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Kalkach-Aparicio M, Fatima S, Selte A, Sheikh IS, Cormier J, Gallagher K, Avagyan G, Cespedes J, Krishnamurthy PV, Elazim AA, Khan N, Hussein OM, Maganti R, Larocque J, Holla S, Desai M, Westover B, Hirsch LJ, Struck AF. Seizure Assessment and Forecasting With Efficient Rapid-EEG: A Retrospective Multicenter Comparative Effectiveness Study. Neurology 2024; 103:e209621. [PMID: 38875512 DOI: 10.1212/wnl.0000000000209621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Approximately 30% of critically ill patients have seizures, and more than half of these seizures do not have an overt clinical correlate. EEG is needed to avoid missing seizures and prevent overtreatment with antiseizure medications. Conventional-EEG (cEEG) resources are logistically constrained and unable to meet their growing demand for seizure detection even in highly developed centers. Brief EEG screening with the validated 2HELPS2B algorithm was proposed as a method to triage cEEG resources, but it is hampered by cEEG requirements, primarily EEG technologists. Seizure risk-stratification using reduced time-to-application rapid response-EEG (rrEEG) systems (∼5 minutes) could be a solution. We assessed the noninferiority of the 2HELPS2B score on a 1-hour rrEEG compared to cEEG. METHODS A multicenter retrospective EEG diagnostic accuracy study was conducted from October 1, 2021, to July 31, 2022. Chart and EEG review performed with consecutive sampling at 4 tertiary care centers, included records of patients ≥18 years old, from January 1, 2018, to June 20, 2022. Monte Carlo simulation power analysis yielded n = 500 rrEEG; for secondary outcomes n = 500 cEEG and propensity-score covariate matching was planned. Primary outcome, noninferiority of rrEEG for seizure risk prediction, was assessed per area under the receiver operator characteristic curve (AUC). Noninferiority margin (0.05) was based on the 2HELPS2B validation study. RESULTS A total of 240 rrEEG with follow-on cEEG were obtained. Median age was 64 (interquartile range 22); 42% were female. 2HELPS2B on a 1-hour rrEEG met noninferiority to cEEG (AUC 0.85, 95% CI 0.78-0.90, p = 0.001). Secondary endpoints of comparison with a matched contemporaneous cEEG showed no significant difference in AUC (0.89, 95% CI 0.83-0.94, p = 0.31); in false negative rate for the 2HELPS2B = 0 group (p = 1.0) rrEEG (0.021, 95% CI 0-0.062), cEEG (0.016, 95% CI 0-0.048); nor in survival analyses. DISCUSSION 2HELPS2B on 1-hour rrEEG is noninferior to cEEG for seizure prediction. Patients with low-risk (2HELPS2B = 0) may be able to forgo prolonged cEEG, allowing for increased monitoring of at-risk patients. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that rrEEG is noninferior to cEEG in calculating the 2HELPS2B score to predict seizure risk.
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Affiliation(s)
- Mariel Kalkach-Aparicio
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Safoora Fatima
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Atakan Selte
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Irfan S Sheikh
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Justine Cormier
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Kaileigh Gallagher
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Gayane Avagyan
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Jorge Cespedes
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Parimala V Krishnamurthy
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Ahmed Abd Elazim
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Natasha Khan
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Omar M Hussein
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Rama Maganti
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Joshua Larocque
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Smitha Holla
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Masoom Desai
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Brandon Westover
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Lawrence J Hirsch
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
| | - Aaron F Struck
- From the Department of Neurology (M.K.-A., R.M., A.F.S.), and Epilepsy Division of the Department of Neurology (S.F., A.S., G.A., P.V.K., J.L., S.H.), University of Wisconsin-Madison; Department of Neurology (S.F.), Southern Illinois University, Carbondale; Department of Neurology (A.S.), UCLA Harbor Medical Center, Torrance, CA; Epilepsy Division of Department of Neurology (I.S.S., K.G.), Massachusetts General Hospital, Boston; Comprehensive Epilepsy Center (J. Cormier, J. Cespedes, L.J.H.), Department of Neurology, Yale University, New Haven, CT; University of Connecticut School of Medicine (J. Cormier), Farmington; Epilepsy Division of Department of Neurology (K.G.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; UHS Wilson Square Neurology (G.A.), Johnson City, NY; Universidad Autonoma de Centro America (UACA) School of Medicine (J. Cespedes), Granadilla, Cipreses, Costa Rica; Neurology Department (A.A.E., N.K., M.D.), University of New Mexico, Albuquerque; University of South Dakota (A.A.E.), Sanford School of Medicine, Vermillion; Comprehensive Epilepsy Team (O.M.H.), Neurology Department, University of New Mexico, Albuquerque; Center for Neuroengineering and Therapeutics (J.L.), University of Pennsylvania, Philadelphia; Department of Neurology (B.W.), Massachusetts General Hospital; and Beth Israel Deaconess Medical Center (B.W.), Boston, MA
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8
