Electroencephalogram in the intensive care unit: a focused look at acute brain injury

Indications, results and consequences of electroencephalography in neurocritical care: A retrospective study

PURPOSE

Electrocencephalography (EEG) is a tool to assess cerebral cortical activity. We investigated the indications and results of routine EEG recordings in neurocritical care patients and corresponding changes in anti-seizure medication (ASM).

MATERIALS AND METHODS

This was a single-center, retrospective cohort study. We included all adult Intensive Care Unit (ICU) patients with severe acute brain injury who received a routine EEG (30-60 min). Indications, background patterns, presence of rhythmic and periodic patterns, seizures, and adjustments in ASM were documented.

RESULTS

A total of 109 patients were included. The EEGs were performed primarily to investigate the presence of (non-convulsive) status epilepticus ((NC)SE) and/or seizures. A (slowed) continuous background pattern was present in 94%. Low voltage, burst-suppression and suppressed background patterns were found in six patients (5.5%). Seizures were diagnosed in two patients and (NC)SE was diagnosed in five patients (6.4%). Based on the EEG results, ASM was changed in 47 patients (43%). This encompassed discontinuation of ASM in 27 patients (24.8%) and initiation of ASM in 20 patients (18.3%).

CONCLUSIONS

All EEGs were performed to investigate the presence of (NC)SE or seizures. A slowed, but continuous background pattern was found in nearly all patients and (NC)SE and seizures were rarely diagnosed. Adjustments in ASM were made in approximately half of the patients.

Optimizing anesthesia management based on early identification of electroencephalogram burst suppression risk in non-cardiac surgery patients: a visualized dynamic nomogram

BACKGROUND

Burst suppression (BS) is a specific electroencephalogram (EEG) pattern that may contribute to postoperative delirium and negative outcomes. Few prediction models of BS are available and some factors such as frailty and intraoperative hypotension (IOH) which have been reported to promote the occurrence of BS were not included. Therefore, we look forward to creating a straightforward, precise, and clinically useful prediction model by incorporating new factors, such as frailty and IOH.

MATERIALS AND METHODS

We retrospectively collected 540 patients and analyzed the data from 418 patients. Univariate analysis and backward stepwise logistic regression were used to select risk factors to develop a dynamic nomogram model, and then we developed a web calculator to visualize the process of prediction. The performance of the nomogram was evaluated in terms of discrimination, calibration, and clinical utility.

RESULTS

According to the receiver operating characteristic (ROC) analysis, the nomogram showed good discriminative ability (AUC = 0.933) and the Hosmer-Lemeshow goodness-of-fit test demonstrated the nomogram had good calibration (p = 0.0718). Age, Clinical Frailty Scale (CFS) score, midazolam dose, propofol induction dose, total area under the hypotensive threshold of mean arterial pressure (MAP_AUT), and cerebrovascular diseases were the independent risk predictors of BS and used to construct nomogram. The web-based dynamic nomogram calculator was accessible by clicking on the URL: https://eegbsnomogram.shinyapps.io/dynnomapp/ or scanning a converted Quick Response (QR) code.

CONCLUSIONS

Incorporating two distinctive new risk factors, frailty and IOH, we firstly developed a visualized nomogram for accurately predicting BS in non-cardiac surgery patients. The model is expected to guide clinical decision-making and optimize anesthesia management.

Antiseizure Medication Use and Outcomes After Suspected or Confirmed Acute Symptomatic Seizures

Importance

Antiseizure medications (ASMs) are frequently prescribed for acute symptomatic seizures and epileptiform abnormalities (EAs; eg, periodic or rhythmic patterns). There are limited data on factors associated with ASM use and their association with outcomes.

Objectives

To determine factors associated with ASM use in patients with confirmed or suspected acute symptomatic seizures undergoing continuous electroencephalography, and to explore the association of ASMs with outcomes.

Design, Setting, and Participants

This multicenter cohort study was performed between July 1 and September 30, 2021, at 5 US centers of the Post Acute Symptomatic Seizure Investigation and Outcomes Network. After screening 1717 patients, the study included 1172 hospitalized adults without epilepsy who underwent continuous electroencephalography after witnessed or suspected acute symptomatic seizures. Data analysis was performed from November 14, 2023, to February 2, 2024.

Exposure

ASM treatment (inpatient ASM continuation ≥48 hours).

Main Outcomes and Measures

Factors associated with (1) ASM treatment, (2) discharge ASM prescription, and (3) discharge and 3-month Glasgow Outcome Scale score of 4 or 5 were ascertained.

Results

A total of 1172 patients (median [IQR] age, 64 [52-75] years; 528 [45%] female) were included. Among them, 285 (24%) had clinical acute symptomatic seizures, 107 (9%) had electrographic seizures, and 364 (31%) had EAs; 532 (45%) received ASM treatment. Among 922 patients alive at discharge, 288 (31%) were prescribed ASMs. The respective frequencies of inpatient ASM treatment and discharge prescription were 82% (233 of 285) and 69% (169 of 246) for patients with clinical acute symptomatic seizures, 96% (103 of 107) and 95% (61 of 64) for electrographic seizures, and 64% (233 of 364) and 48% (128 of 267) for EAs. On multivariable analysis, acute and progressive brain injuries were independently associated with increased odds of inpatient ASM treatment (odds ratio [OR], 3.86 [95% CI, 2.06-7.32] and 8.37 [95% CI, 3.48-20.80], respectively) and discharge prescription (OR, 2.26 [95% CI, 1.04-4.98] and 10.10 [95% CI, 3.94-27.00], respectively). Admission to the neurology or neurosurgery service (OR, 2.56 [95% CI, 1.08-6.18]) or to the neurological intensive care unit (OR, 7.98 [95% CI, 3.49-19.00]) was associated with increased odds of treatment. Acute symptomatic seizures and EAs were significantly associated with increased odds of ASM treatment (OR, 14.30 [95% CI, 8.52-24.90] and 2.30 [95% CI, 1.47-3.61], respectively) and discharge prescription (OR, 12.60 [95% CI, 7.37-22.00] and 1.72 [95% CI, 1.00-2.97], respectively). ASM treatment was not associated with outcomes at discharge (OR, 0.96 [95% CI, 0.61-1.52]) or at 3 months after initial presentation (OR, 1.26 [95% CI, 0.78-2.04]). Among 623 patients alive and with complete data at 3 months after discharge, 30 (5%) had postdischarge seizures, 187 (30%) were receiving ASMs, and 202 (32%) had all-cause readmissions.

