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Andrade-Machado R, Abushanab E, Patel ND, Singh A. Differentiating rhythmic high-amplitude delta with superimposed (poly) spikes from extreme delta brushes: limitations of standardized nomenclature and implications for patient management. World J Pediatr 2024; 20:764-773. [PMID: 38997604 DOI: 10.1007/s12519-024-00816-z] [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: 11/15/2023] [Accepted: 05/03/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND Following the standardized nomenclature proposed by the American Clinical Neurophysiology Society (ACNS), rhythmic high-amplitude delta activity with superimposed spikes (RHADS) can be reported as an extreme delta brush (EDB). The clinical implications of similar electrographic patterns being reported as RHADS versus EDB are important to highlight. We aim to review the electrographic characteristics of RHADS, evaluate whether RHADS is seen in other neurological disorders, and identify the similar and unique characteristics between RHADS and EDB to ultimately determine the most accurate way to differentiate and report these patterns. We believe that the differentiation of RHADS and EDB is important as there is a vast difference in the diagnostic approach and the medical management of associated underlying etiologies. DATA SOURCE We conducted an extensive search on MEDLINE and Pubmed utilizing various combinations of keywords. Searching for "gamma polymerase and EEG", or "RHADS" or "Alpers syndrome and EEG" or "EEG" AND "Alpers-Huttenlocher syndrome". RESULTS Three articles were found to be focused on the description of "RHADS" pattern in Alpers Syndrome. No publication to date were found when searching for the terms "EDB" AND "children", AND "infant" AND "adolescent" excluding "encephalitis" and "neonate". Although RHADS and EDB appear as similar EEG patterns, meticulous analysis can differentiate them. RHADS is not exclusive to patients with Alpers-Huttenlocher syndrome and may manifest in regions beyond the posterior head region. Reactivity to eye-opening and response to anesthesia can be two other elements that help in the differentiation of these patterns. CONCLUSION RHADS is not exclusive to patients with AHS and may manifest in regions beyond the posterior head region. Reactivity to eye-opening and response to anesthesia are features that help in the differentiation of these patterns.
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Affiliation(s)
- Rene Andrade-Machado
- Children's Hospital of Wisconsin Wauwatosa: Milwaukee, 8915 W Connell Ct, Milwaukee, WI, 53226, USA.
| | - Elham Abushanab
- Children's Hospital of Wisconsin Wauwatosa: Milwaukee, 8915 W Connell Ct, Milwaukee, WI, 53226, USA
| | - Namrata D Patel
- Children's Hospital of Wisconsin Wauwatosa: Milwaukee, 8915 W Connell Ct, Milwaukee, WI, 53226, USA
| | - Avantika Singh
- Children's Hospital of Wisconsin Wauwatosa: Milwaukee, 8915 W Connell Ct, Milwaukee, WI, 53226, USA
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Waak M, Laing J, Nagarajan L, Lawn N, Harvey AS. Continuous electroencephalography in the intensive care unit: A critical review and position statement from an Australian and New Zealand perspective. CRIT CARE RESUSC 2023; 25:9-19. [PMID: 37876987 PMCID: PMC10581281 DOI: 10.1016/j.ccrj.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objectives This article aims to critically review the literature on continuous electroencephalography (cEEG) monitoring in the intensive care unit (ICU) from an Australian and New Zealand perspective and provide recommendations for clinicians. Design and review methods A taskforce of adult and paediatric neurologists, selected by the Epilepsy Society of Australia, reviewed the literature on cEEG for seizure detection in critically ill neonates, children, and adults in the ICU. The literature on routine EEG and cEEG for other indications was not reviewed. Following an evaluation of the evidence and discussion of controversial issues, consensus was reached, and a document that highlighted important clinical, practical, and economic considerations regarding cEEG in Australia and New Zealand was drafted. Results This review represents a summary of the literature and consensus opinion regarding the use of cEEG in the ICU for detection of seizures, highlighting gaps in evidence, practical problems with implementation, funding shortfalls, and areas for future research. Conclusion While cEEG detects electrographic seizures in a significant proportion of at-risk neonates, children, and adults in the ICU, conferring poorer neurological outcomes and guiding treatment in many settings, the health economic benefits of treating such seizures remain to be proven. Presently, cEEG in Australian and New Zealand ICUs is a largely unfunded clinical resource that is subsequently reserved for the highest-impact patient groups. Wider adoption of cEEG requires further research into impact on functional and health economic outcomes, education and training of the neurology and ICU teams involved, and securement of the necessary resources and funding to support the service.
