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Rice HJ, Fernandes MB, Punia V, Rubinos C, Sivaraju A, Zafar SF. Predictors of follow-up care for critically-ill patients with seizures and epileptiform abnormalities on EEG monitoring. Clin Neurol Neurosurg 2024; 241:108275. [PMID: 38640778 PMCID: PMC11167629 DOI: 10.1016/j.clineuro.2024.108275] [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: 02/12/2024] [Revised: 03/20/2024] [Accepted: 04/04/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE Post-hospitalization follow-up visits are crucial for preventing long-term complications. Patients with electrographic epileptiform abnormalities (EA) including seizures and periodic and rhythmic patterns are especially in need of follow-up for long-term seizure risk stratification and medication management. We sought to identify predictors of follow-up. METHODS This is a retrospective cohort study of all patients (age ≥ 18 years) admitted to intensive care units that underwent continuous EEG (cEEG) monitoring at a single center between 01/2016-12/2019. Patients with EAs were included. Clinical and demographic variables were recorded. Follow-up status was determined using visit records 6-month post discharge, and visits were stratified as outpatient follow-up, neurology follow-up, and inpatient readmission. Lasso feature selection analysis was performed. RESULTS 723 patients (53 % female, mean (std) age of 62.3 (16.4) years) were identified from cEEG records with 575 (79 %) surviving to discharge. Of those discharged, 450 (78 %) had outpatient follow-up, 316 (55 %) had a neurology follow-up, and 288 (50 %) were readmitted during the 6-month period. Discharge on antiseizure medications (ASM), younger age, admission to neurosurgery, and proximity to the hospital were predictors of neurology follow-up visits. Discharge on ASMs, along with longer length of stay, younger age, emergency admissions, and higher illness severity were predictors of readmission. SIGNIFICANCE ASMs at discharge, demographics (age, address), hospital care teams, and illness severity determine probability of follow-up. Parameters identified in this study may help healthcare systems develop interventions to improve care transitions for critically-ill patients with seizures and other EA.
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Affiliation(s)
- Hunter J Rice
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States; Center for Value-based Health Care and Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - Marta Bento Fernandes
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States; Center for Value-based Health Care and Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - Vineet Punia
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Clio Rubinos
- University of North Carolina, Chapel Hill, NC, United States
| | - Adithya Sivaraju
- Department of Neurology, Yale New Haven Hospital, Yale University, New Haven, CT, United States
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States; Center for Value-based Health Care and Sciences, Massachusetts General Hospital, Boston, MA, United States.
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Chandan P, Byrnes ME, Newey C, Hantus S, Punia V. Outpatient EEG in Routine Clinical Care of Patients With Stroke-Related Acute Symptomatic Seizure Concerns. J Clin Neurophysiol 2024; 41:312-316. [PMID: 36893378 DOI: 10.1097/wnp.0000000000000992] [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: 06/15/2022] [Accepted: 12/12/2022] [Indexed: 03/11/2023] Open
Abstract
PURPOSE Acute symptomatic seizures (ASyS) after stroke contribute the highest risk to poststroke epilepsy (PSE) development. We investigated the use of outpatient EEG (oEEG) among stroke patients with ASyS concerns. METHODS Adults with acute stroke, ASyS concerns (underwent cEEG), and outpatient clinical follow-up were included (study population). Patients with oEEG (oEEG cohort) were analyzed for electrographic findings. Univariable and multivariable analyses helped identify predictors of oEEG use in routine clinical care. RESULTS Among 507 patients, 83 (16.4%) underwent oEEG. The independent predictors of oEEG utilization included age (OR = 1.03 [1.01 to 1.05, P = 0.01]), electrographic ASyS on cEEG (OR 3.9 [1.77 to 8.9], P < 0.001), ASMs at discharge (OR 3.6 [1.9 to 6.6], P < 0.001), PSE development (OR 6.6 [3.5 to 12.6], P < 0.001), and follow-up duration (OR = 1.01 [1.002 to 1.02], P = 0.016). Almost 40% of oEEG cohort developed PSE, but only 12% had epileptiform abnormalities. Close to a quarter (23%) of oEEGs were within normal limits. CONCLUSIONS One in six patients with ASyS concern after stroke undergoes oEEG. Electrographic ASyS, PSE development, and ASM at discharge are primary drivers of oEEG use. While PSE drives oEEG use, we need systematic, prospective investigation of outpatient EEG's role as prognostic tool for PSE development.