Conclusions and Relevance

This study suggests that etiology and electrographic findings are associated with ASM treatment for acute symptomatic seizures and EAs; ASM treatment was not associated with functional outcomes. Comparative effectiveness studies are indicated to identify which patients may benefit from ASMs and to determine the optimal treatment duration.

Epidemiology of Seizures and Association With Mortality in Adult Patients Undergoing ECMO: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) provides lifesaving support to patients with cardiopulmonary failure. Although seizures increase mortality risks among critically ill patients broadly, studies specific to adult ECMO patients have largely been limited to single-center studies. Thus, we aimed to perform a systematic review and meta-analyses of seizure prevalence, mortality, and their associations in adult ECMO patients.

METHODS

PubMed, EMBASE, Cochrane trial registry, Web of Science, and SCOPUS were searched on August 5, 2023. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we included studies of adults undergoing venovenous ECMO (VV-ECMO), venoarterial ECMO (VA-ECMO), or extracorporeal cardiopulmonary resuscitation (ECPR) that reported seizures during ECMO. The extracted data included study characteristics, patient demographics, ECMO support, EEG monitoring, and seizures, organized by ECMO types. Forest plot and meta-regression analyses were performed. Bias assessment was performed with the Egger test and Newcastle-Ottawa Scale.

RESULTS

Twenty-three studies (n = 40,420, mean age = 51.8 years, male = 62%) were included. Data were extracted by ECMO type as follows: VV-ECMO (n = 16,633), non-ECPR VA-ECMO (n = 11,082), ECPR (n = 3,369), combination of VA-ECMO and ECPR (n = 240), and combination of all types (n = 9,096). The pooled seizure prevalence for all ECMO types was 3.0%, not significantly different across ECMO types (VV-ECMO = 2.0% [95% CI 0.8-4.5]; VA-ECMO = 3.5% [95% CI 1.7-7.0]; ECPR = 4.9% [95% CI 1.3-17.2]). The pooled mortality was lower for VV-ECMO (46.2% [95% CI 39.3-53.2]) than VA-ECMO (63.4% [95% CI 56.6-69.6]) and ECPR (61.5% [95% CI 57.3-65.6]). Specifically, for VV-ECMO, the pooled mortality of patients with and without seizures was 55.1% and 36.7%, respectively (relative risk = 1.5 [95% CI 1.3-1.7]). Similarly, for VA-ECMO, the pooled mortality of patients with and without seizures was 74.4% and 56.1%, respectively (relative risk = 1.3 [95% CI 1.2-1.5]). Meta-regression analyses demonstrated that seizure prevalence was not associated with prior neurologic comorbidities, adjusted for ECMO type and study year.

DISCUSSION

Seizures are infrequent during ECMO support. However, they were associated with increased mortality when present. Multi-institutional, larger-scale studies using standardized EEG monitoring are necessary to further understand the risk factors of specific classes of seizures for individual ECMO types, and their effects on mortality. Limitations of our study include missing data for details on seizure types, sedating/antiseizure medications used during ECMO, other ECMO-related complications, and EEG recording protocols.

Non-invasive technology for brain monitoring: definition and meaning of the principal parameters for the International PRactice On TEChnology neuro-moniToring group (I-PROTECT)

Technologies for monitoring organ function are rapidly advancing, aiding physicians in the care of patients in both operating rooms (ORs) and intensive care units (ICUs). Some of these emerging, minimally or non-invasive technologies focus on monitoring brain function and ensuring the integrity of its physiology. Generally, the central nervous system is the least monitored system compared to others, such as the respiratory, cardiovascular, and renal systems, even though it is a primary target in most therapeutic strategies. Frequently, the effects of sedatives, hypnotics, and analgesics are entirely unpredictable, especially in critically ill patients with multiple organ failure. This unpredictability exposes them to the risks of inadequate or excessive sedation/hypnosis, potentially leading to complications and long-term negative outcomes. The International PRactice On TEChnology neuro-moniToring group (I-PROTECT), comprised of experts from various fields of clinical neuromonitoring, presents this document with the aim of reviewing and standardizing the primary non-invasive tools for brain monitoring in anesthesia and intensive care practices. The focus is particularly on standardizing the nomenclature of different parameters generated by these tools. The document addresses processed electroencephalography, continuous/quantitative electroencephalography, brain oxygenation through near-infrared spectroscopy, transcranial Doppler, and automated pupillometry. The clinical utility of the key parameters available in each of these tools is summarized and explained. This comprehensive review was conducted by a panel of experts who deliberated on the included topics until a consensus was reached. Images and tables are utilized to clarify and enhance the understanding of the clinical significance of non-invasive neuromonitoring devices within these medical settings.

