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Guo Q, Chen H, Lin S, Gong Z, Song Z, Chen F. Innovative prognostication: a novel nomogram for post-interventional aneurysmal subarachnoid hemorrhage patients. Front Neurol 2024; 15:1410735. [PMID: 39228509 PMCID: PMC11369945 DOI: 10.3389/fneur.2024.1410735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 08/02/2024] [Indexed: 09/05/2024] Open
Abstract
Background and purpose Spontaneous aneurysmal subarachnoid hemorrhage (aSAH) is a common acute cerebrovascular disease characterized by severe illness, high mortality, and potential cognitive and motor impairments. We carried out a retrospective study at Fujian Provincial Hospital to establish and validate a model for forecasting functional outcomes at 6 months in aSAH patients who underwent interventional embolization. Methods 386 aSAH patients who underwent interventional embolization between May 2012 and April 2022 were included in the study. We established a logistic regression model based on independent risk factors associated with 6-month adverse outcomes (modified Rankin Scale Score ≥ 3, mRS). We evaluated the model's performance based on its discrimination, calibration, clinical applicability, and generalization ability. Finally, the study-derived prediction model was also compared with other aSAH prognostic scales and the model's itself constituent variables to assess their respective predictive efficacy. Results The predictors considered in our study were age, the World Federation of Neurosurgical Societies (WFNS) grade of IV-V, mFisher score of 3-4, secondary cerebral infarction, and first leukocyte counts on admission. Our model demonstrated excellent discrimination in both the modeling and validation cohorts, with an area under the curve of 0.914 (p < 0.001, 95%CI = 0.873-0.956) and 0.947 (p < 0.001, 95%CI = 0.907-0.987), respectively. Additionally, the model also exhibited good calibration (Hosmer-Lemeshow goodness-of-fit test: X2 = 9.176, p = 0.328). The clinical decision curve analysis and clinical impact curve showed favorable clinical applicability. In comparison to other prediction models and variables, our model displayed superior predictive performance. Conclusion The new prediction nomogram has the capability to forecast the unfavorable outcomes at 6 months after intervention in patients with aSAH.
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Affiliation(s)
- Qinyu Guo
- Department of Emergency, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Shengli Clinical Medical College, Fujian Medical University, Fujian, Fuzhou, China
- Fujian Provincial Institute of Emergency Medicine, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Fuzhou University Affiliated Provincial Hospital, Fujian, Fuzhou, China
| | - Hongyi Chen
- Department of Emergency, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Fuzhou University Affiliated Provincial Hospital, Fujian, Fuzhou, China
- Fujian Emergency Medical Center, Fujian Provincial Hospital, Fujian, Fuzhou, China
| | - Shirong Lin
- Department of Emergency, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Shengli Clinical Medical College, Fujian Medical University, Fujian, Fuzhou, China
- Fujian Provincial Institute of Emergency Medicine, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Fuzhou University Affiliated Provincial Hospital, Fujian, Fuzhou, China
- Fujian Provincial Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fujian, Fuzhou, China
| | - Zheng Gong
- Department of Emergency, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Shengli Clinical Medical College, Fujian Medical University, Fujian, Fuzhou, China
- Fujian Provincial Institute of Emergency Medicine, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Fuzhou University Affiliated Provincial Hospital, Fujian, Fuzhou, China
- Fujian Provincial Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fujian, Fuzhou, China
| | - Zhiwei Song
- Department of Emergency, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Shengli Clinical Medical College, Fujian Medical University, Fujian, Fuzhou, China
- Fujian Provincial Institute of Emergency Medicine, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Fuzhou University Affiliated Provincial Hospital, Fujian, Fuzhou, China
| | - Feng Chen
- Department of Emergency, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Shengli Clinical Medical College, Fujian Medical University, Fujian, Fuzhou, China
- Fujian Provincial Institute of Emergency Medicine, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Fuzhou University Affiliated Provincial Hospital, Fujian, Fuzhou, China
- Fujian Emergency Medical Center, Fujian Provincial Hospital, Fujian, Fuzhou, China
- Fujian Provincial Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fujian, Fuzhou, China
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Bitar R, Khan UM, Rosenthal ES. Utility and rationale for continuous EEG monitoring: a primer for the general intensivist. Crit Care 2024; 28:244. [PMID: 39014421 PMCID: PMC11251356 DOI: 10.1186/s13054-024-04986-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/09/2024] [Indexed: 07/18/2024] Open
Abstract
This review offers a comprehensive guide for general intensivists on the utility of continuous EEG (cEEG) monitoring for critically ill patients. Beyond the primary role of EEG in detecting seizures, this review explores its utility in neuroprognostication, monitoring neurological deterioration, assessing treatment responses, and aiding rehabilitation in patients with encephalopathy, coma, or other consciousness disorders. Most seizures and status epilepticus (SE) events in the intensive care unit (ICU) setting are nonconvulsive or subtle, making cEEG essential for identifying these otherwise silent events. Imaging and invasive approaches can add to the diagnosis of seizures for specific populations, given that scalp electrodes may fail to identify seizures that may be detected by depth electrodes or electroradiologic findings. When cEEG identifies SE, the risk of secondary neuronal injury related to the time-intensity "burden" often prompts treatment with anti-seizure medications. Similarly, treatment may be administered for seizure-spectrum activity, such as periodic discharges or lateralized rhythmic delta slowing on the ictal-interictal continuum (IIC), even when frank seizures are not evident on the scalp. In this setting, cEEG is utilized empirically to monitor treatment response. Separately, cEEG has other versatile uses for neurotelemetry, including identifying the level of sedation or consciousness. Specific conditions such as sepsis, traumatic brain injury, subarachnoid hemorrhage, and cardiac arrest may each be associated with a unique application of cEEG; for example, predicting impending events of delayed cerebral ischemia, a feared complication in the first two weeks after subarachnoid hemorrhage. After brief training, non-neurophysiologists can learn to interpret quantitative EEG trends that summarize elements of EEG activity, enhancing clinical responsiveness in collaboration with clinical neurophysiologists. Intensivists and other healthcare professionals also play crucial roles in facilitating timely cEEG setup, preventing electrode-related skin injuries, and maintaining patient mobility during monitoring.
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Affiliation(s)
- Ribal Bitar
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Usaamah M Khan
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA.
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Fernández-Torre JL, Hernández-Hernández MA, Cherchi MS, Mato-Mañas D, de Lucas EM, Gómez-Ruiz E, Vázquez-Higuera JL, Fanjul-Vélez F, Arce-Diego JL, Martín-Láez R. Comparison of Continuous Intracortical and Scalp Electroencephalography in Comatose Patients with Acute Brain Injury. Neurocrit Care 2024:10.1007/s12028-024-02016-z. [PMID: 38918336 DOI: 10.1007/s12028-024-02016-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 05/16/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Depth electroencephalography (dEEG) is a recent invasive monitoring technique used in patients with acute brain injury. This study aimed to describe in detail the clinical manifestations of nonconvulsive seizures (NCSzs) with and without a surface EEG correlate, analyze their long-standing effects, and provide data that contribute to understanding the significance of certain scalp EEG patterns observed in critically ill patients. METHODS We prospectively enrolled a cohort of 33 adults with severe acute brain injury admitted to the neurological intensive care unit. All of them underwent multimodal invasive monitoring, including dEEG. All patients were scanned on a 3T magnetic resonance imaging scanner at 6 months after hospital discharge, and mesial temporal atrophy (MTA) was calculated using a visual scale. RESULTS In 21 (65.6%) of 32 study participants, highly epileptiform intracortical patterns were observed. A total of 11 (34.3%) patients had electrographic or electroclinical seizures in the dEEG, of whom 8 had both spontaneous and stimulus-induced (SI) seizures, and 3 patients had only spontaneous intracortical seizures. An unequivocal ictal scalp correlate was observed in only 3 (27.2%) of the 11 study participants. SI-NCSzs occurred during nursing care, medical procedures, and family visits. Subtle clinical manifestations, such as restlessness, purposeless stereotyped movements of the upper limbs, ventilation disturbances, jerks, head movements, hyperextension posturing, chewing, and oroalimentary automatisms, occurred during intracortical electroclinical seizures. MTA was detected in 18 (81.8%) of the 22 patients. There were no statistically significant differences between patients with MTA with and without seizures or status epilepticus. CONCLUSIONS Most NCSzs in critically ill comatose patients remain undetectable on scalp EEG. SI-NCSzs frequently occur during nursing care, medical procedures, and family visits. Semiology of NCSzs included ictal minor signs and subtle symptoms, such as breathing pattern changes manifested as patient-ventilator dyssynchrony.
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Affiliation(s)
- José L Fernández-Torre
- Department of Clinical Neurophysiology, Marqués de Valdecilla University Hospital, 39008, Santander, Cantabria, Spain.
- Department of Physiology and Pharmacology, School of Medicine, University of Cantabria, 39008, Santander, Cantabria, Spain.
- Biomedical Research Institute (IDIVAL), 39011, Santander, Cantabria, Spain.
| | - Miguel A Hernández-Hernández
- Biomedical Research Institute (IDIVAL), 39011, Santander, Cantabria, Spain
- Department of Intensive Medicine, Marqués de Valdecilla University Hospital, 39008, Santander, Cantabria, Spain
| | - Marina S Cherchi
- Biomedical Research Institute (IDIVAL), 39011, Santander, Cantabria, Spain
- Department of Intensive Medicine, Marqués de Valdecilla University Hospital, 39008, Santander, Cantabria, Spain
| | - David Mato-Mañas
- Biomedical Research Institute (IDIVAL), 39011, Santander, Cantabria, Spain
- Department of Neurosurgery, Marqués de Valdecilla University Hospital, 39008, Santander, Cantabria, Spain
| | - Enrique Marco de Lucas
- Biomedical Research Institute (IDIVAL), 39011, Santander, Cantabria, Spain
- Department of Radiology, Marqués de Valdecilla University Hospital, 39008, Santander, Cantabria, Spain
- Department of Medical-Surgical Sciences, School of Medicine, University of Cantabria, 39008, Santander, Cantabria, Spain
| | - Elsa Gómez-Ruiz
- Department of Psychiatry, Marqués de Valdecilla University Hospital Santander, 39008, Cantabria, Spain
| | - José L Vázquez-Higuera
- Biomedical Research Institute (IDIVAL), 39011, Santander, Cantabria, Spain
- Department of Neurology, Marqués de Valdecilla University Hospital, 39008, Santander, Cantabria, Spain
| | - Félix Fanjul-Vélez
- Biomedical Engineering Group, Tecnología Electrónica, Ingeniería de Sistemas y Automática (TEISA) Department, University of Cantabria, 39005, Santander, Cantabria, Spain
| | - José L Arce-Diego
- Biomedical Engineering Group, Tecnología Electrónica, Ingeniería de Sistemas y Automática (TEISA) Department, University of Cantabria, 39005, Santander, Cantabria, Spain
| | - Rubén Martín-Láez
- Biomedical Research Institute (IDIVAL), 39011, Santander, Cantabria, Spain
- Department of Neurosurgery, Marqués de Valdecilla University Hospital, 39008, Santander, Cantabria, Spain
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Benghanem S, Kubis N, Gayat E, Loiodice A, Pruvost-Robieux E, Sharshar T, Foucrier A, Figueiredo S, Bouilleret V, De Montmollin E, Bagate F, Lefaucheur JP, Guidet B, Appartis E, Cariou A, Varnet O, Jost PH, Megarbane B, Degos V, Le Guennec L, Naccache L, Legriel S, Woimant F, Gregoire C, Cortier D, Crassard I, Timsit JF, Mazighi M, Sonneville R. Prognostic value of early EEG abnormalities in severe stroke patients requiring mechanical ventilation: a pre-planned analysis of the SPICE prospective multicenter study. Crit Care 2024; 28:173. [PMID: 38783313 PMCID: PMC11119574 DOI: 10.1186/s13054-024-04957-5] [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: 04/07/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION Prognostication of outcome in severe stroke patients necessitating invasive mechanical ventilation poses significant challenges. The objective of this study was to assess the prognostic significance and prevalence of early electroencephalogram (EEG) abnormalities in adult stroke patients receiving mechanical ventilation. METHODS This study is a pre-planned ancillary investigation within the prospective multicenter SPICE cohort study (2017-2019), conducted in 33 intensive care units (ICUs) in the Paris area, France. We included adult stroke patients requiring invasive mechanical ventilation, who underwent at least one intermittent EEG examination during their ICU stay. The primary endpoint was the functional neurological outcome at one year, determined using the modified Rankin scale (mRS), and dichotomized as unfavorable (mRS 4-6, indicating severe disability or death) or favorable (mRS 0-3). Multivariable regression analyses were employed to identify EEG abnormalities associated with functional outcomes. RESULTS Of the 364 patients enrolled in the SPICE study, 153 patients (49 ischemic strokes, 52 intracranial hemorrhages, and 52 subarachnoid hemorrhages) underwent at least one EEG at a median time of 4 (interquartile range 2-7) days post-stroke. Rates of diffuse slowing (70% vs. 63%, p = 0.37), focal slowing (38% vs. 32%, p = 0.15), periodic discharges (2.3% vs. 3.7%, p = 0.9), and electrographic seizures (4.5% vs. 3.7%, p = 0.4) were comparable between patients with unfavorable and favorable outcomes. Following adjustment for potential confounders, an unreactive EEG background to auditory and pain stimulations (OR 6.02, 95% CI 2.27-15.99) was independently associated with unfavorable outcomes. An unreactive EEG predicted unfavorable outcome with a specificity of 48% (95% CI 40-56), sensitivity of 79% (95% CI 72-85), and positive predictive value (PPV) of 74% (95% CI 67-81). Conversely, a benign EEG (defined as continuous and reactive background activity without seizure, periodic discharges, triphasic waves, or burst suppression) predicted favorable outcome with a specificity of 89% (95% CI 84-94), and a sensitivity of 37% (95% CI 30-45). CONCLUSION The absence of EEG reactivity independently predicts unfavorable outcomes at one year in severe stroke patients requiring mechanical ventilation in the ICU, although its prognostic value remains limited. Conversely, a benign EEG pattern was associated with a favorable outcome.
