lability. Treatment frequently requires more than one ASM and occasionally escalation to IV anesthetic drugs. When multiple ASMs are required, combining different mechanisms of action should be considered. There are several enteral ASMs that could be used when IV ASM options have been exhausted. Refractory NCSE is not uncommon, and its treatment requires a very judicious selection of ASMs aiming at reducing seizure burden along with management of the underlying condition.
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Hanin A, Demeret S, Nguyen-Michel VH, Lambrecq V, Navarro V. Continuous EEG monitoring in the follow-up of convulsive status epilepticus patients: A proposal and preliminary validation of an EEG-based seizure build-up score (EaSiBUSSEs). Neurophysiol Clin 2021; 51:101-110. [PMID: 33642131 DOI: 10.1016/j.neucli.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 11/30/2022] Open
Abstract
Continuous electroencephalography (EEG) is a major tool for monitoring patients admitted to the intensive care unit after refractory convulsive status epilepticus, following control of convulsive movements. We review the values of different EEG patterns observed in critically ill patients for prognosis and seizure risk, together with proposed criteria for non-convulsive status epilepticus diagnosis (Salzburg Criteria), the EEG scores for prognosis (Epidemiology-based Mortality score in Status Epilepticus, EMSE) and for seizure risk (2HELPS2B). These criteria and scores, based partially on continuous EEG, are not tailored to repetitively monitor the progressive build-up leading to seizure or status epilepticus recurrence. Therefore, we propose a new EEG-based seizure build-up score in status epilepticus (EaSiBUSSEs), based on the morphology and the prevalence of the EEG patterns observed in the follow-up of convulsive status epilepticus patients. It displays subscores from the least (no interictal activity) to the most associated with seizures (focal or generalized status epilepticus). We then evaluated the performance of the EaSiBUSSEs in a cohort of eleven patients who were admitted to intensive care unit for convulsive status epilepticus and who underwent continuous EEG recording. The receiver operating curve revealed good accuracy in identifying patients who would have seizures in the next 24 h, with excellent intra- and inter-rater reliability. We believe that this score is simple to perform, and suitable for repeated monitoring of EEG following refractory convulsive status epilepticus, with quantitative description of major EEG changes leading to seizures.
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Affiliation(s)
- Aurélie Hanin
- Paris Brain Institute, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, F-75013, Paris, France
| | - Sophie Demeret
- AP-HP, Epilepsy Unit and Clinical Neurophysiology Department (VHNM, VL, VN), Neuro-Intensive Care Unit (SD), Pitié-Salpêtrière Hospital, Paris, France
| | - Vi-Huong Nguyen-Michel
- AP-HP, Epilepsy Unit and Clinical Neurophysiology Department (VHNM, VL, VN), Neuro-Intensive Care Unit (SD), Pitié-Salpêtrière Hospital, Paris, France
| | - Virginie Lambrecq
- Paris Brain Institute, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, F-75013, Paris, France; AP-HP, Epilepsy Unit and Clinical Neurophysiology Department (VHNM, VL, VN), Neuro-Intensive Care Unit (SD), Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Paris, France
| | - Vincent Navarro
- Paris Brain Institute, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, F-75013, Paris, France; AP-HP, Epilepsy Unit and Clinical Neurophysiology Department (VHNM, VL, VN), Neuro-Intensive Care Unit (SD), Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Paris, France; Center of Reference for Rare Epilepsies, Pitié-Salpêtrière Hospital, Paris, France.
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Yoo JY, Jetté N, Kwon CS, Young J, Marcuse LV, Fields MC, Gaspard N, Hirsch LJ. Brief potentially ictal rhythmic discharges and paroxysmal fast activity as scalp electroencephalographic biomarkers of seizure activity and seizure onset zone. Epilepsia 2021; 62:742-751. [PMID: 33576500 DOI: 10.1111/epi.16822] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The electroencephalographic (EEG) terms "brief potentially ictal rhythmic discharges" (BIRDs) and "paroxysmal fast activity" (PFA) are considered distinct entities; however, their definitions overlap, and they may have similar clinical significance. We investigated their clinical significance and their association with seizures and the seizure onset zone (SOZ). METHODS We retrospectively identified an adult cohort (July 2015 to March 2018) whose long-term (>12 h) EEGs in any setting reported BIRDs (>4 Hz, lasting .5-10 s) and/or PFA. Different frequency cutoffs for PFA (>13 Hz or ≥8 Hz) were tested to compare their clinical significance. Patient demographics, clinical history, and EEG features were recorded. RESULTS We identified 94 patients with BIRDs/PFA out of 3520 patients (3%); 36 were critically ill (12 with epilepsy), and 58 were noncritically ill (all with epilepsy). The frequency of BIRDs/PFA was largely dependent on EEG background: it tended to be slower (theta) in the absence of a posterior dominant rhythm or in the presence of continuous focal slowing in the same region (p = .01). Sixty-two of 94 patients (66%; 32/36 [89%] critically ill, 30/58 [52%] noncritically ill) had electrographic seizures during the recording. The scalp EEG SOZ colocalized with BIRDs/PFA in all cases. BIRDs with faster frequency (also qualifying as PFA by definition) had similar seizure risk to that of slower BIRDs (62%-71%), regardless of frequency cutoff used to define PFA. In addition, 30 of 30 (100%) patients with evolving BIRDs/PFA (which lasted a median of 6 s, range = 2-9.5 s) had electrographic seizures (>10 s), compared to 32 of 64 (50%) with nonevolving BIRDs (median = 1 s, range = .5-3.5 s; p < .01). SIGNIFICANCE A high proportion of patients with BIRDs/PFA had seizures on EEG, regardless of their frequency (i.e., whether they also qualified as PFA), and their location colocalized with scalp SOZ in all cases. BIRDs appear to be a scalp EEG biomarker of uncontrolled seizure activity and a reliable localizing sign of the SOZ.
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Affiliation(s)
- Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathalie Jetté
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Churl-Su Kwon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James Young
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lara V Marcuse
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Madeline C Fields
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicolas Gaspard
- Department of Neurology, Yale University, New Haven, Connecticut, USA.,Department of Neurology, Free University of Brussels-Erasmus Hospital, Brussels, Belgium
| | - Lawrence J Hirsch
- Department of Neurology, Yale University, New Haven, Connecticut, USA
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Pressler RM, Cilio MR, Mizrahi EM, Moshé SL, Nunes ML, Plouin P, Vanhatalo S, Yozawitz E, de Vries LS, Puthenveettil Vinayan K, Triki CC, Wilmshurst JM, Yamamoto H, Zuberi SM. The ILAE classification of seizures and the epilepsies: Modification for seizures in the neonate. Position paper by the ILAE Task Force on Neonatal Seizures. Epilepsia 2021; 62:615-628. [PMID: 33522601 DOI: 10.1111/epi.16815] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 12/23/2022]
Abstract
Seizures are the most common neurological emergency in the neonatal period and in contrast to those in infancy and childhood, are often provoked seizures with an acute cause and may be electrographic-only. Hence, neonatal seizures may not fit easily into classification schemes for seizures and epilepsies primarily developed for older children and adults. A Neonatal Seizures Task Force was established by the International League Against Epilepsy (ILAE) to develop a modification of the 2017 ILAE Classification of Seizures and Epilepsies, relevant to neonates. The neonatal classification framework emphasizes the role of electroencephalography (EEG) in the diagnosis of seizures in the neonate and includes a classification of seizure types relevant to this age group. The seizure type is determined by the predominant clinical feature. Many neonatal seizures are electrographic-only with no evident clinical features; therefore, these are included in the proposed classification. Clinical events without an EEG correlate are not included. Because seizures in the neonatal period have been shown to have a focal onset, a division into focal and generalized is unnecessary. Seizures can have a motor (automatisms, clonic, epileptic spasms, myoclonic, tonic), non-motor (autonomic, behavior arrest), or sequential presentation. The classification allows the user to choose the level of detail when classifying seizures in this age group.