Feasibility, Safety, and Performance of Full-Head Subscalp EEG Using Minimally Invasive Electrode Implantation

BACKGROUND AND OBJECTIVES

Current practice in clinical neurophysiology is limited to short recordings with conventional EEG (days) that fail to capture a range of brain (dys)functions at longer timescales (months). The future ability to optimally manage chronic brain disorders, such as epilepsy, hinges upon finding methods to monitor electrical brain activity in daily life. We developed a device for full-head subscalp EEG (Epios) and tested here the feasibility to safely insert the electrode leads beneath the scalp by a minimally invasive technique (primary outcome). As secondary outcome, we verified the noninferiority of subscalp EEG in measuring physiologic brain oscillations and pathologic discharges compared with scalp EEG, the established standard of care.

METHODS

Eight participants with pharmacoresistant epilepsy undergoing intracranial EEG received in the same surgery subscalp electrodes tunneled between the scalp and the skull with custom-made tools. Postoperative safety was monitored on an inpatient ward for up to 9 days. Sleep-wake, ictal, and interictal EEG signals from subscalp, scalp, and intracranial electrodes were compared quantitatively using windowed multitaper transforms and spectral coherence. Noninferiority was tested for pairs of neighboring subscalp and scalp electrodes with a Bland-Altman analysis for measurement bias and calculation of the interclass correlation coefficient (ICC).

RESULTS

As primary outcome, up to 28 subscalp electrodes could be safely placed over the entire head through 1-cm scalp incisions in a ∼1-hour procedure. Five of 10 observed perioperative adverse events were linked to the investigational procedure, but none were serious, and all resolved. As a secondary outcome, subscalp electrodes advantageously recorded EEG percutaneously without requiring any maintenance and were noninferior to scalp electrodes for measuring (1) variably strong, stage-specific brain oscillations (alpha in wake, delta, sigma, and beta in sleep) and (2) interictal spikes peak-potentials and ictal signals coherent with seizure propagation in different brain regions (ICC >0.8 and absence of bias).

DISCUSSION

Recording full-head subscalp EEG for localization and monitoring purposes is feasible up to 9 days in humans using minimally invasive techniques and noninferior to the current standard of care. A longer prospective ambulatory study of the full system will be necessary to establish the safety and utility of this innovative approach.

TRIAL REGISTRATION INFORMATION

clinicaltrials.gov/study/NCT04796597.

The Neurocritical Care Examination and Workup

OBJECTIVE

This article provides an overview of the evaluation of patients in neurocritical care settings and a structured approach to recognizing and localizing acute neurologic emergencies, performing a focused examination, and pursuing workup to identify critical findings requiring urgent management.

LATEST DEVELOPMENTS

After identifying and stabilizing imminent threats to survival, including respiratory and hemodynamic compromise, the initial differential diagnosis for patients in neurocritical care is built on a focused history and clinical examination, always keeping in mind critical "must-not-miss" pathologies. A key priority is to identify processes warranting time-sensitive therapeutic interventions, including signs of elevated intracranial pressure and herniation, acute neurovascular emergencies, clinical or subclinical seizures, infections of the central nervous system, spinal cord compression, and acute neuromuscular respiratory failure. Prompt neuroimaging to identify structural abnormalities should be obtained, complemented by laboratory findings to assess for underlying systemic causes. The indication for EEG and lumbar puncture should be considered early based on clinical suspicion.

ESSENTIAL POINTS

In neurocritical care, the initial evaluation is often fast paced, requiring assessment and management to happen in parallel. History, clinical examination, and workup should be obtained while considering therapeutic implications and the need for lifesaving interventions.

Successful Diagnosis of Neuroleptic Malignant Syndrome in an Unconscious Patient Using Amplitude-Integrated Electroencephalography: A Case Report

Neuroleptic malignant syndrome (NMS) is a rare but life-threatening medical condition often characterized by altered consciousness and clinical features resembling seizures. This case report presents a unique and successful diagnosis of NMS in an unconscious patient with an unknown medical history. We demonstrate the potential utility of amplitude-integrated electroencephalography (aEEG) as a valuable tool for the differential diagnosis of seizure-like medical conditions, including NMS. The application of aEEG allowed for early diagnosis and prompt initiation of appropriate treatment, potentially contributing to improved patient outcomes.

Resting-State EEG Signature of Early Consciousness Recovery in Comatose Patients with Traumatic Brain Injury

BACKGROUND

Resting-state electroencephalography (rsEEG) is usually obtained to assess seizures in comatose patients with traumatic brain injury (TBI). We aim to investigate rsEEG measures and their prediction of early recovery of consciousness in patients with TBI.

METHODS

This is a retrospective study of comatose patients with TBI who were admitted to a trauma center (October 2013 to January 2022). Demographics, basic clinical data, imaging characteristics, and EEGs were collected. We calculated the following using 10-min rsEEGs: power spectral density, permutation entropy (complexity measure), weighted symbolic mutual information (wSMI, global information sharing measure), Kolmogorov complexity (Kolcom, complexity measure), and heart-evoked potentials (the averaged EEG signal relative to the corresponding QRS complex on electrocardiography). We evaluated the prediction of consciousness recovery before hospital discharge using clinical, imaging, and rsEEG data via a support vector machine.