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Affiliation(s)
- Pradeep Chandan
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
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Punia V, Daruvala S, Dhakar MB, Zafar SF, Rubinos C, Ayub N, Hirsch LJ, Sivaraju A. Immediate and long-term management practices of acute symptomatic seizures and epileptiform abnormalities: A cross-sectional international survey. Epilepsia 2024; 65:909-919. [PMID: 38358383 DOI: 10.1111/epi.17915] [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: 09/19/2023] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVES Acute symptomatic seizures (ASyS) and epileptiform abnormalities (EAs) on electroencephalography (EEG) are commonly encountered following acute brain injury. Their immediate and long-term management remains poorly investigated. We conducted an international survey to understand their current management. METHODS The cross-sectional web-based survey of 21 fixed-response questions was based on a common clinical encounter: convulsive or suspected ASyS following an acute brain injury. Respondents selected the option that best matched their real-world practice. Respondents completing the survey were compared with those who accessed but did not complete it. RESULTS A total of 783 individuals (44 countries) accessed the survey; 502 completed it. Almost everyone used anti-seizure medications (ASMs) for secondary prophylaxis after convulsive or electrographic ASyS (95.4% and 97.2%, respectively). ASM dose escalation after convulsive ASyS depends on continuous EEG (cEEG) findings: most often increased after electrographic seizures (78% of respondents), followed by lateralized periodic discharges (LPDs; 41%) and sporadic epileptiform discharges (sEDs; 17.5%). If cEEG is unrevealing, one in five respondents discontinue ASMs after a week. In the absence of convulsive and electrographic ASyS, a large proportion of respondents start ASMs due to LPD (66.7%) and sED (44%) on cEEG. At hospital discharge, most respondents (85%) continue ASM without dose change. The recommended duration of outpatient ASM use is as follows: 1-3 months (36%), 3-6 months (30%), 6-12 months (13%), >12 months (11%). Nearly one-third of respondents utilized ancillary testing before outpatient ASM taper, most commonly (79%) a <2 h EEG. Approximately half of respondents had driving restrictions recommended for 6 months after discharge. SIGNIFICANCE ASM use for secondary prophylaxis after convulsive and electrographic ASyS is a universal practice and is continued upon discharge. Outpatient care, particularly the ASM duration, varies significantly. Wide practice heterogeneity in managing acute EAs reflects uncertainty about their significance and management. These results highlight the need for a structured outpatient follow-up and optimized care pathway for patients with ASyS.
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Affiliation(s)
- Vineet Punia
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sanaya Daruvala
- Department of Neurology, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Monica B Dhakar
- Department of Neurology, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Clio Rubinos
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Neishay Ayub
- Department of Neurology, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Adithya Sivaraju
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut, USA
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Byrnes M, Thompson NR, Hantus ST, Fesler JR, Ying Z, Ayub N, Rubinos C, Zafar S, Sivaraju A, Punia V. Characteristics and Attendance of Patients Eligible for the PASS Clinic: A Transition of Care Model After Acute Symptomatic Seizures. Neurol Clin Pract 2024; 14:e200232. [PMID: 38213398 PMCID: PMC10781564 DOI: 10.1212/cpj.0000000000200232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/04/2023] [Indexed: 01/13/2024]
Abstract