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Affiliation(s)
- Ronit M Pressler
- Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK.,Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Maria Roberta Cilio
- Division of Pediatric Neurology, Institute for Experimental and Clinical Research, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Eli M Mizrahi
- Departments of Neurology and Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.,Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Magda L Nunes
- Pontificia Universidade Catolica do Rio Grande do Sul - PUCRS School of Medicine and the Brain Institute, Porto Alegre, RS, Brazil
| | - Perrine Plouin
- Department of Clinical Neurophysiology, Hospital Necker Enfant Malades, Paris, France
| | - Sampsa Vanhatalo
- Department of Clinical Neurophysiology and BABA center Children's Hospital, HUS Imaging, Neuroscience Center, Helsinki Institute of Life Science, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.,Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Linda S de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Chahnez C Triki
- Department of Child Neurology, Hedi Chaker Hospital, LR19ES15 Sfax University, Sfax, Tunisia
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Hitoshi Yamamoto
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children & Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
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12
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Hirsch LJ, Fong MW, Leitinger M, LaRoche SM, Beniczky S, Abend NS, Lee JW, Wusthoff CJ, Hahn CD, Westover MB, Gerard EE, Herman ST, Haider HA, Osman G, Rodriguez-Ruiz A, Maciel CB, Gilmore EJ, Fernandez A, Rosenthal ES, Claassen J, Husain AM, Yoo JY, So EL, Kaplan PW, Nuwer MR, van Putten M, Sutter R, Drislane FW, Trinka E, Gaspard N. American Clinical Neurophysiology Society's Standardized Critical Care EEG Terminology: 2021 Version. J Clin Neurophysiol 2021; 38:1-29. [PMID: 33475321 PMCID: PMC8135051 DOI: 10.1097/wnp.0000000000000806] [Citation(s) in RCA: 337] [Impact Index Per Article: 112.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Lawrence J. Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael W.K. Fong
- Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Suzette M. LaRoche
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Sandor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund and Aarhus University Hospital, Aarhus, Denmark
| | - Nicholas S. Abend
- Departments of Neurology and Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jong Woo Lee
- Brigham and Women’s Hospital, Boston, Massachusetts, U.S.A
| | | | - Cecil D. Hahn
- Division of Neurology, The Hospital for Sick Children, and Department of Pediatrics, University of Toronto, Toronto, Canada
| | | | - Elizabeth E. Gerard
- Comprehensive Epilepsy Center, Department of Neurology, Northwestern University, Chicago, Illinois, U.S.A
| | | | - Hiba Arif Haider
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Gamaleldin Osman
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Andres Rodriguez-Ruiz
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Carolina B. Maciel
- Division of Neurocritical Care, Department of Neurology, University of Florida, Gainesville, Florida, U.S.A
| | - Emily J. Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Andres Fernandez
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Eric S. Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Jan Claassen
- Neurocritical Care, Department of Neurology, Columbia University, New York, New York, U.S.A
| | - Aatif M. Husain
- Department of Medicine (Neurology), Duke University Medical Center, and Veterans Affairs Medical Center, Durham, North Carolina, U.S.A
| | - Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Elson L. So
- Division of Epilepsy, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Peter W. Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
| | - Marc R. Nuwer
- Department of Neurology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, U.S.A
| | - Michel van Putten
- Medisch Spectrum Twente and University of Twente, Enschede, The Netherlands
| | - Raoul Sutter
- Medical Intensive Care Units and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Frank W. Drislane
- Department of Neurology, Harvard Medical School, and Comprehensive Epilepsy Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Nicolas Gaspard
- Department of Neurology, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium
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13
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Ohtomo S, Otsubo H, Arai H, Shimoda Y, Homma Y, Tominaga T. Hyperperfusion in the thalamus on arterial spin labelling indicates non-convulsive status epilepticus. Brain Commun 2020; 3:fcaa223. [PMID: 33501426 PMCID: PMC7811763 DOI: 10.1093/braincomms/fcaa223] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 11/04/2020] [Accepted: 11/24/2020] [Indexed: 12/15/2022] Open
Abstract
Non-convulsive status epilepticus describes the syndrome of unexplained impaired consciousness in critically ill patients. Non-convulsive status epilepticus is very likely to lead to delayed diagnosis and poor outcomes because of the absence of convulsive symptoms. EEG is essential for the diagnosis of non-convulsive status epilepticus to establish the association between periodic discharges and rhythmic delta activity in addition to ictal epileptiform discharges according to the Salzburg criteria. Arterial spin labelling, a type of perfusion MRI, has been applied for rapid and non-invasive evaluation of the ictal state. Ictal cerebral cortical hyperperfusion is the most common finding to demonstrate focal onset seizures. Hyperperfusion of the thalamus on single photon emission computed tomography was found in patients with impaired awareness seizures. We hypothesized that thalamocortical hyperperfusion on arterial spin labelling identifies non-convulsive status epilepticus and such thalamic hyperperfusion specifically associates with periodic/rhythmic discharges producing impaired consciousness without convulsion. We identified 27 patients (17 females; age, 39-91 years) who underwent both arterial spin labelling and EEG within 24 h of suspected non-convulsive status epilepticus. We analysed 28 episodes of suspected non-convulsive status epilepticus and compared hyperperfusion on arterial spin labelling with periodic/rhythmic discharges. We evaluated 21 episodes as a positive diagnosis of non-convulsive status epilepticus according to the Salzburg criteria. We identified periodic discharges in 15 (12 lateralized and 3 bilateral independent) episodes and rhythmic delta activity in 13 (10 lateralized, 1 bilateral independent and 2 generalized) episodes. Arterial spin labelling showed thalamic hyperperfusion in 16 (11 unilateral and 5 bilateral) episodes and cerebral cortical hyperperfusion in 24 (20 unilateral and 4 bilateral) episodes. Thalamic hyperperfusion was significantly associated with non-convulsive status epilepticus (P = 0.0007; sensitivity, 76.2%; specificity, 100%), periodic discharges (P < 0.0001; 93.3%; 84.6%), and rhythmic delta activity (P = 0.0006; 92.3%; 73.3%). Cerebral cortical hyperperfusion was significantly associated with non-convulsive status epilepticus (P = 0.0017; 100%; 57.1%) and periodic discharges (P = 0.0349; 100%; 30.8%), but not with rhythmic delta activity. Thalamocortical hyperperfusion could be a new biomarker of non-convulsive status epilepticus according to the Salzburg criteria in critically ill patients. Specific thalamic hyperexcitability might modulate the periodic discharges and rhythmic delta activity associated with non-convulsive status epilepticus. Impaired consciousness without convulsions could be caused by predominant thalamic hyperperfusion together with cortical hyperperfusion but without ictal epileptiform discharges.
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Affiliation(s)
- Satoru Ohtomo
- Department of Neurosurgery, South Miyagi Medical Center, Shibata-gun, Miyagi, Japan
| | - Hiroshi Otsubo
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hiroaki Arai
- Department of Neurosurgery, South Miyagi Medical Center, Shibata-gun, Miyagi, Japan
| | - Yoshiteru Shimoda
- Department of Neurosurgery, South Miyagi Medical Center, Shibata-gun, Miyagi, Japan
| | - Yoichiro Homma
- Department of General Internal Medicine, Seirei-Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Abstract
The neurological application of long-term electroencephalography (EEG) monitoring in the intensive care unit (ICU) has been implemented in many healthcare institutions. The use of EEG as a monitoring tool in the ICU affords many potential benefits. Uses include the identification of seizures, vasospasm following subarachnoid hemorrhage (SAH), the assessment of coma and the determination of brain death. Neurologic critical care is focused on recognition and treatment of secondary insults. Often treatment is withheld because these insults are not recognized early enough until an irreversible deficit manifest. Continuous EEG (cEEG) monitoring provides a unique potential to recognize these insults and offers an opportunity for early intervention. Why should we continuously monitor the brain with EEG in the ICU? Nonconvulsive seizures (NCS) are common in comatose patients. Nonconvulsive Status Epilepticus (NCSE) and NCS 1 are damaging to brain tissue; thus, rapid control of seizures is essential to preserving brain function. With the increased use of cEEG in critical care areas, the purpose of this paper is to examine the use and benefits of EEG monitoring of ICU patients, review the indications for the use of cEEG and discuss technical issues and concerns when performing cEEG monitoring. This article has been divided into six distinct sections: (1) Seizures, NCS, and NCSE (2) Periodic Discharges 2 and Patterns on the Ictal-interictal Continuum, (3) Cerebral Ischemia, SAH, and Delayed Cerebral Ischemia (DCI), (4) Encephalopathy and Coma (5) ECI and Brain Death, and (6) ICU-cEEG Monitoring Techniques.