RESULTS

We studied 113 of 134 (84%) patients with rsEEGs. A total of 73 (65%) patients recovered consciousness before discharge. Patients who recovered consciousness were younger (40 vs. 50 years, p = 0.01). Patients who recovered also had higher Kolcom (U = 1688, p = 0.01), increased beta power (U = 1,652 p = 0.003) with higher variability across channels (U = 1534, p = 0.034) and epochs (U = 1711, p = 0.004), lower delta power (U = 981, p = 0.04), and higher connectivity across time and channels as measured by wSMI in the theta band (U = 1636, p = 0.026; U = 1639, p = 0.024) than those who did not recover. The area under the receiver operating characteristic curve for rsEEG was higher than that for clinical data (using age, motor response, pupil reactivity) and higher than that for the Marshall computed tomography classification (0.69 vs. 0.66 vs. 0.56, respectively; p < 0.001).

CONCLUSIONS

We describe the rsEEG signature in recovery of consciousness prior to discharge in comatose patients with TBI. rsEEG measures performed modestly better than the clinical and imaging data in predicting recovery.

Prognostic value of early EEG abnormalities in severe stroke patients requiring mechanical ventilation: a pre-planned analysis of the SPICE prospective multicenter study

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.

Challenges and Prospects in Epilepsy Monitoring Units: A Comprehensive Review of Logistic Barriers

Epilepsy is one of the most common neurological diseases with a prevalence ranging from 0.5% to 2% in different sittings. The World Health Organization (WHO) estimated that nearly 80% of this burden is borne by resource-poor countries where even conventional electroencephalogram (EEG) coverage is dramatically short.  Video EEG monitoring applied for days as conducted in epilepsy monitoring units (EMUs) is aimed at seizure localization, anti-seizure medication (ASM) adjustment, or epilepsy surgery evaluation and planning. However, the EEG approach in EMUs has its obstacles. The present article is aimed to concentrate on the logistic challenges of EMUs, discussing existing data and limitations and offering suggestions for future planning to enhance the utilization of existing technology. Shortages of adult and pediatric epileptologists, qualified nurses, as well as EEG technologists have been reported in different countries. Moreover, injuries and falls, psychosis, status epilepticus, and unexpected death have been stated to be the most frequent safety issues in EMUs. Enhancements to mitigate logistical and healthcare system-related barriers in EMUs include the implementation of large cohort studies and the utilization of artificial intelligence (AI) for the identification and categorization of specific risks among EMU admissions. The establishment of EMUs and their associated challenges and barriers are best acknowledged through discussions and dialogue with various stakeholders.

The Evolving Role of Electroencephalography in Postarrest Care

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.

Neuromonitoring in the ICU - what, how and why?

PURPOSE OF REVIEW

We selectively review emerging noninvasive neuromonitoring techniques and the evidence that supports their use in the ICU setting. The focus is on neuromonitoring research in patients with acute brain injury.

RECENT FINDINGS

Noninvasive intracranial pressure evaluation with optic nerve sheath diameter measurements, transcranial Doppler waveform analysis, or skull mechanical extensometer waveform recordings have potential safety and resource-intensity advantages when compared to standard invasive monitors, however each of these techniques has limitations. Quantitative electroencephalography can be applied for detection of cerebral ischemia and states of covert consciousness. Near-infrared spectroscopy may be leveraged for cerebral oxygenation and autoregulation computation. Automated quantitative pupillometry and heart rate variability analysis have been shown to have diagnostic and/or prognostic significance in selected subtypes of acute brain injury. Finally, artificial intelligence is likely to transform interpretation and deployment of neuromonitoring paradigms individually and when integrated in multimodal paradigms.

SUMMARY

The ability to detect brain dysfunction and injury in critically ill patients is being enriched thanks to remarkable advances in neuromonitoring data acquisition and analysis. Studies are needed to validate the accuracy and reliability of these new approaches, and their feasibility and implementation within existing intensive care workflows.

Multimodal neuromonitoring in the pediatric intensive care unit

Neuromonitoring is used to assess the central nervous system in the intensive care unit. The purpose of neuromonitoring is to detect neurologic deterioration and intervene to prevent irreversible nervous system dysfunction. Neuromonitoring starts with the standard neurologic examination, which may lag behind the pathophysiologic changes. Additional modalities including continuous electroencephalography (CEEG), multiple physiologic parameters, and structural neuroimaging may detect changes earlier. Multimodal neuromonitoring now refers to an integrated combination and display of non-invasive and invasive modalities, permitting tailored treatment for the individual patient. This chapter reviews the non-invasive and invasive modalities used in pediatric neurocritical care.

"NeuroVanguard": a contemporary strategy in neuromonitoring for severe adult brain injury patients

Severe acute brain injuries, stemming from trauma, ischemia or hemorrhage, remain a significant global healthcare concern due to their association with high morbidity and mortality rates. Accurate assessment of secondary brain injuries severity is pivotal for tailor adequate therapies in such patients. Together with neurological examination and brain imaging, monitoring of systemic secondary brain injuries is relatively straightforward and should be implemented in all patients, according to local resources. Cerebral secondary injuries involve factors like brain compliance loss, tissue hypoxia, seizures, metabolic disturbances and neuroinflammation. In this viewpoint, we have considered the combination of specific noninvasive and invasive monitoring tools to better understand the mechanisms behind the occurrence of these events and enhance treatment customization, such as intracranial pressure monitoring, brain oxygenation assessment and metabolic monitoring. These tools enable precise intervention, contributing to improved care quality for severe brain injury patients. The future entails more sophisticated technologies, necessitating knowledge, interdisciplinary collaboration and resource allocation, with a focus on patient-centered care and rigorous validation through clinical trials.

Combined depth and scalp electroencephalographic monitoring in acute brain injury: Yield and prognostic value

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.