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Affiliation(s)
- Sarah Benghanem
- AP-HP.Centre, Medical ICU, Cochin Hospital, Paris, France
- University Paris Cité, Medical School, Paris, France
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Paris, France
| | - Nathalie Kubis
- University Paris Cité, Medical School, Paris, France
- APHP.Nord, Clinical Physiology Department, UMRS_1144, Université Paris Cite, Paris, France
| | - Etienne Gayat
- University Paris Cité, Medical School, Paris, France
- APHP.Nord, Department of Anesthesiology and Critical Care, DMU Parabol, Université Paris Cite, Paris, France
| | | | - Estelle Pruvost-Robieux
- University Paris Cité, Medical School, Paris, France
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Paris, France
- Neurophysiology and Epileptology Department, GHU Psychiatry & Neurosciences, Sainte Anne, Paris, France
| | - Tarek Sharshar
- University Paris Cité, Medical School, Paris, France
- Department of Neuroanesthesiology and Intensive Care, Sainte Anne Hospital, Paris, France
| | - Arnaud Foucrier
- APHP, Department of Anesthesiology and Critical Care, Beaujon University Hospital, Clichy, France
| | - Samy Figueiredo
- APHP, Department of Anesthesiology and Critical Care, Bicêtre University Hospitals, Le Kremlin Bicêtre, France
| | - Viviane Bouilleret
- Neurophysiology and Epileptology Department, Bicêtre University Hospitals, Le Kremlin Bicêtre, France
| | | | - François Bagate
- APHP, Department of Intensive Care Medicine, Henri Mondor University Hospital and Université de Paris Est Créteil, Créteil, France
| | | | - Bertrand Guidet
- APHP, Department of Intensive Care Medicine, Saint Antoine University Hospital, Paris, France
| | - Emmanuelle Appartis
- Neurophysiology Department, Saint Antoine University Hospital, Paris, France
| | - Alain Cariou
- AP-HP.Centre, Medical ICU, Cochin Hospital, Paris, France
- University Paris Cité, Medical School, Paris, France
| | - Olivier Varnet
- APHP, Department of Physiology, Bichat-Claude Bernard University Hospital, 75018, Paris, France
| | - Paul Henri Jost
- APHP, Department of Anesthesiology and Intensive Care, Henri Mondor Hospital, Creteil, France
| | | | - Vincent Degos
- APHP, Department of Anesthesiology and Neurointensive Care, Pitié Salpétrière Hospital, Paris, France
| | - Loic Le Guennec
- APHP, Medical ICU, Pitié Salpétrière Hospital, Paris, France
| | - Lionel Naccache
- APHP, Department of Physiology, Pitié Salpétrière Hospital, Paris, France
| | | | | | - Charles Gregoire
- Department of Intensive Care, Rothschild Hospital Foundation, Paris, France
| | - David Cortier
- Department of Intensive Care, Foch Hospital, Paris, France
| | | | - Jean-François Timsit
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75018, Paris, France
- Université Paris Cité, INSERM UMR 1137, IAME, Paris, France
| | - Mikael Mazighi
- APHP Nord, Department of Neurology, Lariboisière University Hospital, Department of Interventional Neuroradiology, Fondation Rothschild Hospital, FHU Neurovasc, Paris, France
- Université Paris Cité, INSERM UMR 1144, Paris, France
| | - Romain Sonneville
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75018, Paris, France.
- Université Paris Cité, INSERM UMR 1137, IAME, Paris, France.
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Robba C, Busl KM, Claassen J, Diringer MN, Helbok R, Park S, Rabinstein A, Treggiari M, Vergouwen MDI, Citerio G. Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist. Intensive Care Med 2024; 50:646-664. [PMID: 38598130 PMCID: PMC11078858 DOI: 10.1007/s00134-024-07387-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) is a rare yet profoundly debilitating condition associated with high global case fatality and morbidity rates. The key determinants of functional outcome include early brain injury, rebleeding of the ruptured aneurysm and delayed cerebral ischaemia. The only effective way to reduce the risk of rebleeding is to secure the ruptured aneurysm quickly. Prompt diagnosis, transfer to specialized centers, and meticulous management in the intensive care unit (ICU) significantly improved the prognosis of aSAH. Recently, multimodality monitoring with specific interventions to correct pathophysiological imbalances has been proposed. Vigilance extends beyond intracranial concerns to encompass systemic respiratory and haemodynamic monitoring, as derangements in these systems can precipitate secondary brain damage. Challenges persist in treating aSAH patients, exacerbated by a paucity of robust clinical evidence, with many interventions showing no benefit when tested in rigorous clinical trials. Given the growing body of literature in this field and the issuance of contemporary guidelines, our objective is to furnish an updated review of essential principles of ICU management for this patient population. Our review will discuss the epidemiology, initial stabilization, treatment strategies, long-term prognostic factors, the identification and management of post-aSAH complications. We aim to offer practical clinical guidance to intensivists, grounded in current evidence and expert clinical experience, while adhering to a concise format.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
- IRCCS Policlinico San Martino, Genoa, Italy.
| | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jan Claassen
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Raimund Helbok
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Clinical Research Institute for Neuroscience, Johannes Kepler University Linz, Linz, Austria
| | - Soojin Park
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | | | - Miriam Treggiari
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano Bicocca University, Milan, Italy
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
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Campos-Fernandez D, Rodrigo-Gisbert M, Abraira L, Quintana Luque M, Santafé M, Lallana S, Fonseca E, Toledo M, Gándara DF, Arikan F, Tomasello A, Sala Padró JX, Falip M, López-Ojeda P, Gabarrós A, Sánchez A, Santamarina E. Predictive Model for Estimating the Risk of Epilepsy After Aneurysmal Subarachnoid Hemorrhage: The RISE Score. Neurology 2024; 102:e209221. [PMID: 38527232 DOI: 10.1212/wnl.0000000000209221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/02/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The occurrence of seizures after aneurysmal subarachnoid hemorrhage (aSAH) is associated with a poorer functional and cognitive prognosis and less favorable quality of life. It would be of value to promptly identify patients at risk of epilepsy to optimize follow-up protocols and design preventive strategies. Our aim was to develop a predictive score to help stratify epilepsy risk in patients with aSAH. METHODS This is a retrospective, longitudinal study of all adults with aSAH admitted to our center (2012-2021). We collected demographic data, clinical and radiologic variables, data on early-onset seizures (EOSs), and data on development of epilepsy. Exclusion criteria were previous structural brain lesion, epilepsy, and ≤7 days' follow-up. Multiple Cox regression was used to evaluate factors independently associated with unprovoked remote seizures (i.e., epilepsy). The best fitting regression model was used to develop a predictive score. Performance was evaluated in an external validation cohort of 308 patients using receiver-operating characteristic curve analysis. RESULTS From an initial database of 743 patients, 419 met the inclusion criteria and were included in the analysis. The mean age was 60 ± 14 years, 269 patients (64%) were women, and 50 (11.9%) developed epilepsy within a median follow-up of 4.2 years. Premorbid modified Rankin Score (mRS) (hazard ratio [HR] 4.74 [1.8-12.4], p = 0.001), VASOGRADE score (HR 2.45 [1.4-4.2], p = 0.001), surgical treatment (HR 2.77 [1.6-4.9], p = 0.001), and presence of EOSs (HR 1.84 [1.0-3.4], p = 0.05) were independently associated with epilepsy. The proposed scale, designated RISE, scores 1 point for premorbid mRS ≥ 2 (R), VASOGRADE-Yellow (I, Ischemia), surgical intervention (S), and history of EOSs (E) and 2 points for VASOGRADE-Red. RISE stratifies patients into 3 groups: low (0-1), moderate (2-3), and high (4-5) risk (2.9%, 20.8%, and 75.7% developed epilepsy, respectively). On validation in a cohort from a different tertiary care center (N = 308), the new scale yielded a similar risk distribution and good predictive power for epilepsy within 5 years after aSAH (area under the curve [AUC] 0.82; 95% CI 0.74-0.90). DISCUSSION The RISE scale is a robust predictor of post-SAH epilepsy with immediate clinical applicability. In addition to facilitating personalized diagnosis and treatment, RISE may be of value for exploring future antiepileptogenesis strategies.
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Affiliation(s)
- Daniel Campos-Fernandez
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Marc Rodrigo-Gisbert
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Laura Abraira
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Manuel Quintana Luque
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Manel Santafé
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Sofia Lallana
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Elena Fonseca
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Manuel Toledo
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Darío F Gándara
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Fuat Arikan
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Alejandro Tomasello
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Jacint X Sala Padró
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Merce Falip
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Pablo López-Ojeda
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Andreu Gabarrós
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Anna Sánchez
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
| | - Estevo Santamarina
- From the Epilepsy Unit (D.C.-F., M.R.-G., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Neurology Department, Vall d'Hebron University Hospital; Epilepsy Research Group (D.C.-F., L.A., M.Q.L., S.L., E.F., M.T., E.S.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Medicine Department (D.C.-F., S.L., M.T., E.S.), Universitat Autònoma de Barcelona, Bellaterra; Intensive Care Department (M.S., A.S.); Neurosurgery Department (D.F.G., F.A.); Neuroradiology Department (A.T.), Vall d'Hebron University Hospital; Epilepsy Unit (J.X.S.P., M.F.), Neurology Department; and Neurosurgery Department (P.L.-O., A.G.), Bellvitge University Hospital, Barcelona, Spain
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Bencsik C, Josephson C, Soo A, Ainsworth C, Savard M, van Diepen S, Kramer A, Kromm J. The Evolving Role of Electroencephalography in Postarrest Care. Can J Neurol Sci 2024:1-13. [PMID: 38572611 DOI: 10.1017/cjn.2024.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Electroencephalography is an accessible, portable, noninvasive and safe means of evaluating a patient's brain activity. It can aid in diagnosis and management decisions for post-cardiac arrest patients with seizures, myoclonus and other non-epileptic movements. It also plays an important role in a multimodal approach to neuroprognostication predicting both poor and favorable outcomes. Individuals ordering, performing and interpreting these tests, regardless of the indication, should understand the supporting evidence, logistical considerations, limitations and impact the results may have on postarrest patients and their families as outlined herein.
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Affiliation(s)
- Caralyn Bencsik
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Colin Josephson
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Martin Savard
- Département de Médecine, Université Laval, Quebec City, QC, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andreas Kramer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Julie Kromm
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Yuan F, Damien C, Schuind S, Salvagno M, Taccone FS, Legros B, Gaspard N. Combined depth and scalp electroencephalographic monitoring in acute brain injury: Yield and prognostic value. Eur J Neurol 2024; 31:e16208. [PMID: 38270448 PMCID: PMC11235592 DOI: 10.1111/ene.16208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/08/2023] [Accepted: 12/28/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND AND PURPOSE Depth electroencephalography (dEEG) is an emerging neuromonitoring technology in acute brain injury (ABI). We aimed to explore the concordances between electrophysiological activities on dEEG and on scalp EEG (scEEG) in ABI patients. METHODS Consecutive ABI patients who received dEEG monitoring between 2018 and 2022 were included. Background, sporadic epileptiform discharges, rhythmic and periodic patterns (RPPs), electrographic seizures, brief potentially ictal rhythmic discharges, ictal-interictal continuum (IIC) patterns, and hourly RPP burden on dEEG and scEEG were compared. RESULTS Sixty-one ABI patients with a median dEEG monitoring duration of 114 h were included. dEEG significantly showed less continuous background (75% vs. 90%, p = 0.03), higher background amplitude (p < 0.001), more frequent rhythmic spike-and-waves (16% vs. 3%, p = 0.03), more IIC patterns (39% vs. 21%, p = 0.03), and greater hourly RPP burden (2430 vs. 1090 s/h, p = 0.01), when compared to scEEG. Among five patients with seizures on scEEG, one patient had concomitant seizures on dEEG, one had periodic discharges (not concomitant) on dEEG, and three had no RPPs on dEEG. Features and temporal occurrence of electrophysiological activities observed on dEEG and scEEG are not strongly associated. Patients with seizures and IIC patterns on dEEG seemed to have a higher rate of poor outcomes at discharge than patients without these patterns on dEEG (42% vs. 25%, p = 0.37). CONCLUSIONS dEEG can detect abnormal electrophysiological activities that may not be seen on scEEG and can be used as a complement in the neuromonitoring of ABI patients.