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Affiliation(s)
- Walt Banoczi
- Professor Emeritus, Orange Coast College , Costa Mesa, California
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15
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Abstract
AbstractContinuous electroencephalogram (cEEG) has become an indispensable technique in the management of critically ill patients for early detection and treatment of non-convulsive seizures (NCS) and non-convulsive status epilepticus (NCSE). It has also brought about a renaissance in a wide range of rhythmic and periodic patterns with heterogeneous frequency and morphology. These patterns share the rhythmic and sharp appearances of electrographic seizures, but often lack the necessary frequency, spatiotemporal evolution and clinical accompaniments to meet the definitive criteria for ictal patterns. They may be associated with cerebral metabolic crisis and neuronal injury, therefore not clearly interictal either, but lie along an intervening spectrum referred to as ictal-interictal continuum (IIC). Generally speaking, rhythmic and periodic patterns are categorized as interictal patterns when occurring at a rate of <1Hz, and are categorized as NCS and NCSE when occurring at a rate of >2.5 Hz with spatiotemporal evolution. As such, IIC commonly includes the rhythmic and periodic patterns occurring at a rate of 1–2.5 Hz without spatiotemporal evolution and clinical correlates. Currently there are no evidence-based guidelines on when and if to treat patients with IIC patterns, and particularly how aggressively to treat, presenting a challenging electrophysiological and clinical conundrum. In practice, a diagnostic trial with preferably a non-sedative anti-seizure medication (ASM) can be considered with the end point being both clinical and electrographic improvement. When available and necessary, correlation of IIC with biomarkers of neuronal injury, such as neuronal specific enolase (NSE), neuroimaging, depth electrode recording, cerebral microdialysis and oxygen measurement, can be assessed for the consideration of ASM treatment. Here we review the recent advancements in their clinical significance, risk stratification and treatment algorithm.
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16
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Katyal N, Singh I, Narula N, Idiculla PS, Premkumar K, Beary JM, Nattanmai P, Newey CR. Continuous Electroencephalography (CEEG) in Neurological Critical Care Units (NCCU): A Review. Clin Neurol Neurosurg 2020; 198:106145. [PMID: 32823186 DOI: 10.1016/j.clineuro.2020.106145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/20/2020] [Accepted: 08/07/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Nakul Katyal
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Ishpreet Singh
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Naureen Narula
- Staten Island University Hospital, Department of Pulmonary- critical Care Medicine, 475 Seaview Avenue Staten Island, NY, 10305, United States.
| | - Pretty Sara Idiculla
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Keerthivaas Premkumar
- University of Missouri, Department of biological sciences, Columbia, MO 65211, United States.
| | - Jonathan M Beary
- A. T. Still University, Department of Neurobehavioral Sciences, Kirksville, MO, United States.
| | - Premkumar Nattanmai
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Christopher R Newey
- Cleveland clinic Cerebrovascular center, 9500 Euclid Avenue, Cleveland, OH 44195, United States.
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17
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Li HT, Lee CH, Wu T, Cheng MY, Tseng WEJ, Chang CW, Hsieh HY, Chiang HI, Lin CY, Chang BL, Lin WR, Lim SN. Clinical, Electroencephalographic Features and Prognostic Factors of Cefepime-Induced Neurotoxicity: A Retrospective Study. Neurocrit Care 2020; 31:329-337. [PMID: 30756319 DOI: 10.1007/s12028-019-00682-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The incidence of cefepime-induced neurotoxicity (CIN) has been previously underestimated, and there have only been sporadic reports from critical neurological settings. The present study aimed to investigate the potential factors associated with disease development, electroencephalography (EEG) sub-classification, and outcome measures. METHODS The 10-year medical records of patients who underwent EEG between 2007 and 2016 at a tertiary medical center in Taiwan, and developed encephalopathy after cefepime therapy were retrospectively reviewed. Age- and sex-matched controls were included for further analysis. Demographic data, the occurrence of clinical seizures, non-convulsive status epilepticus (NCSE), use of antiepileptic drugs (AEDs), receiving maintenance or urgent hemodialysis, EEG findings, and functional outcomes were analyzed. The Chi-square test and a logistic regression model were applied to survey significant prognostic factors relating to mortality. RESULTS A total of 42 CIN patients were identified, including 25 patients from wards and 17 from intensive care units; their mean age was 75.8 ± 11.8 years. Twenty-one patients (50%) had chronic kidney disease, and 18 (43%) had acute kidney injury. Among these patients, 32 (76%) received appropriate cefepime dose adjustment. Three patients had a normal renal function at the time of CIN onset. The logistic regression model suggested that maintenance hemodialysis and longer duration of cefepime use were independently associated with the development of CIN, with odds ratios of 3.8 and 1.2, respectively. NCSE was frequently noted in the CIN patients (64%). Generalized periodic discharge with or without triphasic morphology was the most common EEG pattern (38%), followed by generalized rhythmic delta activity and generalized spike-and-waves. AEDs were administered to 86% of the patients. A total of 17 patients (40%) did not survive to hospital discharge. Adequate cefepime dose adjustment and early cefepime discontinuation led to a better prognosis. CONCLUSIONS CIN was associated with high mortality and morbidity rates. Neurotoxic symptoms could still occur when the cefepime dose was adjusted, or in patients with normal renal function. Patients with maintenance hemodialysis or a longer duration of cefepime therapy tended to develop CIN. Early recognition of abnormal EEG findings allowed for the withdrawal of the offending agent, resulting in clinical improvements and a better prognosis at discharge.
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Affiliation(s)
- Han-Tao Li
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chih-Hong Lee
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Tony Wu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Mei-Yun Cheng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Wei-En Johnny Tseng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chun-Wei Chang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Hsiang-Yao Hsieh
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Hsing-I Chiang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chih-Yin Lin
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Bao-Luen Chang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan
| | - Siew-Na Lim
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan.
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Cissé FA, Osman GM, Legros B, Depondt C, Hirsch LJ, Struck AF, Gaspard N. Validation of an algorithm of time-dependent electro-clinical risk stratification for electrographic seizures (TERSE) in critically ill patients. Clin Neurophysiol 2020; 131:1956-1961. [PMID: 32622337 DOI: 10.1016/j.clinph.2020.05.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/05/2020] [Accepted: 05/20/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The clinical implementation of continuous electroencephalography (CEEG) monitoring in critically ill patients is hampered by the substantial burden of work that it entails for clinical neurophysiologists. Solutions that might reduce this burden, including by shortening the duration of EEG to be recorded, would help its widespread adoption. Our aim was to validate a recently described algorithm of time-dependent electro-clinical risk stratification for electrographic seizure (ESz) (TERSE) based on simple clinical and EEG features. METHODS We retrospectively reviewed the medical records and EEG recordings of consecutive patients undergoing CEEG between October 1, 2015 and September, 30 2016 and assessed the sensitivity of TERSE for seizure detection, as well as the reduction in EEG time needed to be reviewed. RESULTS In a cohort of 407 patients and compared to full CEEG review, the model allowed the detection of 95% of patients with ESz and 97% of those with electrographic status epilepticus. The amount of CEEG to be recorded to detect ESz was reduced by two-thirds, compared to the duration of CEEG taht was actually recorded. CONCLUSIONS TERSE allowed accurate time-dependent ESz risk stratification with a high sensitivity for ESz detection, which could substantially reduce the amount of CEEG to be recorded and reviewed, if applied prospectively in clinical practice. SIGNIFICANCE Time-dependent electro-clinical risk stratification, such as TERSE, could allow more efficient practice of CEEG and its more widespread adoption. Future studies should aim to improve risk stratification in the subgroup of patients with acute brain injury and absence of clinical seizures.