Acute encephalopathy in the ICU: a practical approach

PURPOSE OF REVIEW

Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury.

RECENT FINDINGS

Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes.

SUMMARY

Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.

Status epilepticus: what's new for the intensivist

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.

Neuromonitoring of Pediatric and Adult Extracorporeal Membrane Oxygenation Patients: The Importance of Continuous Bedside Tools in Driving Neuroprotective Clinical Care

Extracorporeal membrane oxygenation (ECMO) is a form of temporary cardiopulmonary bypass for patients with acute respiratory or cardiac failure refractory to conventional therapy. Its usage has become increasingly widespread and while reported survival after ECMO has increased in the past 25 years, the incidence of neurological injury has not declined, leading to the pressing question of how to improve time-to-detection and diagnosis of neurological injury. The neurological status of patients on ECMO is clinically difficult to evaluate due to multiple factors including illness, sedation, and pharmacological paralysis. Thus, increasing attention has been focused on developing tools and techniques to measure and monitor the brain of ECMO patients to identify dynamic risk factors and monitor patients' neurophysiological state as a function in time. Such tools may guide neuroprotective interventions and thus prevent or mitigate brain injury. Current means to continuously monitor and prevent neurological injury in ECMO patients are rather limited; most techniques provide indirect or postinsult recognition of irreversible brain injury. This review will explore the indications, advantages, and disadvantages of standard-of-care, emerging, and investigational technologies for neurological monitoring on ECMO, focusing on bedside techniques that provide continuous assessment of neurological health.

Quantitative Electroencephalographic Changes Associated With Brain Tissue Hypoxia After Pediatric Traumatic Brain Injury: A Retrospective Exploratory Analysis

PURPOSE

Brain tissue hypoxia is associated with poor outcomes after pediatric traumatic brain injury. Although invasive brain oxygenation (PbtO 2 ) monitoring is available, noninvasive methods assessing correlates to brain tissue hypoxia are needed. We investigated EEG characteristics associated with brain tissue hypoxia.

METHODS

We performed a retrospective analysis of 19 pediatric traumatic brain injury patients undergoing multimodality neuromonitoring that included PbtO 2 and quantitative electroencephalography(QEEG). Quantitative electroencephalography characteristics were analyzed over electrodes adjacent to PbtO 2 monitoring and over the entire scalp, and included power in alpha and beta frequencies and the alpha-delta power ratio. To investigate relationships of PbtO 2 to quantitative electroencephalography features using time series data, we fit linear mixed effects models with a random intercept for each subject and one fixed effect, and an auto-regressive order of 1 to model between-subject variation and correlation for within-subject observations. Least squares (LS) means were used to investigate for fixed effects of quantitative electroencephalography features to changes in PbtO 2 across thresholds of 10, 15, 20, and 25 mm Hg.

RESULTS

Within the region of PbtO 2 monitoring, changes in PbtO 2 < 10 mm Hg were associated with reductions of alpha-delta power ratio (LS mean difference -0.01, 95% confidence interval (CI) [-0.02, -0.00], p = 0.0362). Changes in PbtO 2 < 25 mm Hg were associated with increases in alpha power (LS mean difference 0.04, 95% CI [0.01, 0.07], p = 0.0222).

CONCLUSIONS

Alpha-delta power ratio changes are observed across a PbtO 2 threshold of 10 mm Hg within regions of PbtO 2 monitoring, which may reflect an EEG signature of brain tissue hypoxia after pediatric traumatic brain injury.

Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group in the Pediatric Population

BACKGROUND

The fundamental gap obstructing forward progress of evidenced-based care in pediatric and neonatal disorders of consciousness (DoC) is the lack of defining consensus-based terminology to perform comparative research. This lack of shared nomenclature in pediatric DoC stems from the inherently recursive dilemma of the inability to reliably measure consciousness in the very young. However, recent advancements in validated clinical examinations and technologically sophisticated biomarkers of brain activity linked to future abilities are unlocking this previously formidable challenge to understanding the DoC in the developing brain.

METHODS

To address this need, the first of its kind international convergence of an interdisciplinary team of pediatric DoC experts was organized by the Neurocritical Care Society's Curing Coma Campaign. The multidisciplinary panel of pediatric DoC experts proposed pediatric-tailored common data elements (CDEs) covering each of the CDE working groups including behavioral phenotyping, biospecimens, electrophysiology, family and goals of care, neuroimaging, outcome and endpoints, physiology and big Data, therapies, and pediatrics.

RESULTS

We report the working groups' pediatric-focused DoC CDE recommendations and disseminate CDEs to be used in studies of pediatric patients with DoC.

CONCLUSIONS

The CDEs recommended support the vision of progressing collaborative and successful internationally collaborative pediatric coma research.