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Affiliation(s)
- Fang Yuan
- Neurology DepartmentSecond Affiliated Hospital of Guangzhou University of Chinese MedicineGuangzhouChina
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
- State Key Laboratory of Traditional Chinese Medicine SyndromeGuangzhouChina
| | - Charlotte Damien
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
| | - Sophie Schuind
- Service de Neurochirurgie, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
| | - Michele Salvagno
- Service des Soins Intensifs, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
| | - Fabio Silvio Taccone
- Service des Soins Intensifs, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
| | - Benjamin Legros
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
- Neurology DepartmentYale University School of MedicineNew HavenConnecticutUSA
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Benghanem S, Pruvost-Robieux E, Neligan A, Walker MC. Status epilepticus: what's new for the intensivist. Curr Opin Crit Care 2024; 30:131-141. [PMID: 38441162 DOI: 10.1097/mcc.0000000000001137] [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: 03/12/2024]
Abstract
PURPOSE OF REVIEW Status epilepticus (SE) is a common neurologic emergency affecting about 36.1/100 000 person-years that frequently requires intensive care unit (ICU) admission. There have been advances in our understanding of epidemiology, pathophysiology, and EEG monitoring of SE, and there have been large-scale treatment trials, discussed in this review. RECENT FINDINGS Recent changes in the definitions of SE have helped guide management protocols and we have much better predictors of outcome. Observational studies have confirmed the efficacy of benzodiazepines and large treatment trials indicate that all routinely used second line treatments (i.e., levetiracetam, valproate and fosphenytoin) are equally effective. Better understanding of the pathophysiology has indicated that nonanti-seizure medications aimed at underlying pathological processes should perhaps be considered in the treatment of SE; already immunosuppressant treatments are being more widely used in particular for new onset refractory status epilepticus (NORSE) and Febrile infection-related epilepsy syndrome (FIRES) that sometimes revealed autoimmune or paraneoplastic encephalitis. Growing evidence for ICU EEG monitoring and major advances in automated analysis of the EEG could help intensivist to assess the control of electrographic seizures. SUMMARY Research into the morbi-mortality of SE has highlighted the potential devastating effects of this condition, emphasizing the need for rapid and aggressive treatment, with particular attention to cardiorespiratory and neurological complications. Although we now have a good evidence-base for the initial status epilepticus management, the best treatments for the later stages are still unclear and clinical trials of potentially disease-modifying therapies are long overdue.
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Affiliation(s)
- Sarah Benghanem
- Medical Intensive Care Unit, Cochin hospital, APHP.Centre
- University of Paris cite - Medical School
- INSERM 1266, psychiatry and neurosciences institute of Paris (IPNP)
| | - Estelle Pruvost-Robieux
- University of Paris cite - Medical School
- INSERM 1266, psychiatry and neurosciences institute of Paris (IPNP)
- Neurophysiology and epileptology department, Sainte Anne hospital, Paris, France
| | - Aidan Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row
- UCL Queen Square Institute of Neurology, Queen Square, London
- Centre for Preventive Neurology, Wolfson Institute of Population Health, QMUL, UK
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Appavu BL, Fox J, Kuwabara M, Burrows BT, Temkit M'H, Adelson PD. Association of Cerebral and Systemic Physiology With Quantitative Electroencephalographic Characteristics of Early Posttraumatic Seizures. J Clin Neurophysiol 2024; 41:257-264. [PMID: 36007060 DOI: 10.1097/wnp.0000000000000965] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Early posttraumatic seizures (EPTS) occur after pediatric traumatic brain injury and have been associated with unfavorable outcomes. We aimed to characterize the relationship among quantitative EEG characteristics of early posttraumatic seizures, cerebral and somatic physiologic measures. METHODS Differences in baseline physiologic, neuroimaging, and demographic characteristics between those with and without early posttraumatic seizures were investigated using Mann-Whitney U test or Fisher exact test. Multivariable dynamic structural equations modeling was used to investigate time series associations between ictal quantitative EEG characteristics with intracranial pressure, arterial blood pressure, heart rate (HR), and cerebral regional oximetry. Quantitative EEG characteristics included amplitude, total power, spectral edge frequency, peak value frequency, complexity, and periodicity. RESULTS Among 72 children, 146 seizures were identified from 19 patients. Early posttraumatic seizures were associated with younger age ( P = 0.0034), increased HR ( P = 0.0018), and increased Glasgow Outcome Scale-Extended scores ( P = 0.0377). Group dynamic structural equations modeling analysis of the first seizure for patients demonstrated that intracranial pressure is negatively associated with spectral edge frequency (standardized regression coefficient -0.12, 99% credible interval [-0.21 to -0.04]), and HR is positively associated with peak value frequency (standardized regression coefficient 0.16, [0.00-0.31]). Among nine patients with seizures arising over the frontal lobe regions, HR was positively associated with peak value frequency (standardized regression coefficient 0.26 [0.02-0.50]) and complexity (standardized regression coefficient 0.14 [0.03-0.26]). Variation in strength and direction of associations was observed between subjects for relationships that were significant during group analysis. CONCLUSIONS Quantitative EEG characteristics of pediatric early posttraumatic seizures are associated with variable changes in cerebral and systemic physiology, with spectral edge frequency negatively associated with intracranial pressure and peak value frequency positively associated with HR.
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Affiliation(s)
- Brian L Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
- Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona, U.S.A.; and
| | - Jordana Fox
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
- Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona, U.S.A.; and
| | - Michael Kuwabara
- Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona, U.S.A.; and
- Department of Radiology, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
| | - M 'Hamed Temkit
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
| | - Phillip D Adelson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
- Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona, U.S.A.; and
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Suzuki H, Miura Y, Yasuda R, Yago T, Mizutani H, Ichikawa T, Miyazaki T, Kitano Y, Nishikawa H, Kawakita F, Fujimoto M, Toma N. Effects of New-Generation Antiepileptic Drug Prophylaxis on Delayed Neurovascular Events After Aneurysmal Subarachnoid Hemorrhage. Transl Stroke Res 2023; 14:899-909. [PMID: 36333650 DOI: 10.1007/s12975-022-01101-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/17/2022] [Accepted: 10/24/2022] [Indexed: 11/07/2022]
Abstract
Neuroelectric disruptions such as seizures and cortical spreading depolarization may contribute to the development of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH). However, effects of antiepileptic drug prophylaxis on outcomes remain controversial in SAH. The authors investigated if prophylactic administration of new-generation antiepileptic drugs levetiracetam and perampanel was beneficial against delayed neurovascular events after SAH. This was a retrospective single-center cohort study of 121 consecutive SAH patients including 56 patients of admission World Federation of Neurological Surgeons grades IV - V who underwent aneurysmal obliteration within 72 h post-SAH from 2013 to 2021. Prophylactic antiepileptic drugs differed depending on the study terms: none (2013 - 2015), levetiracetam for patients at high risks of seizures (2016 - 2019), and perampanel for all patients (2020 - 2021). The 3rd term had the lowest occurrence of delayed cerebral microinfarction on diffusion-weighted magnetic resonance imaging, which was related to less development of DCI. Other outcome measures were similar among the 3 terms including incidences of angiographic vasospasm, computed tomography-detectable delayed cerebral infarction, seizures, and 3-month good outcomes (modified Rankin Scale 0 - 2). The present study suggests that prophylactic administration of levetiracetam and perampanel was not associated with worse outcomes and that perampanel may have the potential to reduce DCI by preventing microcirculatory disturbances after SAH. Further studies are warranted to investigate anti-DCI effects of a selective α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptor antagonist perampanel in SAH patients in a large-scale prospective study.
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Affiliation(s)
- Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yoichi Miura
- Center for Vessels and Heart, Mie University Hospital, Tsu, Japan
| | - Ryuta Yasuda
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Tetsushi Yago
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hisashi Mizutani
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Tomonori Ichikawa
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takahiro Miyazaki
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yotaro Kitano
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hirofumi Nishikawa
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Fumihiro Kawakita
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masashi Fujimoto
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Naoki Toma
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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Bhatti KS, Rajagopalan S. Case report: Invasive neuromonitoring in status epilepticus induced hypoxic ischemic brain injury. Front Neurol 2023; 14:1284098. [PMID: 38099068 PMCID: PMC10720614 DOI: 10.3389/fneur.2023.1284098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/08/2023] [Indexed: 12/17/2023] Open
Abstract
Objectives Literature on invasive neuromonitoring and bilateral decompressive craniectomies (BDC) in patients with refractory status epilepticus (RSE)-mediated hypoxic-ischemic brain injury (HIBI) is limited. Neuromonitoring can guide decision making and treatment escalation. Methods and results We report a case of a 17 years-old male who was admitted to our hospital's intensive care unit for RSE. HIBI was detected on neuroimaging on this patient's second day of admission after he developed central diabetes insipidus (DI). Invasive neuromonitoring revealed raised intracranial pressure (ICP) and brain hypoxia as measured by reduced brain tissue oxygen tension (PbtO2). Treatments were escalated in a tiered fashion, including administration of hyperosmolar agents, analgesics, sedatives, and a neuromuscular blocking drug. Eventually, BDC was performed as a salvage therapy as a means of controlling refractory ICP crisis in the setting of diffuse cerebral edema (DCE) following HIBI. Discussion SE-mediated HIBI can result in refractory ICP crisis. Neuromonitoring can help identify secondary brain injury (SBI), guide treatment strategies, including surgical interventions, and may lead to better outcomes.
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13
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Sanicola HW, Stewart CE, Luther P, Yabut K, Guthikonda B, Jordan JD, Alexander JS. Pathophysiology, Management, and Therapeutics in Subarachnoid Hemorrhage and Delayed Cerebral Ischemia: An Overview. PATHOPHYSIOLOGY 2023; 30:420-442. [PMID: 37755398 PMCID: PMC10536590 DOI: 10.3390/pathophysiology30030032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
Subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke resulting from the rupture of an arterial vessel within the brain. Unlike other stroke types, SAH affects both young adults (mid-40s) and the geriatric population. Patients with SAH often experience significant neurological deficits, leading to a substantial societal burden in terms of lost potential years of life. This review provides a comprehensive overview of SAH, examining its development across different stages (early, intermediate, and late) and highlighting the pathophysiological and pathohistological processes specific to each phase. The clinical management of SAH is also explored, focusing on tailored treatments and interventions to address the unique pathological changes that occur during each stage. Additionally, the paper reviews current treatment modalities and pharmacological interventions based on the evolving guidelines provided by the American Heart Association (AHA). Recent advances in our understanding of SAH will facilitate clinicians' improved management of SAH to reduce the incidence of delayed cerebral ischemia in patients.
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Affiliation(s)
- Henry W. Sanicola
- Department of Neurology, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - Caleb E. Stewart
- Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - Patrick Luther
- School of Medicine, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA; (P.L.); (K.Y.)
| | - Kevin Yabut
- School of Medicine, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA; (P.L.); (K.Y.)
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - J. Dedrick Jordan
- Department of Neurology, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - J. Steven Alexander
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA
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14
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Gouvea Bogossian E, Battaglini D, Fratino S, Minini A, Gianni G, Fiore M, Robba C, Taccone FS. The Role of Brain Tissue Oxygenation Monitoring in the Management of Subarachnoid Hemorrhage: A Scoping Review. Neurocrit Care 2023; 39:229-240. [PMID: 36802011 DOI: 10.1007/s12028-023-01680-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Abstract
Monitoring of brain tissue oxygenation (PbtO2) is an important component of multimodal monitoring in traumatic brain injury. Over recent years, use of PbtO2 monitoring has also increased in patients with poor-grade subarachnoid hemorrhage (SAH), particularly in those with delayed cerebral ischemia. The aim of this scoping review was to summarize the current state of the art regarding the use of this invasive neuromonitoring tool in patients with SAH. Our results showed that PbtO2 monitoring is a safe and reliable method to assess regional cerebral tissue oxygenation and that PbtO2 represents the oxygen available in the brain interstitial space for aerobic energy production (i.e., the product of cerebral blood flow and the arterio-venous oxygen tension difference). The PbtO2 probe should be placed in the area at risk of ischemia (i.e., in the vascular territory in which cerebral vasospasm is expected to occur). The most widely used PbtO2 threshold to define brain tissue hypoxia and initiate specific treatment is between 15 and 20 mm Hg. PbtO2 values can help identify the need for or the effects of various therapies, such as hyperventilation, hyperoxia, induced hypothermia, induced hypertension, red blood cell transfusion, osmotic therapy, and decompressive craniectomy. Finally, a low PbtO2 value is associated with a worse prognosis, and an increase of the PbtO2 value in response to treatment is a marker of good outcome.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Denise Battaglini
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Sara Fratino
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Giuseppina Gianni
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Fiore
- Department of Women, Child, and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
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15
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Kochar A, Hildebrandt K, Silverstein R, Appavu B. Approaches to neuroprotection in pediatric neurocritical care. World J Crit Care Med 2023; 12:116-129. [PMID: 37397588 PMCID: PMC10308339 DOI: 10.5492/wjccm.v12.i3.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/30/2023] [Accepted: 04/12/2023] [Indexed: 06/08/2023] Open
Abstract
Acute neurologic injuries represent a common cause of morbidity and mortality in children presenting to the pediatric intensive care unit. After primary neurologic insults, there may be cerebral brain tissue that remains at risk of secondary insults, which can lead to worsening neurologic injury and unfavorable outcomes. A fundamental goal of pediatric neurocritical care is to mitigate the impact of secondary neurologic injury and improve neurologic outcomes for critically ill children. This review describes the physiologic framework by which strategies in pediatric neurocritical care are designed to reduce the impact of secondary brain injury and improve functional outcomes. Here, we present current and emerging strategies for optimizing neuroprotective strategies in critically ill children.