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Affiliation(s)
- F A Cissé
- Department of Neurology, Université Libre de Bruxelles - Hôpital Erasme, Bruxelles, Belgium; Department of Neurology, CHU de Conakry, Conakry, Guinea
| | - G M Osman
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA; Department of Neurology and Comprehensive Epilepsy Center, Yale University, New Haven, CT, USA
| | - B Legros
- Department of Neurology, Université Libre de Bruxelles - Hôpital Erasme, Bruxelles, Belgium
| | - C Depondt
- Department of Neurology, Université Libre de Bruxelles - Hôpital Erasme, Bruxelles, Belgium
| | - L J Hirsch
- Department of Neurology and Comprehensive Epilepsy Center, Yale University, New Haven, CT, USA
| | - A F Struck
- Department of Neurology, University of Wisconsin, Madison, WI, USA
| | - N Gaspard
- Department of Neurology, Université Libre de Bruxelles - Hôpital Erasme, Bruxelles, Belgium; Department of Neurology and Comprehensive Epilepsy Center, Yale University, New Haven, CT, USA.
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19
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Zafar SF, Subramaniam T, Osman G, Herlopian A, Struck AF. Electrographic seizures and ictal-interictal continuum (IIC) patterns in critically ill patients. Epilepsy Behav 2020; 106:107037. [PMID: 32222672 DOI: 10.1016/j.yebeh.2020.107037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/07/2020] [Accepted: 03/07/2020] [Indexed: 02/06/2023]
Abstract
Critical care long-term continuous electroencephalogram (cEEG) monitoring has expanded dramatically in the last several decades spurned by technological advances in EEG digitalization and several key clinical findings: 1-Seizures are relatively common in the critically ill-large recent observational studies suggest that around 20% of critically ill patients placed on cEEG have seizures. 2-The majority (~75%) of patients who have seizures have exclusively "electrographic seizures", that is, they have no overt ictal clinical signs. Along with the discovery of the unexpectedly high incidence of seizures was the high prevalence of EEG patterns that share some common features with archetypical electrographic seizures but are not uniformly considered to be "ictal". These EEG patterns include lateralized periodic discharges (LPDs) and generalized periodic discharges (GPDs)-patterns that at times exhibit ictal-like behavior and at other times behave more like an interictal finding. Dr. Hirsch and colleagues proposed a conceptual framework to describe this spectrum of patterns called the ictal-interictal continuum (IIC). In the following years, investigators began to answer some of the key pragmatic clinical concerns such as which patients are at risk of seizures and what is the optimal duration of cEEG use. At the same time, investigators have begun probing the core questions for critical care EEG-what is the underlying pathophysiology of these patterns, at what point do these patterns cause secondary brain injury, what are the optimal treatment strategies, and how do these patterns affect clinical outcomes such as neurological disability and the development of epilepsy. In this review, we cover recent advancements in both practical concerns regarding cEEG use, current treatment strategies, and review the evidence associating IIC/seizures with poor clinical outcomes.
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Affiliation(s)
- Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States of America
| | - Thanujaa Subramaniam
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Gamaleldin Osman
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States of America
| | - Aline Herlopian
- Department of Neurology, Yale University, New Haven, CT, United States of America
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, United States of America.
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20
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Critically ill benign EEG variants: Is there such a thing? Clin Neurophysiol 2020; 131:1243-1251. [PMID: 32305854 DOI: 10.1016/j.clinph.2020.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 02/22/2020] [Accepted: 03/04/2020] [Indexed: 11/22/2022]
Abstract
Despite growing use of critical care electroencephalography (ccEEG) to detect seizures and status epilepticus in the intensive care unit (ICU), integrating ccEEG findings with traditionally described benign EEG variants (BEVs) is a relatively new concept. BEV-like waveforms are now increasingly encountered in the ICU, and have also been explicitly included in proposed definitions of brief potentially ictal rhythmic discharges (BIRDs) in the ICU, bringing to the fore the question of if and which EEG patterns in critically ill patients can be safely deemed "benign". Though well-characterized as benign in healthy outpatients at low pre-test risk for neurologic disease, the significance of BEVs in the ICU remains largely unknown. Simultaneously, there has been mounting evidence to suggest that certain BEVs can arise from heterogeneous intracranial sources, including some pathologic generators. We conducted an extensive literature review on all known BEVs to assess what is known of BEVs in the ICU. Here we discuss critically ill BEVs and how to interpret them.
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Abstract
OBJECTIVES To pool prevalence of nonconvulsive seizure, nonconvulsive status epilepticus, and epileptiform activity detected by different electroencephalography types in critically ills and to compare detection rates among them. DATA SOURCES MEDLINE (via PubMed) and SCOPUS (via Scopus) STUDY SELECTION:: Any type of study was eligible if studies were done in adult critically ill, applied any type of electroencephalography, and reported seizure rates. Case reports and case series were excluded. DATA EXTRACTION Data were extracted independently by two investigators. Separated pooling of prevalence of nonconvulsive seizure/nonconvulsive status epilepticus/epileptiform activity and odds ratio of detecting outcomes among different types of electroencephalography was performed using random-effect models. This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and also adhered to the Meta-analyses Of Observational Studies in Epidemiology guidelines. Quality of evidence was assessed with the Newcastle-Ottawa Quality Assessment Scale for observational studies and Cochrane methods for randomized controlled trial studies. DATA SYNTHESIS A total of 78 (16,707 patients) and eight studies (4,894 patients) were eligible for pooling prevalence and odds ratios. For patients with mixed cause of admission, the pooled prevalence of nonconvulsive seizure, nonconvulsive status epilepticus, either nonconvulsive seizure or nonconvulsive status epilepticus detected by routine electroencephalography was 3.1%, 6.2%, and 6.3%, respectively. The corresponding prevalence detected by continuous electroencephalography monitoring was 17.9%, 9.1%, and 15.6%, respectively. In addition, the corresponding prevalence was high in post convulsive status epilepticus (33.5%, 20.2%, and 32.9%), CNS infection (23.9%, 18.1%, and 23.9%), and post cardiac arrest (20.0%, 17.3%, and 22.6%). The pooled conditional log odds ratios of nonconvulsive seizure/nonconvulsive status epilepticus detected by continuous electroencephalography versus routine electroencephalography from studies with paired data 2.57 (95% CI, 1.11-5.96) and pooled odds ratios from studies with independent data was 1.57 (95% CI, 1.00-2.47). CONCLUSIONS Prevalence of seizures detected by continuous electroencephalography was significantly higher than with routine electroencephalography. Prevalence was particularly high in post convulsive status epilepticus, CNS infection, and post cardiac arrest.
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Abstract
PURPOSE OF REVIEW Epilepsy is a heterogeneous disorder that is often associated with abnormal electroencephalogram (EEG) findings. This article provides an overview of common EEG findings in epileptic disorders. The physiologic basis of EEG and intracranial EEG studies is also discussed. RECENT FINDINGS EEG is widely used in clinical practice. Because of the paroxysmal nature of seizure disorders, interictal epileptiform discharges, such as spikes and sharp waves, are often used to support the diagnosis of epilepsy when a habitual seizure is not captured by EEG. Interictal and ictal EEG findings also underlie the classification of seizures and epilepsy. Continuous critical care EEG monitoring has become an invaluable study in the diagnosis and treatment of subclinical seizures and nonconvulsive status epilepticus. Intracranial EEG with subdural or intraparenchymal electrodes is warranted when localization of the seizure focus and mapping of eloquent brain areas are required to plan epilepsy surgery. SUMMARY The EEG is a key tool in the diagnosis of epilepsy. Interictal and ictal EEG findings are crucial for the confirmation and classification of seizure disorders. Intracranial EEG monitoring is also indispensable for planning surgery for some patients.
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Abstract
Continuous electroencephalography (cEEG) monitoring is becoming increasingly used in neurologic and non-neurologic intensive care units (ICUs). Non-convulsive seizures (NCSz) and periodic discharges (PDs) are commonly seen in critically ill patients. Some of these PD patterns, also known as the ictal-interictal continuum (IIC), are associated with an increased risk of seizures and poor outcome. However, we do not fully understand the significance of these periodic patterns and the decision of how aggressively to treat remains controversial. IIC patterns are associated with pathophysiologic changes that closely resemble those of seizures. Here we make the argument that, rather than feature description on EEG, associated changes in brain physiology should dictate management choices.