Reliable and fast automatic artifact rejection of Long-Term EEG recordings based on Isolation Forest

Long-term electroencephalogram (Long-Term EEG) has the capacity to monitor over a long period, making it a valuable tool in medical institutions. However, due to the large volume of patient data, selecting clean data segments from raw Long-Term EEG for further analysis is an extremely time-consuming and labor-intensive task. Furthermore, the various actions of patients during recording make it difficult to use algorithms to denoise part of the EEG data, and thus lead to the rejection of these data. Therefore, tools for the quick rejection of heavily corrupted epochs in Long-Term EEG records are highly beneficial. In this paper, a new reliable and fast automatic artifact rejection method for Long-Term EEG based on Isolation Forest (IF) is proposed. Specifically, the IF algorithm is repetitively applied to detect outliers in the EEG data, and the boundary of inliers is promptly adjusted by using a statistical indicator to make the algorithm proceed in an iterative manner. The iteration is terminated when the distance metric between clean epochs and artifact-corrupted epochs remains unchanged. Six statistical indicators (i.e., min, max, median, mean, kurtosis, and skewness) are evaluated by setting them as centroid to adjust the boundary during iteration, and the proposed method is compared with several state-of-the-art methods on a retrospectively collected dataset. The experimental results indicate that utilizing the min value of data as the centroid yields the most optimal performance, and the proposed method is highly efficacious and reliable in the automatic artifact rejection of Long-Term EEG, as it significantly improves the overall data quality. Furthermore, the proposed method surpasses compared methods on most data segments with poor data quality, demonstrating its superior capacity to enhance the data quality of the heavily corrupted data. Besides, owing to the linear time complexity of IF, the proposed method is much faster than other methods, thus providing an advantage when dealing with extensive datasets.

Resting-State EEG Signature of Early Consciousness Recovery in Comatose Traumatic Brain Injury Patients

Background Resting-state electroencephalogram (rsEEG) is usually obtained to assess seizures in comatose patients with traumatic brain injury (TBI) patients. We aim to investigate rsEEG measures and their prediction of early recovery of consciousness in comatose TBI patients. Methods This is a retrospective study of comatose TBI patients who were admitted to a level-1 trauma center (10/2013-1/2022). Demographics, basic clinical data, imaging characteristics, and EEG data were collected. We calculated using 10-minute rsEEGs: power spectral density (PSD), permutation entropy (PE - complexity measure), weighted symbolic-mutual-information (wSMI - global information sharing measure), Kolmogorov complexity (Kolcom - complexity measure), and heart-evoked potentials (HEP - the averaged EEG signal relative to the corresponding QRS complex on electrocardiogram). We evaluated the prediction of consciousness recovery before hospital discharge using clinical, imaging, rsEEG data via Support Vector Machine with a linear kernel (SVM). Results We studied 113 (out of 134, 84%) patients with rsEEGs. A total of 73 (65%) patients recovered consciousness before discharge. Patients who recovered consciousness were younger (40 vs. 50, p .01). Patients who recovered consciousness had higher Kolcom (U = 1688, p = 0.01,), increased beta power (U = 1652 p = 0.003), with higher variability across channels ( U = 1534, p = 0.034), and epochs (U = 1711, p = 0.004), lower delta power (U = 981, p = 0.04) and showed higher connectivity across time and channels as measured by wSMI in the theta band (U = 1636, p = .026, U = 1639, p = 0.024) than those who didn't recover. The ROC-AUC improved from 0.66 (using age, motor response, pupils' reactivity, and CT Marshall classification) to 0.69 (p < 0.001) when adding rsEEG measures. Conclusion We describe the rsEEG EEG signature in recovery of consciousness prior to discharge in comatose TBI patients. Resting-state EEG measures improved prediction beyond the clinical and imaging data.

Continuous versus Routine Electroencephalography in the Intensive Care Unit: A Review of Current Evidence

BACKGROUND

Electroencephalography (EEG) has long been used to detect seizures in patients with disorders of consciousness. In recent years, there has been a drastically increased adoption of continuous EEG (cEEG) in the intensive care units (ICUs). Given the resources necessary to record and interpret cEEG, this is still not available in every center and widespread recommendations to use continuous instead of routine EEG (typically lasting 20 min) are still a matter of some debate. Considering recent literature and personal experience, this review offers a rationale and practical advice to address this question.

SUMMARY

Despite the development of increasingly performant imaging techniques and several validated biomarkers, EEG remains central to clinicians in the intensive care unit and has been experiencing expanding popularity for at least 2 decades. Not only does EEG allow seizure or status epilepticus detection, which in the ICU often present without clinical movements, but it is also paramount for the prognostic evaluation of comatose patients, especially after cardiac arrest, and for detecting delayed ischemia after subarachnoid hemorrhage. At the end of the last Century, improvements of technical and digital aspects regarding recording and storage of EEG tracings have progressively led to the era of cEEG and automated quantitative analysis.

KEY MESSAGES

As compared to repeated rEEG, cEEG in comatose patients does not seem to improve clinical prognosis to a relevant extent, despite allowing a more performant of detection ictal events and consequent therapeutic modifications. The choice between cEEG and rEEG must therefore always be patient-tailored.

Quantitative electroencephalography predicts postoperative delirium in cardiac surgical patients after cardiopulmonary bypass: a prospective observational study

Objective

Despite its frequency and associated negative effect, delirium remains poorly recognized in postoperative patients after ICU admission, especially among those who have undergone cardiac surgery with cardiopulmonary bypass. Postoperative delirium is triggered by a wide variety of acute medical conditions associated with impaired neuronal network connectivity. The lack of objective biomarkers primarily hinders the early detection of delirium. Seeking early biomarkers for tracking POD could potentially assist in predicting the onset of delirium and assessing the severity of delirium and response to interventions.

Methods

QEEGs were taken from 46 sedated postoperative patients, with 24 of them having undergone cardiac surgery. The assessment of delirium was performed twice daily using the Confusion Assessment Method for the ICU (CAM-ICU) to screen for postoperative delirium (POD). QEEG data were interpreted clinically by neurophysiologists and processed by open-source EEGLAB to identify features in patients who had or did not have POD after cardiac or non-cardiac surgery.