Background and Objectives Most acute symptomatic seizure (ASyS) patients stay on antiseizure medications (ASM) long-term, despite low epilepsy development risk. The Post-Acute Symptomatic Seizure (PASS) clinic is a transition of care model for ASyS patients who individualize ASM management with the goal of a safe deprescription. We evaluated patients discharged on ASMs after a witnessed or suspected ASyS to analyze their PASS clinic visit attendance and its predictors. Methods A single-center, retrospective cohort study of adults without epilepsy who were discharged from January 1, 2019, to September 30, 2019, on first-time ASMs due to witnessed or suspected ASyS (PASS clinic-eligible). We fit a cause-specific Cox proportional hazards model to analyze factors associated with PASS clinic attendance, which depends on survival in this patient population that has a high early postdischarge mortality (a competing risk). We checked for multicollinearity and the assumption of proportional hazards. Results Among 307 PASS clinic-eligible patients, 95 (30.9%) attended the clinic and 136 (44.3%) died during a median follow-up of 14 months (interquartile range = 2-34). ASyS occurred in 60.2% (convulsive 47%; electrographic 26.7%) of patients. ASMs were continued in the absence of ASyS or epileptiform abnormalities (EAs) in 27% of patients. Multivariable analysis revealed that the presence of EAs (HR = 1.69, 95% CI 1.10-2.59), PASS clinic appointments provided before discharge (HR = 3.39, 95% CI 2.15-5.33), and less frequently noted ASyS etiologies such as autoimmune encephalitis (HR = 2.03, 95% CI 1.07-3.86) were associated with an increased clinic attendance rate. Medicare/Medicaid insurance (HR = 0.43, 95% CI 0.24-0.78, p = 0.005) and the presence of progressive brain injury (i.e., tumors; HR = 0.55, 95% CI 0.32-0.95, p = 0.032) were associated with reduced rate of PASS clinic attendance. Discussion Our real-world data highlight the need for appropriate postdischarge follow-up of ASyS patients, which can be fulfilled by the PASS clinic model. Modest PASS clinic attendance can be significantly improved by adhering to a structured discharge planning process whereby appointments are provided before discharge. Future research comparing patient outcomes, specifically safe ASM discontinuation in a PASS clinic model to routine clinical care, is needed.
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Affiliation(s)
- MarieElena Byrnes
- Epilepsy Center (MB, STH, JRF, ZY, VP), Neurological Institute; Department of Quantitative Health Sciences (NRT), Lerner Research Institute; Center for Outcomes Research and Evaluation (NRT), Neurological Institute, Cleveland Clinic, OH; Rhode Island Hospital (NA), Brown University; University of North Carolina (CR), Chapel Hill; Massachusetts General Hospital (SZ), Harvard University; Yale New Haven Hospital (AS), Yale University
| | - Nicolas R Thompson
- Epilepsy Center (MB, STH, JRF, ZY, VP), Neurological Institute; Department of Quantitative Health Sciences (NRT), Lerner Research Institute; Center for Outcomes Research and Evaluation (NRT), Neurological Institute, Cleveland Clinic, OH; Rhode Island Hospital (NA), Brown University; University of North Carolina (CR), Chapel Hill; Massachusetts General Hospital (SZ), Harvard University; Yale New Haven Hospital (AS), Yale University
| | - Stephen T Hantus
- Epilepsy Center (MB, STH, JRF, ZY, VP), Neurological Institute; Department of Quantitative Health Sciences (NRT), Lerner Research Institute; Center for Outcomes Research and Evaluation (NRT), Neurological Institute, Cleveland Clinic, OH; Rhode Island Hospital (NA), Brown University; University of North Carolina (CR), Chapel Hill; Massachusetts General Hospital (SZ), Harvard University; Yale New Haven Hospital (AS), Yale University
| | - Jessica R Fesler
- Epilepsy Center (MB, STH, JRF, ZY, VP), Neurological Institute; Department of Quantitative Health Sciences (NRT), Lerner Research Institute; Center for Outcomes Research and Evaluation (NRT), Neurological Institute, Cleveland Clinic, OH; Rhode Island Hospital (NA), Brown University; University of North Carolina (CR), Chapel Hill; Massachusetts General Hospital (SZ), Harvard University; Yale New Haven Hospital (AS), Yale University
| | - Zhong Ying
- Epilepsy Center (MB, STH, JRF, ZY, VP), Neurological Institute; Department of Quantitative Health Sciences (NRT), Lerner Research Institute; Center for Outcomes Research and Evaluation (NRT), Neurological Institute, Cleveland Clinic, OH; Rhode Island Hospital (NA), Brown University; University of North Carolina (CR), Chapel Hill; Massachusetts General Hospital (SZ), Harvard University; Yale New Haven Hospital (AS), Yale University
| | - Neishay Ayub
- Epilepsy Center (MB, STH, JRF, ZY, VP), Neurological Institute; Department of Quantitative Health Sciences (NRT), Lerner Research Institute; Center for Outcomes Research and Evaluation (NRT), Neurological Institute, Cleveland Clinic, OH; Rhode Island Hospital (NA), Brown University; University of North Carolina (CR), Chapel Hill; Massachusetts General Hospital (SZ), Harvard University; Yale New Haven Hospital (AS), Yale University