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Affiliation(s)
- Angad Kochar
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
| | - Kara Hildebrandt
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
| | - Rebecca Silverstein
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
| | - Brian Appavu
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
- Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ 85016, United States
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16
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Waak M, Laing J, Nagarajan L, Lawn N, Harvey AS. Continuous electroencephalography in the intensive care unit: A critical review and position statement from an Australian and New Zealand perspective. CRIT CARE RESUSC 2023; 25:9-19. [PMID: 37876987 PMCID: PMC10581281 DOI: 10.1016/j.ccrj.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objectives This article aims to critically review the literature on continuous electroencephalography (cEEG) monitoring in the intensive care unit (ICU) from an Australian and New Zealand perspective and provide recommendations for clinicians. Design and review methods A taskforce of adult and paediatric neurologists, selected by the Epilepsy Society of Australia, reviewed the literature on cEEG for seizure detection in critically ill neonates, children, and adults in the ICU. The literature on routine EEG and cEEG for other indications was not reviewed. Following an evaluation of the evidence and discussion of controversial issues, consensus was reached, and a document that highlighted important clinical, practical, and economic considerations regarding cEEG in Australia and New Zealand was drafted. Results This review represents a summary of the literature and consensus opinion regarding the use of cEEG in the ICU for detection of seizures, highlighting gaps in evidence, practical problems with implementation, funding shortfalls, and areas for future research. Conclusion While cEEG detects electrographic seizures in a significant proportion of at-risk neonates, children, and adults in the ICU, conferring poorer neurological outcomes and guiding treatment in many settings, the health economic benefits of treating such seizures remain to be proven. Presently, cEEG in Australian and New Zealand ICUs is a largely unfunded clinical resource that is subsequently reserved for the highest-impact patient groups. Wider adoption of cEEG requires further research into impact on functional and health economic outcomes, education and training of the neurology and ICU teams involved, and securement of the necessary resources and funding to support the service.
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Affiliation(s)
- Michaela Waak
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Joshua Laing
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
- Comprehensive Epilepsy Program, Alfred Health, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Lakshmi Nagarajan
- Department of Neurology, Perth Children's Hospital, Perth, Australia
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Australia
| | - Nicholas Lawn
- Western Australian Adult Epilepsy Service, Sir Charles Gardiner Hospital, Perth, Australia
| | - A. Simon Harvey
- Department of Neurology, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Neurosciences Research Group, Murdoch Children's Research Institute, Melbourne, Australia
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17
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Gomez LA, Shen Q, Doyle K, Vrosgou A, Velazquez A, Megjhani M, Ghoshal S, Roh D, Agarwal S, Park S, Claassen J, Kleinberg S. Classification of Level of Consciousness in a Neurological ICU Using Physiological Data. Neurocrit Care 2023; 38:118-128. [PMID: 36109448 PMCID: PMC9935697 DOI: 10.1007/s12028-022-01586-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 08/08/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Impaired consciousness is common in intensive care unit (ICU) patients, and an individual's degree of consciousness is crucial to determining their care and prognosis. However, there are no methods that continuously monitor consciousness and alert clinicians to changes. We investigated the use of physiological signals collected in the ICU to classify levels of consciousness in critically ill patients. METHODS We studied 61 patients with subarachnoid hemorrhage (SAH) and 178 patients with intracerebral hemorrhage (ICH) from the neurological ICU at Columbia University Medical Center in a retrospective observational study of prospectively collected data. The level of consciousness was determined on the basis of neurological examination and mapped to comatose, vegetative state or unresponsive wakefulness syndrome (VS/UWS), minimally conscious minus state (MCS-), and command following. For each physiological signal, we extracted time-series features and performed classification using extreme gradient boosting on multiple clinically relevant tasks across subsets of physiological signals. We applied this approach independently on both SAH and ICH patient groups for three sets of variables: (1) a minimal set common to most hospital patients (e.g., heart rate), (2) variables available in most ICUs (e.g., body temperature), and (3) an extended set recorded mainly in neurological ICUs (absent for the ICH patient group; e.g., brain temperature). RESULTS On the commonly performed classification task of VS/UWS versus MCS-, we achieved an area under the receiver operating characteristic curve (AUROC) in the SAH patient group of 0.72 (sensitivity 82%, specificity 57%; 95% confidence interval [CI] 0.63-0.81) using the extended set, 0.69 (sensitivity 83%, specificity 51%; 95% CI 0.59-0.78) on the variable set available in most ICUs, and 0.69 (sensitivity 56%, specificity 78%; 95% CI 0.60-0.78) on the minimal set. In the ICH patient group, AUROC was 0.64 (sensitivity 56%, specificity 65%; 95% CI 0.55-0.74) using the minimal set and 0.61 (sensitivity 50%, specificity 80%; 95% CI 0.51-0.71) using the variables available in most ICUs. CONCLUSIONS We find that physiological signals can be used to classify states of consciousness for patients in the ICU. Building on this with intraday assessments and increasing sensitivity and specificity may enable alarm systems that alert physicians to changes in consciousness and frequent monitoring of consciousness throughout the day, both of which may improve patient care and outcomes.
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Affiliation(s)
- Louis A Gomez
- Stevens Institute of Technology, 1 Castle Point on Hudson, Hoboken, NJ, 07030, USA
| | - Qi Shen
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Kevin Doyle
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Athina Vrosgou
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Angela Velazquez
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Murad Megjhani
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Shivani Ghoshal
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - David Roh
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Samantha Kleinberg
- Stevens Institute of Technology, 1 Castle Point on Hudson, Hoboken, NJ, 07030, USA.
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18
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Holla SK, Krishnamurthy PV, Subramaniam T, Dhakar MB, Struck AF. Electrographic Seizures in the Critically Ill. Neurol Clin 2022; 40:907-925. [PMID: 36270698 PMCID: PMC10508310 DOI: 10.1016/j.ncl.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Identifying and treating critically ill patients with seizures can be challenging. In this article, the authors review the available data on patient populations at risk, seizure prognostication with tools such as 2HELPS2B, electrographic seizures and the various ictal-interictal continuum patterns with their latest definitions and associated risks, ancillary testing such as imaging studies, serum biomarkers, and invasive multimodal monitoring. They also illustrate 5 different patient scenarios, their treatment and outcomes, and propose recommendations for targeted treatment of electrographic seizures in critically ill patients.
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Affiliation(s)
- Smitha K Holla
- Department of Neurology, UW Medical Foundation Centennial building, 1685 Highland Avenue, Madison, WI 53705, USA.
| | | | - Thanujaa Subramaniam
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 15 York Street, Building LLCI, 10th Floor, Suite 1003 New Haven, CT 06520, USA
| | - Monica B Dhakar
- Department of Neurology, The Warren Alpert Medical School of Brown University, 593 Eddy St, APC 5, Providence, RI 02903, USA
| | - Aaron F Struck
- Department of Neurology, UW Medical Foundation Centennial building, 1685 Highland Avenue, Madison, WI 53705, USA; William S Middleton Veterans Hospital, Madison WI, USA
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19
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Alkhachroum A, Appavu B, Egawa S, Foreman B, Gaspard N, Gilmore EJ, Hirsch LJ, Kurtz P, Lambrecq V, Kromm J, Vespa P, Zafar SF, Rohaut B, Claassen J. Electroencephalogram in the intensive care unit: a focused look at acute brain injury. Intensive Care Med 2022; 48:1443-1462. [PMID: 35997792 PMCID: PMC10008537 DOI: 10.1007/s00134-022-06854-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/31/2022] [Indexed: 02/04/2023]
Abstract
Over the past decades, electroencephalography (EEG) has become a widely applied and highly sophisticated brain monitoring tool in a variety of intensive care unit (ICU) settings. The most common indication for EEG monitoring currently is the management of refractory status epilepticus. In addition, a number of studies have associated frequent seizures, including nonconvulsive status epilepticus (NCSE), with worsening secondary brain injury and with worse outcomes. With the widespread utilization of EEG (spot and continuous EEG), rhythmic and periodic patterns that do not fulfill strict seizure criteria have been identified, epidemiologically quantified, and linked to pathophysiological events across a wide spectrum of critical and acute illnesses, including acute brain injury. Increasingly, EEG is not just qualitatively described, but also quantitatively analyzed together with other modalities to generate innovative measurements with possible clinical relevance. In this review, we discuss the current knowledge and emerging applications of EEG in the ICU, including seizure detection, ischemia monitoring, detection of cortical spreading depolarizations, assessment of consciousness and prognostication. We also review some technical aspects and challenges of using EEG in the ICU including the logistics of setting up ICU EEG monitoring in resource-limited settings.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Brian Appavu
- Department of Child Health and Neurology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Satoshi Egawa
- Neurointensive Care Unit, Department of Neurosurgery, and Stroke and Epilepsy Center, TMG Asaka Medical Center, Saitama, Japan
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Free University of Brussels, Brussels, Belgium
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Neurocritical Care and Emergency Neurology, Department of Neurology, Ale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Pedro Kurtz
- Department of Intensive Care Medicine, D'or Institute for Research and Education, Rio de Janeiro, Brazil
- Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Virginie Lambrecq
- Department of Clinical Neurophysiology and Epilepsy Unit, AP-HP, Pitié Salpêtrière Hospital, Reference Center for Rare Epilepsies, 75013, Paris, France
| | - Julie Kromm
- Departments of Critical Care Medicine and Clinical Neurosciences, Cumming School of Medicine, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, AB, Canada
| | - Paul Vespa
- Brain Injury Research Center, Department of Neurosurgery, University of California, Los Angeles, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin Rohaut
- Department of Neurology, Sorbonne Université, Pitié-Salpêtrière-AP-HP and Paris Brain Institute, ICM, Inserm, CNRS, Paris, France
| | - Jan Claassen
- Department of Neurology, Neurological Institute, Columbia University, New York Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
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20
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Abstract
Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA.
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
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21
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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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22
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Karamched BR, Hripcsak G, Leibel RL, Albers D, Ott W. Delay-induced uncertainty in the glucose-insulin system: Pathogenicity for obesity and type-2 diabetes mellitus. Front Physiol 2022; 13:936101. [PMID: 36117719 PMCID: PMC9476552 DOI: 10.3389/fphys.2022.936101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
We have recently shown that physiological delay can induce a novel form of sustained temporal chaos we call delay-induced uncertainty (DIU) (Karamched et al. (Chaos, 2021, 31, 023142)). This paper assesses the impact of DIU on the ability of the glucose-insulin system to maintain homeostasis when responding to the ingestion of meals. We address two questions. First, what is the nature of the DIU phenotype? That is, what physiological macrostates (as encoded by physiological parameters) allow for DIU onset? Second, how does DIU impact health? We find that the DIU phenotype is abundant in the space of intrinsic parameters for the Ultradian glucose-insulin model-a model that has been successfully used to predict glucose-insulin dynamics in humans. Configurations of intrinsic parameters that correspond to high characteristic glucose levels facilitate DIU onset. We argue that DIU is pathogenic for obesity and type-2 diabetes mellitus by linking the statistical profile of DIU to the glucostatic theory of hunger.
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Affiliation(s)
- Bhargav R. Karamched
- Department of Mathematics, Florida State University, Tallahassee, FL, United States
- Institute of Molecular Biophysics, Florida State University, Tallahassee, FL, United States
- Program in Neuroscience, Florida State University, Tallahassee, FL, United States
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Rudolph L. Leibel
- Division of Molecular Genetics, Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, NY, NY, United States
- Naomi Berrie Diabetes Center, Columbia University Irving Medical Center, NY, NY, United States
| | - David Albers
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
- Section of Informatics and Data Science, Department of Pediatrics, Department of Biomedical Engineering, and Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - William Ott
- Department of Mathematics, University of Houston, Houston, TX, United States
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23
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Bozarth XL, Ko PY, Bao H, Abend NS, Watson RS, Qu P, Dervan LA, Morgan LA, Wainwright M, McGuire JK, Novotny E. Use of Continuous EEG Monitoring and Short-Term Outcomes in Critically Ill Children. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1749433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractThis study aimed to compare short-term outcomes at pediatric intensive care unit (PICU) discharge in critically ill children with and without continuous electroencephalography (cEEG) monitoring. We retrospectively compared 234 patients who underwent cEEG with 2294 patients without cEEG. Propensity score matching was used to compare patients with seizures and status epilepticus between cEEG and historical cohorts. The EEG cohort had higher in-hospital mortality, worse Pediatric Cerebral Performance Category (PCPC) scores, and greater PCPC decline at discharge. In patients with status epilepticus, the PCPC decline was higher in the cEEG cohort. PCPC decline at PICU discharge was associated with cEEG monitoring in patients with status epilepticus.