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Affiliation(s)
- Michaela Waak
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Joshua Laing
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
- Comprehensive Epilepsy Program, Alfred Health, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Lakshmi Nagarajan
- Department of Neurology, Perth Children's Hospital, Perth, Australia
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Australia
| | - Nicholas Lawn
- Western Australian Adult Epilepsy Service, Sir Charles Gardiner Hospital, Perth, Australia
| | - A. Simon Harvey
- Department of Neurology, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Neurosciences Research Group, Murdoch Children's Research Institute, Melbourne, Australia
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da Silva EJC, da Silva Bahia CMC, Ferreira MER, da Conceição PO, Zaeyen EJB. Electroencephalographic Monitoring Technology Role in Remote Ped Intensive Care Units in Rio de Janeiro, Brasil. CURRENT PEDIATRICS REPORTS 2021. [DOI: 10.1007/s40124-021-00243-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Variation in Pediatric Palliative Care Allocation Among Critically Ill Children in the United States. Pediatr Crit Care Med 2021; 22:462-473. [PMID: 33116070 DOI: 10.1097/pcc.0000000000002603] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The objectives are as follows: 1) estimate palliative care consult rates and trends among critically ill children and 2) characterize which children receive palliative care consults, including those meeting previously proposed ICU-specific palliative care screening criteria. DESIGN Retrospective cohort. SETTING Fifty-two United States children's hospitals participating in the Pediatric Health Information Systems database. PATIENTS Hospitalized children with nonneonatal ICU admissions from 2007 to 2018. MEASUREMENTS AND MAIN RESULTS The primary outcome was palliative care consultation, as identified by the palliative care International Classification of Disease code. Patient characteristics and outcomes were compared between those with and without palliative care. We used a mixed-effects multivariable model to estimate the independent association between the palliative care and patient characteristics accounting for institution and subject clustering. Hospitalizations were categorized into three mutually exclusive groups for comparative analyses: 1) meeting ICU-specific palliative care criteria, 2) presence of a complex chronic condition not in ICU-specific palliative care criteria, or 3) not meeting ICU-specific palliative care or complex chronic condition criteria. Rates and trends of palliative care consultation were estimated including variation among institutions and variation among subcategories of ICU-specific palliative care criteria. The study cohort included 740,890 subjects with 1,024,666 hospitalizations. About 1.36% of hospitalizations had a palliative care consultation. Palliative care consult was independently associated with older age, female sex, government insurance, inhospital mortality, and ICU-specific palliative care or complex chronic condition criteria. Among the hospitalizations, 30% met ICU-specific palliative care criteria, 40% complex chronic condition criteria, and 30% neither. ICU-specific palliative care patients received more mechanical ventilation and cardiopulmonary resuscitation, had longer hospital and ICU lengths of stay, and had higher inhospital mortality (p < 0.001). Palliative care utilization increased over the study period with considerable variation between the institutions especially in the ICU-specific palliative care cohort and its subgroups. CONCLUSIONS Palliative care consultation for critically ill children in the United States is low. Palliative care utilization is increasing but considerable variation exists across institutions, suggesting inequity in palliative care allocation among this vulnerable population. Future studies should evaluate factors influencing allocation of palliative care among critically ill children in the United States and the drivers of differences between the institutional practices.
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Kim LH, Parker JJ, Ho AL, Pendharkar AV, Sussman ES, Halpern CH, Porter B, Grant GA. Postoperative outcomes following pediatric intracranial electrode monitoring: A case for stereoelectroencephalography (SEEG). Epilepsy Behav 2020; 104:106905. [PMID: 32028127 DOI: 10.1016/j.yebeh.2020.106905] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/15/2019] [Accepted: 01/06/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND For patients with medically refractory epilepsy, intracranial electrode monitoring can help identify epileptogenic foci. Despite the increasing utilization of stereoelectroencephalography (SEEG), the relative risks or benefits associated with the technique when compared with the traditional subdural electrode monitoring (SDE) remain unclear, especially in the pediatric population. Our aim was to compare the outcomes of pediatric patients who received intracranial monitoring with SEEG or SDE (grids and strips). METHODS We retrospectively studied 38 consecutive pediatric intracranial electrode monitoring cases performed at our institution from 2014 to 2017. Medical/surgical history and operative/postoperative records were reviewed. We also compared direct inpatient hospital costs associated with the two procedures. RESULTS Stereoelectroencephalography and SDE cohorts both showed high likelihood of identifying epileptogenic zones (SEEG: 90.9%, SDE: 87.5%). Compared with SDE, SEEG patients had a significantly shorter operative time (118.7 versus 233.4 min, P < .001) and length of stay (6.2 versus 12.3 days, P < .001), including days spent in the intensive care unit (ICU; 1.4 versus 5.4 days, P < .001). Stereoelectroencephalography patients tended to report lower pain scores and used significantly less narcotic pain medications (54.2 versus 197.3 mg morphine equivalents, P = .005). No complications were observed. Stereoelectroencephalography and SDE cohorts had comparable inpatient hospital costs (P = .47). CONCLUSION In comparison with subdural electrode placement, SEEG results in a similarly favorable clinical outcome, but with reduced operative time, decreased narcotic usage, and superior pain control without requiring significantly higher costs. The potential for an improved postoperative intracranial electrode monitoring experience makes SEEG especially suitable for pediatric patients.