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Yamanaka H, Hashimoto S, Suenaga T. [Neuronal intranuclear inclusion disease with prolonged impaired consciousness and status epilepticus: a case report]. Rinsho Shinkeigaku 2019; 59:425-430. [PMID: 31243248 DOI: 10.5692/clinicalneurol.cn-001264] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neuronal intranuclear inclusion disease (NIID) is a neurodegenerative disease presenting with various manifestations including dementia, weakness, transient impaired consciousness, encephalitis-like episodes and also epileptic seizures. However, the nature of epileptic seizures, focal or generalized onset, remains unclear. A man at age 76 was admitted to a local hospital due to febrile impaired consciousness lasting several days. During the hospital stay, a generalized convulsion occurred, and afterward he remained obtunded. He was transferred to our hospital for further treatment. One additional seizure occurred while on an ambulance to our hospital and two additional seizures shortly after the arrival, which indicated convulsive status epilepticus (SE). The ictal EEG showed low amplitude fast activity arising from the left centro-parietal area with an evolutionary pattern. The clinical concomitant was the contralateral versive seizure evolving to a bilateral convulsion. Inter-ictal epileptiform abnormalities seen on the tracings taken on later days consisted of brief potentially ictal rhythmic discharges (B(I)RDs) and frequent sharp waves recorded from both frontal areas. These findings along with the ictal discharges would indicate a multifocal epileptic disorder in this patient. Diffusion weighted images (DWIs) of this patient showed hyperintensity signals in the cortico-medullary junctions in the bilateral frontal and the left parietal regions. Skin biopsy revealed characteristic intranuclear inclusions, and hence the diagnosis of NIID was made. The regions of epileptic foci on EEG corresponded well to the hyperintensity areas in DWIs, which suggests the cerebral cortices near the DWI hyperintensity could be more hyperactive than other regions. This case report suggests that some of the prolonged impaired consciousness and the encephalitis-like episodes in NIID could be related to epileptic seizures and even non-convulsive SE or a post-ictal twilight state after an unwitnessed convulsion. This issue should be further studied for the appropriate treatment of episodic encephalopathy and epileptic seizures in NIID.
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Sambin S, Gaspard N, Legros B, Depondt C, De Breucker S, Naeije G. Role of Epileptic Activity in Older Adults With Delirium, a Prospective Continuous EEG Study. Front Neurol 2019; 10:263. [PMID: 30941098 PMCID: PMC6434717 DOI: 10.3389/fneur.2019.00263] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/27/2019] [Indexed: 12/29/2022] Open
Abstract
Background/Objectives: Delirium occurs in up to 50 % of hospitalized old patients and is associated with increased morbidity and mortality. Acute medical conditions favor delirium, but the pathophysiology is unclear. Preliminary evidence from retrospective and prospective studies suggests that a substantial minority of old patients with unexplained delirium have non-convulsive seizures or status epilepticus (NCSE). Yet, seeking epileptic activity only in unexplained cases of delirium might result in misinterpretation of its actual prevalence. We aimed to systematically investigate the role of epileptic activity in all older patients with delirium regardless of the underlying etiology. Design, Setting: Prospective observational study in a tertiary medical center. Adults >65 years with delirium underwent at least 24 h of continuous electro-encephalographic monitoring (cEEG). Background patterns and ictal and interictal epileptic discharges were identified, as well as clinical and biological characteristics. Participants: Fifty patients were included in the study. Results: NCSE was found in 6 (12%) patients and interictal discharges in 15 (30%). There was no difference in the prevalence of epileptic activity rates between delirium associated with an acute medical condition and delirium of unknown etiology. Conclusion: Epileptic activity may play a substantial role in the pathophysiology of delirium by altering brain functioning and neuronal metabolism. No clinical or biological marker was found to distinguish delirious patients with or without epileptic activity, underlining the importance of cEEG in this context.
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Affiliation(s)
- Sara Sambin
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Nicolas Gaspard
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Benjamin Legros
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Chantal Depondt
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sandra De Breucker
- Geriatrics Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Gilles Naeije
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Viarasilpa T, Panyavachiraporn N, Osman G, Parres C, Varelas P, Van Harn M, Mayer SA. Electrographic Seizures in Patients with Acute Encephalitis. Neurocrit Care 2019; 30:207-215. [PMID: 30203384 DOI: 10.1007/s12028-018-0599-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Clinical seizures and status epilepticus are frequent complications of encephalitis, can lead to depressed level of consciousness, and are associated with poor outcome. We sought to determine the frequency, risk factors, and clinical impact of electrographic seizures detected with continuing electroencephalography (cEEG) in patients with encephalitis and altered level of consciousness. METHODS We retrospectively identified all patients with presumed or definite viral or autoimmune encephalitis who underwent cEEG monitoring at Henry Ford Hospital from January 2012 to October 2017. Clinical data and cEEG monitoring reports were abstracted and recorded. The primary outcome was electrographic seizures detected by cEEG. RESULTS Of 1,735 patients who underwent a minimum of 12 h of cEEG monitoring, we identified 54 with a verified discharge diagnosis of encephalitis. Twenty-two of these patients (41%) had electrographic seizures on cEEG. Compared with encephalitis patients without seizures, electrographic seizures were associated with lower serum sodium levels (137 ± 5 vs 141 ± 7, P = 0.027) and more often were on antiepileptic therapy (100% vs 78%, P = 0.033) on the first day of monitoring. Seizures were also associated with a higher frequency of cortical imaging abnormalities (68% vs 28%, P = 0.005), lateralized periodic discharges (LPDs; 50% vs 16%, P = 0.014), delta background frequency (81% vs 45%, P = 0.010), low or suppressed voltage (96% vs 62%, P = 0.005), and focal slowing (86% vs 47%, P = 0.004). There was no association between electrographic seizures and clinical outcome at discharge. CONCLUSION Electrographic seizures occur in approximately 40% of patients with acute encephalitis. Low serum sodium, cortical imaging abnormalities, and on cEEG LPDs and background abnormalities are associated factors. The lack of association with short-term outcome suggests that with aggressive treatment, the clinical impact of electrographic seizures in encephalitis can be minimized.
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Affiliation(s)
- Tanuwong Viarasilpa
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA.,Division of Critical Care, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nicha Panyavachiraporn
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA.,Division of Critical Care, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gamaleldin Osman
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Christopher Parres
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Panayiotis Varelas
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Meredith Van Harn
- Department of Public Health Sciences of Henry Ford Health System, Detroit, USA
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA.
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Multimodal Approach to Decision to Treat Critically Ill Patients With Periodic or Rhythmic Patterns Using an Ictal-Interictal Continuum Spectral Severity Score. J Clin Neurophysiol 2018; 35:314-324. [PMID: 29979290 DOI: 10.1097/wnp.0000000000000468] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
We propose a comprehensive review of the subject of epileptiform and potentially harmful EEG patterns that lie on the interictal continuum (IIC) to help with therapeutic decision-making and target future research. This approach to "electro-physiological SE" encompasses five dimensions of the IIC: it characterizes a periodic or rhythmic pattern, not only regarding its ictal morphology and potential harm with secondary neuronal injury, but also addresses the "metabolic footprint," clinical repercussion, and epileptogenic potential. Recent studies have attempted to determine and qualify the ictal nature and the epileptogenic potential (i.e., risk of subsequent acute seizures) of particular IIC patterns and their intrinsic EEG characteristics. Others have correlated non-convulsive seizures with cognitive outcomes beyond mortality; non-convulsive seizures and sporadic, periodic, or rhythmic discharges to encephalopathy severity; and the spectrum of periodic or rhythmic patterns to measurable secondary brain injury. Equivocal periodic or rhythmic patterns on the IIC are frequently encountered in critical care neurology where clinicians often incorporate advanced neuroimaging, metabolic neuromonitoring, and anti-seizure drug short trials, in an effort to gauge these patterns. We propose portraying the IIC with a multiaxial graph to disambiguate each of these risks. Quantification along each axis may help calibrate therapeutic urgency. An adaptable scoring system assesses which quasi-ictal EEG patterns in this spectrum might reach the tipping point toward anti-seizure drug escalation, in neurocritically ill patients.
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Abstract
Use of continuous EEG monitoring in the intensive care unit setting has increased detection of not only subclinical seizures, but also patterns of discharges that have epileptiform features and periodicity yet do not meet the criteria for seizures. These periodic discharges present a clinical challenge: some patterns may reflect brain injury that has already occurred, although there is evidence that some periodic discharges represent an ongoing process causing additional brain injury and necessitate treatment. Herein, we review the available data regarding the clinical significance of different categories of periodic discharges, specifically those that have features physiologically similar to seizures. We propose a stepwise approach to assessment and management of periodic discharges and lay out the general paradigm of (1) clinical assessment including benzodiazepine trial, (2) EEG assessment, with a focus on discharge frequency, and (3) integration of adjunctive data such as neuroimaging and metabolic data when available. A flowchart is provided to simplify and summarize this approach. The goal of this approach is to treat patterns associated with increased risk of seizures and/or additional brain injury, while avoiding unnecessary interventions.