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Affiliation(s)
- Xiuhua Liang Bozarth
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - Pin-Yi Ko
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - Hao Bao
- Biostatistics, Epidemiology, Econometrics and Programming Core, Seattle Children's Research Institute, Washington, United States
| | - Nicholas S. Abend
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, United States
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington, United States
| | - Pingping Qu
- Biostatistics, Epidemiology, Econometrics and Programming Core, Seattle Children's Research Institute, Washington, United States
| | - Leslie A. Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Lindsey A. Morgan
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - Mark Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - John K. McGuire
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Edward Novotny
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
- Center for Integrative Brain Research, Seattle Children's Research Institute, Washington, United States
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24
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Ferlini L, Nonclercq A, Su F, Creteur J, Taccone FS, Gaspard N. Sepsis modulates cortical excitability and alters the local and systemic hemodynamic response to seizures. Sci Rep 2022; 12:11336. [PMID: 35790848 PMCID: PMC9256588 DOI: 10.1038/s41598-022-15426-w] [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: 04/08/2022] [Accepted: 06/23/2022] [Indexed: 11/09/2022] Open
Abstract
Non-convulsive seizures and status epilepticus are frequent and associated with increased mortality in septic patients. However, the mechanism through which seizures impact outcome in these patients is unclear. As previous studies yielded an alteration of neurovascular coupling (NVC) during sepsis, we hypothesized that non-convulsive seizures, might further impair NVC, leading to brain tissue hypoxia. We used a previously developed ovine model of sepsis. Animals were allocated to sham procedure or sepsis; septic animals were studied either during the hyperdynamic phase (sepsis group) or after septic shock occurrence (septic shock group). After allocation, seizures were induced by cortical application of penicillin. We recorded a greater seizure-induced increase in the EEG gamma power in the sepsis group than in sham. Using a neural mass model, we also found that the theoretical activity of the modeled inhibitory interneurons, thought to be important to reproduce gamma oscillations, were relatively greater in the sepsis group. However, the NVC was impaired in sepsis animals, despite a normal brain tissue oxygenation. In septic shock animals, it was not possible to induce seizures. Cortical activity declined in case of septic shock, but it did not differ between sham or sepsis animals. As the alteration in NVC preceded cortical activity reduction, we suggest that, during sepsis progression, the NVC inefficiency could be partially responsible for the alteration of brain function, which might prevent seizure occurrence during septic shock. Moreover, we showed that cardiac output decreased during seizures in sepsis animals instead of increasing as in shams. The alteration of the seizure-induced systemic hemodynamic variations in sepsis might further affect cerebrovascular response to neuronal activation. Our findings support the hypothesis that anomalies in the cerebral blood flow regulation may contribute to the sepsis-associated encephalopathy and that seizures might be dangerous in such a vulnerable setting.
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Affiliation(s)
- Lorenzo Ferlini
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Antoine Nonclercq
- Bio-, Electro- And Mechanical Systems (BEAMS), Université Libre de Bruxelles, Avenue F.D. Roosevelt 50 CP165/56, 1050, Brussels, Belgium
| | - Fuhong Su
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
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25
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Alkhachroum A, Ganesan SL, Koren JP, Kromm J, Massad N, Reyes RA, Miller MR, Roh D, Agarwal S, Park S, Claassen J. Quantitative EEG-Based Seizure Estimation in Super-Refractory Status Epilepticus. Neurocrit Care 2022; 36:897-904. [PMID: 34791594 PMCID: PMC9987776 DOI: 10.1007/s12028-021-01395-x] [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] [Received: 07/12/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the accuracy of seizure burden in patients with super-refractory status epilepticus (SRSE) by using quantitative electroencephalography (qEEG). METHODS EEG recordings from 69 patients with SRSE (2009-2019) were reviewed and annotated for seizures by three groups of reviewers: two board-certified neurophysiologists using only raw EEG (gold standard), two neurocritical care providers with substantial experience in qEEG analysis (qEEG experts), and two inexperienced qEEG readers (qEEG novices) using only a qEEG trend panel. RESULTS Raw EEG experts identified 35 (51%) patients with seizures, accounting for 2950 seizures (3,126 min). qEEG experts had a sensitivity of 93%, a specificity of 61%, a false positive rate of 6.5 per day, and good agreement (κ = 0.64) between both qEEG experts. qEEG novices had a sensitivity of 98.5%, a specificity of 13%, a false positive rate of 15 per day, and fair agreement (κ = 0.4) between both qEEG novices. Seizure burden was not different between the qEEG experts and the gold standard (3,257 vs. 3,126 min), whereas qEEG novices reported higher burden (6066 vs. 3126 min). CONCLUSIONS Both qEEG experts and novices had a high sensitivity but a low specificity for seizure detection in patients with SRSE. qEEG could be a useful tool for qEEG experts to estimate seizure burden in patients with SRSE.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, Columbia University and NewYork Presbyterian Hospital, New York, NY, USA
- Department of Neurology, University of Miami, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Saptharishi Lalgudi Ganesan
- Children's Hospital of Western Ontario, London Health Sciences Centre, London, ON, Canada
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - Julie Kromm
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Nina Massad
- Department of Neurology, Columbia University and NewYork Presbyterian Hospital, New York, NY, USA
| | - Renz A Reyes
- Department of Neurology, Columbia University and NewYork Presbyterian Hospital, New York, NY, USA
| | - Michael R Miller
- Children's Hospital of Western Ontario, London Health Sciences Centre, London, ON, Canada
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - David Roh
- Department of Neurology, Columbia University and NewYork Presbyterian Hospital, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University and NewYork Presbyterian Hospital, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University and NewYork Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University and NewYork Presbyterian Hospital, New York, NY, USA.
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26
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Singh T, Batabyal T, Kapur J. Neuronal circuits sustaining neocortical-injury-induced status epilepticus. Neurobiol Dis 2022; 165:105633. [PMID: 35065250 PMCID: PMC8860889 DOI: 10.1016/j.nbd.2022.105633] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 01/04/2022] [Accepted: 01/16/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES Acute injuries or insults to the cortex, such as trauma, subarachnoid hemorrhage, lobar hemorrhage, can cause seizures or status epilepticus(SE). Neocortical SE is associated with coma, worse prognosis, delayed recovery, and the development of epilepsy. The anatomical structures progressively recruited during neocortical-onset status epilepticus (SE) is unknown. Therefore, we constructed large-scale maps of brain regions active during neocortical SE. METHODS We used a neocortical injury-induced SE mouse model. We implanted cobalt (Co) in the right supplementary motor cortex (M2). We 16 h later administered a homocysteine injection (845 mg/kg, intraperitoneal) to C57Bl/6 J mice to induce SE and monitored it by video and EEG. We harvested animals for 1 h (early-stage) and 2 h (late-stage) following homocysteine injections. To construct activation maps, we immunolabeled whole-brain sections for cFos and NeuN, imaged them using a confocal microscope and quantified cFos immunoreactivity (IR). RESULTS SE in the early phase consisted of discrete, focal intermittent seizures, which became continuous and bilateral in the late stage. In this early stage, cFos IR was primarily observed in the right hemisphere, ipsilateral to the Co lesion, specifically in the motor cortex, retrosplenial cortex, somatosensory cortex, anterior cingulate cortex, lateral and medial septal nuclei, and amygdala. We observed bilateral cFos IR in brain regions during the late stage, indicating the bilateral spread of focal seizures. We found increased cFOS IR in the bilateral somatosensory cortex and the motor cortex and subcortical regions, including the amygdala, thalamus, and hypothalamus. There was noticeably different, intense cFos IR in the bilateral hippocampus compared to the early stage. In addition, there was higher activity in the cortex ipsilateral to the seizure focus during the late stage compared with the early one. CONCLUSION We present a large-scale, high-resolution map of seizure spread during neocortical injury-induced SE. Cortico-cortical and cortico subcortical re-entrant circuits sustain neocortical SE. Neuronal loss following neocortical SE, distant from the neocortical focus, may result from seizures.
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Affiliation(s)
- Tanveer Singh
- Department of Neurology, University of Virginia, Charlottesville, VA 22908, USA
| | - Tamal Batabyal
- UVA Brain Institute, University of Virginia, Charlottesville, VA 22908, USA
| | - Jaideep Kapur
- Department of Neurology, University of Virginia, Charlottesville, VA 22908, USA; UVA Brain Institute, University of Virginia, Charlottesville, VA 22908, USA; Department of Neuroscience, University of Virginia, Charlottesville, VA 22908, USA.
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27
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Foreman B, Lee H, Okonkwo DO, Strong AJ, Pahl C, Shutter LA, Dreier JP, Ngwenya LB, Hartings JA. The Relationship Between Seizures and Spreading Depolarizations in Patients with Severe Traumatic Brain Injury. Neurocrit Care 2022; 37:31-48. [PMID: 35174446 DOI: 10.1007/s12028-022-01441-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 01/04/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Both seizures and spreading depolarizations (SDs) are commonly detected using electrocorticography (ECoG) after severe traumatic brain injury (TBI). A close relationship between seizures and SDs has been described, but the implications of detecting either or both remain unclear. We sought to characterize the relationship between these two phenomena and their clinical significance. METHODS We performed a post hoc analysis of a prospective observational clinical study of patients with severe TBI requiring neurosurgery at five academic neurotrauma centers. A subdural electrode array was placed intraoperatively and ECoG was recorded during intensive care. SDs, seizures, and high-frequency background characteristics were quantified offline using published standards and terminology. The primary outcome was the Glasgow Outcome Scale-Extended score at 6 months post injury. RESULTS There were 138 patients with valid ECoG recordings; the mean age was 47 ± 19 years, and 104 (75%) were men. Overall, 2,219 ECoG-detected seizures occurred in 38 of 138 (28%) patients in a bimodal pattern, with peak incidences at 1.7-1.8 days and 3.8-4.0 days post injury. Seizures detected on scalp electroencephalography (EEG) were diagnosed by standard clinical care in only 18 of 138 (13%). Of 15 patients with ECoG-detected seizures and contemporaneous scalp EEG, seven (47%) had no definite scalp EEG correlate. ECoG-detected seizures were significantly associated with the severity and number of SDs, which occurred in 83 of 138 (60%) of patients. Temporal interactions were observed in 17 of 24 (70.8%) patients with both ECoG-detected seizures and SDs. After controlling for known prognostic covariates and the presence of SDs, seizures detected on either ECoG or scalp EEG did not have an independent association with 6-month functional outcome but portended worse outcome among those with clustered or isoelectric SDs. CONCLUSIONS In patients with severe TBI requiring neurosurgery, seizures were half as common as SDs. Seizures would have gone undetected without ECoG monitoring in 20% of patients. Although seizures alone did not influence 6-month functional outcomes in this cohort, they were independently associated with electrographic worsening and a lack of motor improvement following surgery. Temporal interactions between ECoG-detected seizures and SDs were common and held prognostic implications. Together, seizures and SDs may occur along a dynamic continuum of factors critical to the development of secondary brain injury. ECoG provides information integral to the clinical management of patients with TBI.
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Affiliation(s)
- Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA. .,Collaborative for Research on Acute Neurological Injuries, University of Cincinnati, Cincinnati, OH, USA.
| | - Hyunjo Lee
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA.,Collaborative for Research on Acute Neurological Injuries, University of Cincinnati, Cincinnati, OH, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anthony J Strong
- Department of Basic and Clinical Neuroscience, King's College London, London, UK
| | - Clemens Pahl
- Department of Intensive Care Medicine, King's College Hospital, London, UK
| | - Lori A Shutter
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine and Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jens P Dreier
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Laura B Ngwenya
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA.,Collaborative for Research on Acute Neurological Injuries, University of Cincinnati, Cincinnati, OH, USA.,Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jed A Hartings
- Collaborative for Research on Acute Neurological Injuries, University of Cincinnati, Cincinnati, OH, USA.,Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
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28
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Prediction and Risk Assessment Models for Subarachnoid Hemorrhage: A Systematic Review on Case Studies. BIOMED RESEARCH INTERNATIONAL 2022; 2022:5416726. [PMID: 35111845 PMCID: PMC8802084 DOI: 10.1155/2022/5416726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 01/09/2023]
Abstract
Subarachnoid hemorrhage (SAH) is one of the major health issues known to society and has a higher mortality rate. The clinical factors with computed tomography (CT), magnetic resonance image (MRI), and electroencephalography (EEG) data were used to evaluate the performance of the developed method. In this paper, various methods such as statistical analysis, logistic regression, machine learning, and deep learning methods were used in the prediction and detection of SAH which are reviewed. The advantages and limitations of SAH prediction and risk assessment methods are also being reviewed. Most of the existing methods were evaluated on the collected dataset for the SAH prediction. In some researches, deep learning methods were applied, which resulted in higher performance in the prediction process. EEG data were applied in the existing methods for the prediction process, and these methods demonstrated higher performance. However, the existing methods have the limitations of overfitting problems, imbalance data problems, and lower efficiency in feature analysis. The artificial neural network (ANN) and support vector machine (SVM) methods have been applied for the prediction process, and considerably higher performance is achieved by using this method.