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Affiliation(s)
- Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, United States of America
| | - Jonathon J Parker
- Department of Neurosurgery, Stanford University School of Medicine, United States of America
| | - Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, United States of America
| | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, United States of America
| | - Eric S Sussman
- Department of Neurosurgery, Stanford University School of Medicine, United States of America
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, United States of America
| | - Brenda Porter
- Department of Neurology, Stanford University School of Medicine, United States of America; Division of Pediatric Neurology, Lucile Packard Children's Hospital Stanford, United States of America
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University School of Medicine, United States of America; Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital Stanford, United States of America.
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Conventional and quantitative EEG in status epilepticus. Seizure 2018; 68:38-45. [PMID: 30528098 DOI: 10.1016/j.seizure.2018.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/11/2018] [Accepted: 09/14/2018] [Indexed: 01/10/2023] Open
Abstract
PURPOSE To summarize the use of continuous electroencephalographic monitoring (cEEG) in the diagnosis and management of pediatric convulsive status epilepticus (CSE) and subsequent non-convulsive seizures (NCS) with a focus on available guidelines and infrastructure. In addition, we provide an overview of quantitative EEG (QEEG) for the identification of NCS in critically ill children. METHODS We performed a review of the medical literature on the use of cEEG and QEEG in pediatric CSE. This included published guideline, consensus statements, and literature focused on the use of cEEG and QEEG to detect NCS. RESULTS cEEG monitoring is recommended for prompt recognition of ongoing seizures that may be subtle, masked by pharmacologic paralysis, and or converted from convulsive seizures to NCS after administration of anti-seizure medications. Evidence indicating that high seizure burden is associated with worse outcome has motivated prompt recognition and management of NCS. The American Clinical Neurophysiology Society's consensus statement recommends a minimum of 24 h to exclude electrographic seizures, while the Neurocritical Care Society's guideline suggests 48 h in patients that are comatose. The use of QEEG amongst electroencephalographers and critical care medicine providers is increasing for NCS detection in critically ill children. The sensitivity and specificity of QEEG to detect NCS ranges from 65 to 83% and 65-92%, respectively. CONCLUSION The use of cEEG is important to the diagnosis and treatment of NCS or subtle clinical seizures after pediatric CSE. QEEG allows cEEG data to be reviewed and interpreted quickly and is a useful tool for detection of NCS after CSE.
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Sánchez Fernández I, Sansevere AJ, Gaínza-Lein M, Buraniqi E, Tasker RC, Loddenkemper T. Time to continuous electroencephalogram in repeated admissions to the pediatric intensive care unit. Seizure 2017; 54:19-26. [PMID: 29182970 DOI: 10.1016/j.seizure.2017.11.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/14/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Describe timing from intensive care unit (ICU) admission to initiation of continuous electroencephalogram (cEEG) in repeated ICU admissions. METHOD We performed a retrospective observational study in pediatric patients who underwent repeated ICU admissions with cEEG from 2011 to 2013. The main outcome measure was time from ICU admission to cEEG. RESULTS There were 41 patients (54% males) with at least 2 ICU admissions with cEEG (median (p25-p75) age at first admission: 3.3 (0.3-8.4) years, at second admission: 3.9 (1.1-9.4) years), 7 patients (57% males, 9.9 (2.9-11.5) years) with at least 3 ICU admissions, and 5 patients (60% males, 10.1 (4-10.5) years) with at least 4 ICU admissions. One patient had 21 ICU admissions. The median (p25-p75) time from ICU admission to cEEG was not different during the first and second ICU admissions [10.7 (1.9-22.9) hours versus 13 (0.2-36.7) hours; p=0.908]. Among patients with electrographic seizures on first admission, time to cEEG was not different during the first and second admissions [7.9 (0.5-23.4) hours versus 14.5 (-2 to 44.5) hours; p=0.636]. Among patients with status epilepticus during the first admission, time to cEEG was not different between the first and second admissions [15.3 (9-79) hours versus 40.7 (19.3-42.6) hours; p=0.75]. CONCLUSIONS The time from ICU admission to the initiation of cEEG did not decrease in second or subsequent ICU admissions, even in patients with seizures or status epilepticus on the first admission.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Spain
| | - Arnold J Sansevere
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
| | - Ersida Buraniqi
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert C Tasker
- Division of Critical Care, Departments of Neurology, Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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