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Abstract
Previous studies have shown that extreme delta brush and high beta/delta power ratio on electroencephalogram are suggestive of anti- N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis. Here we report 3 anti-NMDAR encephalitis patients with ictal rhythmic alpha sinusoidal waves in temporal regions, which suggested electrographic seizures in anti-NMDAR encephalitis and indicated potential for seizure occurrence in the future. Rhythmic alpha sinusoidal waves may be an electrographic feature and helpful in distinguishing anti-NMDAR encephalitis. In addition, extreme delta brush was also observed at 47-50 days after morbidity in 2 of 3 patients.
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Affiliation(s)
- Ailiang Miao
- 1 Department of Neurology, Nanjing Brain Hospital, Nanjing Medical University, Nanjing, Jiangsu, China.,2 Department of Video-Electroencephalography, Nanjing Brain Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaoshan Wang
- 1 Department of Neurology, Nanjing Brain Hospital, Nanjing Medical University, Nanjing, Jiangsu, China.,2 Department of Video-Electroencephalography, Nanjing Brain Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
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Kinney MO, Kaplan PW. An update on the recognition and treatment of non-convulsive status epilepticus in the intensive care unit. Expert Rev Neurother 2017; 17:987-1002. [PMID: 28829210 DOI: 10.1080/14737175.2017.1369880] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Non-convulsive status epilepticus (NCSE) is a complex and diverse condition which is often an under-recognised entity in the intensive care unit. When NCSE is identified the optimal treatment strategy is not always clear. Areas covered: This review is based on a literature review of the key literature in the field over the last 5-10 years. The articles were selected based on their importance to the field by the authors. Expert commentary: This review discusses the complex situations when a neurological consultation may occur in a critical care setting and provides an update on the latest evidence regarding the recognition of NCSE and the decision making around determining the aggressiveness of treatment. It also considers the ictal-interictal continuum of conditions which may be met with, particularly in the era of continuous EEG, and provides an approach for dealing with these. Suggestions for how the field will develop are discussed.
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Affiliation(s)
- Michael O Kinney
- a Department of Neurology , Belfast Health and Social Care Trust , Belfast , Northern Ireland
| | - Peter W Kaplan
- b Department of Neurology , Johns Hopkins School of Medicine , Baltimore , MD , USA
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Struck AF, Osman G, Rampal N, Biswal S, Legros B, Hirsch LJ, Westover MB, Gaspard N. Time-dependent risk of seizures in critically ill patients on continuous electroencephalogram. Ann Neurol 2017; 82:177-185. [PMID: 28681492 DOI: 10.1002/ana.24985] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 06/12/2017] [Accepted: 06/19/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Find the optimal continuous electroencephalographic (CEEG) monitoring duration for seizure detection in critically ill patients. METHODS We analyzed prospective data from 665 consecutive CEEGs, including clinical factors and time-to-event emergence of electroencephalographic (EEG) findings over 72 hours. Clinical factors were selected using logistic regression. EEG risk factors were selected a priori. Clinical factors were used for baseline (pre-EEG) risk. EEG findings were used for the creation of a multistate survival model with 3 states (entry, EEG risk, and seizure). EEG risk state is defined by emergence of epileptiform patterns. RESULTS The clinical variables of greatest predictive value were coma (31% had seizures; odds ratio [OR] = 1.8, p < 0.01) and history of seizures, either remotely or related to acute illness (34% had seizures; OR = 3.0, p < 0.001). If there were no epileptiform findings on EEG, the risk of seizures within 72 hours was between 9% (no clinical risk factors) and 36% (coma and history of seizures). If epileptiform findings developed, the seizure incidence was between 18% (no clinical risk factors) and 64% (coma and history of seizures). In the absence of epileptiform EEG abnormalities, the duration of monitoring needed for seizure risk of <5% was between 0.4 hours (for patients who are not comatose and had no prior seizure) and 16.4 hours (comatose and prior seizure). INTERPRETATION The initial risk of seizures on CEEG is dependent on history of prior seizures and presence of coma. The risk of developing seizures on CEEG decays to <5% by 24 hours if no epileptiform EEG abnormalities emerge, independent of initial clinical risk factors. Ann Neurol 2017;82:177-185.
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Affiliation(s)
- Aaron F Struck
- Department of Neurology, University of Wisconsin, Madison, WI
| | - Gamaleldin Osman
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Nishi Rampal
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | | | - Benjamin Legros
- Department of Neurology, Free University of Brussels, Brussels, Belgium
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | | | - Nicolas Gaspard
- Department of Neurology, Free University of Brussels, Brussels, Belgium
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Continuous electroencephalographic-monitoring in the ICU: an overview of current strengths and future challenges. Curr Opin Anaesthesiol 2017; 30:192-199. [PMID: 28151826 DOI: 10.1097/aco.0000000000000443] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW In ICUs, numerous physiological parameters are continuously monitored and displayed. Yet, functional monitoring of the organ of primary concern, the brain, is not routinely performed. Despite the benefits of ICU use of continuous electroencephalographic (EEG)-monitoring (cEEG) is increasingly recognized, several issues nevertheless seem to hamper its widespread clinical implementation. RECENT FINDINGS Utilization of ICU cEEG has significantly improved detection and characterization of cerebral pathology, prognostication and clinical management in specific patient groups. Potential solutions to several remaining challenges are currently being established. Descriptive EEG-terminology is evolving, whereas logistical issues are dealt with using telemedicine and quantitative EEG trends, training of nonexpert personnel and development of specialized detection algorithms. These concerted solutions are advancing cEEG-registration towards cEEG-monitoring. Notwithstanding these advances, obstacles such as ambiguous EEG-interpretation and differences in treatment based on EEG-findings need yet to be overcome. SUMMARY In selected critically ill patient groups, ICU cEEG has clear benefits over (repeated) standard EEG or no functional brain monitoring at all and if available, cEEG should be used. However, several issues preventing optimal ICU cEEG usage persist and should be further explored.
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Brief Potentially Ictal Rhythmic Discharges [B(I)RDs] in Noncritically Ill Adults. J Clin Neurophysiol 2017; 34:222-229. [DOI: 10.1097/wnp.0000000000000357] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Development and Feasibility Testing of a Critical Care EEG Monitoring Database for Standardized Clinical Reporting and Multicenter Collaborative Research. J Clin Neurophysiol 2017; 33:133-40. [PMID: 26943901 DOI: 10.1097/wnp.0000000000000230] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE The rapid expansion of the use of continuous critical care electroencephalogram (cEEG) monitoring and resulting multicenter research studies through the Critical Care EEG Monitoring Research Consortium has created the need for a collaborative data sharing mechanism and repository. The authors describe the development of a research database incorporating the American Clinical Neurophysiology Society standardized terminology for critical care EEG monitoring. The database includes flexible report generation tools that allow for daily clinical use. METHODS Key clinical and research variables were incorporated into a Microsoft Access database. To assess its utility for multicenter research data collection, the authors performed a 21-center feasibility study in which each center entered data from 12 consecutive intensive care unit monitoring patients. To assess its utility as a clinical report generating tool, three large volume centers used it to generate daily clinical critical care EEG reports. RESULTS A total of 280 subjects were enrolled in the multicenter feasibility study. The duration of recording (median, 25.5 hours) varied significantly between the centers. The incidence of seizure (17.6%), periodic/rhythmic discharges (35.7%), and interictal epileptiform discharges (11.8%) was similar to previous studies. The database was used as a clinical reporting tool by 3 centers that entered a total of 3,144 unique patients covering 6,665 recording days. CONCLUSIONS The Critical Care EEG Monitoring Research Consortium database has been successfully developed and implemented with a dual role as a collaborative research platform and a clinical reporting tool. It is now available for public download to be used as a clinical data repository and report generating tool.