Results

The incidence of delirium in patients after undergoing cardiac surgery was nine times greater than in those after non-cardiac surgeries (41.7% vs. 4.5%; p = 0.0046). Patients with delirium experienced longer use of mechanical ventilation (118 h (78,323) compared to 20 h (18,23); p < 0.0001) and an extended ICU length of stay (7 days (6, 20) vs. 2 days (2, 4); p < 0.0001). The depth of anesthesia, as measured by RASS scores (p = 0.3114) and spectral entropy (p = 0.1504), showed no significant difference. However, notable differences were observed between delirious and non-delirious patients in terms of the amplitude-integrated EEG (aEEG) upper limit, the relative power of the delta band, and spectral edge frequency 95 (SEF95) (p = 0.0464, p = 0.0417, p = 0.0337, respectively).

Conclusion

In a homogenous population of sedated postoperative patients, robust qEEG parameters strongly correlate with delirium and could serve as valuable biomarkers for early detection of delirium and assist in clinical decision-making.

Valproate-related hyperammonemic encephalopathy with generalized suppression EEG: a case report

BACKGROUND

Valproic acid (VPA) is a prevalent antiseizure medication (ASM) used to treat epilepsy. Valproate-related hyperammonemic encephalopathy (VHE) is a type of encephalopathy that can occur during neurocritical situations. In VHE, the electroencephalogram (EEG) displays diffuse slow waves or periodic waves, and there is no generalized suppression pattern.

CASE PRESENTATION

We present a case of a 29-year-old female with a history of epilepsy who was admitted for convulsive status epilepticus (CSE), which was controlled by intravenous VPA, as well as oral VPA and phenytoin. The patient did not experience further convulsions but instead developed impaired consciousness. Continuous EEG monitoring revealed a generalized suppression pattern, and the patient was unresponsive. The patient's blood ammonia level was significantly elevated at 386.8 μmol/L, indicating VHE. Additionally, the patient's serum VPA level was 58.37 μg/ml (normal range: 50-100 μg/ml). After stopping VPA and phenytoin and transitioning to oxcarbazepine for anti-seizure and symptomatic treatment, the patient's EEG gradually returned to normal, and her consciousness was fully restored.

DISCUSSION

VHE can cause the EEG to display a generalized suppression pattern. It is crucial to recognize this specific situation and not to infer a poor prognosis based on this EEG pattern.

Approaches to neuroprotection in pediatric neurocritical care

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.

Discrepancies in the late auditory potentials of post-anoxic patients: watch out for focal brain lesions, a pilot retrospective study

AIMS

Late auditory evoked potentials, and notably mismatch negativity (MMN) and P3 responses, can be used as part of the multimodal prognostic evaluation in post-anoxic disorders of consciousness (DOC). MMN response preferentially stems from the temporal cortex and the arcuate fasciculus. Situations with discrepant evaluations, for example MMN absent but P3 present, are frequent and difficult to interpret. We hypothesize that discrepant MMN-/P3+ results could reflect a higher prevalence of lesions in MMN generating regions. This study presents correlations between neurophysiological and neuroradiological results.

METHODS

This retrospective study was conducted on 38 post-anoxic DOC patients. Brain lesions were analyzed on 3T MRI both anatomically and through computation of the local arcuate fasciculus fractional anisotropy values on Diffusion Tensor Imaging sequences. Neurophysiological data and outcome were also analyzed.

RESULTS

Our cohort included 8 MMN-/P3+, 7 MMN+/P3+, 21 MMN-/P3- and 2 MMN-/P3+ patients, assessed at a median delay of 20.5 days since cardiac arrest. Our results show that MMN-/P3+ patients tended to have fewer temporal and basal ganglia lesions than MMN-/P3- patients, and more than MMN+/P3+ patients (p-values for trend: p=0.02 for temporal and p=0.02 for basal ganglia lesions). There was a statistical difference across groups for mean fractional anisotropy values in the arcuate fasciculus (p=0.008). The percentage of patients regaining consciousness at three months in MMN-/P3+ patients was higher than in MMN-/P3- patients and lower than in MMN+/P3+ patients.

CONCLUSION

This study suggests that discrepancies in late auditory evoked potentials may be linked to focal post-anoxic brain lesions, visible on brain MRI.

A Novel OpenBCI Framework for EEG-Based Neurophysiological Experiments

An Open Brain-Computer Interface (OpenBCI) provides unparalleled freedom and flexibility through open-source hardware and firmware at a low-cost implementation. It exploits robust hardware platforms and powerful software development kits to create customized drivers with advanced capabilities. Still, several restrictions may significantly reduce the performance of OpenBCI. These limitations include the need for more effective communication between computers and peripheral devices and more flexibility for fast settings under specific protocols for neurophysiological data. This paper describes a flexible and scalable OpenBCI framework for electroencephalographic (EEG) data experiments using the Cyton acquisition board with updated drivers to maximize the hardware benefits of ADS1299 platforms. The framework handles distributed computing tasks and supports multiple sampling rates, communication protocols, free electrode placement, and single marker synchronization. As a result, the OpenBCI system delivers real-time feedback and controlled execution of EEG-based clinical protocols for implementing the steps of neural recording, decoding, stimulation, and real-time analysis. In addition, the system incorporates automatic background configuration and user-friendly widgets for stimuli delivery. Motor imagery tests the closed-loop BCI designed to enable real-time streaming within the required latency and jitter ranges. Therefore, the presented framework offers a promising solution for tailored neurophysiological data processing.

Brain monitoring after cardiac arrest

PURPOSE OF REVIEW

To describe the available neuromonitoring tools in patients who are comatose after resuscitation from cardiac arrest because of hypoxic-ischemic brain injury (HIBI).