| | - Clio Rubinos
- Epilepsy Center (MB, STH, JRF, ZY, VP), Neurological Institute; Department of Quantitative Health Sciences (NRT), Lerner Research Institute; Center for Outcomes Research and Evaluation (NRT), Neurological Institute, Cleveland Clinic, OH; Rhode Island Hospital (NA), Brown University; University of North Carolina (CR), Chapel Hill; Massachusetts General Hospital (SZ), Harvard University; Yale New Haven Hospital (AS), Yale University
| | - Sahar Zafar
- Epilepsy Center (MB, STH, JRF, ZY, VP), Neurological Institute; Department of Quantitative Health Sciences (NRT), Lerner Research Institute; Center for Outcomes Research and Evaluation (NRT), Neurological Institute, Cleveland Clinic, OH; Rhode Island Hospital (NA), Brown University; University of North Carolina (CR), Chapel Hill; Massachusetts General Hospital (SZ), Harvard University; Yale New Haven Hospital (AS), Yale University
| | - Adithya Sivaraju
- Epilepsy Center (MB, STH, JRF, ZY, VP), Neurological Institute; Department of Quantitative Health Sciences (NRT), Lerner Research Institute; Center for Outcomes Research and Evaluation (NRT), Neurological Institute, Cleveland Clinic, OH; Rhode Island Hospital (NA), Brown University; University of North Carolina (CR), Chapel Hill; Massachusetts General Hospital (SZ), Harvard University; Yale New Haven Hospital (AS), Yale University
| | - Vineet Punia
- Epilepsy Center (MB, STH, JRF, ZY, VP), Neurological Institute; Department of Quantitative Health Sciences (NRT), Lerner Research Institute; Center for Outcomes Research and Evaluation (NRT), Neurological Institute, Cleveland Clinic, OH; Rhode Island Hospital (NA), Brown University; University of North Carolina (CR), Chapel Hill; Massachusetts General Hospital (SZ), Harvard University; Yale New Haven Hospital (AS), Yale University
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Punia V, Li Y, Lapin B, Chandan P, Newey C, Hantus S, Dhakar M, Rubinos C, Zafar S, Sivaraju A, Katzan IL. Impact of acute symptomatic seizures and their management on patient-reported outcomes after stroke. Epilepsy Behav 2023; 140:109115. [PMID: 36804847 DOI: 10.1016/j.yebeh.2023.109115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/21/2023] [Accepted: 01/27/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE Acute symptomatic seizures (ASyS) after stroke are not uncommon. However, the impact of ASyS and its management with anti-seizure medications (ASMs) on patient-reported outcome measures (PROMs) remains poorly investigated. The objective of our study is to evaluate the association between PROMs and ASyS and ASMs following stroke. METHODS We performed a retrospective cohort study of all stroke patients who underwent inpatient continuous EEG (cEEG) monitoring performed due to suspected ASyS, including the ones with observed convulsive ASyS, from 04/01/2012 to 03/31/2018, who completed PROMs within 6 months of hospital discharge. Patient-reported outcome measures, including one Neuro-QoL and six PROMIS v1.0 domain scales, were completed by patients as the standard of care in ambulatory stroke clinics. Since ASMs are sometimes used without clearly diagnosed ASyS, we performed group comparisons based on ASM status at discharge, irrespective of their ASyS status. T-tests or Wilcoxon rank sum tests compared continuous variables across groups and chi-square tests or Fisher's exact tests were used for categorical variables. RESULTS A total of 508 patients were included in the study [mean age 62.0 ± 14.1 years, 51.6% female; 244 (48.0%) ischemic stroke, 165 (32.5%) intracerebral hemorrhage, and 99 (19.5%) subarachnoid hemorrhage]. A total of 190 (37.4%) patients were discharged on ASMs. At the time of the first PROM, conducted a median of 47 (IQR = 33-78) days after the suspected ASyS, and 162 (31.9%) were on ASMs. ASM use was significantly higher in patients diagnosed with ASyS. Physical Function and Satisfaction with Social Roles and Activities were the most affected health domains. Patient-reported outcome measures were not significantly different between groups based on ASyS (electrographic and/or convulsive), ASM use at hospital discharge, or ASM status on the day of PROM completion. SIGNIFICANCE There were no differences in multiple domain-specific PROMs in patients with recent stroke according to ASyS status or ASM use suggesting the possible lack of the former's sensitivity to detect their impact. Additional research is necessary to determine if there is a need for developing ASyS-specific PROMs.