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Tu B, Young GB, Kokoszka A, Rodriguez-Ruiz A, Varma J, Eerikäinen LM, Assassi N, Mayer SA, Claassen J, Särkelä MOK. Diagnostic accuracy between readers for identifying electrographic seizures in critically ill adults. Epilepsia Open 2017; 2:67-75. [PMID: 29750214 PMCID: PMC5939393 DOI: 10.1002/epi4.12034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2016] [Indexed: 01/17/2023] Open
Abstract
Objective Electrographic seizures in critically ill patients are often equivocal. In this study, we sought to determine the diagnostic accuracy of electrographic seizure annotation in adult intensive care units (ICUs) and to identify affecting factors. Methods To investigate diagnostic accuracy, interreader agreement (IRA) measures were derived from 5,769 unequivocal and 6,263 equivocal seizure annotations by five experienced electroencephalogram (EEG) readers after reviewing 74 days of EEGs from 50 adult ICU patients. Factors including seizure equivocality (unequivocal vs. equivocal) and laterality (generalized, partial, or bilaterally independent), cyclicity (cyclic vs. noncyclic), persistency (occurrence of status epilepticus), and patient consciousness level (coma vs. noncoma) were further investigated for their influence on IRA measures. Results On average, 70% of seizures marked by a reference reader overlapped, at least in part, with those marked by a test reader (any-overlap sensitivity, AO-Sn). Agreed seizure duration between reader pairs (overlap-integral sensitivity, OI-Sn) was 62%, while agreed nonseizure duration (overlap-integral specificity, OI-Sp) was 99%. A test reader would annotate one additional seizure not overlapping with a reference reader's annotation in every 11.7 h of EEG, that is, the false-positive rate (FPR) was 0.0854/h. Classifying seizure patterns into unequivocal and equivocal improved specificity and FPR (unequivocal patterns) but compromised sensitivity only for equivocal patterns. Sensitivity of all and unequivocal annotations was higher for patients with status epilepticus. Specificity was higher for partial than for bilaterally independent unequivocal seizure patterns, and lower for cyclic all seizure patterns. Significance Diagnosing electrographic seizures in critically ill adults is highly specific and moderately sensitive. Improved criteria for diagnosing electrographic seizures in the ICU are needed.
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Affiliation(s)
- Bin Tu
- Columbia University Comprehensive Epilepsy Center New York New York U.S.A
| | | | | | | | - Jay Varma
- Barrow Neurological Institute Phoenix Arizona U.S.A
| | | | - Nadege Assassi
- New York University Pre-Medicine Neural Science Program New York New York U.S.A
| | - Stephan A Mayer
- Institute for Critical Care Medicine Icahn School of Medicine at Mount Sinai New York New York U.S.A
| | - Jan Claassen
- Division of Neurocritical Care Columbia University New York New York U.S.A
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Ung H, Davis KA, Wulsin D, Wagenaar J, Fox E, McDonnell JJ, Patterson N, Vite CH, Worrell G, Litt B. Temporal behavior of seizures and interictal bursts in prolonged intracranial recordings from epileptic canines. Epilepsia 2016; 57:1949-1957. [PMID: 27807850 DOI: 10.1111/epi.13591] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Epilepsy is a chronic disorder, but seizure recordings are usually obtained in the acute setting. The chronic behavior of seizures and the interictal bursts that sometimes initiate them is unknown. We investigate the variability of these electrographic patterns over an extended period of time using chronic intracranial recordings in canine epilepsy. METHODS Continuous, yearlong intracranial electroencephalography (iEEG) recordings from four dogs with naturally occurring epilepsy were analyzed for seizures and interictal bursts. Following automated detection and clinician verification of interictal bursts and seizures, temporal trends of seizures, burst count, and burst-burst similarities were determined. One dog developed status epilepticus, the recordings of which were also investigated. RESULTS Multiple seizure types, determined by onset channels, were observed in each dog, with significant temporal variation between types. The first 14 days of invasive recording, analogous to the average duration of clinical invasive recordings in humans, did not capture the entirety of seizure types. Seizures typically occurred in clusters, and isolated seizures were rare. The count and dynamics of interictal bursts form distinct groups and do not stabilize until several weeks after implantation. SIGNIFICANCE There is significant temporal variability in seizures and interictal bursts after electrode implantation that requires several weeks to reach steady state. These findings, comparable to those reported in humans implanted with the NeuroPace Responsive Neurostimulator System (RNS) device, suggest that transient network changes following electrode implantation may need to be taken into account when interpreting or analyzing iEEG during evaluation for epilepsy surgery. Chronic, ambulatory iEEG may be better suited to accurately map epileptic networks in appropriate individuals.
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Affiliation(s)
- Hoameng Ung
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Kathryn A Davis
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.,Penn Epilepsy Center, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Drausin Wulsin
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Joost Wagenaar
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Emily Fox
- Department of Statistics, University of Washington, Seattle, Washington, U.S.A
| | - John J McDonnell
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Ned Patterson
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, Minnesota, U.S.A
| | - Charles H Vite
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Gregory Worrell
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Brian Litt
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.,Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.,Penn Epilepsy Center, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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Abstract
The interpretation of the EEG in the critically ill remains a clinical challenge. Because continuous EEG monitoring plays an increasing role in patients' care, it is important that research efforts investigate the clinical significance of periodic and rhythmic discharges and of background abnormalities. The 2012 American Clinical Neurophysiology Society critical care EEG terminology was designed to provide a comprehensive and objective vocabulary for that purpose. The interrater reliability of most of the proposed terms has been established, confirming that they represent a solid basis for research. Studies using the terminology have already started to define the clinical and prognostic values of several known or newly described EEG patterns. Yet, as the field of critical care EEG evolves, improvements will be required to further enhance the clarity of the terminology and incorporate new findings from ongoing research.
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Abbas A, Garg A, Jain R, Mazibrada G, Jacob S. Extreme delta brushes and BIRDs in the EEG of anti-NMDA-receptor encephalitis. Pract Neurol 2016; 16:326-7. [DOI: 10.1136/practneurol-2016-001380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2016] [Indexed: 11/04/2022]
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Rodríguez V, Rodden MF, LaRoche SM. Ictal-interictal continuum: A proposed treatment algorithm. Clin Neurophysiol 2016; 127:2056-64. [PMID: 26971489 DOI: 10.1016/j.clinph.2016.02.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 01/18/2016] [Accepted: 02/05/2016] [Indexed: 01/27/2023]
Abstract
The ictal-interictal continuum (IIC) is characterized by periodic and/or rhythmic EEG patterns that occur with relative high frequency in critically ill patients. Several studies have reported that some patterns seen within the continuum are independently associated with poor outcome. However there is no consensus regarding when to treat them or how aggressive treatment should be. In this review we examine peer-reviewed original scientific articles, guidelines and reviews indexed in PubMed and summarize current knowledge related to the ictal-interictal continuum. A treatment algorithm to guide management of critically ill patients with EEG patterns that fall along the IIC is proposed. The algorithm-based on best current practice in adults-takes into account associated clinical events, risk factors for developing seizures, response to medication trials and biomarkers of neuronal injury.
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Affiliation(s)
- Valia Rodríguez
- Cuban Neuroscience Center & Clinical-Surgical Hospital 'Hnos Ameijeiras', Cuba.
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40
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Davis KA, Ung H, Wulsin D, Wagenaar J, Fox E, Patterson N, Vite C, Worrell G, Litt B. Mining continuous intracranial EEG in focal canine epilepsy: Relating interictal bursts to seizure onsets. Epilepsia 2016; 57:89-98. [PMID: 26608448 PMCID: PMC4770560 DOI: 10.1111/epi.13249] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Brain regions are localized for resection during epilepsy surgery based on rare seizures observed during a short period of intracranial electroencephalography (iEEG) monitoring. Interictal epileptiform bursts, which are more prevalent than seizures, may provide complementary information to aid in epilepsy evaluation. In this study, we leverage a long-term iEEG dataset from canines with naturally occurring epilepsy to investigate interictal bursts and their electrographic relationship to seizures. METHODS Four dogs were included in this study, each monitored previously with continuous iEEG for periods of 475.7, 329.9, 45.8, and 451.8 days, respectively, for a total of >11,000 h. Seizures and bursts were detected and validated by two board-certified epileptologists. A published Bayesian model was applied to analyze the dynamics of interictal epileptic bursts on EEG and compare them to seizures. RESULTS In three dogs, bursts were stereotyped and found to be statistically similar to periods before or near seizure onsets. Seizures from one dog during status epilepticus were markedly different from other seizures in terms of burst similarity. SIGNIFICANCE Shorter epileptic bursts explored in this work have the potential to yield significant information about the distribution of epileptic events. In our data, bursts are at least an order of magnitude more prevalent than seizures and occur much more regularly. Our finding that bursts often display pronounced similarity to seizure onsets suggests that they contain relevant information about the epileptic networks from which they arise and may aide in the clinical evaluation of epilepsy in patients.