RECENT FINDINGS

Electroencephalogram (EEG) is useful for detecting seizures and guiding antiepileptic treatment. Moreover, specific EEG patterns accurately identify patients with irreversible HIBI. Cerebral blood flow (CBF) decreases in HIBI, and a greater decrease with no CBF recovery indicates poor outcome. The CBF autoregulation curve is narrowed and right-shifted in some HIBI patients, most of whom have poor outcome. Parameters derived from near-infrared spectroscopy (NIRS), intracranial pressure (ICP) and transcranial Doppler (TCD), together with brain tissue oxygenation, are under investigation as tools to optimize CBF in patients with HIBI and altered autoregulation. Blood levels of brain biomarkers and their trend over time are used to assess the severity of HIBI in both the research and clinical setting, and to predict the outcome of postcardiac arrest coma. Neuron-specific enolase (NSE) is recommended as a prognostic tool for HIBI in the current postresuscitation guidelines, but other potentially more accurate biomarkers, such as neurofilament light chain (NfL) are under investigation.

SUMMARY

Neuromonitoring provides essential information to detect complications, individualize treatment and predict prognosis in patients with HIBI.

EEG: Current relevance and promising quantitative analyses

Electroencephalography (EEG) remains an essential tool, characterized by an excellent temporal resolution and offering a real window on cerebral functions. Surface EEG signals are mainly generated by the postsynaptic activities of synchronously activated neural assemblies. EEG is also a low-cost tool, easy to use at bed-side, allowing to record brain electrical activities with a low number or up to 256 surface electrodes. For clinical purpose, EEG remains a critical investigation for epilepsies, sleep disorders, disorders of consciousness. Its temporal resolution and practicability also make EEG a necessary tool for cognitive neurosciences and brain-computer interfaces. EEG visual analysis is essential in clinical practice and the subject of recent progresses. Several EEG-based quantitative analyses may complete the visual analysis, such as event-related potentials, source localizations, brain connectivity and microstates analyses. Some developments in surface EEG electrodes appear also, potentially promising for long term continuous EEGs. We overview in this article some recent progresses in visual EEG analysis and promising quantitative analyses.

Prognostication after cardiac arrest: how EEG and evoked potentials may improve the challenge

About 80% of patients resuscitated from CA are comatose at ICU admission and nearly 50% of survivors are still unawake at 72 h. Predicting neurological outcome of these patients is important to provide correct information to patient's relatives, avoid disproportionate care in patients with irreversible hypoxic-ischemic brain injury (HIBI) and inappropriate withdrawal of care in patients with a possible favorable neurological recovery. ERC/ESICM 2021 algorithm allows a classification as "poor outcome likely" in 32%, the outcome remaining "indeterminate" in 68%. The crucial question is to know how we could improve the assessment of both unfavorable but also favorable outcome prediction. Neurophysiological tests, i.e., electroencephalography (EEG) and evoked-potentials (EPs) are a non-invasive bedside investigations. The EEG is the record of brain electrical fields, characterized by a high temporal resolution but a low spatial resolution. EEG is largely available, and represented the most widely tool use in recent survey examining current neuro-prognostication practices. The severity of HIBI is correlated with the predominant frequency and background continuity of EEG leading to "highly malignant" patterns as suppression or burst suppression in the most severe HIBI. EPs differ from EEG signals as they are stimulus induced and represent the summated activities of large populations of neurons firing in synchrony, requiring the average of numerous stimulations. Different EPs (i.e., somato sensory EPs (SSEPs), brainstem auditory EPs (BAEPs), middle latency auditory EPs (MLAEPs) and long latency event-related potentials (ERPs) with mismatch negativity (MMN) and P300 responses) can be assessed in ICU, with different brain generators and prognostic values. In the present review, we summarize EEG and EPs signal generators, recording modalities, interpretation and prognostic values of these different neurophysiological tools. Finally, we assess the perspective for futures neurophysiological investigations, aiming to reduce prognostic uncertainty in comatose and disorders of consciousness (DoC) patients after CA.

Dynamic structures and emerging trends in the management of major trauma: A bibliometric analysis of publications between 2012 and 2021

Objective

Major trauma is currently a global public health issue with a massive impact on health at both the individual and population levels. However, there are limited bibliometric analyses on the management of major trauma. Thus, in this study we aimed to identify global research trends, dynamic structures, and scientific frontiers in the management of major trauma between 2012 and 2021.

Methods

We searched the Web of Science Core Collection to access articles and reviews concerning the management of major traumas and conducted a bibliometric analysis using CiteSpace.

Results

Overall, 2,585 studies were screened and published by 403 institutions from 110 countries/regions. The most productive country and institution in this field of research were the USA and Monash University, respectively. Rolf Lefering was the most prolific researcher and Holcomb JB had the most co-citations. Injury published the highest number of articles, and the Journal of Trauma was the most co-cited journal. A dual-map overlay of the literature showed that the articles of most publications were confined to the areas of medicine/medical/clinical and neurology/sports/ophthalmology. Document clustering indicated severe traumatic brain injury, traumatic coagulopathy, and resuscitative endovascular balloon occlusion as the recent hot topics. The most recent burst keywords were "trauma management," "neurocritical care," "injury severity," and "emergency medical services."

Conclusion

The dynamic structures and emerging trends in the management of major trauma were extensively analyzed using CiteSpace, a visualization software. Based on the analysis, the following research hotspots emerged: management of severe traumatic brain injury and massive hemorrhage, neurocritical care, injury severity, and emergency medical service. Our findings provide pertinent information for future research and contribute toward policy making in this field.