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29
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Alkhachroum A, Kromm J, De Georgia MA. Big data and predictive analytics in neurocritical care. Curr Neurol Neurosci Rep 2022; 22:19-32. [PMID: 35080751 DOI: 10.1007/s11910-022-01167-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe predictive data and workflow in the intensive care unit when managing neurologically ill patients. RECENT FINDINGS In the era of Big Data in medicine, intensive critical care units are data-rich environments. Neurocritical care adds another layer of data with advanced multimodal monitoring to prevent secondary brain injury from ischemia, tissue hypoxia, and a cascade of ongoing metabolic events. A step closer toward personalized medicine is the application of multimodal monitoring of cerebral hemodynamics, bran oxygenation, brain metabolism, and electrophysiologic indices, all of which have complex and dynamic interactions. These data are acquired and visualized using different tools and monitors facing multiple challenges toward the goal of the optimal decision support system. In this review, we highlight some of the predictive data used to diagnose, treat, and prognosticate the neurologically ill patients. We describe information management in neurocritical care units including data acquisition, wrangling, analysis, and visualization.
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Affiliation(s)
- Ayham Alkhachroum
- Miller School of Medicine, Neurocritical Care Division, Department of Neurology, University of Miami, Miami, FL, 33146, USA
| | - Julie Kromm
- Cumming School of Medicine, Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Cumming School of Medicine, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Michael A De Georgia
- Center for Neurocritical Care, Neurological Institute, University Hospital Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106-5040, USA.
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30
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Chen C, Fang M, Zheng H, Xie S, Wang Y, Tong Y, Ma X, Guo L, Lu R. The characteristics of clinical laboratory indicators in anticardiolipin antibody positive cerebral infarction patients. Int Immunopharmacol 2021; 102:108276. [PMID: 34810127 DOI: 10.1016/j.intimp.2021.108276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/03/2021] [Accepted: 10/14/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Cuncun Chen
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong'an Road, Shanghai 200032, China
| | - Meng Fang
- Department of Musculoskeletal Oncology, Fudan University Shanghai Cancer Center, No. 270, Dong'an Road, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong'an Road, Shanghai 200032, China
| | - Hui Zheng
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong'an Road, Shanghai 200032, China
| | - Suhong Xie
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong'an Road, Shanghai 200032, China
| | - Yanchun Wang
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong'an Road, Shanghai 200032, China
| | - Ying Tong
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong'an Road, Shanghai 200032, China
| | - Xiaolu Ma
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong'an Road, Shanghai 200032, China
| | - Lin Guo
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong'an Road, Shanghai 200032, China.
| | - Renquan Lu
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong'an Road, Shanghai 200032, China.
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31
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Ferlini L, Su F, Creteur J, Taccone FS, Gaspard N. Cerebral and systemic hemodynamic effect of recurring seizures. Sci Rep 2021; 11:22209. [PMID: 34782705 PMCID: PMC8593180 DOI: 10.1038/s41598-021-01704-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022] Open
Abstract
The increase in neuronal activity induced by a single seizure is supported by a rise in the cerebral blood flow and tissue oxygenation, a mechanism called neurovascular coupling (NVC). Whether cerebral and systemic hemodynamics are able to match neuronal activity during recurring seizures is unclear, as data from rodent models are at odds with human studies. In order to clarify this issue, we used an invasive brain and systemic monitoring to study the effects of chemically induced non-convulsive seizures in sheep. Despite an increase in neuronal activity as seizures repeat (Spearman’s ρ coefficient 0.31, P < 0.001), ictal variations of cerebral blood flow remained stable while it progressively increased in the inter-ictal intervals (ρ = 0.06, P = 0.44 and ρ = 0.22; P = 0.008). We also observed a progressive reduction in the inter-ictal brain tissue oxygenation (ρ = − 0.18; P = 0.04), suggesting that NVC was unable to compensate for the metabolic demand of these closely repeating seizures. At the systemic level, there was a progressive reduction in blood pressure and a progressive rise in cardiac output (ρ = − 0.22; P = 0.01 and ρ = 0.22; P = 0.01, respectively), suggesting seizure-induced autonomic dysfunction.
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Affiliation(s)
- Lorenzo Ferlini
- Department of Neurology, Erasme Hospital, Free University of Brussels, Brussels, Belgium
| | - Fuhong Su
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Free University of Brussels, Brussels, Belgium.
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Abstract
PURPOSE OF REVIEW Subarachnoid hemorrhage (SAH) remains an important cause of mortality and long-term morbidity. This article uses a case-based approach to guide readers through the fundamental epidemiology and pathogenesis of SAH, the approach to diagnosis and management, the results of clinical trials and evidence to date, prognostic considerations, controversies, recent developments, and future directions in SAH. RECENT FINDINGS Historically, management of SAH focused on prevention and treatment of subsequent cerebral vasospasm, which was thought to be the primary cause of delayed cerebral ischemia. Clinical and translational studies over the past decade, including several therapeutic phase 3 randomized clinical trials, suggest that the pathophysiology of SAH-associated brain injury is multiphasic and multifactorial beyond large vessel cerebral vasospasm. The quest to reduce SAH-associated brain injury and improve outcomes is shifting away from large vessel cerebral vasospasm to a new paradigm targeting multiple brain injury mechanisms, including early brain injury, delayed cerebral ischemia, microcirculatory dysfunction, spreading cortical depolarization, inflammation, and the brain-body interaction in vascular brain injury with critical illness.Despite multiple negative randomized clinical trials in search of potential therapeutic agents ameliorating the downstream effects after SAH, the overall outcome of SAH has improved over recent decades, likely related to improvements in interventional options for ruptured cerebral aneurysms and in critical care management. Emerging clinical evidence also suggests potential harmful impact of historic empiric treatments for SAH-associated vasospasm, such as prophylactic induction of hypertension, hypervolemia, and hemodilution (triple H therapy).With decreasing mortality, long-term SAH survivorship and efforts to reduce chronic morbidity and to improve quality of life and patient-centered outcome are growing areas of unmet need. Despite existing guidelines, significant variabilities in local and regional practices and in scientific terminologies have historically limited advancement in SAH care and therapeutic development. Large global collaborative efforts developed harmonized SAH common data elements in 2019, and studies are under way to examine how existing variabilities in SAH care impact long-term SAH outcomes. SUMMARY Although the overall incidence and mortality of SAH is decreasing with advances in preventive and acute care, SAH remains a major cause of long-term morbidity in survivors. Significant variabilities in care settings and empiric treatment protocols and inconsistent scientific terminologies have limited advancement in patient care and therapeutic clinical studies. Large consensus efforts are under way to introduce clinical guidelines and common data elements to advance therapeutic approaches and improve patient outcome.
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Rosenthal ES. Seizures, Status Epilepticus, and Continuous EEG in the Intensive Care Unit. Continuum (Minneap Minn) 2021; 27:1321-1343. [PMID: 34618762 DOI: 10.1212/con.0000000000001012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW This article discusses the evolving definitions of seizures and status epilepticus in the critical care environment and the role of critical care EEG in both diagnosing seizure activity and serving as a predictive biomarker of clinical trajectory. RECENT FINDINGS Initial screening EEG has been validated as a tool to predict which patients are at risk of future seizures. However, accepted definitions of seizures and nonconvulsive status epilepticus encourage a treatment trial when the diagnosis on EEG is indeterminate because of periodic or rhythmic patterns or uncertain clinical correlation. Similarly, recent data have demonstrated the diagnostic utility of intracranial EEG in increasing the yield of seizure detection. EEG has additionally been validated as a diagnostic biomarker of covert consciousness, a predictive biomarker of cerebral ischemia and impending neurologic deterioration, and a prognostic biomarker of coma recovery and status epilepticus resolution. A recent randomized trial concluded that patients allocated to continuous EEG had no difference in mortality than those undergoing intermittent EEG but could not demonstrate whether this lack of difference was because of studying heterogeneous conditions, examining a monitoring tool rather than a therapeutic approach, or examining an outcome measure (mortality) perhaps more strongly associated with early withdrawal of life-sustaining therapy than to a sustained response to pharmacotherapy. SUMMARY Seizures and status epilepticus are events of synchronous hypermetabolic activity that are either discrete and intermittent or, alternatively, continuous. Seizures and status epilepticus represent the far end of a continuum of ictal-interictal patterns that include lateralized rhythmic delta activity and periodic discharges, which not only predict future seizures but may be further classified as status epilepticus on the basis of intracranial EEG monitoring or a diagnostic trial of antiseizure medication therapy. In particularly challenging cases, neuroimaging or multimodality neuromonitoring may be a useful adjunct documenting metabolic crisis. Specialized uses of EEG as a prognostic biomarker have emerged in traumatic brain injury for predicting language function and covert consciousness, cardiac arrest for predicting coma recovery, and subarachnoid hemorrhage for predicting neurologic deterioration due to delayed cerebral ischemia.
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Aneurysmal Subarachnoid Hemorrhage: Review of the Pathophysiology and Management Strategies. Curr Neurol Neurosci Rep 2021; 21:50. [PMID: 34308493 DOI: 10.1007/s11910-021-01136-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Aneurysmal subarachnoid hemorrhage remains a devastating disease process despite medical advances made over the past 3 decades. Much of the focus was on prevention and treatment of vasospasm to reduce delayed cerebral ischemia and improve outcome. In recent years, there has been a shift of focus onto early brain injury as the precursor to delayed cerebral ischemia. This review will focus on the most recent data surrounding the pathophysiology of aneurysmal subarachnoid hemorrhage and current management strategies. RECENT FINDINGS There is a paucity of successful trials in the management of subarachnoid hemorrhage likely related to the targeting of vasospasm. Pathophysiological changes occurring at the time of aneurysmal rupture lead to early brain injury including cerebral edema, inflammation, and spreading depolarization. These events result in microvascular collapse, vasospasm, and ultimately delayed cerebral ischemia. Management of aneurysmal subarachnoid hemorrhage has remained the same over the past few decades. No recent trials have resulted in new treatments. However, our understanding of the pathophysiology is rapidly expanding and will advise future therapeutic targets.
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Foreman B, Lee H, Mizrahi MA, Hartings JA, Ngwenya LB, Privitera M, Tortella FC, Zhang N, Kramer JH. Seizures and Cognitive Outcome After Traumatic Brain Injury: A Post Hoc Analysis. Neurocrit Care 2021; 36:130-138. [PMID: 34232458 DOI: 10.1007/s12028-021-01267-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/27/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Seizures and abnormal periodic or rhythmic patterns are observed on continuous electroencephalography monitoring (cEEG) in up to half of patients hospitalized with moderate to severe traumatic brain injury (TBI). We aimed to determine the impact of seizures and abnormal periodic or rhythmic patterns on cognitive outcome 3 months following moderate to severe TBI. METHODS This was a post hoc analysis of the multicenter randomized controlled phase 2 INTREPID2566 clinical trial conducted from 2010 to 2016 across 20 United States Level I trauma centers. Patients with nonpenetrating TBI and postresuscitation Glasgow Coma Scale scores 4-12 were included. Bedside cEEG was initiated per protocol on admission to intensive care, and the burden of ictal-interictal continuum (IIC) patterns, including seizures, was quantified. A summary global cognition score at 3 months following injury was used as the primary outcome. RESULTS 142 patients (age mean + / - standard deviation 32 + / - 13 years; 131 [92%] men) survived with a mean global cognition score of 81 + / - 15; nearly one third were considered to have poor functional outcome. 89 of 142 (63%) patients underwent cEEG, of whom 13 of 89 (15%) had severe IIC patterns. The quantitative burden of IIC patterns correlated inversely with the global cognition score (r = - 0.57; p = 0.04). In multiple variable analysis, the log-transformed burden of severe IIC patterns was independently associated with the global cognition score after controlling for demographics, premorbid estimated intelligence, injury severity, sedatives, and antiepileptic drugs (odds ratio 0.73, 95% confidence interval 0.60-0.88; p = 0.002). CONCLUSIONS The burden of seizures and abnormal periodic or rhythmic patterns was independently associated with worse cognition at 3 months following TBI. Their impact on longer-term cognitive endpoints and the potential benefits of seizure detection and treatment in this population warrant prospective study.
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Affiliation(s)
- Brandon Foreman
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, 45267-0517, USA.
- Collaborative for Research on Acute Neurological Injuries, University of Cincinnati,, Cincinnati, OH, USA.