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Affiliation(s)
- Vineet Punia
- Charles Shor Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States.
| | - Yadi Li
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States; Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Brittany Lapin
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States; Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Pradeep Chandan
- Charles Shor Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Christopher Newey
- Charles Shor Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States; Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Stephen Hantus
- Charles Shor Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Monika Dhakar
- Rhode Island Hospital, Brown University, United States
| | - Clio Rubinos
- University of North Carolina, Chapel Hill, United States
| | - Sahar Zafar
- Massachusetts General Hospital, Harvard University, United States
| | | | - Irene L Katzan
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
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Sanches PR, Tabaeizadeh M, Moura LMVR, Rosenthal ES, Caboclo LO, Hsu J, Patorno E, Westover MB, Zafar SF. Anti-seizure medication treatment and outcomes in acute ischemic stroke patients undergoing continuous EEG monitoring. Neurol Sci 2022; 43:5441-5449. [PMID: 35713732 DOI: 10.1007/s10072-022-06183-9] [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: 04/13/2022] [Accepted: 05/28/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To determine the association of anti-seizure medication (ASM) treatment with outcomes in acute ischemic stroke (AIS) patients undergoing continuous electroencephalography (cEEG). METHODS Retrospective analysis of AIS patients admitted between 2012 and 2019. The following are the inclusion criteria: age ≥ 18 years and ≥ 16 h of cEEG within the first 7 days of admission. ASM treatment exposure was defined as > 48 h of treatment after the first 24 h of cEEG. The primary outcome measure was 90-day mortality, and the secondary outcome was 90-day functional recovery (Modified Ranking Scale 0-3). Propensity scores were used to adjust for baseline covariates and presence of epileptiform abnormalities (seizures, periodic and rhythmic patterns). RESULTS One hundred thirteen patients met the inclusion criteria; 39 (34.5%) were exposed to ASM. ASM treatment was not associated with 90-day mortality (propensity adjusted HR 1.0 [0.31-3.27], p = 0.999) or functional outcomes (adjusted HR 0.99 [0.32-3.02], p = 0.989), compared to no treatment. CONCLUSIONS In our study, ASM treatment in AIS patients with cEEG abnormalities was not significantly associated with a change in 90-day mortality and functional recovery. Larger comparative effectiveness studies are indicated to identify which acute ischemic stroke patients with cEEG abnormalities benefit most from ASM treatment.
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Affiliation(s)
- Paula R Sanches
- Lunder 6 Neurosciences Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Mohammad Tabaeizadeh
- Lunder 6 Neurosciences Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.,Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Lidia M V R Moura
- Lunder 6 Neurosciences Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Eric S Rosenthal
- Lunder 6 Neurosciences Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Luis Otavio Caboclo
- Department of Clinical Neurophysiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - John Hsu
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Brandon Westover
- Lunder 6 Neurosciences Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sahar F Zafar
- Lunder 6 Neurosciences Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Rubinos C, Waters B, Hirsch LJ. Predicting and Treating Post-traumatic Epilepsy. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00727-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Shaker H, Milan A, Alsallom F, Newey C, Hantus S, Punia V. Long-term electro-clinical profile of sudden cardiac arrest survivors. Epilepsia Open 2021; 6:559-568. [PMID: 34181820 PMCID: PMC8408603 DOI: 10.1002/epi4.12516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Recent research has explored the use of continuous EEG (cEEG) monitoring for prognostication of spontaneous cardiac arrest (SCA). However, there is limited literature on the long-term (post-hospital discharge) electrographic findings among SCA survivors and their clinical correlates. Our study aims to fill this critical knowledge gap. METHODS We retrospectively used our EEG database to identify adults (≥18 years) with SCA history who underwent an outpatient laboratory-based EEG between 01/01/2011 and 12/31/2018. After electronic medical records (EMR) review, patients with epilepsy history and unclear/poorly documented SCA history were excluded. Outpatient EEGs were reviewed by authors. Acute EEG findings were extracted from the EEG database and EMR. In addition, we extracted