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Peter-Derex L, Philippeau F, Garnier P, André-Obadia N, Boulogne S, Catenoix H, Convers P, Mazzola L, Gouttard M, Esteban M, Fontaine J, Mechtouff L, Ong E, Cho TH, Nighoghossian N, Perreton N, Termoz A, Haesebaert J, Schott AM, Rabilloud M, Pivot C, Dhelens C, Filip A, Berthezène Y, Rheims S, Boutitie F, Derex L. Safety and efficacy of prophylactic levetiracetam for prevention of epileptic seizures in the acute phase of intracerebral haemorrhage (PEACH): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Neurol 2022; 21:781-791. [PMID: 35963261 DOI: 10.1016/s1474-4422(22)00235-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/15/2022] [Accepted: 05/24/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND The incidence of early seizures (occurring within 7 days of stroke onset) after intracerebral haemorrhage reaches 30% when subclinical seizures are diagnosed by continuous EEG. Early seizures might be associated with haematoma expansion and worse neurological outcomes. Current guidelines do not recommend prophylactic antiseizure treatment in this setting. We aimed to assess whether prophylactic levetiracetam would reduce the risk of acute seizures in patients with intracerebral haemorrhage. METHODS The double-blind, randomised, placebo-controlled, phase 3 PEACH trial was conducted at three stroke units in France. Patients (aged 18 years or older) who presented with a non-traumatic intracerebral haemorrhage within 24 h after onset were randomly assigned (1:1) to levetiracetam (intravenous 500 mg every 12 h) or matching placebo. Randomisation was done with a web-based system and stratified by centre and National Institutes of Health Stroke Scale (NIHSS) score at baseline. Treatment was continued for 6 weeks. Continuous EEG was started within 24 h after inclusion and recorded over 48 h. The primary endpoint was the occurrence of at least one clinical seizure within 72 h of inclusion or at least one electrographic seizure recorded on continuous EEG, analysed in the modified intention-to-treat population, which comprised all patients who were randomly assigned to treatment and who had a continuous EEG performed. This trial was registered at ClinicalTrials.gov, NCT02631759, and is now closed. Recruitment was prematurely stopped after 48% of the recruitment target was reached due to a low recruitment rate and cessation of funding. FINDINGS Between June 1, 2017, and April 14, 2020, 50 patients with mild-to-moderate severity intracerebral haemorrhage were included: 24 were assigned to levetiracetam and 26 to placebo. During the first 72 h, a clinical or electrographic seizure was observed in three (16%) of 19 patients in the levetiracetam group versus ten (43%) of 23 patients in the placebo group (odds ratio 0·16, 95% CI 0·03-0·94, p=0·043). All seizures in the first 72 h were electrographic seizures only. No difference in depression or anxiety reporting was observed between the groups at 1 month or 3 months. Depression was recorded in three (13%) patients who received levetiracetam versus four (15%) patients who received placebo, and anxiety was reported for two (8%) patients versus one (4%) patient. The most common treatment-emergent adverse events in the levetiracetam group versus the placebo group were headache (nine [39%] vs six [24%]), pain (three [13%] vs ten [40%]), and falls (seven [30%] vs four [16%]). The most frequent serious adverse events were neurological deterioration due to the intracerebral haemorrhage (one [4%] vs four [16%]) and severe pneumonia (two [9%] vs two [8%]). No treatment-related death was reported in either group. INTERPRETATION Levetiracetam might be effective in preventing acute seizures in intracerebral haemorrhage. Larger studies are needed to determine whether seizure prophylaxis improves functional outcome in patients with intracerebral haemorrhage. FUNDING French Ministry of Health.
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Affiliation(s)
- Laure Peter-Derex
- Centre for Sleep Medicine and Respiratory Diseases, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France.
| | - Frédéric Philippeau
- Stroke Unit, Department of Neurology, Fleyriat Hospital, Bourg en Bresse, France
| | - Pierre Garnier
- Stroke Centre, Department of Neurology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Nathalie André-Obadia
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Sébastien Boulogne
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Hélène Catenoix
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Philippe Convers
- Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France; Clinical Neurophysiology Unit, Department of Neurology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Laure Mazzola
- Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France; Clinical Neurophysiology Unit, Department of Neurology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Michel Gouttard
- Stroke Unit, Department of Neurology, Fleyriat Hospital, Bourg en Bresse, France
| | - Maud Esteban
- Stroke Centre, Lyon University Hospital, Lyon, France
| | | | | | - Elodie Ong
- Stroke Centre, Lyon University Hospital, Lyon, France
| | - Tae-Hee Cho
- Stroke Centre, Lyon University Hospital, Lyon, France
| | | | - Nathalie Perreton
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Anne Termoz
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Julie Haesebaert
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Anne-Marie Schott
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Muriel Rabilloud
- Department of Biostatistics, Lyon University Hospital, Lyon, France; Biometry and Evolutionary Biology Laboratory, CNRS UMR 5558, Biostatistics Health Team, Villeurbanne, France
| | - Christine Pivot
- Pharmacy, FRIPHARM, Edouard Herriot Hospital, Lyon University Hospital, Lyon, France
| | - Carole Dhelens
- Pharmacy, FRIPHARM, Edouard Herriot Hospital, Lyon University Hospital, Lyon, France
| | - Andrea Filip
- Department of Neuroradiology, Neurological Hospital, Lyon University Hospital, Lyon, France
| | - Yves Berthezène
- Department of Neuroradiology, Neurological Hospital, Lyon University Hospital, Lyon, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Florent Boutitie
- Department of Biostatistics, Lyon University Hospital, Lyon, France; Biometry and Evolutionary Biology Laboratory, CNRS UMR 5558, Biostatistics Health Team, Villeurbanne, France
| | - Laurent Derex
- Stroke Centre, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
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