- Department of Neurosurgery, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA.
| | - Hyunjo Lee
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, 45267-0517, USA
- Collaborative for Research on Acute Neurological Injuries, University of Cincinnati,, Cincinnati, OH, USA
| | - Moshe A Mizrahi
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, 45267-0517, USA
| | - Jed A Hartings
- Collaborative for Research on Acute Neurological Injuries, University of Cincinnati,, Cincinnati, OH, USA
- Department of Neurosurgery, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Laura B Ngwenya
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, 45267-0517, USA
- Collaborative for Research on Acute Neurological Injuries, University of Cincinnati,, Cincinnati, OH, USA
- Department of Neurosurgery, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Michael Privitera
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, 45267-0517, USA
| | - Frank C Tortella
- Walter Reed Army Institute of Research, Brain Trauma, Neuroprotection and Neurorestoration Branch, Silver Springs, MD, USA
| | - Nanhua Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joel H Kramer
- San Francisco Memory and Aging Center, University of California, San Francisco,, CA, USA
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Song JL, Kim JA, Struck AF, Zhang R, Westover MB. A model of metabolic supply-demand mismatch leading to secondary brain injury. J Neurophysiol 2021; 126:653-667. [PMID: 34232754 DOI: 10.1152/jn.00674.2020] [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] [Indexed: 01/10/2023] Open
Abstract
Secondary brain injury (SBI) is defined as new or worsening injury to the brain after an initial neurologic insult, such as hemorrhage, trauma, ischemic stroke, or infection. It is a common and potentially preventable complication following many types of primary brain injury (PBI). However, mechanistic details about how PBI leads to additional brain injury and evolves into SBI are poorly characterized. In this work, we propose a mechanistic model for the metabolic supply demand mismatch hypothesis (MSDMH) of SBI. Our model, based on the Hodgkin-Huxley model, supplemented with additional dynamics for extracellular potassium, oxygen concentration, and excitotoxity, provides a high-level unified explanation for why patients with acute brain injury frequently develop SBI. We investigate how decreased oxygen, increased extracellular potassium, excitotoxicity, and seizures can induce SBI and suggest three underlying paths for how events following PBI may lead to SBI. The proposed model also helps explain several important empirical observations, including the common association of acute brain injury with seizures, the association of seizures with tissue hypoxia and so on. In contrast to current practices which assume that ischemia plays the predominant role in SBI, our model suggests that metabolic crisis involved in SBI can also be nonischemic. Our findings offer a more comprehensive understanding of the complex interrelationship among potassium, oxygen, excitotoxicity, seizures, and SBI.NEW & NOTEWORTHY We present a novel mechanistic model for the metabolic supply demand mismatch hypothesis (MSDMH), which attempts to explain why patients with acute brain injury frequently develop seizure activity and secondary brain injury (SBI). Specifically, we investigate how decreased oxygen, increased extracellular potassium, excitotoxicity, seizures, all common sequalae of primary brain injury (PBI), can induce SBI and suggest three underlying paths for how events following PBI may lead to SBI.
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Affiliation(s)
- Jiang-Ling Song
- The Medical Big Data Research Center, Northwest University, Xi'an, China.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer A Kim
- Department of Neurology, Yale New Haven Hospital, New Haven, Connecticut
| | - Aaron F Struck
- Departments of Neurology, University of Wisconsin-Madison, Madison, Wisconsin.,William S Middleton Veterans Administration Hospital, Madison, Wisconsin
| | - Rui Zhang
- The Medical Big Data Research Center, Northwest University, Xi'an, China
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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37
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Fung FW, Wang Z, Parikh DS, Jacobwitz M, Vala L, Donnelly M, Topjian AA, Xiao R, Abend NS. Electrographic Seizures and Outcome in Critically Ill Children. Neurology 2021; 96:e2749-e2760. [PMID: 33893203 PMCID: PMC8205469 DOI: 10.1212/wnl.0000000000012032] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 03/04/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the association between electroencephalographic seizure (ES) and electroencephalographic status epilepticus (ESE) exposure and unfavorable neurobehavioral outcomes in critically ill children with acute encephalopathy. METHODS This was a prospective cohort study of acutely encephalopathic critically ill children undergoing continuous EEG monitoring (CEEG). ES exposure was assessed as (1) no ES/ESE, (2) ES, or (3) ESE. Outcomes assessed at discharge included the Glasgow Outcome Scale-Extended Pediatric Version (GOS-E-Peds), Pediatric Cerebral Performance Category (PCPC), and mortality. Unfavorable outcome was defined as a reduction in GOS-E-Peds or PCPC score from preadmission to discharge. Stepwise selection was used to generate multivariate logistic regression models that assessed associations between ES exposure and outcomes while adjusting for multiple other variables. RESULTS Among 719 consecutive critically ill patients, there was no evidence of ES in 535 patients (74.4%), ES occurred in 140 patients (19.5%), and ESE in 44 patients (6.1%). The final multivariable logistic regression analyses included ES exposure, age dichotomized at 1 year, acute encephalopathy category, initial EEG background category, comatose at CEEG initiation, and Pediatric Index of Mortality 2 score. There was an association between ESE and unfavorable GOS-E-Peds (odds ratio 2.21, 95% confidence interval 1.07-4.54) and PCPC (odds ratio 2.17, 95% confidence interval 1.05-4.51) but not mortality. There was no association between ES and unfavorable outcome or mortality. CONCLUSIONS Among acutely encephalopathic critically ill children, there was an association between ESE and unfavorable neurobehavioral outcomes, but no association between ESE and mortality. ES exposure was not associated with unfavorable neurobehavioral outcomes or mortality.
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Affiliation(s)
- France W Fung
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA.
| | - Zi Wang
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Darshana S Parikh
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Marin Jacobwitz
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Lisa Vala
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Maureen Donnelly
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Alexis A Topjian
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Rui Xiao
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Nicholas S Abend
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
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Bosl WJ, Leviton A, Loddenkemper T. Prediction of Seizure Recurrence. A Note of Caution. Front Neurol 2021; 12:675728. [PMID: 34054713 PMCID: PMC8155381 DOI: 10.3389/fneur.2021.675728] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/20/2021] [Indexed: 12/31/2022] Open
Abstract
Great strides have been made recently in documenting that machine-learning programs can predict seizure occurrence in people who have epilepsy. Along with this progress have come claims that appear to us to be a bit premature. We anticipate that many people will benefit from seizure prediction. We also doubt that all will benefit. Although machine learning is a useful tool for aiding discovery, we believe that the greatest progress will come from deeper understanding of seizures, epilepsy, and the EEG features that enable seizure prediction. In this essay, we lay out reasons for optimism and skepticism.
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Affiliation(s)
- William J Bosl
- Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Health Informatics Program, University of San Francisco, San Francisco, CA, United States
| | - Alan Leviton
- Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Tobias Loddenkemper
- Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
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39
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Abstract
INTRODUCTION Evidence for continuous EEG monitoring in the pediatric intensive care unit (PICU) is increasing. However, 24/7 access to EEG is not routinely available in most centers, and clinical management is often informed by more limited EEG resources. The experience of EEG was reviewed in a tertiary PICU where 24/7 EEG cover is unavailable. METHODS Retrospective EEG and clinical review of 108 PICU patients. Correlations were carried out between EEG and clinical variables including mortality. The role of EEG in clinical decision making was documented. RESULTS One hundred ninety-six EEGs were carried out in 108 PICU patients over 2.5 years (434 hours of recording). After exclusion of 1 outlying patient with epileptic encephalopathy, 136 EEGs (median duration, 65 minutes; range, 20 minutes to 4 hours 40 minutes) were included. Sixty-two patients (57%) were less than 12 months old. Seizures were detected in 18 of 107 patients (17%); 74% of seizures were subclinical; 72% occurred within the first 30 minutes of recording. Adverse EEG findings were associated with high mortality. Antiepileptic drug use was high in the studied population irrespective of EEG seizure detection. Prevalence of epileptiform discharges and EEG seizures diminished with increasing levels of sedation. CONCLUSIONS EEG provides important diagnostic information in a large proportion of PICU patients. In the absence of 24/7 EEG availability, empirical antiepileptic drug utilization is high.
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Early Seizures Are Predictive of Worse Health-Related Quality of Life at Follow-Up After Intracerebral Hemorrhage. Crit Care Med 2021; 49:e578-e584. [PMID: 33729725 PMCID: PMC8140982 DOI: 10.1097/ccm.0000000000004936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Early seizures are a common complication of intracerebral hemorrhage, occurring in ~10% of patients. However, the independent effect of early seizures on patient outcomes, particularly health-related quality of life, is unclear. Without a potential benefit to patient outcomes, the widespread use (~40%) of prophylactic seizure medications has no reasonable chance of improving patient outcomes. We tested the hypothesis that health-related quality of life at follow-up is different between patients with and without early seizures (and secondarily, with nonconvulsive status epilepticus) after intracerebral hemorrhage. DESIGN Patients with intracerebral hemorrhage were enrolled in an observational cohort study that prospectively collected clinical data and health-related quality of life at follow-up. SETTING Academic medical center. PATIENTS One-hundred thirty-three patients whose health-related quality of life was assessed 3 months after intracerebral hemorrhage onset. MEASUREMENTS AND MAIN RESULTS Health-related quality of life was obtained at 3 months after intracerebral hemorrhage onset. T Scores of health-related quality of life were modeled with multivariable linear models accounting for severity with the intracerebral hemorrhage Score and hematoma location. Health-related quality of life was measured with National Institutes of Health Patient Reported Outcomes Measurement Information System/Neuroquality of life, expressed in T Scores (U.S. normal 50 ± 10). The modified Rankin Scale (a global measure) was a secondary outcome. There were 12 patients (9%) with early seizures. T Scores of health-related quality of life at follow-up were lower (worse) in patients with early seizure compared with patients without an early seizure (44 [32.75-51.85] vs 30.25 [18.9-39.15]; p = 0.04); results for other domains of health-related quality of life were similar. The association persisted in multivariable models. There was no association between early seizures and prophylactic seizure medications (p = 0.4). Results for patients with nonconvulsive status epilepticus were similar. There was no association between early seizures and the modified Rankin Scale at 3 months. CONCLUSIONS Early seizures and nonconvulsive status epilepticus were associated with lower health-related quality of life at follow-up in survivors of intracerebral hemorrhage.
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Kromm J, Fiest KM, Alkhachroum A, Josephson C, Kramer A, Jette N. Structure and Outcomes of Educational Programs for Training Non-electroencephalographers in Performing and Screening Adult EEG: A Systematic Review. Neurocrit Care 2021; 35:894-912. [PMID: 33591537 DOI: 10.1007/s12028-020-01172-2] [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: 08/11/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To qualitatively and quantitatively summarize curricula, teaching methods, and effectiveness of educational programs for training bedside care providers (non-experts) in the performance and screening of adult electroencephalography (EEG) for nonconvulsive seizures and other patterns. METHODS PRISMA methodological standards were followed. MEDLINE, EMBASE, Cochrane, CINAHL, WOS, Scopus, and MedEdPORTAL databases were searched from inception until February 26, 2020 with no restrictions. Abstract and full-text review was completed in duplicate. Studies were included if they were original research; involved non-experts performing, troubleshooting, or screening adult EEG; and provided qualitative descriptions of curricula and teaching methods and/or quantitative assessment of non-experts (vs gold standard EEG performance by neurodiagnostic technologists or interpretation by neurophysiologists). Data were extracted in duplicate. A content analysis and a meta-narrative review were performed. RESULTS Of 2430 abstracts, 35 studies were included. Sensitivity and specificity of seizure identification varied from 38 to 100% and 65 to 100% for raw EEG; 40 to 93% and 38 to 95% for quantitative EEG, and 95 to 100% and 65 to 85% for sonified EEG, respectively. Non-expert performance of EEG resulted in statistically significant reduced delay (86 min, p < 0.0001; 196 min, p < 0.0001; 667 min, p < 0.005) in EEG completion and changes in management in approximately 40% of patients. Non-experts who were trained included physicians, nurses, neurodiagnostic technicians, and medical students. Numerous teaching methods were utilized and often combined, with instructional and hands-on training being most common. CONCLUSIONS Several different bedside providers can be educated to perform and screen adult EEG, particularly for the purpose of diagnosing nonconvulsive seizures. While further rigorous research is warranted, this review demonstrates several potential bridges by which EEG may be integrated into the care of critically ill patients.
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Affiliation(s)
- Julie Kromm
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Room 04112, Foothills Medical Centre, McCaig Tower, 3134 Hospital Drive NW, Calgary, Alberta, T2N 5A1, Canada. .,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada.
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Room 04112, Foothills Medical Centre, McCaig Tower, 3134 Hospital Drive NW, Calgary, Alberta, T2N 5A1, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ayham Alkhachroum
- Neurocritical Care Division, Miller School of Medicine, University of Miami, Miami, USA
| | - Colin Josephson
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Andreas Kramer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Room 04112, Foothills Medical Centre, McCaig Tower, 3134 Hospital Drive NW, Calgary, Alberta, T2N 5A1, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine, Mount Sinai, New York, USA
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42
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Derex L, Rheims S, Peter-Derex L. Seizures and epilepsy after intracerebral hemorrhage: an update. J Neurol 2021; 268:2605-2615. [PMID: 33569652 DOI: 10.1007/s00415-021-10439-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/30/2021] [Indexed: 02/05/2023]
Abstract
Seizures are common after intracerebral hemorrhage, occurring in 6-15% of the patients, mostly in the first 72 h. Their incidence reaches 30% when subclinical or non-convulsive seizures are diagnosed by continuous electroencephalogram. Several risk factors for seizures have been described including cortical location of intracerebral hemorrhage, presence of intraventricular hemorrhage, total hemorrhage volume, and history of alcohol abuse. Seizures after intracerebral hemorrhage may theoretically be harmful as they can lead to sudden blood pressure fluctuations, increased intracranial pressure, and neuronal injury due to increased metabolic demand. Some recent studies suggest that acute symptomatic seizures (occurring within 7 days of stroke) are associated with worse functional outcome and increased risk of death despite accounting for other known prognostic factors such as age and baseline hemorrhage volume. However, the impact of seizures on prognosis is still debated and it remains unclear if treating or preventing seizures might lead to improved clinical outcome. Thus, the currently available scientific evidence does not support the routine use of antiseizure medication as primary prevention among patients with intracerebral hemorrhage. Only prospective adequately powered randomized-controlled trials will be able to answer whether seizure prophylaxis in the acute or longer term settings is beneficial or not in patients with intracerebral hemorrhage.