data on acute and long-term neuroimaging findings (CT/MRI), post-SCA seizures, and anti-seizure medications (ASM) status. Descriptive analysis and Fisher's exact test were performed. RESULTS We included 32 SCA survivors (50% women; mean age = 52.1 ± 13.6 years) in the study. During a median clinical follow-up of 28.2 months, 3 patients suffered only clinical seizures, 3 only chronic post-hypoxic myoclonus, and 5 had both [11 (34.4%) in total]. Interictal epileptiform discharges (IEDs) were noted in one-third of the patients, which localized to vertex and frontocentral regions in all but one patient. Five (15.6%) of them did not suffer a clinical seizure despite the presence of EAs. Patients who developed epilepsy were significantly more likely to have abnormal neuroimaging findings [10/11 (90.9%)] during the follow-up compared to the rest of the patients [OR = 25 (95% CI 2.6->100, P = .002)]. Half of the study cohort was taking ASM at the last follow-up. SIGNIFICANCE Our small study reveals a signature location of IEDs in SCA survivors. Neuroimaging abnormalities seem to be a better indicator of epilepsy development, while EEG may reveal markers of potential epileptogenicity in the absence of clinical seizures. Future, larger studies are needed to confirm our findings.
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Affiliation(s)
- Hussam Shaker
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhioUSA
- Epilepsy CenterMercy Health Hauenstein CenterGrand RapidsMichiganUSA
| | - Anna Milan
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhioUSA
| | - Faisal Alsallom
- Beth Israel Deaconess Medical CenterCleveland ClinicClevelandOHUSA
| | - Christopher Newey
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhioUSA
- Cerebrovascular CenterNeurological InstituteCleveland ClinicClevelandOHUSA
- Center for Clinical Artificial IntelligenceCleveland ClinicClevelandOHUSA
| | - Stephen Hantus
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhioUSA
| | - Vineet Punia
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhioUSA
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Punia V, Honomichl R, Chandan P, Ellison L, Thompson N, Sivaraju A, Katzan I, George P, Newey C, Hantus S. Long-term continuation of anti-seizure medications after acute stroke. Ann Clin Transl Neurol 2021; 8:1857-1866. [PMID: 34355539 PMCID: PMC8419404 DOI: 10.1002/acn3.51440] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/01/2021] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
Objective To investigate the factors associated with the long‐term continuation of anti‐seizure medications (ASMs) in acute stroke patients. Methods We performed a retrospective cohort study of stroke patients with concern for acute symptomatic seizures (ASySs) during hospitalization who subsequently visited the poststroke clinic. All patients had continuous EEG (cEEG) monitoring. We generated a multivariable logistic regression model to analyze the factors associated with the primary outcome of continued ASM use after the first poststroke clinic visit. Results A total of 507 patients (43.4% ischemic stroke, 35.7% intracerebral hemorrhage, and 20.9% aneurysmal subarachnoid hemorrhage) were included. Among them, 99 (19.5%) suffered from ASySs, 110 (21.7%) had epileptiform abnormalities (EAs) on cEEG, and 339 (66.9%) had neither. Of the 294 (58%) patients started on ASMs, 171 (33.7%) were discharged on them, and 156 (30.3% of the study population; 53.1% of patients started on ASMs) continued ASMs beyond the first poststroke clinic visit [49.7 (±31.7) days after cEEG]. After adjusting for demographical, stroke‐ and hospitalization‐related variables, the only independent factors associated with the primary outcome were admission to the NICU [Odds ratio (OR) 0.37 (95% CI 0.15–0.9)], the presence of ASySs [OR 20.31(95% CI 9.45–48.43)], and EAs on cEEG [OR 2.26 (95% CI 1.14–4.58)]. Interpretation Almost a third of patients with poststroke ASySs concerns may continue ASMs for the long term, including more than half started on them acutely. Admission to the NICU may lower the odds, and ASySs (convulsive or electrographic) and EAs on cEEG significantly increase the odds of long‐term ASM use.
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Affiliation(s)
- Vineet Punia
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ryan Honomichl
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pradeep Chandan
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lisa Ellison
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicolas Thompson
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adithya Sivaraju
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Irene Katzan
- Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pravin George
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Chris Newey
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stephen Hantus
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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