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Affiliation(s)
- Kathryn A. Davis
- Department of Neurology, University of Pennsylvania
- Penn Epilepsy Center, University of Pennsylvania
- Penn Center for Neuroengineering and Therapeutics
| | - Hoameng Ung
- Department of Bioengineering, University of Pennsylvania
- Penn Center for Neuroengineering and Therapeutics
| | - Drausin Wulsin
- Department of Bioengineering, University of Pennsylvania
| | | | - Emily Fox
- Department of Statistics, University of Washington
| | - Ned Patterson
- Department of Veterinary Clinical Sciences, University of Minnesota
| | - Charles Vite
- School of Veterinary Medicine, University of Pennsylvania
| | | | - Brian Litt
- Department of Neurology, University of Pennsylvania
- Penn Epilepsy Center, University of Pennsylvania
- Department of Bioengineering, University of Pennsylvania
- Penn Center for Neuroengineering and Therapeutics
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Löscher W, Hirsch LJ, Schmidt D. The enigma of the latent period in the development of symptomatic acquired epilepsy - Traditional view versus new concepts. Epilepsy Behav 2015; 52:78-92. [PMID: 26409135 DOI: 10.1016/j.yebeh.2015.08.037] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 08/30/2015] [Indexed: 01/21/2023]
Abstract
A widely accepted hypothesis holds that there is a seizure-free, pre-epileptic state, termed the "latent period", between a brain insult, such as traumatic brain injury or stroke, and the onset of symptomatic epilepsy, during which a cascade of structural, molecular, and functional alterations gradually mediates the process of epileptogenesis. This review, based on recent data from both animal models and patients with different types of brain injury, proposes that epileptogenesis and often subclinical epilepsy can start immediately after brain injury without any appreciable latent period. Even though the latent period has traditionally been the cornerstone concept representing epileptogenesis, we suggest that the evidence for the existence of a latent period is spotty both for animal models and human epilepsy. Knowing whether a latent period exists or not is important for our understanding of epileptogenesis and for the discovery and the trial design of antiepileptogenic agents. The development of antiepileptogenic treatments to prevent epilepsy in patients at risk from a brain insult is a major unmet clinical need.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, 30559 Hannover, Germany; Center for Systems Neuroscience, 30559 Hannover, Germany.
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Passareli V, Medeiros L, Simabukuro M, Baldocci M, Brucki S, Rocha MSG. Early occurrence of brief potentially ictal rhythmic discharges [B(I)RDs], and subsequent emergence of asymmetric extreme delta brush (EDB) in Anti-NMDA receptors encephalitis. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 74:177. [PMID: 26486493 DOI: 10.1590/0004-282x20150176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/02/2015] [Indexed: 11/22/2022]
Affiliation(s)
- Valmir Passareli
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Lais Medeiros
- Departamento de Neurologia, Hospital Santa Marcelina, Sao Paulo, SP, Brazil
| | - Mateus Simabukuro
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Meire Baldocci
- Departamento de Neurologia, Hospital Santa Marcelina, Sao Paulo, SP, Brazil
| | - Sonia Brucki
- Departamento de Neurologia, Hospital Santa Marcelina, Sao Paulo, SP, Brazil
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Quigg M, Sun F, Fountain NB, Jobst BC, Wong VSS, Mirro E, Brown S, Spencer DC. Interrater reliability in interpretation of electrocorticographic seizure detections of the responsive neurostimulator. Epilepsia 2015; 56:968-71. [PMID: 25895054 PMCID: PMC5008166 DOI: 10.1111/epi.12998] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2015] [Indexed: 12/01/2022]
Abstract
Objective Electrocorticographic (ECoG) recordings from patients with medically intractable partial‐onset seizures treated with a responsive neurostimulator system (the RNS System) that detects and stores physician‐specified ECoG events provide a new data resource. Interpretation of these recordings has not yet been validated. The purpose was to evaluate the interrater interpretation of chronic ambulatory ECoG recordings obtained by the RNS System. Methods Five pairs of five experts independently classified 7,221 ECoG recordings obtained from 128 patients with medically intractable partial seizures who participated in a randomized controlled trial of the safety and efficacy of the RNS System. ECoG detections—“long episodes” or “saturations”—were classified as “seizures” or “not seizures” based on a reference definition. Interrater agreement rates and kappa score reliabilities were calculated between rater pairs from the ECoG sample as a whole and within individual patients who had more than the median number of individual ECoG recordings. Results The overall interrater agreement was 79%, with a reliability κ = 0.57 (moderate agreement). Agreement between pairs of reviewers ranged from 0.69 to 0.85. Agreement rates were 94% or better for 50% of patients. Only 25% of patients had ECoG recordings agreement rates worse than 75%. ECoGs with mixed interpretations (one reviewer “seizure”/the other—“not seizure”) consisted of periods of low amplitude activity that evolved in amplitude or periodic discharges near 2 Hz. Significance Although reliability as a whole was moderate, for the majority of patients, detections yielded highly reliably interpreted events of either electrographic seizures or nonictal epileptiform activity.
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Affiliation(s)
- Mark Quigg
- Department of Neurology, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Felice Sun
- NeuroPace Inc, Mountain View, California, U.S.A
| | - Nathan B Fountain
- Department of Neurology, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Barbara C Jobst
- Department of Neurology, Dartmouth University, Lebanon, New Hampshire, U.S.A
| | - Victoria S S Wong
- Department of Neurology, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Emily Mirro
- NeuroPace Inc, Mountain View, California, U.S.A
| | - Sarah Brown
- Department of Neurology, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - David C Spencer
- Department of Neurology, Oregon Health and Science University, Portland, Oregon, U.S.A
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45
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Hosokawa K, Gaspard N, Su F, Oddo M, Vincent JL, Taccone FS. Clinical neurophysiological assessment of sepsis-associated brain dysfunction: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:674. [PMID: 25482125 PMCID: PMC4277650 DOI: 10.1186/s13054-014-0674-y] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 11/17/2014] [Indexed: 01/27/2023]
Abstract
Introduction Several studies have reported the presence of electroencephalography (EEG) abnormalities or altered evoked potentials (EPs) during sepsis. However, the role of these tests in the diagnosis and prognostic assessment of sepsis-associated encephalopathy remains unclear. Methods We performed a systematic search for studies evaluating EEG and/or EPs in adult (≥18 years) patients with sepsis-associated encephalopathy. The following outcomes were extracted: a) incidence of EEG/EP abnormalities; b) diagnosis of sepsis-associated delirium or encephalopathy with EEG/EP; c) outcome. Results Among 1976 citations, 17 articles met the inclusion criteria. The incidence of EEG abnormalities during sepsis ranged from 12% to 100% for background abnormality and 6% to 12% for presence of triphasic waves. Two studies found that epileptiform discharges and electrographic seizures were more common in critically ill patients with than without sepsis. In one study, EEG background abnormalities were related to the presence and the severity of encephalopathy. Background slowing or suppression and the presence of triphasic waves were also associated with higher mortality. A few studies demonstrated that quantitative EEG analysis and EP could show significant differences in patients with sepsis compared to controls but their association with encephalopathy and outcome was not evaluated. Conclusions Abnormalities in EEG and EPs are present in the majority of septic patients. There is some evidence to support EEG use in the detection and prognostication of sepsis-associated encephalopathy, but further clinical investigation is needed to confirm this suggestion.
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Affiliation(s)
- Koji Hosokawa
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Nicolas Gaspard
- Comprehensive Epilepsy Center and Computational Neurophysiology Laboratory, Dept. of Neurology, School of Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT, 06520, USA. .,Department of Neurology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Fuhong Su
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Mauro Oddo
- Department of Intensive Care Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
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