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Affiliation(s)
- Laurent Derex
- Stroke Center, Department of Neurology, Neurological Hospital, Hospices Civils de Lyon, University of Lyon, 59 boulevard Pinel, 69677, Bron cedex, France.
- Research On Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France.
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, University of Lyon, Lyon, France
- Lyon 1 University, Lyon, France
- INSERM U1028-CNRS UMR 5292, Lyon Neuroscience Research Center, Lyon, France
| | - Laure Peter-Derex
- Lyon 1 University, Lyon, France.
- INSERM U1028-CNRS UMR 5292, Lyon Neuroscience Research Center, Lyon, France.
- Center for Sleep Medicine and Respiratory Diseases, Croix-Rousse Hospital, Hospices Civils de Lyon, University of Lyon, 103 Grande rue de la Croix-Rousse, 69004, Lyon, France.
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43
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Schoknecht K, Kikhia M, Lemale CL, Liotta A, Lublinsky S, Mueller S, Boehm-Sturm P, Friedman A, Dreier JP. The role of spreading depolarizations and electrographic seizures in early injury progression of the rat photothrombosis stroke model. J Cereb Blood Flow Metab 2021; 41:413-430. [PMID: 32241203 PMCID: PMC7812510 DOI: 10.1177/0271678x20915801] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Spreading depolarization (SD) and seizures are pathophysiological events associated with cerebral ischemia. Here, we investigated their role for injury progression in the cerebral cortex. Cerebral ischemia was induced in anesthetized male Wistar rats using the photothrombosis (PT) stroke model. SD and spontaneous neuronal activity were recorded in the presence of either urethane or ketamine/xylazine anesthesia. Blood-brain barrier (BBB) permeability, cerebral perfusion, and cellular damage were assessed through a cranial window and repeated intravenous injection of fluorescein sodium salt and propidium iodide until 4 h after PT. Neuronal injury and early lesion volume were quantified by stereological cell counting and manual and automated assessment of ex vivo T2-weighted magnetic resonance imaging. Onset SDs originated at the thrombotic core and invaded neighboring cortex, whereas delayed SDs often showed opposite propagation patterns. Seizure induction by 4-aminopyridine caused no increase in lesion volume or neuronal injury in urethane-anesthetized animals. Ketamine/xylazine anesthesia was associated with a lower number of onset SDs, reduced lesion volume, and neuronal injury despite a longer duration of seizures. BBB permeability increase inversely correlated with the number of SDs at 3 and 4 h after PT. Our results provide further evidence that ketamine may counteract the early progression of ischemic injury.
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Affiliation(s)
- Karl Schoknecht
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Neuroscience Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Institute for Neurophysiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Carl-Ludwig-Institute for Physiology, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Majed Kikhia
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Agustin Liotta
- Neuroscience Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Institute for Neurophysiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Anesthesiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Svetlana Lublinsky
- Departments of Physiology & Cell Biology, Cognitive & Brain Sciences, the Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Susanne Mueller
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Philipp Boehm-Sturm
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alon Friedman
- Departments of Physiology & Cell Biology, Cognitive & Brain Sciences, the Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Medical Neuroscience, Dalhousie University, Halifax, Canada
| | - Jens P Dreier
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Center for Computational Neuroscience Berlin, Humboldt-Universität zu Berlin, Germany
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44
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Karamched B, Hripcsak G, Albers D, Ott W. Delay-induced uncertainty for a paradigmatic glucose-insulin model. CHAOS (WOODBURY, N.Y.) 2021; 31:023142. [PMID: 33653035 PMCID: PMC7910007 DOI: 10.1063/5.0027682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/02/2021] [Indexed: 06/12/2023]
Abstract
Medical practice in the intensive care unit is based on the assumption that physiological systems such as the human glucose-insulin system are predictable. We demonstrate that delay within the glucose-insulin system can induce sustained temporal chaos, rendering the system unpredictable. Specifically, we exhibit such chaos for the ultradian glucose-insulin model. This well-validated, finite-dimensional model represents feedback delay as a three-stage filter. Using the theory of rank one maps from smooth dynamical systems, we precisely explain the nature of the resulting delay-induced uncertainty (DIU). We develop a framework one may use to diagnose DIU in a general oscillatory dynamical system. For infinite-dimensional delay systems, no analog of the theory of rank one maps exists. Nevertheless, we show that the geometric principles encoded in our DIU framework apply to such systems by exhibiting sustained temporal chaos for a linear shear flow. Our results are potentially broadly applicable because delay is ubiquitous throughout mathematical physiology.
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Affiliation(s)
- Bhargav Karamched
- Department of Mathematics and Institute of Molecular Biophysics, Florida State University, Tallahassee, Florida 32306, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, New York 10032, USA
| | | | - William Ott
- Department of Mathematics, University of Houston, Houston, Texas 77204, USA
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45
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Neuromonitoring: No Longer a Spectator Sport. Neurocrit Care 2021; 33:646-647. [PMID: 32253730 DOI: 10.1007/s12028-020-00957-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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46
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Rubinos C, Alkhachroum A, Der-Nigoghossian C, Claassen J. Electroencephalogram Monitoring in Critical Care. Semin Neurol 2020; 40:675-680. [PMID: 33176375 DOI: 10.1055/s-0040-1719073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Seizures are common in critically ill patients. Electroencephalogram (EEG) is a tool that enables clinicians to provide continuous brain monitoring and to guide treatment decisions-brain telemetry. EEG monitoring has particular utility in the intensive care unit as most seizures in this setting are nonconvulsive. Despite the increased use of EEG monitoring in the critical care unit, it remains underutilized. In this review, we summarize the utility of EEG and different EEG modalities to monitor patients in the critical care setting.
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Affiliation(s)
- Clio Rubinos
- Division of Critical Care Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ayham Alkhachroum
- Department of Neurology, Miller School of Medicine, Jackson Memorial Health System, University of Miami, Miami, Florida
| | - Caroline Der-Nigoghossian
- Neurosciences Intensive Care Unit, Department of Pharmacy, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Jan Claassen
- Department of Neurology, Columbia University, New York
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48
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Alkhamis F, Nazish S. Electroencephalographic Grading of Neuronal Dysfunction in Various Etiologies of Encephalopathy. Clin EEG Neurosci 2020; 51:420-425. [PMID: 32483980 DOI: 10.1177/1550059420925962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The objective of this work was to study the electroencephalographic (EEG) grading of neuronal dysfunction in encephalopathy of various etiologies and assess their association with clinical outcomes. SUBJECTS AND METHODS This retrospective cross-sectional study was performed between June and November 2018 at the Neurology Department of King Fahd Hospital of University, Kingdom of Saudi Arabia (KSA) and involved a review and analysis of EEG and medical records pertaining to 222 patients in whom encephalopathy was diagnosed. RESULTS In patients suffering from encephalopathy, advanced age (P = .01), low Glasgow Coma Scale (GCS) scores (P = .00), and certain etiologies, namely hypoxic-ischemic encephalopathy (HIE) (P = .00), septic encephalopathy (P = .01), and other illnesses (P = .00), were significantly associated with unfavorable clinical outcomes, whereas traumatic brain injury (TBI) (P = .01) and GCS >7 (P = .00) were associated with favorable outcomes. Among different etiologies, EEG grade I (P = .02) and grade IV (P = .04) neuronal dysfunction was significantly associated with TBI while grade III (P = .05) and grade V (P = .02) neuronal dysfunction was significantly associated with HIE. Grade I (P = .03) neuronal dysfunction was mostly observed in septic encephalopathy cases, while patients suffering from other illnesses were also found to have grade I (P = .04) and grade IV (P = .05) neuronal dysfunction based on their EEG. CONCLUSION EEG is being conducted routinely to determine the course and severity of various forms of encephalopathy. However, the clinical implications of EEG grading for neuronal dysfunction are largely dependent on underlying etiology and other clinical parameters, such as age and GCS score. Further larger prospective cohort studies involving other important prognostic parameters and continuous EEG monitoring are thus needed.
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Affiliation(s)
- Fahad Alkhamis
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Saima Nazish
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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49
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Singh T, Joshi S, Williamson JM, Kapur J. Neocortical injury-induced status epilepticus. Epilepsia 2020; 61:2811-2824. [PMID: 33063874 DOI: 10.1111/epi.16715] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To characterize neocortical onset status epilepticus (SE) in the C57BL/6J mouse. METHODS We induced SE by administering homocysteine 16-18 hours after cobalt (Co) implantation. SE was monitored by video and electroencephalography (EEG). We evaluated brain structure with magnetic resonance imaging (MRI). Neurodegeneration was evaluated 72 hours after SE using Fluoro-Jade C staining. RESULTS Cobalt triggered seizures in a dose-dependent manner (median effective dose, ED50 = 0.78 mg) and the latency to peak seizure frequency shortened with increased dose. Animals developed SE after homocysteine administration. SE began with early intermittent focal seizures, consisting of frontal onset rhythmic spike-wave discharges manifested as focal dystonia with clonus. These focal seizures then evolved into generalized continuous convulsive activity. Behavioral manifestations of SE included tonic stiffening, bilateral limb clonus, and bilateral tonic-clonic movements, which were accompanied by generalized rhythmic spike-wave discharges on EEG. After prolonged seizures, animals became comatose with intermittent bilateral myoclonic seizures or jerks. During this period, EEG showed seizures interspersed with generalized periodic discharges on a suppressed background. MRI obtained when animals were in a coma revealed edema, midline shift in frontal lobe around the Co implantation site, and ventricular effacement. Fluoro-Jade C staining revealed neurodegeneration in the cortex, amygdala, and thalamus. SIGNIFICANCE We have developed a mouse model of severe, refractory cortical-onset SE, consisting of convulsions merging into a coma, EEG patterns of cortical seizures, and injury, with evidence of widespread neocortical edema and damage. This model replicates many features of acute seizures and SE resulting from traumatic brain injury, subarachnoid, and lobar hemorrhage.
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Affiliation(s)
- Tanveer Singh
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - Suchitra Joshi
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - John M Williamson
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - Jaideep Kapur
- Department of Neurology, University of Virginia, Charlottesville, VA, USA.,UVA Brain Institute, University of Virginia, Charlottesville, VA, USA.,Department of Neuroscience, University of Virginia, Charlottesville, VA, USA
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50
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Sinkin MV, Kaimovsky IL, Komoltsev IG, Trifonov IS, Shtekleyn AA, Tsygankova ME, Guekht AB. [Electroencephalography in acute stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:10-16. [PMID: 33016671 DOI: 10.17116/jnevro202012008210] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the incidence of non-convulsive status epilepticus, epileptiform activity, rhythmic and periodic patterns in patients with acute stroke. MATERIAL AND METHOD An analysis of electroencephalography (EEG) in 86 stroke patients in the neurointensive care unit of the tertiary medical center was performed. Criteria for starting EEG recording were epileptic seizures or clinical suspicion of uncontrolled epileptic status. The ictal-interictal continuum biomarkers and the diagnostic value of EEG for prediction of survival and recovery were assessed. RESULTS Pathological changes on EEG were recorded in 84% of patients. These patients showed the absence of the dominant occipital rhythm (66%) and hemispheric slowing (42%). Diffuse slowing below the theta range was observed in 41% of patients. EEG reactivity was absent in 20%. Sporadic epileptiform discharges were recorded in 36% of patients and rhythmic and periodic patterns in 26%. Reliable predictors of the unfavorable outcome were the absence of dominant occipital rhythm, lack of reactivity, and low amplitude of the background EEG. No association between the recording of epileptiform activity and the probability of death was shown. CONCLUSION The most useful EEG biomarkers for predicting survival are amplitude, dominant frequency of background EEG activity and reactivity to external stimulus. Sporadic epileptiform discharges, rhythmic, and periodic patterns are not mandatory associated with a negative prognosis in stroke patients.
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Affiliation(s)
- M V Sinkin
- Sklifosovsky Research Institute of Emergenscy Medicine, Moscow, Russia.,Evdokimov Moscow State University of Medical Dentistry, Moscow, Russia
| | - I L Kaimovsky
- Evdokimov Moscow State University of Medical Dentistry, Moscow, Russia.,Buyanov City Clinical Hospital, Moscow, Russia
| | - I G Komoltsev
- Buyanov City Clinical Hospital, Moscow, Russia.,Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia
| | - I S Trifonov
- Evdokimov Moscow State University of Medical Dentistry, Moscow, Russia
| | - A A Shtekleyn
- Peoples' Friendship University of Russia, Moscow, Russia
| | - M E Tsygankova
- Federal Center of Brain and Neurotechnology of the Federal Biomedical Agency, Moscow, Russia
| | - A B Guekht
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
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